Breast Reconstruction 2020 by PlasticSurgeryNews

FALL 2020

●

A Supplement to Plastic Surgery News

A patient’s guide to understanding her treatment options

Hope Lives Here Survivor helps women find healing and closure after breast cancer PAGE 6

Sisterhood: Changing the narrative for Black women PAGE 12

Young scientist shares her BRCA journey PAGE 16

Breast reconstruction during COVID-19 PAGE 19

Understanding the breast cancer gene PAGE 28

TABLE OF CONTENTS Get involved: Breast Reconstruction Awareness Day

ASPS president shares lessons learned during cancer journey By Kendra Y. Mims-Applewhite

Survivor helps uninsured women find closure after breast cancer By Kendra Y. Mims-Applewhite

12 Four-time cancer survivor changing the narrative in the Black community By Kendra Y. Mims-Applewhite

15 Preserving and restoring sensation after surgery By Anne Peled, MD, and Ziv Peled, MD

16 Young scientist empowers women through her BRCA journey By Adam Kivel

19 Breast reconstruction during COVID-19 By Daniel Liu, MD

20 Plastic surgeon’s mission trips restore hope – and lives – in Ghana By Kendra Y. Mims-Applewhite

24 Survivor helps spearhead community-based fundraisers for reconstruction By Paul Snyder

26 Is ‘seasoned’ age a valid concern in breast reconstruction? By Monica Llado-Farrulla, MD, and Paris D. Butler, MD, MPH

28 Answers to common questions about the breast cancer gene By Christopher Shale, MD

30 Four ways to maintain self-care during reconstruction By Terri Coutee

31 Industry support is vital to Breast Reconstruction Awareness efforts The views expressed in the articles in this supplement are those of the authors and do not necessarily reflect the opinions of ASPS. Acceptance of advertisements is at the sole discretion of ASPS. ASPS does not guarantee, warrant or endorse any product, program or service advertised.

Download a free electronic copy of PSN: Breast Reconstruction at plasticsurgery.org/breastreconissue

l PSN: BREAST RECONSTRUCTION 2020

FALL 2020

A note from the editor

lthough the rate of mastectomy procedures continues to rise in the United States, the rate of breast reconstruction accounts for less than half of those diagnosed with breast cancer. These numbers will be altered for 2020, much like everything else during the COVID-19 pandemic, as screening tests were deferred, non-life-saving procedures were delayed and breast reconstruction often became an afterthought as a result. As a community of board-certified plastic surgeons, members of the American Society of Plastic Surgeons took on myriad responsibilities during the pandemic. Some were redeployed to critical-care units while others organized the collection and distribution of personal protective equipment (PPE) and other critical medical equipment to hospitals most affected by the pandemic. In reviewing this year’s edition of Breast Reconstruction in comparison to last year, I’m struck by how, in spite of the differences this year posed, our mission remains unchanged. Breast reconstruction is a uniquely personal decision. Of the factors that go into making the choice, being unaware of the available options remains a significant factor for many of the more than 260,000 women who are diagnosed each year. Since 2012, The Plastic Surgery Foundation and ASPS have supported the Breast Reconstruction Awareness USA campaign to promote education and awareness of options for breast reconstruction. To my knowledge, this is the only public campaign that focuses the breast cancer discussion on reconstruction. As a reconstructive microsurgeon, I love what I do. I have the opportunity to help rebuild more than just the breast and have seen first-hand the effect that cancer treatment – with or without reconstruction – can have on a woman’s quality of life and survivorship. Every woman is entitled to a conversation about breast reconstruction, to have the opportunity to restore what cancer has taken away. As practices begin to safely resume, I’m excited about more women having the chance to learn about some of the innovations in reconstruction that have had a significant impact on my practice and patients. Building on our understanding of anatomy and nerve repair, plastic surgeons are able to aid the body in nerve regeneration with the goal of restoring sensation. Treatment of post-mastectomy lymphedema syndrome continues to expand with immediate lymphatic reconstruction at the time of oncologic surgery, in addition to physiologic procedures such as lymph-node transfers and lymphovenous bypass to reduce congestion and improve volume overload in the affected extremity. As always, patient safety is paramount in any reconstruction – and The PSF has two international initiatives tracking outcomes of reconstruction by our board-certified plastic surgeons: the National Breast Implant Registry (NBIR) and the General Reconstruction Autologous Fat Transfer (GRAFT) registry. In celebration of this year’s Breast Reconstruction Awareness Day, slated for Oct. 21, Plastic Surgery News has again put together a special magazine focused on breast reconstruction education and advocacy. Within these pages are stories to promote patient care, education, advocacy and research. You will read personal narratives from breast cancer survivors and reconstructive surgeons. We highlight key things to know when considering breast reconstruction at any age or any time in your recovery. You will read the plastic surgeon’s perspective when helping women rebuild – particularly in the COVID era and beyond. Finally, we feature community and patient advocates in breast reconstruction, helping others to understand and access this critical component of comprehensive cancer care. We hope you enjoy this fifth special edition of Breast Reconstruction and join our efforts in closing the loop on breast cancer. Summer E. Hanson, MD, PhD PSN Associate Editor

COVER PHOTO: ISTOCKPHOTO.COM

MENTOR® Silicone Gel Implants Are Safe and Effective1

Your Trusted Partner Then, Now & Into the Future

NEARLY

OVER

Patients highly satisfied at 10 years with MemoryGel® Breast Implants3

YEARS

in Breast Aesthetics

Clinical Studies

200K Women

Participated 4-13

MILLION

Women with MENTOR® Breast Implants

9 10 OUT OF

Consumers choose MENTOR® MemoryGel® Xtra Breast Implants as feeling more like a natural breast 14

1. 1.1 MemoryShape Post-Approval Cohort Study (formerly Contour Profile Gel Core Study) Final Clinical Study Report. Mentor Worldwide, LLC; 02 June 2015. 1.2 MemoryGel Core Gel Clinical Study Final Report. Mentor Worldwide, LLC; April 2013. 1.3 Mentor MemoryShape Post-Approval Continued Access Study (formerly Contour Profile Gel Continued Access Study), Final Report. October 2014. 1.4 Mentor MemoryGel Breast Implant Large Post Approval Study Re-Op Phase Annual Report. 17 June 2016. 1.5 Adjunct Study Final Report for Mentor’s MemoryGel Silicone Gel-filled Breast Implants. 02 November 2012. 1.6 Mentor MemoryShape CPG Styles Study: A Study of the Safety of the Contour Profile Gel Breast Implants in Subjects who are Undergoing Primary Breast Augmentation, Primary Breast Reconstruction or Revision, Final Clinical Study Report. 20 October 2015. 2. Mentor Worldwide LLC. Mentor Worldwide Sales Data – 2019. 3. Based on patient survey at 10 years in the Mentor® MemoryGel® Breast Implant 10-Year Core Gel Clincial Study Final Report. Mentor Worldwide LLC. MemoryGel® Core Gel Clinical Study Final Report, April 2013. 4. Summary of the Safety and Effectiveness of Mentor’s MemoryGel® Silicone Gel-Filled Implants in Patients who are Undergoing Primary Breast Augmentation, Primary Breast Reconstruction, or Revision. 10-Year Core Gel Final Clinical Study Report. April 2013. 5. MemoryGel® Post Approval Study Seventh Annual Report, November 5, 2013. 6. Adjunct Study Final Report for Mentor’s MemoryGel® Silicone Gel-Filled Breast Implants, 02 November 2012. 7. Mentor Worldwide, LLC. MemoryShape™ Post-Approval Cohort Study (formerly Contour Profile Gel Core Study) Final Clinical Study Report. 02 June 2015. 8. Mentor Becker Expander/Breast Implant Clinical Trial 2013 Annual Report. 9. Adjunct Study Annual Report for Mentor’s Becker Adjustable Breast Implants: Year 18 (September 1992-November 2010) October 3, 2011. 10. CPG Styles Study: A Study of the Safety of the Contour Profile Gel Breast Implants in Subjects who are Undergoing Primary Breast Augmentation, Primary Breast Reconstruction, or Revision. 2015. 11. MemoryShape™ Post-Approval Continued Access Study (formerly Contour Profile Gel Continued Access Study). 2014. 12. Athena Study annual report (Sept 2018): A Study of the Safety and Effectiveness of the Mentor® Smooth and Textured Larger Size MemoryGel® Ultra High Profile (UHP-L) Breast Implants in Subjects who are Undergoing Primary Breast Reconstruction or Revision Reconstruction. 13. Glow Study annual report (Feb 2018): Memory Gel and Shape Combined Cohort Post Approval Study. 14. Head-to-head blinded in-person tabletop product comparison (MemoryGel Xtra vs. Inspira Responsive vs. Inspira Cohesive) with 452 respondents. Mentor Consumer Preference Market Research Report - July 2017. IMPORTANT SAFETY INFORMATION The MENTOR® Collection of Breast Implants are indicated for breast augmentation - in women who are at least 22 years old for MENTOR® MemoryGel® Breast Implants or MENTOR® MemoryShape® Breast Implants, and at least 18 years old for MENTOR® Saline Breast Implants.Breast implant surgery should not be performed in women: With active infection anywhere in their body; With existing cancer or pre-cancer of their breast who have not received adequate treatment for those conditions; Who are currently pregnant or nursing. Safety and effectiveness have not been established in patients with autoimmune diseases (for example lupus and scleroderma), a weakened immune system, conditions that interfere with wound healing and blood clotting, or reduced blood supply to breast tissue. Patients with a diagnosis of depression, or other mental health disorders, should wait until resolution or stabilization of these conditions prior to undergoing breast implantation surgery. There are risks associated with breast implant surgery. You should be aware that breast implants are not lifetime devices and breast implantation may not be a one-time surgery. You may need additional unplanned surgeries on your breasts because of complications or unacceptable cosmetic outcomes. Many of the changes to your breast following implantation are irreversible (cannot be undone) and breast implants may affect your ability to breastfeed, either by reducing or eliminating milk production. Breast implants are not lifetime devices and breast implantation may not be a one-time surgery. The most common complications for breast augmentation with MemoryGel® Implants include any reoperation, capsular contracture, nipple sensation changes, and implant removal with or without replacement. The most common complications with MemoryShape® Implants for breast augmentation include reoperation for any reason, implant removal with or without replacement, and ptosis. A lower risk of complication is rupture. The health consequences of a ruptured silicone gel breast implant have not been fully established. MRI screenings are recommended three years after initial implant surgery and then every two years after to detect silent rupture. Detailed information regarding the risks and benefits associated with MENTOR® Breast Implants is provided in several educational brochures. For MemoryGel® Implants: Important Information for Augmentation Patients about MENTOR® MemoryGel® Breast Implants. For MemoryShape® Implants: Patient Educational Brochure – Breast Augmentation with MENTOR® MemoryShape® Breast Implants and Quick Facts about Breast Augmentation & Reconstruction with MENTOR® MemoryShape® Breast Implants. For MENTOR® Saline-filled Implants: Saline-Filled Breast Implants: Making an Informed Decision. These brochures are available from your surgeon or visit www.mentorwwllc.com. It is important that you read and understand these brochures when considering MENTOR® Breast Implants. Mentor Worldwide, LLC | Irvine, CA 92618 USA © Mentor Worldwide, LLC 2020 136012-200401

