Surprisingly, there is no evidence-based consensus on this amongst breast cancer physicians.
Some doctors feel that since there is no "natural" breast tissue left, there is no need to continue monitoring patients. Others decide on a patient-by-patient basis.
Though the risk is very low, breast cancer can come back after a mastectomy. Breast reconstruction does not increase or decrease the risk of recurrence at all - the recurrence rate is the same whether women have reconstruction or not.
However, since the risk of breast cancer recurrence is a real one, I feel we need to continue some sort of monitoring once the reconstruction process is completed. This is especially the case in nipple-sparing mastectomy patients and patients who carry breast cancer associated gene mutations (eg BRCA).
Self breast exam is a no-brainer. It's relatively easy to perform and it's free.
For implant reconstruction patients it’s easier to feel changes in the skin against the underlying implant. Deep recurrences on the muscle (less common) are also theoretically easier to feel; the pectoralis muscle previously located under the breast tissue (ie at the "deep mastectomy margin") is now displaced superficially and under the skin since it is pushed upwards by the implant placed beneath it.
For patients with silicone implants, the FDA recommends an MRI 3 years after the implants are placed followed by repeat MRIs every 2 years after that. This recommendation was provided when silicone implants were re-introduced to the US market for cosmetic use as a means of checking implant integrity long-term. In the case of breast reconstruction, recurrent cancer is always going to be a more worrying concern for patients than documenting implant integrity. However, the MRI test is the same in both instances. Ironically, when it comes to having the MRI covered by insurance, it is often easier to use the FDA recommendation as the underlying reason for having the test rather than trying to justify a screening test in a mastectomy patient with a benign exam. I don't personally feel routine MRIs are necessary but this approach is certainly an option.
Patients that have had a flap reconstruction may also benefit from further imaging studies in addition to self exam.
The most commonly used breast imaging studies are mammograms and MRI. The appearance of a mammogram changes completely after autologous (flap) breast reconstruction. Even if the breast looks naturals on the outside, the inside of the breast is completely different since the breast tissue has been replaced by fat.
Some surgeons recommend flap patients have a mammogram, in essence a "flapogram", after reconstruction just to get a new baseline. If the self breast exam reveals anything new of concern then the mammogram can be repeated, often in conjunction with an ultrasound for more information. Now the new mammogram can be compared to the baseline mammogram.
Another option is a one-off baseline MRI after breast reconstruction instead of a mammogram but this is a more expensive approach. MRIs are much more sensitive. Again, if self breast exam reveals a new area of concern in the future, the MRI can be repeated to see if anything has changed.
The counter argument to this approach is that any new breast lumps that appear in the future will likely lead to the recommendation for a biopsy anyway, so what is the point of getting a baseline mammogram or MRI at all?
I understand this point of view but I don't agree with it. Flap reconstructions can develop areas of fat necrosis. This is fat in the reconstructed breast that becomes hard and creates a new mass. While a biopsy may indeed be planned anyway to rule out a recurrence, there is a lot to be said for the physician and patient knowing this "lump" has been there all along and that the chance of this representing a new cancer is extremely low. The additional information and peace of mind a baseline study provides in this situation warrants it in my opinion.
I hope this info helps!
Dr C
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Dr Chrysopoulo is a breast reconstruction surgeon in San Antonio, TX, specializing in the DIEP flap and other state-of-the-art breast reconstruction procedures. In-Network for most US insurance plans. Patients are welcomed from across and outside the US. Please call (800) 692-5565 or email patientadvocate@PRMAplasticsurgery.com to learn more about your breast reconstruction options. Connect with others touched by breast cancer on Facebook.
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Very Interesting article, I used to think that after a mastectomy there was no more risk of breast cancer and that no more monitoring should be done. It’s very useful for all breast cancer patients to know this information and visit their doctor on a regular basis to make sure everything is ok. If interested in Mastectomy visit Symposier Site www.symposier.com, different of videos on this topic are available.
ReplyDeletewhen I had found my 2nd to last lump, my doctor sent me for a biopsy with a breast surgeon. There is was found to be very abnormal with 6-7 different cell growths. I was told it was no longer "if" I was going to get breast cancer but now "when". I was told I now had to get a mammogram and a doctor's checkup every 6 months. The first mammo was fine and when my doc sent me for the 2nd one they wouldn't do it telling me they could not be expected to do mammos on every woman over 50 as chances are they are just hormonal. When I found the last lump 4 months after my last checkup I got sent right away and the lab refused to do it. My doc tore a stripe off of them when I went back and saw her and she automatically sent me to see the breast surgeon who had originally told me to go every 6 months. She did a lumpectomy and it came back cancerous. Had I not listened to my gut and the specialist AND not had a family doctor who listened to me I would not be here now. It has almost made 2 years since I was diagnosed and once again have been told now that the reconstruction process is done ( I had to have a bilateral mastectomy done)I have to go for mammograms again. My concern is what if I get turned away again? What if I am told there is no need to have it done because I don't have breasts anymore? Then what?
