C is for ‘Choice’

/tʃɔɪs/

  1. An act of choosing between two or more possibilities
architecture black and white challenge chance
Photo by Pixabay on Pexels.com

A cancer diagnosis is bewildering.  You are bombarded with complex medical data; confusing details about staging, grade, type; an onslaught of information about treatment paths, surgical options and prognosis.  You feel lost.  Like really lost.  In a forest with no marked path, no signposts, no GPS signal, not even a bit of f**king moss on the side of a tree, lost.  And then you get told you need a mastectomy and you need to make a choice.

Because for younger women with breast cancer (yes, it still freaks me out that in the cancer world I’m ‘young’) in most cases, it’s not as straightforward as ‘we have to remove your breast to get rid of the cancer’.  There are options.  Lots of options.  Lots of make-your-f**king-head-spin-with-uncertainty-doubt-confusion-bewilderment options.  At a time when your ability to make rational, well thought-through decisions has been severely eroded by sheer terror.

I’m going to write a blog post later about my own decision-making process and how it was flawed (thankfully not permanently) due to panic, fear and red-tape mistakes but for now I’m going to lay out the most common choices spread out in front of breast cancer patients needing a mastectomy so you can understand how bewildering it can be.  It’s kinda like one of those ‘Choose Your Own Adventure’ books that I was addicted to in the 80s.   You know the ones, where you get asked ‘Do you open the locked door with the big red cross on it (turn to page 81) or take the passage with the sunny garden at the end (turn to page 89)?’ And when you stupidly open the locked door and turn to page 81, it says ‘there’s a big poisonous snake inside which bites you and you die a lonely agonizing death’.  Except in this delightful Choose Your Own Breast Cancer Adventure, you can’t flip back to your original choice, choose page 89 instead and have a do-over.

When initially told that you need a mastectomy, the choices seem limited:

Have a mastectomy to remove the breast and the cancer vs Not having a mastectomy and face the significantly increased risk of a cancer death at some point in the future.

That decision probably isn’t too hard to make. It’s a no-brainer right? Lose a breast, increase your chances of not dying yet.  But bare in mind even the best decisions have consequences and it’s likely that for many women the psychological impact of losing a breast, even if it saves their life, is going to sneak up on them at a later point.

And while choosing not to have a mastectomy closes many doors, opting for the surgery opens up a plethora of others:

Have a mastectomy and remain ‘flat’, with nothing replacing the lost breast (apart from maybe a prosthesis or the wonderful ‘knitted knocker’) vs Have a mastectomy and then have a breast reconstruction

This decision is harder to make and depends on so many factors – current medical need, personal emotional and psychological feelings about body image, sexuality, intimacy.  I’ve seen many women talk about how they simply couldn’t bear the idea of waking up from a mastectomy surgery to see that they were ‘flat’, while others have felt able to embrace that flatness more readily. Everyone is different and, resurrecting the CYOA metaphor, what seems like the obvious path to one (go to page 94) is a path filled with thorns for another (go to page 102).

But opting for reconstruction isn’t the end of the decision-making because then you have:

Immediate reconstruction vs Delayed reconstruction

And whichever one of those two you pick then you still have to decide between:

Having a reconstruction using an implant. vs Having a reconstruction using autologous tissue (ie using some of your own body tissue)

Another difficult decision and depending on factors both personal and medical.  For some women using your own tissue just isn’t an option (you need to be carrying a little bit of extra weight and have a viable blood flow through the various veins and arteries that will be moved) while for others the idea of an implant is anathema.

Then regardless of your choice here, more options spiderweb their way out, each with their own set of pros/cons, risks/benefits:

Implant reconstruction:

One Stage procedure – either fixed size or expandable;

Two stage procedure.

vs Autologous Tissue reconstruction:

DIEP – using tummy tissue;

TRAM – using tummy tissue and muscle;
LD – using back tissue and muscle;

SGAP/IGAP – using buttock tissue;

TUG/PAP – using thigh tissue;

As you can see, the array of decisions that have to be made is overwhelming, laden with jargon and requiring the sort of cost/benefit analysis that only investment bankers normally undertake.

So what does it all mean?  Here are some quick (or not so quick, as I’m quite a wordy type of gal) definitions and explanations:

Immediate or Delayed Reconstruction

After a mastectomy, in which all the breast tissue is removed from either one or both breasts, women can have immediate or delayed reconstruction.  Immediate reconstruction simply means that the mastectomy and the reconstruction takes place at the same time, during the same surgery.  Usually this means that a breast surgeon removes the breast tissue, then a plastic surgeon steps in to take over the reconstruction element, although sometimes a breast surgeon will do an implant reconstruction. As a consequence the surgery is long but all the major surgical processes are done in one sitting (or one lying down).