GET INVOLVED:

Join the fight ASPS member practices across the country – along with breast cancer patients, their families and friends – participated in last year’s Breast Reconstruction Awareness Day to honor courageous cancer patients, promote patient care and educate their local communities on women’s health and breast reconstruction. Although breast reconstruction has long been a public awareness initiative of ASPS and The PSF, the effort to inform women of their reconstruction options following a breast cancer diagnosis in 2012 solidified an ongoing campaign. Sponsored by ASPS and The PSF, the celebration of Breast Reconstruction Awareness Day USA continues this year on Oct. 21 as individuals, breast cancer support groups, plastic surgeons and organizations join the movement to honor and advocate for cancer patients and close the loop on breast cancer. Individuals and organizations are encouraged to become a Breast Reconstruction Awareness affiliate and host a local or virtual Breast Reconstruction Awareness Day event. There is no fee to participate, and ASPS provides a free starter-guide to help plan the activities. For questions or more information to receive your free affiliate Event Starter Guide and join women in the fight against cancer, please email breastrecon@plasticsurgery.org.

Register for the virtual Close the Loop 5K The Breast Reconstruction Awareness Close the Loop 5K is going completely virtual this year! The virtual physical challenges and contests will bring together more people from across the globe and emphasize the need for physical activity. The Close the Loop 5K will conclude at 7:30 p.m. CST on Sunday, Oct. 18. You can register for the virtual Close the Loop 5K or donate to the Breast Reconstruction Awareness Campaign as a virtual participant and participate from wherever you are anytime between now and Oct. 18. Encourage your family and friends to join you in this fundraising effort. Every registrant will receive a race T-shirt and an “I Participated” medal. Funds generated from the Close the Loop 5K will be awarded to organizations that support uninsured or underinsured women who choose to have breast reconstruction following a lumpectomy or mastectomy due to breast cancer. Register now at https://p2p.onecause.com/bra5k/home.

l PSN: BREAST RECONSTRUCTION 2020

DUAL PERSPECTIVE

On the other side

ASPS President shares lessons learned during her breast cancer and reconstruction journey

By Kendra Y. Mims-Applewhite

ASPS President Lynn Jeffers, MD, MBA, discovered she had breast cancer in 2018 after

an MRI revealed a malignant lesion Lynn Jeffers, MD, MBA that her routine screening mammogram missed. She underwent a bilateral mastectomy and reconstruction with tissue expanders, and began chemotherapy and radiation while serving as president-elect, and subsequently, president of the Society. Dr. Jeffers refused to let her cancer diagnosis slow her down. During her treatment, she traveled nationally and internationally to represent ASPS; organized two annual Breast Symposia on breast cancer treatment, reconstruction and survivorship; and completed her MBA at the University of Michigan Ross School of Business, graduating in the top 10 percent of the class. In addition to leading ASPS, Dr. Jeffers is the chief medical officer at St. John’s Pleasant Valley Hospital and the medical director of the hospital’s Integrated Breast Center. She steered both the Society and the hospital through the COVID-19 crisis. Dr. Jeffers focused her clinical practice on aesthetic and reconstructive breast surgery and continues to inspire others as a breast cancer survivor through her

Dr. Jeffers with her family (top); and (right) inspiring attendees at St. John's 8th Annual Breast Symposium.

commitment to giving back to patients, the medical community and society at large. Dr. Jeffers took time to discuss the lessons she learned during her own breast reconstruction journey.

On building a support system: “I was undergoing treatment during my presidential year, and sometimes, I would attend meetings or travel for ASPS right after chemotherapy. I completed my final round of chemotherapy last October. It’s been a long journey, and one I couldn’t get through alone. COVID-19 has also kept me extremely busy – and sleep deprived – as I’m navigating the Society, my hospital and our sister hospital (St. John’s Regional Medical Center) through the crisis. Through my highs and lows, I’ve learned it’s crucial to have a strong support system and to surround yourself with people who empower and encourage you. I’m thankful I’ve received continual support from my husband, family, colleagues and ASPS leadership and staff during every stage of my breast cancer and reconstruction journey.”

On patient care: “I perform breast reconstruction often, so choosing my procedure wasn’t a difficult decision for me. However, as a breast cancer patient, I experienced first-hand how much nonmedical factors can impact

a patient’s journey. I now have a better understanding of what they might be going through and the inner turmoil they experience. Ultimately, I had an advantage as a physician and plastic surgeon because I know the right questions to ask – but my diagnosis did bring to light how much harder it is for patients to go through this journey without a medical background. It’s important for patients to know their physicians are working together as a team and advocating for them. I really appreciate everyone on my breast care team for being there for me. The team-based approach to breast cancer care and reconstruction is key.”

On identifying your priorities: “It’s normal to feel overwhelmed after receiving a cancer diagnosis. The days following your diagnosis are particularly challenging because you need to make decisions amid uncertainty, and you’re not sure which way to go. Reconstruction is a personal choice, and patients choose to undergo the procedure for different reasons. You should have an in-depth discussion with your plastic surgeon to determine your goals and identify your priorities. Talking to other women who’ve undergone the procedure may also help. Breast reconstruction may not be the right choice for every woman, but it’s important that all women are fully aware of their options, so they can confidently make informed choices and manage their expectations.”

On understanding your options: “Breast reconstruction can be fulfilling from a patient perspective, and the decision to undergo reconstruction or not can be an empowering one. Everyone’s cancer journey is different. There are many options for breast reconstruction and with the help of their plastic surgeons, women should determine what is right for them. ASPS is committed to patient education and informing women of their options postmastectomy. There is more information at plasticsurgery.org, and you can find an ASPS member board-certified plastic surgeon you can trust to guide you through your breast reconstruction journey.” PSN: BREAST RECONSTRUCTION 2020 l

SURVIVOR HELPS WOMEN FIND HOPE, HEALING & CLOSURE AFTER BREAST CANCER

Transforming lives through reconstruction By Kendra Y. Mims-Applewhite • Portraits by Ruslana Studio

l PSN: BREAST RECONSTRUCTION 2020

PSN: BREAST RECONSTRUCTION 2020 l

COVER STORY

Alisa Savoretti never imagined returning to the Las Vegas stage without her breast. The former showgirl

Alisa Savoretti, My Hope Chest Founder

Alisa returns to the stage following her mastectomy and markets herself as "The Lopsided Showgirl."

l PSN: BREAST RECONSTRUCTION 2020

retired her dancing shoes to build an e-commerce business after years of touring the world. She poured her time, energy and money into launching a successful online furniture store, but her plans took an unexpected turn in 2001 when she felt a lump in her right breast. “I didn’t think for one second that it was breast cancer, so I didn’t do anything about it at first,” she recalls. “I was busy and focused on getting my business off the ground. I didn’t have insurance as a new entrepreneur, so I went to the health department a few months later to get it checked out and had a biopsy. It was a shocking blow.” At age 38, Alisa was an uninsured cancer patient with limited funds, massive credit card debt and a denied Medicaid application. Although she found a local social services agency to cover her single mastectomy and eight rounds of chemotherapy in 2002, her search for breast reconstruction funding was unsuccessful. In need of steady employment and insurance, she accepted a dance gig at the Riviera Hotel five months after her mastectomy and final chemotherapy treatment. Alisa performed in two shows a night, six nights a week, padding her showgirl costume before every performance to camouflage her missing breast. Surviving breast cancer was a huge feat, but losing her breast took a toll on her confidence and well-being. “I had traveled the world as a professional dancer and made a living with my body, and now I felt disfigured and deformed,” she says. “The girls backstage could see I had a line where I was supposed to have a breast. It was horrible. All I needed was the last step in

my treatment (reconstruction). I called local and national institutions, but no one had a nickel to help me.” Alisa’s struggle to find funding sparked an idea to start a nonprofit for uninsured women who fall through the cracks of healthcare. To raise awareness, she marketed herself as “The Lopsided Showgirl,” attracting local media attention to her plight. She also shared her predicament with members of the National Association of Women Business Owners, and with the organization’s support and assistance, she formed My Hope Chest in 2003. “I knew I couldn’t be the only woman this was happening to,” she says. “I couldn’t believe there wasn’t a charity in our country to help uninsured women. Being forced to live without my breast because I lacked the means was horrible. I was depressed, but I believed this was my calling, and I was on a crusade to make a change.”