ReplyDeleteSally,
ReplyDeleteI'm sorry for your nightmare experience. Good news is that you won't need mammograms every 6 months anymore now that you've had mastectomies and reconstruction.
My personal preference for women reconstructed with their own tissue (a flap reconstruction) is to get a new baseline study, either a mammogram or MRI a few months after the reconstruction has been completed. This is a one-off just to give us the new "norm". From that point on I recommend you continue self-exam monthly.
If you or your doc feel anything new on exam then obviously a new test should be ordered which can then be compared to the last baseline exam. After the baseline exam, you're only going to need another test if there is something new on exam. You'll therefore have a reason for needing the exam. No-one can deny you on medical grounds. You're more likely to have difficulties getting the new baseline exam approved, but then again your breast surgeon can make a case for it (if he/she agrees).
Dr C
Someone told me that tummy fat can't get cancer. Is this true? Since I had a bilateral mastectomy with DIEP flap reconstruction I thought the risk of breast cancer returning was minimized since the breast tissue was gone (and now tummy fat has taken its place). I understand that there is risk at the chest wall and the actual breast "shell" since I had a skin sparing mastectomy. Is this true? Thanks!!!
ReplyDeleteYes Tammy, that's true.
ReplyDeleteTummy fat, or any other tissue that is used to reconstruct the breast after mastectomy, cannot get cancer (but cancer can grow in to it from the surrounding tissue).
You have decreased your risk of cancer as much as possible by having a mastectomy , but the risk in never zero. There is still a risk (minimal) that a breast cancer will develop in the remaining tissues ("shell" as you said). This can then grow into the tummy fat but the fat itself will never develop a new breast cancer.
Dr.C,
ReplyDeleteNot sure if you're still updating this site. Breast lumps after DIEP Flap... how common are they?
- Lori
Lorena,
ReplyDeleteBetween 3% and 14% depending on which study you believe. It's somewhere in this range. 10% is a good ball-park figure if you include even the smallest areas of slight firmness.
These "lumps" after DIEP flap surgery and other tissue flap procedures are typically due to fat necrosis. This basically means the blood supply to that area of fat is not a good as other areas. The fat essentially turns into scar.
There isn't much published on the treatment of fat necrosis, but firm massage and ultrasound can help soften these areas if started early enough (within a few weeks of surgery).
The other cause of a "lump" which must be excluded of course is another breast cancer lesion (if the mastectomy was performed for breast cancer). Thankfully this is much less common. These also typically occur much further down the road compared to fat necrosis.
For this reason you should always be evaluated by your physician if you feel something new or different on self breast exam - yes, you should still do that even after mastectomy and breast reconstruction!
Dr C
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wife had masectomy,and flat flap reconstruction done. but looks like its come back in chest wall under or around the repair flap. this was seen on a c. t scan...
ReplyDeleteWhat about someone who had bilateral mastectomy and only saline implant reconstruction? Should they get mammograms?
ReplyDeleteI have been getting breast MRIs since I feel that they are better screening tools to diagnose cancer. My insurance paid for them, but now they refuse...
My question is this:
Mammograms wouldn't see anything, would they, since all I have is implants in there, and minimal breast tissue... am I right?
The mammogram is uselss for someone like me....
Anonymous,
ReplyDeleteYou're right, following implant breast reconstruction there can be really very little to see on mammogram so MRI is preferable if there's something new on breast exam.
I'm not surprised your insurance won't pay for an MRI anymore as a screening test... that's become the norm I'm afraid.
Dr C
What would you recommend for a patient who had bilateral mastectomy currently has saline expanders in place (metallic port included) and the breast surgeon is not sure that she got a wide enough margin on the skin over the area where the tumor was? Ultrasound prior to the second surgery; re-excision or MRI after expander replacement?
ReplyDeleteThe pathology results from your surgery should provide an exact margin in terms of millimiters. There are 3 possibilites: they got it all with an adequate margin, they got it all with a close margin, or they didn't get it all.
ReplyDeleteGenerally speaking, if there is any doubt or the margins are very close, our approach is typically to go back and take a little more tissue (ie re-excision) to ensure complete excision with adequate margins. The priority obviously is to ensure all the cancer is gone.
Please discuss this further with your docs though. Only they know the specifics of your case to advise you fully.