For various reasons sometimes a delayed reconstructionis necessary, with the mastectomy done in one operation, and the reconstruction done months or sometimes years later.  This might be because further treatment is needed first (such as radiotherapy) that might damage a reconstructed breast, or because the woman wants to delay making a choice about the reconstructive opportunities open to her.

Implant Reconstruction

Using surgical techniques developed for cosmetic boob jobs, women can opt to have silicon implants to reconstruct their missing breast(s), using either a one or two step procedure.

  1. One Step – either a fixed size implant or an expandable implant can be used. The fixed size simply slips a silicon implant behind the chest muscle to create a breast shape.  An expandable implant is used when the chest muscle needs to be stretched.  The implant has the usual chamber of silicone gel and an additional hollow inner chamber that is, over a period of a few weeks, filled slowly with saline to stretch the muscle and give the final shape.
  2. Two Step – this procedure involves inserting a temporary hollow ‘expander’ under the chest muscle, which is, like the expandable implant above, slowly filled with saline. When the muscle is sufficiently stretched, an operation removes the temporary expander and replaces it with a permanent silicone implant.
Benefits Limitations
Simple operation with shorter recovery time Several visits to the hospital might be needed for tissue expansion
Less scarring on the body Implants can feel cold and hard
Balanced breast outline Reconstructed breast might not have same natural ‘droop’ as natural breast
Further surgeries are likely to be needed as implant breast will not change over time as the natural breast will
Risk of implant leaking or the tissue around the implant tightening (capsular contraction)

Autologous Reconstruction

Reconstruction using tissue from your own body can take many forms:

  • LD Flap – using tissue from the back

A Latissimus Dorsi flap (LD) uses the LD muscle from the back as well as overlying fat and tissue.  The flap and its blood supply is tunnelled under the skin in the armpit, then positioned on the chest to make a new breast shape. Often an implant is also used to give more volume to the new breast.

  • DIEP/SIEA/TRAM flaps – using tissue from the tummy

These three surgeries (with DIEP being the one most commonly used) involves detaching tissue and blood vessels from the tummy then moving the tissue to the breast and connecting it to a new blood supply in the chest with microsurgery.  The DIEP and SIEA use different blood vessels (hence the different names) while the TRAM also takes some muscle in addition to the fat and skin.

  • SGAP/IGAP flap – using tissue from the buttocks

Again fat and skin is taken, from either the upper or lower part of the buttocks and moved to the chest to form a new breast shape.

  • TUG/PAP flap – using tissue from the thigh

Both of these procedures use fat and skin from the upper inner thigh, with the TUG additionally using muscle.

Each of these procedures has their own cost/benefit balance to address but overall:

Benefits Limitations
Can give a more natural look to the reconstructed breast Involves more scarring both on the breast and on another part of the body
The breast will age and change shape with you, reducing the need for further surgeries Surgery is longer (can be up to 14 hours) so time needed in hospital and post-op recovery is much longer
Some procedures might lead to restriction in movement (ie LD might impact arm movements)
A reconstructed breast will have less sensation than the original breast
Risk of the flap failing and needing to be removed
Further surgery might be needed to balance out breasts, reconstruct nipple etc

You see? Confusing, bewildering, overwhelming and frightening.  Choosing what is right for you involves choosing between a wide array of options that will leave you scarred, hospitalised, in pain, immobilised and altered beyond reckoning.  But it is also a choice that is necessary to save your life.  So you do it.  With help from the medical team around you, your family, your friends, and, for me, the peer support on some amazing Facebook groups.

How I made that choice, the emotional and psychological impact of it, the physical trauma of it will come later.  But I wanted to end with a film analogy (because I’m a movie geek after all).  Making these choices reminded me of a scene from (one of my all time favourite films) ‘Indiana Jones and the Last Crusade’.  As Indy faces the Grail challenges, he is asked to spell out the ‘name of God’ using tiles on the floor.  Choose the wrong letter and the tiles give way, potentially sending him tumbling to his death in a massive cavern below.  At each step he has to trust that his knowledge, his education, his experience will leave him on firm footing.

ch1Iv
Indy’s ‘Name of God’ test – click here to see the video

And as breast cancer patients, we too have to rely on the experience and education of the medical experts, to guide us across the perilous floor of mastectomy choices, to solid ground on the other side.

 

For more detail about breast reconstruction options, please go to:

Breast Cancer Care – Types of Breast Reconstruction 

Macmillan – Types of Breast Reconstruction 

British Association of Plastic Reconstructive and Aesthetic Surgeons – Breast Reconstruction

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