Hope and healing Alisa lived without her breast for nearly three years before she finally secured a health-insurance plan to cover her reconstruction in 2005. “I was restored as a woman in body, mind and spirit,” she says. “It wasn’t until I looked in the mirror and saw two breasts, nipples and areolas that I felt like myself and that my cancer journey was complete.” Alisa, now 57, estimates that more than 22,000 uninsured women per year lose one or both breasts while battling cancer based on a study her charity conducted in 2010. As the only national organization focused on reconstructive surgery for uninsured and underinsured breast cancer survivors, My Hope Chest’s mission is to provide hope, healing and transformation for survivors everywhere. “Women feel deformed after losing

Survivor Laurie Gilsdorf lived without both breasts for eight years before My Hope Chest helped her attain reconstruction. While waiting, she worked with Ruslana Studio to capture photos for the organization's documentary "Breastless in America... Still Waiting."

their breast to cancer, and they may think they have to live that way, but they don’t,” she says. “Part of our mission is to ‘create butterflies’ and transform lives through breast reconstruction and closure from cancer treatment. We celebrate the transformation and metamorphosis that our clients go through.” My Hope Chest helps up to 10 women each year attain their “butterfly” transformation surgeries. More than 100 survivors are on the growing waitlist from around the country. Some women remain on the waitlist for years before My Hope Chest receives funding or surgeon partners to help with their reconstruction. “We don’t give up, and we follow-up with them as soon as we raise more funds,” she says, noting their referrals often come from large pink ribbon breast cancer organizations that do not provide aid or fund the surgery. “Many women who reach out have lived without one or both breasts for years – it’s horrible and unacceptable. We don’t promise if or when we can help, only that we will do our very best. Reconstruction is the glimmer of hope for them to find closure from their disease.” Her nonprofit relies heavily on individual donations, corporate sponsorships and partnerships with board-certified plastic surgeons who donate their time and surgical skills to reduce the patient’s surgery expenses. My Hope Chest provides funding for hospitals, surgical facilities, anesthesia, laboratories, supplies and other related expenses. In 2018, it amended its grant criteria to help underinsured women pay their copayments, deductibles and nonmedical bills such as rent, medication and utilities. Alisa estimates breast reconstruction costs more than $25,000

per patient at a cash-pay rate; however, partnering with plastic surgeons reduces the expense to approximately $13,500. “Plastic surgeons provide the final step in breast cancer treatment,” she says. “Reconstruction is not cosmetic. Some surgeons no longer perform reconstruction surgery because it’s not lucrative and takes nearly a year to finish. Thank goodness there are some great plastic surgeons already providing free surgeries, but there could be more when they know we exist.” In the early stages of establishing My Hope Chest’s mission and vision, Alisa approached her surgeon, the late William Zamboni, MD, with her idea of a formal organization and invited him to come onboard as the founding surgeon. His immediate response was, “Count me in.” Those three words clinched the charity’s first surgeon partnership and moved their mission forward. Since then, My Hope Chest has recruited ASPS members to help and provide free or significantly reduced surgeries in many states. Their long-term goal is to develop surgeon partnerships in every state – ideally, with hospital partners that could ease the organization’s long and growing wait list.

ASPS member Antonio Gayoso, MD, Florida, became the first surgeon to help restart My Hope Chest in the Tampa Bay area. Dr. Gayoso, who dedicates a significant portion of his practice to breast reconstruction, encourages other plastic surgeons to join the cause and donate their services to the organization. “Plastic surgeons understand the importance of breast reconstruction after a mastectomy,” he says. “If women don’t have their breasts, they think about it every time they get dressed or put on their prostheses. Part of my job is to help women not to think about their breasts anymore or stare at a deformity every day. Some doctors haven’t placed an emphasis on reconstruction, or they offer mastectomy without reconstruction to uninsured or low-income patients – as if reconstruction is a luxury. “We are providing medically necessary care for neglected patients,” he adds. “Breast reconstruction fulfills a need.”

Taking action Alisa’s determination to help survivors fueled her during trying times. She refinanced her Las Vegas home three times to keep PSN: BREAST RECONSTRUCTION 2020 l

COVER STORY

the charity afloat. After losing her property in the 2008 financial crisis, Alisa moved back to Seminole, Fla., and restarted the organization. She built a new Board of Directors and ran the charity from her mother’s dining room table for years, volunteering her time as the CEO, client navigator, event planner, fundraiser and social media specialist until funds were raised for her small salary and their first office. “The applications never stopped,” she recalls. “I was running the company with one-and-a-half staff members by pulling all-nighters without caffeine to push through all the work. If any other charity was doing this work, I wouldn’t have started My Hope Chest because I don’t believe in redundancy of mission. Breast cancer was not my charitable cause, nor the future I anticipated. I was an e-commerce pioneer in the furniture business in 2000 and likely could have funded My Hope Chest myself had I stayed the course after cancer. But I decided to change direction because this is bigger than me. God had a plan, and I’ve been doing my part in this lane for a very long time. I truly hope this year is a turning point to help these women.” Alisa concedes the organization’s unique mission to focus on the back-end of cancer treatment remains overlooked. She discovered grant programs were highly competitive and grantors didn’t allocate funding for breast reconstruction. She also struggled to rally support for her cause due to the lack of awareness in the breast cancer world. “Before The Plastic Surgery Foundation developed the Charitable Care grant, there was no other entity we could reach out to that provided funding specifically for what we do,” says Alisa, adding the grant she received from The PSF will fund her nonprofit's virtual Bling A Bra for Breast Cancer campaign in October to raise funds for reconstruction. “Charities sadly compete for dollars, and the charities with the biggest marketing budgets always win. Most people see and support the bigger charities and the little ones struggle to stay afloat – no matter the disease or cause.”

l PSN: BREAST RECONSTRUCTION 2020

(left) Dr. Gayoso and Alisa at the annual fundraising event, "Hope Floats for My Hope Chest"; and (right) Tampa Bay Buccaneers honor My Hope Chest for NFL Pink Weekend.

Beyond raising funds, My Hope Chest aims to educate survivors on their options and raise public awareness of breast reconstruction as the missing part of treatment for uninsured survivors. Alisa says more people need to take action to meet the needs of breastless survivors and underinsured patients struggling financially. “Pink crusades and breast cancer awareness campaigns in this country are redundant,” she says. “We’re all aware that breast cancer exists but awareness is not a formal organization. Breast cancer dollars are needed for research, reconstruction and bill-pay and co-pay assistance – that’s it. Women needed to be educated on their options. “At My Hope Chest, we never insinuate a woman isn’t whole or complete if she doesn’t desire breast reconstruction, but everyone on our waitlist wants it,” she adds. “All women should know their options and have the guidance and resources to start and finish treatment.”

Underinsured: An answered prayer My Hope Chest surgery recipient Bonnie Medina, 46, underwent her first breast reconstruction procedure in May. Although her health insurance covered her double mastectomy and chemotherapy in 2017, breast reconstruction seemed out of reach due to her $7,500 deductible. Bonnie convinced herself to forget about the procedure and embrace her breast prosthetics, but a shopping experience last year changed her mind.

“I didn’t realize how much not having my breasts impacted my self-image until I started shopping for my Christmas dress,” she recalls. “It finally hit me, and I started crying. I realized I wanted to look into the surgery and do whatever I needed to help myself feel complete.” As a single mother with a new mortgage and mounting medical bills from her mastectomy, Bonnie struggled finding funds for the procedure. She says her prayers were answered when she stumbled across a news segment on My Hope Chest. She took it as a sign. “I read the testimonials on the website and started to fill out my application, but I stopped because I didn’t think I would qualify,” she notes. “I’m a nurse and I make a good income, but I stopped working for a full year for my surgery and treatment. Alisa called me directly and encouraged me to complete the application.” Although the Women’s Health and Cancer Rights Act of 1998 requires all group health plans that cover mastectomies to also provide coverage for breast reconstruction, Alisa notes many underinsured women in a gap, as Bonnie was, reach out for assistance. Their search for a plastic surgeon in Bonnie’s insurance network led to ASPS member Dallas Buchanan, MD, who volunteered to perform his first reconstruction for My Hope Chest. The procedure changed Bonnie’s life. “Thanks to My Hope Chest and Dr. Buchanan, I got something back that was taken from me without a choice,” she says.

“I feel like a full woman again and like my normal self before cancer. I can walk out holding my head up better because I feel complete. When you lose something that’s part of you, you don’t realize how much you will miss it until it’s really gone.” Dr. Buchanan says he will donate his time and skills to My Hope Chest in the future, and he commends Alisa’s efforts for helping women often forgotten by the healthcare system. “Bonnie’s case rings true all around the country,” he says. “Treating cancer is certainly paramount, but reconstruction is a huge step in the process and can restore a woman’s femininity and help her move on with her life. It’s really important for a charity like My Hope Chest to step in and not only help people who don’t have coverage, but also to provide for the people who are underinsured and be the bridge to get them the services they need.”

