The moment a woman learns she has breast cancer — or even that she is likely to get it — she faces decisions.
How will she tell family and friends? Which cancer specialists will she choose? What treatments sound best? Should she get a second opinion? A third?
The list is endless. And if she's having a mastectomy, surgical removal of one or both breasts, there's another decision: whether to have surgery to create new breasts.
These days, most women opt for breast-sparing treatments such as lumpectomies. But a sizable number — about 37 percent of women diagnosed with breast cancer — choose mastectomy.
Just one-third of those women opt for reconstructive plastic surgery, according to the Web-based patient support group Cancer Support Community.
Medicare and private insurance plans provide coverage for reconstruction after mastectomy, thanks in part to the Women's Health and Cancer Rights Act of 1998.
But the fact that so many woman decide against it doesn't surprise Dr. Christine Laronga, a breast surgeon and program leader of the Don and Erica Wallace Comprehensive Breast Program at Moffitt Cancer Center in Tampa.
For one thing, breast cancer is more common in older women, and her patients over age 70 are less likely to want reconstruction, she said.
"They realize it's a longer surgery, recovery is more difficult, there's a longer hospital stay. The older patients think about that twice," says Laronga.
Younger women who get mastectomies either to treat or prevent cancer are far more eager for plastic surgery. In fact, some experts say that the small increase in younger women getting preventive mastectomies may be due both to advances in genetic testing — and improved plastic surgery techniques.
"Younger patients are very quick to say, 'I don't care, I want a breast,' " Laronga says.
But she adds, "There are still lots of women who are 70 and up who opt for the surgery."
Cable TV plastic surgery shows make cosmetic breast enhancement look like a simple matter.
But post-mastectomy reconstruction is a multistep process that can take up to a year to complete.
If a woman wants reconstruction, the process usually begins immediately or shortly after mastectomy.
One option is for the plastic surgeon to replace the removed breast tissue with an implant filled with silicone gel or a saline solution, placed under the skin and muscle.
Another option is tissue flap reconstruction. It's a more extensive surgery, but it uses the woman's own tissue — skin, fat and muscle from the woman's abdomen, back or buttocks — to create the breast shape. The American Society for Plastic Surgeons estimates that in 2007, of the more than 57,000 women who had noncosmetic breast reconstruction, about 34,000 chose to have implants and about 23,000 used their own tissue.
Implant surgery can be done at the same time as the mastectomy. Or the surgeon can place a special implant in the woman's chest that expands to make room for a permanent implant later, or holds a place for her own tissue to be transferred, once lymph node testing is completed.
Many surgeons recommend that women decide on reconstruction before the mastectomy so that steps can be taken to accommodate an implant. But it's often possible to do reconstruction years later.
In women who only have one breast removed, the plastic surgeon will usually suggest having the natural breast lifted or shaped to match the newly created breast — additional surgery that not all women are interested in.
After recovering from the implant surgery, many women undergo another procedure to have a nipple constructed and the ring of skin around it tattooed to a darker color, to more closely approximate a natural breast.
Reluctance to undergo additional surgery isn't the only reason many women don't have breast reconstruction. It may not be an option if the cancer has spread extensively, the woman has severe diabetes or is otherwise in poor overall health. If radiation therapy is needed, reconstruction usually is postponed. (Some lumpectomy patients are also candidates for some degree of reconstruction but that, too, usually is delayed until after radiation.)
Lifestyle issues are also considered because they can increase the chances for complications and poor healing. For example, some surgeons won't operate on obese patients until they lose a significant amount of weight; other surgeons exclude smokers or insist on no smoking for weeks or months before the surgery.
Some patients decline reconstruction, believing that implants may make it more difficult to detect a recurrence of cancer. Because it's impossible to remove all the breast tissue, even after mastectomy there's a 3 to 5 percent lifelong risk of having cancer again in the same breast — whether or not you have reconstruction, Laronga said.
That's why breast cancer survivors are urged to continue seeing their doctors for clinical breast exams and mammograms, if recommended. Having implants may require special X-ray views during mammography, and they may require MRI scans periodically to check for rupture or leaking.
Dr. Antonio Gayoso, chief of plastic surgery at Bayfront Medical Center and St. Anthony's Hospital in St. Petersburg, says there's a lot of misinformation about implants among breast cancer patients. One myth he hears about frequently is that implants must be removed and replaced after 7 to 10 years.
"That's an urban legend,'' he says. "If there's a problem, they should be replaced, but if there's no problem, then most plastic surgeons will not recommend removal."
A survey released last month by the online Cancer Support Community found that almost half of the women surveyed didn't receive information about plastic surgery when they were diagnosed with breast cancer and were making their treatment decisions.
Dr. Frank DellaCroce, a New Orleans plastic surgeon who specializes in breast reconstruction, blames his colleagues.
"I think there's a built-in bias when a surgeon is taking care of elderly women," he says, adding that some surgeons wrongly assume that older women have no interest in their body image. "It might not even occur to the surgeon that she would want reconstruction so it isn't offered," says DellaCroce, who is trying to increase awareness that all women should be informed of their reconstruction options.
Dr. Gayoso says he's starting to see older breast cancer patients who had a mastectomy years ago and have recently decided to have reconstruction.
"They have changed their minds," he says. "They've lived without a breast, used a prosthesis, a rubber shaped implant in a special bra, for years. They don't like it, it's hot, uncomfortable, they have to put it on everyday. They don't want to do that anymore."
Irene Maher can be reached at firstname.lastname@example.org.