I Am BRCA Positive, What Are My Options?

There are multiple gene mutations that are associated with breast cancer.  With extensive research efforts focused on human genomics this number will continue to rise.  BRCA1 and BRCA2 gene mutations are the most common and most thoroughly studied gene mutations.  Overall incidence of BRCA mutations is quite rare (roughly 1/400 people affected), but the incidence is higher in certain patient populations.  Right now hereditary breast cancers are thought to make up roughly 5-10% of new diagnoses, but this number will likely rise as additional genes are identified.  This link provides a good summary of the background and demographics of hereditary breast cancers: http://ww5.komen.org/BreastCancer/InheritedGeneticMutations.html Patients with BRCA mutations have a 40-84% risk of developing breast cancer by age 70; contrast this with the general population who have an 8% chance of developing breast cancer by age 70 and a 12% chance by age 85. Preventive (or prophylactic) mastectomy in patients known to be BRCA positive is becoming more common.  Recent studies have shown a significant risk reduction of developing breast and ovarian cancers with prophylactic mastectomies and prophylactic salpingo-oopherectomy (removal of the fallopian tubes and ovaries).  This link provides a summary of a recent article demonstrating the benefit of prophylactic surgery: http://www.cancer.gov/clinicaltrials/results/summary/2010/prophylactic-surgery0910 If a patient elects to have prophylactic mastectomies due to hereditary factors to reduce risk of cancer all reconstructive options are...

Skin-Sparing Vs Nipple-Sparing Mastectomy, What’s The Difference? Am I A Candidate For Nipple Sparing?

Skin-sparing mastectomy refers to preserving the breast skin at the time of mastectomy, usually done with ‘immediate reconstruction’.  It’s important to clarify, many studies have shown the safety of a skin-sparing mastectomy as it pertains to breast cancer recurrence.  Depending on how much ‘sag’ present, there are varying degrees of skin-sparing. Importantly, aesthetic outcomes with reconstructive surgery have improved dramatically with routine integration of this type of mastectomy by breast surgeons.  Often scars can be designed to look similar to ‘breast lift’ scars. Nipple-sparing mastectomy is more controversial than skin-sparing mastectomy.  Since the nipple-areola complex is part of the breast, cancer recurrence rates are higher.  This type of mastectomy has more stringent criteria for patient selection.  The breast surgeon typically prefers a patient with smaller tumors which are a safe distance from the nipple, and/or in cases of prophylactic mastectomies (ex. BRCA patient).   Reconstructive surgeons typically prefer patients with small to moderate breast size and minimal ptosis (or sag) of the...

Obesity And Breast Cancer…Breast Cancer Recurrence…And Reconstruction?

There is increasing knowledge of the relationship between obesity and breast cancer, obesity and breast cancer recurrence, and reconstructive outcomes in obese patients. There is an association between post-menopausal breast cancers and obesity.  This relationship is significant given the recent statistics showing 40% of patients over age 60 are obese.  There are studies that suggest that obese, post-menopausal breast cancer patients are at higher risk of estrogen-positive breast cancers, as well as triple-negative breast cancers.  http://www.livescience.com/13030-obesity-increase-risk-aggressive-breast-cancer.html With regards to breast cancer recurrence, the relationship with obesity is quite ominous.  When looking at hormone receptor positive breast cancers (the most common type), and after excluding patients with other medical problems, researchers found higher BMI alone predicts a higher rate of recurrence and premature death.  This finding is despite meeting adequate standards of care with surgery, chemotherapy, and hormonal therapy. This link summarizes the findings of the study. http://www.eurekalert.org/pub_releases/2012-08/w-oao082212.php With regards to breast reconstruction, recent outcome studies have shed light on additional risk of complications in the obese.  Obesity is a significant risk factor for failure with implant-based reconstruction done at the same time as mastectomy (immediate reconstruction); this issue is more pronounced in the morbidly obese (BMI > 35) and tends to correlate with breast size.  In a study out of MD Anderson in 2012, failure rates of immediate implant reconstruction in the obese population (BMI 30-35) was 11%, and in the morbidly obese population (BMI >35) it was 25%.  Contrast this to abdominal free flap reconstruction (DIEP flap or muscle-sparing TRAM flap), which showed failure rate of roughly 1% across all patient populations.  Based on this data, as well...

Radiation And Tissue Expander, What Should I Know?

The indications for radiation therapy after mastectomy are becoming more common.  In some scenarios the need for radiation is known prior to the mastectomy, and in some scenarios it’s not determined until after the mastectomy, when the ‘surgical stage’ is determined. Patients who elect to have a tissue expander placed prior to radiation therapy have choices for the second stage of reconstruction.  Many elect to have the permanent implant placed, whereas others will elect to convert the reconstruction to tissue-based reconstruction.  In patients who elect to have the permanent implant placed they are at higher risk of short-term and long-term complications.  Short term complications include delayed healing and infection, long term risk includes an accelerated progression to capsular contracture. (…article reference…).  Converting the reconstruction to tissue-based reconstruction has the advantage of avoiding these risks as the overall complications do not differ from non-radiated...