Uninsured: Glimpse of wholeness Carleen Hobbs of Alaska was expecting her fifth child when she received a stage 3 breast cancer diagnosis at age 30 and a 15 percent, five-year survival rate. After passing her seven-year mark, Carleen decided she wanted reconstruction. The first stage of the procedure wiped out her family's savings, and she couldn’t find anyone to fund her remaining procedures.

(Top) Dr. Buchanan poses with MHC surgery recipient Bonnie Medina ; (right) Carleen Hobbs celebrates her transformation into a MHC butterfly.

“We started the process hopeless and wondered how we could make it happen, because we couldn’t afford it and no one would cover me because they considered my condition pre-existing,” Carleen says. “There’s so much support for breast cancer out there, but I was shocked that no one was helping uninsured women get reconstruction. My Hope Chest was the only organization that helped us.” Before her breast reconstruction, Carleen, now 42, remembers constant throbbing pain around her chest after her bilateral mastectomy. The mother of five often shielded her chest with a pillow before she hugged or interacted with her children. She notes she experienced immediate relief after her procedure and says the pain never returned. “I remember holding my infant niece one day after my reconstruction process, and she snuggled her head against my chest,” she recalls. “The whole room around me was talking, but I just melted into tears because it had been eight years since a child had laid their head against my chest without pain. I previously took those moments for granted. Reconstruction is a gift that puts a little normalcy back into my life.” My Hope Chest covered Carleen’s remaining four procedures and partnered with Angel Flight to transport her to her volunteer plastic surgeon in Seattle. It took five trips over a two-year period to complete the process. Carleen says the procedure improved her quality of life, including intimacy in her marriage. “Cancer at 30 robbed so much of my life and took years from us,” she says. “My scars were so severe and visible all the time. I saw a constant image of brokenness before me every time I got dressed. Dealing with brokenness is a constant journey as a breast cancer survivor, but these glimpses of wholeness and healing make it bearable. “I’m amazed Alisa had a vision for those of us who don’t have insurance but are unreconstructed,” she adds. “It’s a small niche, but it’s a mountain we could not climb alone.”

‘Still waiting’ When Alisa reflects on her journey – the sleepless nights, sacrifices, tears and dreams she put on hold – she says she has no regrets. Witnessing survivors’ joy and newfound confidence after their reconstruction keeps her going and reminds her why she started the charity 17 years ago. “I believe 100 percent I was divinely chosen for this task,” Alisa says. “I wasn’t married and didn’t have children, so I was able to dedicate every bit of my being to this cause. My Hope Chest was my baby. I birthed it. I cared for it. I watched it grow.” Looking ahead, Alisa hopes to raise funds to further expose the problem in her passion project, “Breastless in America ... Still Waiting,” a short documentary featuring survivor stories and plastic surgeon testimonials. Her ultimate goal is to eliminate the waitlist, which will require more funding and sponsorships. “I’ve been so dedicated and passionate about fixing this problem, and I pray it’s going to leave a legacy,” she says. “It’s going to take continued support, more plastic surgeons, increased awareness and lots of money to sustain the work and help us grow.” Alisa is overcome with emotion while reflecting on the number of women still living without their breasts and waiting to complete their cancer journey. “At some point, you get angry and frustrated with the system,” she says. “These women are counting on us. I want My Hope Chest to be around until there’s a cure for breast cancer. I want it to be sustainable and immediately help every woman who applies to us. “Regardless of your age, sacrificing life over limb to survive cancer is devastating,” she continues. “For us to be able to fill this gap in treatment and provide breast reconstruction to women feeling truly hopeless, is priceless. They are unbelievably grateful for the rest of their lives. You simply can’t put a price on its impact. I’m honored to be a part of this happy part of their lives and bring closure to their cancer journey.” PSN: BREAST RECONSTRUCTION 2020 l

COMMUNITY AWARENESS

Sisterhood:

STRONGER TOGETHER By Kendra Y. Mims-Applewhite

Four-time breast cancer survivor changing the narrative, restoring hope in the Black community

Karen Eubanks Jackson knew something was wrong with her body. She didn’t feel a lump or

experience any physical symptoms, but an unexplainable sensation in her right breast spurred her to request further testing after a routine mammogram showed no signs of breast cancer. The subsequent ultrasound revealed a 3.5-cm. mass in her breast. Karen was diagnosed with stage 2 breast cancer in 1993, and her prognosis was grim. Twenty-seven years later, she says being an advocate for her health saved her life. “I demanded an ultrasound because I knew the sensation wasn’t normal and the mammogram wasn’t telling me everything,” Karen says. “I lost two aunts to breast cancer, so I knew my family history. I was proactive and started getting mammograms before I turned 40. Knowledge is power.” Karen desired to connect with other women fighting for survival, so she sought breast-cancer support groups during her treatment. The alarming breast cancer mortality rate for African-American women – and the lack of sisterhood and culturally sensitive material – concerned her, but she couldn’t find an organization that addressed the needs of African-American breast cancer survivors on a national level – because none existed. “The support groups helped me understand AfricanAmerican women weren’t receiving equal access or the necessary information and services to help ourselves,” she says. “I knew there was a universal need for sisterhood and awareness in the Black community. If I was feeling this way in California, which was a more progressive environment for African-Americans, I could only imagine what was happening in the South, North or rural areas.”

l PSN: BREAST RECONSTRUCTION 2020

Karen Eubanks Jackson, Founder & CEO of Sisters Network Inc.

Karen relocated to Houston and actively searched for African-American breast cancer survivors at local conferences, churches and social outings. She eventually found 15 women to support her vision. She also reached out to connections in other cities to establish a national presence. “I approached survivors from the sisterhood perspective and showed how we would become advocates taking the journey together,” she says. “That was very appealing to them. The other support groups gave me education, but that bonding of sisterhood was a missing element and extremely important to me as a survivor and to the women I attracted.” Without money, grants or any fundraising experience, Karen took a leap of faith and in 1994 founded Sisters Network® Inc., the only national African-American breast cancer survivorship organization in the country. Within the first year, the organization formed three chapters without any funding.

Credited as the first National African-American Breast Cancer 5K Walk/Run in Houston, Karen launched the annual Stop the Silence® event in 2010 to raise breast cancer awareness and replace fear with hope.

“When I started Sisters Network, I never dreamed we’d last 26 years,” she says. “I didn’t think about not having a medical background. Just having passion and determination and recognizing the need was enough to get me going.” Since its inception, Sisters Network has established more than 40 affiliate, survivor-run chapters nationwide. Newly diagnosed women are paired with survivors in their area to help them navigate through challenges. As founder and CEO, Karen leads the organization’s efforts to bring national attention to breast cancer’s devastating impact on the African-American community and reduce the mortality rate of breast cancer among AfricanAmerican women. “We’ve put our community first and gained their trust for more than 25 years,” Karen says. “We don’t tell people what to do, but we lay out all the information for them. We’ve broken ground and proven ourselves not only to be needed by our community but also by the medical industry.” Sisters Network offers financial support, breast health education and national community outreach programs such as The Pink Ribbon Awareness Project, the annual national African-American Breast Cancer Conference and the Stop the Silence campaign to eradicate the shame and fear of breast cancer – and encourage African Americans to take action and discuss their family’s medical history and join the movement. The Breast Cancer Assistance Program (BCAP) has helped more than 10,000 women pay their living expenses, childcare, copays, groceries and mammograms, and it currently provides financial support to breast cancer survivors affected by COVID-19. Breast cancer isn’t in anyone’s budget even if you have insurance, she notes.

“We’ve been impacted lately because more people need assistance today for expenses to get to their appointment, such as gas, childcare and parking fees,” Karen says. “For a person with a low income and breast cancer, it’s a lot.”

Bridging the gap Research shows African-American women are less likely to survive breast cancer, less likely to have access to early detection and less likely to be aware of breast reconstruction options. Although Karen chose not to undergo breast reconstruction after her four lumpectomies, she recognizes the benefits of the procedure and provides education to ensure AfricanAmerican women know their options and have equal access to breast cancer services. She points out that the healthcare industry is not yet immune from some glaring racial inequalities or systemic injustices. “African-American women still aren’t being referred to services we’re entitled to – even women who have insurance and can pay for their own reconstruction,” she says. “Breast reconstruction didn’t come up in our community years ago, but more women want to know about the procedure today. Awareness has improved, but it’s not where it should be. It’s devastating when we don’t have the proper information. “As an organization, we allow breast reconstruction education to flow freely through our chapters and community because we believe women should have choices,” she continues. “For some women, it’s imperative that they look like they did before. That helps them get back to a place in their life where they can find a new PSN: BREAST RECONSTRUCTION 2020 l

COMMUNITY AWARENESS

(Below) Dr. Cash and her daughters at the 2011 Stop the Silence 5K walk/run; (right) Karen and her family.

Sisters Network® Inc. national creed: “In Unity there is Strength, In Strength there is Power, In Power there is Change. Changing the narrative normal. It wasn’t something I needed to do for myself, but I’ve seen the joy it brings others.” ASPS member Camille Cash, MD, Houston, serves on the Sisters Network board to increase awareness of breast reconstruction and help all women access this aspect of breast cancer survivorship. Dr. Cash says the organization’s mission to educate and empower African-American women – a historically overlooked and underrepresented patient demographic – inspired her to join the board 10 years ago. “Sisters Network really gets to the heart of the community to help African-American women navigate through breast cancer and find resources,” she says. “Breast reconstruction can be a complicated and emotional process. I help women with Sisters Network understand their options and teach them how to advocate for themselves. I also help them think about reconstruction as the final part of their breast cancer treatment. There aren’t a lot of AfricanAmerican female plastic surgeons in the country, so it’s an honor to share my expertise and give back to the community.” Dr. Cash commends the organization’s effect on the AfricanAmerican community and efforts to reduce racial inequalities in breast cancer care under Karen’s leadership. “It’s been Karen’s passion and life’s work to bridge that gap for over 25 years,” she says. “There’s still a lot of work to be done, and that’s why the mission of Sisters is so vital. It’s going to take a consistent, concerted effort to address racial disparities. That’s why I continue to serve.”

l PSN: BREAST RECONSTRUCTION 2020

Karen experienced her last bout with breast cancer in 2019 – an MRI she requested revealed two cancerous nodules in her left breast (her mammogram and ultrasound missed it). The four-time breast cancer survivor encourages Black women to listen to their bodies, trust their instinct and speak up when something doesn’t feel right – lessons she learned with each breast cancer diagnosis. Don’t wait until something happens to your health before you become proactive, she warns. Make health a top priority. “The good news is I found my second, third and fourth cancer at the ductal carcinoma in situ (not yet spreading into surrounding tissue) level,” she says. “I thank God that I’m sensitive to my body. Doctors didn’t suggest the MRI, but I knew what to ask for at this point. From my own experience and others, you have to be an advocate for yourself.” Karen, 77, has no plans to slow down. She enjoys activities such as skydiving and indoor rock climbing, and she plans to release her debut book, In the Company of My Sisters: My Story, My Truth, this fall. More than 25 years after Karen formed her first chapter in Houston, she remains devoted to changing the narrative around breast cancer as a death sentence in the African-American community and spreading a message of hope. She surpassed her prognosis and wants women to know they can, too. “When I get a call from a woman who’s scared she will die from stage 2 breast cancer, I can tell her I thought the same thing, but I’ve been here for 27 years,” she says. “Breast cancer can be a lonely thing to go through, but it doesn’t have to be an awful journey when you have a sisterhood to back you up and encourage you. Women need to know they aren’t alone in the fight.”

PATIENT EDUCATION

Preserving Restoring Sensation after Mastectomy and Reconstruction: What You Need to Know By Anne Peled, MD, & Ziv Peled, MD

In recent years, there’s been a growing focus on the after-effects of breast cancer treatment and breast surgery, with the goal of minimizing any long-term negative impact on breast cancer survivors and previvors. One of the current topics being discussed is the loss of sensation that typically occurs after mastectomy. Losing chest and breast sensation can have significant psychological, functional and relationship effects on women who’ve undergone mastectomy. However, new advances have arrived in breast reconstruction that allow people to preserve and regain sensation after mastectomy. Here are some key issues to consider and understand about breast sensation and the ways to restore it.

Although everyone is different, meaningful chest and breast sensation is unlikely to return on their own without careful and thoughtful preservation of nerves during mastectomy. There remains more research needed pertaining to sensation after mastectomy, but studies show unacceptably low rates of return of chest/nipple sensation, and the majority of women do not ever regain sensation to light touch throughout their breasts (let alone any pleasurable sensation). Due to the variable nerve anatomy in the breasts, some women may get lucky and experience a return in sensation over time without active preservation of nerves during surgery – but most women will not. Nevertheless, surgeons are learning ways to carefully look for nerves during mastectomies to avoid injuring them, which can help increase

sensation after mastectomy and minimize the chance of painful nerve endings.

When done carefully, mastectomies where sensation is preserved do not compromise cancer outcomes for women having mastectomies for breast cancer treatment or risk-reduction. The goal with any mastectomy – whether for cancer treatment or for breast-cancer risk reduction – is to remove all visible breast tissue. The majority of mastectomies can now be done as nipple-sparing mastectomies, where the entire breast skin envelope is preserved. This procedure is demonstrated to be oncologically safe in several major studies. Nerve preservation during mastectomy is possible when the nerves run in the fatty tissue layer beneath the skin, which can be saved during the mastectomies performed for cancer treatment or prevention. If the nerves don’t have favorable anatomy for preservation (meaning they run straight through the breast and don’t stay in the fatty tissue layer), then they will need to be repaired with nerve grafts to restore breast skin and nipple sensation.

is usually done by taking a nerve with the flap (typically a DIEP flap for this approach) and connecting that nerve to another within the chest wall during the reconstruction. Sometimes a nerve graft is needed to bridge the gap between the nerve in the flap and the nerve in the chest. When nerve reconstruction is done with flaps, reconnection can occur at the time of the mastectomy or a later date if reconstruction is done in a delayed fashion. Nerve reconstruction can also be done with implant reconstruction – in this case, nerve grafts are always required, and this approach is typically best done at the time of mastectomy rather than during a delayed reconstruction or second-stage surgery. For women who opt not to have reconstruction and instead “go flat,” sensation-preserving mastectomies to help keep sensation to the chest skin is definitely an option, either with nerve preservation alone or with the addition of nerve grafting. Many questions still remain regarding ways to restore sensation after mastectomy and reconstruction, but with time, plastic surgeons continue to learn more and provide better outcomes as these approaches become more widespread.

Sensation preservation and restoration can be done with different types of reconstruction, as well as for women choosing not to have reconstruction. Nerve reconstruction undertaken at the time of breast reconstruction to improve sensation after mastectomy is becoming an increasingly offered option as more surgeons are trained in the techniques. With flap reconstruction (using a woman’s own tissue to reconstruct the breast), this

ASPS members Anne Peled, MD, breast cancer survivor, and Ziv Peled, MD, practice in San Francisco. They are educators and innovators of novel breast surgery techniques. PSN: BREAST RECONSTRUCTION 2020 l

SURVIVOR STORY

A scientific mind at work on behalf of others By Adam Kivel

s an astrophysicist, Sarafina Nance spends much of her time studying supernovae and how stellar explosions affect the cosmos.

But in the midst of her PhD program, the Bay Area native experienced a massive shockwave of her own. “My dad had just been diagnosed with stage four prostate cancer and also came back positive for BRCA2, so I knew I needed to get tested,” she says. The cancer-causing mutation can be passed down from either parent, and her father’s diagnosis – in addition to her grandmother’s experience with ovarian cancer – spurred Sarafina to get tested as well. “I learned that I was positive right around my 23rd birthday,” she says. Prior to her father’s diagnosis, Sarafina was familiar with the concept of genetic screening but was unaware that doctors could test for specific mutations and guide individuals based on their unique background. “It wasn’t something I was super-familiar with until I had to be familiar with it,” she says. Two years later, at the first of her normal screenings based on her positive mutation, Sarafina’s MRI raised new concern. Although the resulting core needle-biopsy returned negative, the fear that a positive result seemed inevitable loomed large. As a scientist, Sarafina’s natural instinct in that moment was to learn from experts and dig through scientific publications for hours on end. She met with an oncologist shortly after her first biopsy experience and learned what her future might entail. It wasn’t a certainty that she would get breast cancer, but the risk was remarkably high, and she would need to go through screenings every six months. At the end of the day, her research-first approach boiled down to statistics as much as it did emotion. “I knew that I couldn’t keep fearing a positive biopsy for my mental health, and I learned that with preventative surgical options, my risk could fall from 87 percent likely to develop cancer down to 5 percent,” Sarafina says. “I knew I would do anything to decrease my risk, to be proactive

l PSN: BREAST RECONSTRUCTION 2020

and empowered, and to hopefully never have to think about breast cancer ever again.” The more that Sarafina learned, the more frustrated she grew with the lack of information targeting women and regarding genetic screening and preventative treatments. She knew that major changes needed to be made to ensure that other women wouldn’t need to scour medical journals to understand their options. In addition to medical research, Sarafina dove headfirst into social media and online forums to connect with others having similar experiences. She developed a particularly strong connection with The Breasties, a group dedicated to empowering individuals affected by breast and reproductive cancers. “The women in that group tend to be young – I could connect with their experiences,” Sarafina explains. From there, she was connected to ASPS member Anne Peled, MD – a researcher and information sharer after her own heart.

Sarafina Nance undergoes a preventative mastectomy for peace of mind.

“She had so many educational resources and videos on her website where she just answers questions for 20 minutes,” Sarafina notes. Shortly thereafter, Sarafina showed up to her first appointment with Dr. Peled with a notebook full of research and questions. The two began simultaneously discussing two major topics: Sarafina’s own surgical options and how she could share information with more women. “As a young breast cancer survivor myself, I know how difficult it can be to navigate decisions around breast surgery and reconstruction at any age, but particularly in the context of the unique issues facing younger women,” Dr. Peled says. “She was shocked to find out how few patients and medical professionals were talking about the loss of sensation that typically occurs after mastectomy, for example, as well as ways to try to preserve it.” For many, Sarafina explains, the concept of a preventative mastectomy is a blanket term without any sort of nuance or choice. Some women learn about the procedure and know that it can prevent cancer for those genetically predisposed to it, but they actually know very little about the ins and outs of the procedure. In late 2019, Sarafina decided to undergo nipplesparing mastectomy with sensation preservation and nerve grafting, and implant reconstruction. Prior to connecting with Dr. Peled, the doctors with whom Sarafina met told her that her only option for surgery was under-the-muscle reconstruction. Dr. Peled not only discussed the option for the over-the-muscle option, which had recently become prominent, she also openly discussed strategies to retain sensation. Other doctors with whom Sarafina spoke never even mentioned that patients lose sensation. “Sadly, a lot of women don’t get the breadth of options that they should,” Sarafina says. “Being equipped with as much knowledge as I could fit in my brain meant I could advocate for myself. But I want to make sure more surgeons and doctors listen to women and present them with all their options.” Safafina believes that women frequently feel unheard in their medical experiences, noting that racism and misogyny have a powerful negative effect on patient experiences. Early in her experience, she set her mind toward spreading the knowledge she was able to acquire in an effort to level the playing field. “I was also super-privileged in that I didn’t have cancer, so I was able to take the time to make these decisions in a way that someone with cancer may not have,” she says. “Those of us with privilege really need to do the work to remove inequities in women’s healthcare so that everybody gets access to resources.”

“I knew that I couldn’t keep fearing a positive biopsy for my mental health, and I learned that with preventative surgical options, my risk could fall from 87 percent likely to develop cancer down to 5 percent.” —Sarafina Nance

PSN: BREAST RECONSTRUCTION 2020 l

SURVIVOR STORY

Sarafina shares her preventative mastectomy and reconstruction journey to educate and empower others.

Based on her experience, Sarafina decided to assemble a comprehensive “Guide to Breast Surgery” and shared it via her website. She also shared her experience with a variety of publications to further spread knowledge and empower other women. “Sharing personal details around breast sensation and sense of femininity takes exceptional courage, particularly at such a young age,” Dr. Peled says, “but I have no doubt in my mind that she’s changing women’s lives on a daily basis. Our partnership and friendship has been one of the most wonderful parts of my plastic surgery career – I can’t wait to see the incredible contributions to patient education and awareness that Sarafina will continue to make in the future.” Sarafina’s strength and belief in changing the lives of others powered her through her own surgery and the process of sharing her story with the world. “It sounds cliché, but if I reach even one person, I know that it’s worth it,” she says. “When I tested positive for BRCA, I felt so overwhelmed. I was a young 23-year-old, and all I thought about was my boyfriend and school. I wished that I had someone to reach out to and talk to about all of this who knew what it was like. I learned that there are a lot of people out there doing really amazing work, and it feels really powerful to share and make a difference.”

Ready for a consultation? Here’s what you can expect: During your breast reconstruction consultation, be prepared to discuss: • • • •

Your surgical goals Medical conditions, drug allergies and medical treatments Current medications, vitamins, herbal supplements, alcohol, tobacco and drug use Previous surgeries

Your plastic surgeon will also: • • • • •

Evaluate your general health status and any pre-existing health conditions or risk factors Examine your breasts and take measurements of their size and shape, skin quality and placement of nipples and areolae Take photographs Discuss your options and recommend a course of treatment Discuss likely outcomes of breast reconstruction and any risks or potential complications

Be sure to ask your plastic surgeon questions. It’s very important to understand all aspects of your breast reconstruction.

l PSN: BREAST RECONSTRUCTION 2020

PATIENT SAFETY

Breast Reconstruction During COVID-19 By Daniel Liu, MD

The world has transformed with the unprecedented spread of SARS-CoV-2, which is more commonly known as the coronavirus, or COVID-19, pandemic. Millions of infections have resulted in substantial morbidity and mortality, while substantially more people remain asymptomatic or experience mild symptoms. In the United States, COVID-19 began to spread across most communities in early 2020, and extraordinary lockdown measures were instituted by federal and local governmental entities in March to slow the pandemic for public health. Nevertheless, these restrictions have direct impacts on individuals undergoing breast cancer treatment and those with undiagnosed breast cancer. Breast cancer screening has decreased, and “elective” breast procedures have been postponed around the world. During the early weeks of the pandemic, most hospitals and healthcare facilities delayed or cancelled elective procedures for cancer patients, including screenings, surgery (particularly breast reconstruction) and other non-urgent treatments. The purpose was to not only protect vulnerable patients, but primarily to preserve scarce personal protective equipment (PPE) and hospital beds for the anticipated surge of COVID-19 admissions. The American College of Surgeons recommended that certain breast cancer surgeries should continue, but breast reconstruction became a lower priority. In fact, ASPS initially recommended that microsurgical autologous breast reconstruction be delayed, due to the need for higher resources and prolonged hospitalization. Breast cancer surgery may be safely delayed for certain subtypes of earlystage cancer, using neoadjuvant systemic therapy strategies.1 Plastic surgeons and other cancer specialists can maintain communication with their patients through

telemedicine for routine monitoring, but in-person visits remain crucial for suspected oncologic emergencies, cancer progression, recurrence and new diagnoses. A multidisciplinary approach must be used to navigate the delicate risk-benefit balance for individual treatment decisions, applying guidance from international protocols.2 Based on currently available epidemiology data, most people have a low risk of becoming seriously ill from COVID-19. Cancer patients are not necessarily at higher risk of becoming infected, but the risk for severe illness (if they do become infected) may be higher among people on active treatments that compromise the immune system (chemotherapy). A recent study from France analyzed a small group of breast cancer patients who developed COVID-19 symptoms and compared their outcomes. Results showed that COVID-19 deaths were more likely due to other medical comorbidities (hypertension, obesity, diabetes and heart disease) rather than current or previous breast cancer treatments.3

Safety first All cancer patients must take every possible precaution to reduce the risk of contracting and spreading COVID-19 in accordance with CDC guidelines: • Wash hands frequently • Universal mask wear, especially indoors • Avoid close contact with others • Clean and disinfect surfaces • Monitor for symptoms Once the initial fear of overwhelming the healthcare system was alleviated, facilities reopened for elective surgeries to varying degrees around the country. However, the perioperative experience has changed dramatically and continues to evolve to maximize safety for our patients. Travel restrictions based on regional casepositivity rates continue to make it difficult

for some cancer patients to reach the hospital. As COVID-19 testing capability expands, routine screening of asymptomatic patients with cancer will be mandatory before surgery, interventional radiology procedures and chemotherapy. Stringent infection-control safety protocols have been instituted across hospitals and clinics, limiting the number of caregivers and visitors to support patients while admitted to the hospital. Long-term social distancing has taken a toll on mental health, especially for cancer patients who are already stressed. Loneliness, feelings of uncertainty and emotional distress have been associated with negative clinical outcomes and higher mortality in cancer patients. This cannot be ignored. Outdoor physical exercise may help, combined with social support from close family and virtual support groups. Telemedicine has also been used by psychologists and psychiatrists to benefit certain patients. COVID-19 changed how we practice reconstructive surgery. We have learned to be more efficient with resources and to reduce the number of in-person visits. Breast reconstruction is certainly possible, but we must be more flexible with timing and unplanned delays. Only time will tell if patient outcomes will be compromised due to altered treatment patterns that have emerged out of necessity. We have not forgotten you. Stay strong, stay healthy and stay hopeful! ASPS member Daniel Liu, MD, is a boardcertified plastic and reconstructive surgeon at Cancer Treatment Centers of America® in northern Illinois. He specializes in all forms of breast reconstruction and is passionate about promoting public education on breast reconstruction and plastic surgery. Sources: 1. Minami et al. JACS. (2020) DOI: 10.1016/j. jamcollsurg.2020.06.021 2. Curigliano et al. The Breast. (2020) 52:8-16 3. Vuagnat et al. Breast Cancer Research. (2020) 22:55 PSN: BREAST RECONSTRUCTION 2020 l

GLOBAL AWARENESS

Restoring lives

Plastic surgeon's mission trips back home are helping women choose life after diagnosis By Kendra Y. Mims-Applewhite

ASPS member Michael K. Obeng, MD, first witnessed the transformative power of reconstructive surgery

at age 15 when Operation Smile volunteers came to his village in Ghana and performed surgery on a neighbor who sustained severe burns after her husband threw acid on her face. Michael K. Obeng, MD The reconstructive procedure brought her out of hiding, he notes. “This woman became a recluse and never left her home,” Dr. Obeng recalls. “I didn’t know much about medicine at the time, but when I saw the impact of Operation Smile, I knew I wanted to become a surgeon when I grew up. I never forgot that moment.” Dr. Obeng, now a Beverly Hills plastic surgeon, came to the United States at age 20 and pursued a career in plastic surgery. During medical school, his mentor, ASPS member John H. Miller, MD, suggested they lead a mission trip to Ghana to provide free reconstructive surgery, but he was unable to do so due to his busy

l PSN: BREAST RECONSTRUCTION 2020

schedule. Still, the idea stayed with him. mission trips focused on breast cancer Eight years later, Dr. Obeng founded and breast reconstruction, and he says he his nonprofit R.E.S.T.O.R.E (Restoring hopes the organization’s efforts in Ghana Emotional Stability Through Outstanding can alleviate women’s fear and change Reconstructive Efforts) Worldwide Inc., their mindset, as many women prolong to provide free reconstructive surgery treatment until they are in advanced stages in developing countries to children and of the disease. adults with congenital and accidental “Women in their 40s presented with deformities. To date, Dr. Obeng and his stage 3 and 4 breast cancer,” he says. RESTORE team of volunteers have “Young women were dying because they traveled to seven countries and provided didn’t want to have a mastectomy. They more than 1,000 surgeries. are so afraid. Many would rather die with After learning the grim breast cancer their breasts than to have a mastectomy, mortality rate for Ghanaian women (more than 15 percent), Dr. Obeng returned to his home country for his nonprofit’s first mission trip and performed the region’s first immediate breast reconstruction in 2009 using abdominal tissue on a nurse who had refused to undergo a mastectomy without reconstruction because she feared losing her husband – a widespread concern among Ghanaian women, he Dr. Obeng and his team. notes. Several RESTORE

and not have a surgeon there to perform reconstruction. They believe you’re not a woman if you don’t have breasts. We let them know losing your breasts from cancer does not make you less of a woman.” He adds that their fear also stems from the country’s history of poor surgical outcomes. Part of his nonprofit’s mission is to educate local healthcare personnel. To that end, Dr. Obeng has taught local surgeons how to perform breast reconstruction, and he’s confident they can now provide quality care. “When I was growing up in Ghana, surgery was a death sentence – most people did not make it,” he explains. “Women don’t feel comfortable having surgery. We train surgeons so that they can train their staff after we leave. We educate them to make the public feel more confident in the surgeons they have there. We want to ensure the local surgeons are trained and comfortable to perform breast reconstruction.”

Ghana’s inaugural Breast Reconstruction Awareness Day To raise awareness about breast reconstruction and educate women about

Survivor and breast reconstruction advocate Beth Goodman visits women’s clinics and shares her story of survivorship during Ghana’s inaugural Breast Reconstruction Awareness Day in 2018.

GLOBAL AWARENESS

the procedure, Dr. Obeng collaborated with Paa Ekow Hoyte-Williams, MD, head of plastic surgery at Komfo Anokye Teaching Hospital (KATH), to host Ghana’s first Breast Reconstruction Awareness Day in 2018. As part of the commemoration, KATH’s plastic and reconstructive surgery division raised funds to provide free breast reconstruction surgeries for five patients. The week-long celebration and public awareness campaign included radio and TV presentations, a health walk, medical screenings and educational events in the communities. Dr. Obeng sponsored his patient Beth Goodman’s trip to Ghana to promote breast reconstruction and share how the procedure had a positive effect on her life. As a 10-year breast cancer survivor and breast reconstruction advocate, Beth candidly provided her perspective on bedside manner and survivorship with local surgeons during a radio interview and encouraged them to improve their patient communication while treating breast cancer patients. “They kept referring to breast reconstruction as ‘cutting off the breast”, she says. “No woman wants to hear that. I told them how it’s simply not the cutting off the breast. It’s the removal of cancer from the body that happens to be in the breast. They said they never thought about it from that perspective. Providing a patient’s perspective can improve communication with their patients going forward.” Beth visited women’s clinics to encourage patients undergoing chemotherapy and radiation, and to answer their questions about breast reconstruction. She vividly remembers a woman repeatedly telling her, “I don’t want to die because of a mastectomy.” Not only did Beth share her own journey, but she bared her reconstructed breasts to ease the woman’s mind. “She stared in amazement because she couldn’t tell which breast was

l PSN: BREAST RECONSTRUCTION 2020

(Top) Dr. Hoyte-Williams (second from right) and Beth at Ghana’s Breast Reconstruction Awareness Day events. (Bottom) Ghanaian women learn about their options after a breast cancer diagnosis.

reconstructed,” Beth says. “I told her the cancer was going to be removed from her body and she didn’t have to be fearful. Peace came upon her. I don’t want women to be afraid. I want women to be informed.” Beth says two sisters adamantly against breast reconstruction scheduled consultations after talking to her. She learned the stigma of mastectomy

resulting in death prevents women from seeking treatment. “When people hear mastectomy, they think they have to live with these horrid scars without the opportunity to close the loop on breast cancer,” Beth says. “They remain fearful because they don’t know their options. It’s so important – particularly with RESTORE’s efforts in Ghana – that women understand you can

have breast reconstruction, regain a sense of normalcy and live well after breast cancer. Dr. Obeng and his RESTORE team are helping women regain their wholeness, one procedure at a time.” Dr. Hoyte-Williams, who was trained by Dr. Obeng, says it’s too early to assess the impact of Breast Reconstruction Awareness Day Ghana, but he has noticed progress. Clinicians are gradually beginning to inform patients about their options after a breast cancer diagnosis, he notes. “It’s a slow process, just as it used to be in the United States,” he says. “But that doesn’t mean there’s no impact. Change is a gradual process and we must be more consistent in creating awareness to see some measurable impact. “We’ve created awareness that didn’t exist previously,” he continues. “Over this period of raising awareness, most patients have come to know their options – and most importantly, they’re learning that breast reconstruction services are readily available in our hospital and locally. Most patients would be happy to consider breast reconstruction.” Although Dr. Obeng’s plans to sponsor the third Breast Reconstruction Awareness Day in Ghana this October were put on hold due to COVID-19, he looks forward to resuming future mission trips to his home country and other developing countries on the continent to help breast cancer patients rebuild their lives and break the stigma around the disease. The work RESTORE started during its first mission trip to Ghana 11 years ago is proving transformational. “When we started going to Ghana, there were four plastic surgeons,” Dr. Obeng notes. “Now they have more than 15 plastic surgeons from the work that we’ve done. RESTORE has had a tremendous impact and raised the profile of plastic surgery in Ghana. This is the legacy we want to leave behind when all is said and done.”

Breast Implants: What Patients Need to Know

reast implants are FDA-approved devices that offer many quality-of-life benefits for patients. Each year, hundreds of thousands of patients undergo breast implant procedures worldwide. Breast implants remain an important option for breast reconstruction procedures. Collaboration among the scientific community, patient advocacy groups and governments from around the world will continue to enhance the device and ensure the global plastic surgery community works together to keep all parties educated about the latest news and advancements to improve patient safety.

Breast Implant Reconstruction Procedures

Patients considering breast implants should seek out a board-certified plastic surgeon to help weigh the benefits and potential risks to make the best possible decision. For more information on reconstructive breast implant procedures, please visit our Breast Reconstruction procedure page.

Breast Implant Safety

The American Society of Plastic Surgeons takes all patient safety concerns seriously. In collaboration with the FDA and breast implant device manufacturers, The Plastic Surgery Foundation has developed the National Breast Implant Registry (NBIR) to strengthen the national surveillance for breast implant devices in the United States. ASPS/PSF and FDA also developed a Breast Implant-Associated ALCL Registry, the PROFILE Registry, to increase the scientific data on ALCL in women with breast implants. Nearly 400,000 patients opt for breast implants every year and report no adverse effects. When a possible association with a rare disease is reported, plastic surgeons follow the science to provide detailed, accurate information for full patient consent and decision making. As noted, breast implants have been studied worldwide for decades, and the scientific literature shows no causal relationship between implants and autoimmune diseases. That’s not to say a patient could not have a negative reaction to any medical device, and if a patient desires to have her breast implants removed – for any reason – she should consult her plastic surgeon. Like any medical device, breast implants carry a risk of complications, and in the event any complication develops, patients should consult their plastic surgeon to address it in a timely manner. PSN: BREAST RECONSTRUCTION 2020 l

SURVIVOR STORY

The decision maker: A breast cancer diagnosis wrested control away from Pamela Bailey – but she took it back quickly By Paul Snyder

hroughout her life, Pam Bailey prided herself on her ability to take control.

The daughter of parents who took part in various philanthropic efforts, she dedicated much of her time to continuing that cause, leading organizations that supported children’s hospitals and took care of neglected and abused children. “I’m a type-A personality,” she says. “I like to take responsibility and I like to be the one making decisions.” So when a routine mammogram at age 60 (Pam notes she did not get regular mammograms and had never previously had any health concerns in her life) led to a breast cancer diagnosis in 2011, she was shocked. However, the cancer was deemed treatable with targeted radiation, so Pam went through the procedure and plowed ahead with her charitable work and planning her son’s upcoming wedding. “Most people didn’t even know I’d gone through it,” she concedes. “I’m a private person, but after that procedure you’re going in every six months for another mammogram – and in December 2014, I went in and was called back into the radiation room. I knew something was up.” The cancer had shown up in two new sites on Pam’s right breast. Although she had turned down a mastectomy after her initial diagnosis, this was now the only way to remove the cancer from her body. “I’m still an optimist,” she says. “Out of a sense of self preservation, you say, ‘OK, let’s schedule the surgery.’ But of course, I was quite nervous about it.” Pam wanted reconstruction and her surgeon, Nora Hanson, MD, immediately put her in touch with a plastic surgeon, Mohammed Alghoul, MD, Chicago, who handled breast reconstruction cases at the time. Following her mastectomy, Pam underwent a reconstruction process in

l PSN: BREAST RECONSTRUCTION 2020

which a tissue expander is used at first to accommodate an implant. The implant was placed in July 2015, and in April 2016, she underwent nipple reconstruction, which completed the process.

A new focus The following year, Dr. Alghoul put Pam in touch with Arun Gosain, MD, who was The Plastic Surgery Foundation president at the time – and who wanted to establish a charitable effort to help raise breast reconstruction awareness. “The PSF was nationally recognized for its contributions to research, education and international outreach in plastic surgery, but Pam and I realized there was an untapped potential for The Foundation to fill a need within its Chicago headquarters,” Dr. Gosain says. Upon reviewing breast reconstruction statistics in Chicago, Dr. Gosain says he found there were roughly 3,300 women who had undergone mastectomy in the greater Chicago area, but only 1,300 subsequently had breast reconstruction. Either because they were not aware that reconstruction was an option or because they felt guilty, stigmatized or other reasons, 2,000 women in the city did not pursue breast reconstruction. Furthermore, more than 280 of these women fell below the poverty level, making the concept of breast reconstruction unattainable given the added time away from work, childcare, transportation and other outpatient expenses not covered by Medicaid insurance plans. “There were numerous local and national charities that focused on improving outcomes of breast cancer, but there was no such charity that focused on breast reconstruction to improve the quality of life for breast cancer victims,” Dr. Gosain says. “Pam applied her skills in fundraising and community service to help The PSF spearhead a

“I’m not as afraid of cancer now. I don’t like it, but I’m determined to remain positive and will not let something like that get me down. I know I can beat it if I get the right team involved.” — Pam Bailey

group of well-known breast cancer survivors in the greater Chicago area, helping to initiate the first community-based fundraiser for breast reconstruction in the city. “This resulted in a series of community-based fundraisers for The PSF, in which every dollar raised by The PSF would be reinvested into promoting awareness of breast reconstruction or providing charitable care for indigent women who couldn’t afford to pay the expenses associated with outpatient visits entailed in breast reconstruction – expenses that are overlooked by Medicaid insurance plans.” The first event by the organization in 2018 was attended by 150 guests, including three famous Chicago names – Nora Daley (the daughter of former Chicago mayor Richard M. Daley), Zoraida Sambolin (an award-winning TV news anchor) and Cheryl Jackson (a journalist and former Illinois Senate candidate) – and raised more than $50,000 for The Foundation, and subsequent fundraising efforts would bring that total to more than $100,000. “Pam did the brunt of the work, arranging the minute details to make a successful event – right down to the table decorations,” Dr. Gosain notes. Pam recognizes that not every woman will be as fortunate as she was following their own diagnoses, but she says a support system of friends and family and a focus on continuing your commitments are key to maintaining energy and positivity. Her focus is now on ensuring that women no longer look at breast reconstruction through a stigmatized light or consider it unattainable. She wants to help other women know it’s a viable option. “How many people think of plastic surgery as being a frivolous thing?” she asks. “When faced with something that changes your physical appearance, it’s gratifying – and amazing – that you can be wheeled into a room to be worked on by someone with a God-given talent to reassemble you and make you feel positive about yourself again. That’s underrated by a lot of people. There’s no way I could possibly give my surgical team enough gratitude, because if it hadn’t been for them, I would not be as happy, willing or productive as I am today.” Still positive, optimistic – and lest we forget, in control – Pam says she wants other women working through breast cancer treatment to know that she’s on their team.

(Above) Second Annual Plastic Surgery Foundation Breast Reconstruction Fundraiser, Chicago, 2019. (Left to right) Cheryl Jackson; Sarah Wood; Pam Bailey (co-chair); Arun Gosain, MD, (co-chair); Zoraida Sambolin; Nora Daley.

Mohammed Alghoul, MD, and Pam Bailey.

“Even though I’m a private person, I have found such a source of strength in making sure the information is available and trying to help other women who are going through these challenges,” she says. “I’m not as afraid of cancer now. I don’t like it, but I’m determined to remain positive and will not let something like that get me down. I know I can beat it if I get the right team involved.” PSN: BREAST RECONSTRUCTION 2020 l

PATIENT EDUCATION

‘seasoned’

Is age alone a valid concern in breast reconstruction?

(Division of Plastic Surgery, University of Pennsylvania Health System, Philadelphia)

The events that unfolded during the first half of 2020 renewed the national conversation around persistent disparities in modernday healthcare. Among the many

documented inequalities in U.S. healthcare, post-mastectomy breast cancer reconstruction remains a continuing concern. National statistics reveal that disparities in breast reconstruction involve not only race/ ethnicity and socioeconomic status, but also age. More specifically, it’s been found that women older than 65 are much less likely to undergo reconstructive surgery compared to their younger counterparts.

l PSN: BREAST RECONSTRUCTION 2020

This data fuels several questions. First, do these differences span all breast reconstructive surgery options? Second, is this disparity a result of patients’ preferences or are they due to existing biases within the healthcare system? Finally, if biases do exist, are they medically warranted?

Still learning In 1998, a pivotal turning point in the history of breast cancer reconstruction surgery occurred with the passage of the Women’s Health and Cancer Rights Act (WHCRA). The legislation was instrumental in expanding healthcare benefits to thousands of women diagnosed

PHOTO: ISTOCKPHOTO.COM

By Monica Llado-Farrulla, MD, and Paris D. Butler, MD, MPH

with breast cancer who sought immediate or delayed reconstructive surgery after mastectomy. Specifically, the WHCRA mandated that medical insurance providers include coverage for women who desired reconstruction after undergoing unilateral or bilateral mastectomy – as well as a “balancing” surgery for the unaffected breast for purposes of achieving symmetry when indicated. The law’s impact is unquestionable. According to the American College of Surgeons – National Surgery Quality Improvement Program (ACS-NSQIP) database, in a matter of six years, a 14 percent increase was recorded in the number of women who received breast reconstruction surgery, bringing the national average to 33 percent of all mastectomy patients.1 In spite of the entitlement afforded by the WHCRA, however, it has become increasingly apparent that women have benefited dissimilarly depending on a multitude of demographic factors. Our group demonstrated that when compared to women younger than 45, women between the ages of 45-64 and those older than 65 underwent reconstruction 12.8 percent and 41.8 percent less often, respectively. Similarly, African-American and Latina patients had decreased rates of surgery compared to Caucasian patients, by 10.6 percent and 2.2 percent, respectively.1 Interestingly, when evaluating autologous reconstruction – which entails the transfer of tissue from another part of the body to re-create a breast mound – or implant-based reconstruction – which entails using a prosthetic to re-create a breast mound – women older than 45 had lower rates than women younger than 45, regardless of technique used.1 Taking all this into account, the question remains: Are these differences patient- or provider-driven? Contrary to when evaluating racial differences – which vary depending on the type of reconstruction – elderly age has a pervasive negative association, regardless of breast reconstruction type. Unfortunately, evaluating patients’ desires to pursue or forego immediate reconstruction is poorly

studied. The shortage of data prohibits our ability to draw meaningful conclusions that could help us address prevailing disparities. There remains an assumption that the health system and physician bias play a role in this disparity. If a bias exists, presumably secondary to safety concerns in women older than 45, and even more so in women older than 65, is there any scientific evidence to support it? To help answer that question, several retrospective studies actually concluded that age does not independently preclude breast reconstruction efficacy – even in the setting of slightly increased postoperative morbidity. One of those studies, by Angarita et al., demonstrated a 2.2 percent increase in postoperative complications for women older than 70, relative to younger women (7.5 percent vs 5.3 percent, respectively). The study also found that given the greater number of relative comorbidities in their older cohort, the increase in morbidity is considerably small and should not automatically disqualify this older demographic’s eligibility for breast reconstruction.2 Similarly, the study from our institution also revealed that postoperative breastreconstruction complications were not significantly different for women solely on the basis of age. Breast reconstruction after mastectomy has greatly changed the quality of life for thousands of women with breast cancer regardless of their age.3 Accessibility to these services has been largely expanded by the WHCRA, but a large chasm continues to exist between the relative percent of older and younger women that undergo reconstruction. Unfortunately, studies evaluating patient-driven factors are lacking, but from a medical standpoint, the data proves that breast reconstruction is safe and just as efficacious in older patients as it is for younger ones. Age as an independent factor should not preclude any patient from a thorough discussion with her physician regarding their breast reconstruction options.

ASPS member Paris D. Butler, MD, MPH, is an assistant professor in the Division of Plastic Surgery at the University of Pennsylvania. His clinical interests reside in both reconstructive and cosmetic plastic surgery. He’s board certified by the American Board of Surgery and the American Board of Plastic Surgery, and he’s earned an MPH in health policy and management with a special certificate in minority health. Dr. Butler currently serves on the American College of Surgeons (ACS) Committee on Surgical Health Care Disparities, as well as the ASPS Diversity & Inclusion Committee. Monica LladoFarrulla, MD, is a board-certified general surgeon completing her training in plastic and reconstructive surgery at the University of Pennsylvania. She is interested in serving the transgender community and is presently preparing to apply for a Fellowship in transgender affirming surgery. Sources: 1. Butler, et al. “Racial and age disparities persist in immediate breast reconstruction: an updated analysis of 48,564 patients from the 2005 to 2011 American College of Surgeons National Surgery Quality Improvement Program data sets” 2. Angarita, F.A., Dossa, F., Zuckerman, J. et al. Is immediate breast reconstruction safe in women over 70? An analysis of the National Surgical Quality Improvement Program (NSQIP) database. Breast Cancer Res Treat 177, 215–224 (2019). 3. Sisco Mark, Johnson Donald, Wang Chihsiung, Rasinski Kenneth, Rundell V.L.M., Yao Katharine. (2015). The qualityof-life benefits of breast reconstruction do not diminish with age: Breast Reconstruction in Older Women. Journal of Surgical Oncology. 111. 10.1002/jso.23864.

PSN: BREAST RECONSTRUCTION 2020 l

PATIENT EDUCATION

Answers to common questions about the breast cancer gene ( how it can impact your family) By Christopher Shale, MD

Working with patients during breast reconstruction is both challenging and rewarding. Helping women deal

with a breast cancer diagnosis can be tough, but I’m continually inspired by their incredible strength and resolve. Breast cancer patients are often mothers, and invariably their thoughts turn to protecting their families. My patients often ask, “What does this diagnosis mean for my family, my daughters?” They are concerned about passing “the breast cancer gene” to their children, but only 5-10 percent of women with breast cancer have a gene that could convey an increased risk for breast cancer. More accurately, “breast cancer genes,” when normal, can actually protect you from getting certain types of cancer. It’s when these genes mutate that there’s an increased risk of developing certain types of cancer, of which breast and ovarian cancer are the most common. The following questions will help you understand how genetics affect breast cancer so that you and your family can find answers and stay healthy.

Who should be tested? Specific mutations in the BRCA gene, such as BRCA 1 and BRCA 2, have demonstrated an increased risk of breast and ovarian cancer, but they are very uncommon. In the general public, it’s estimated that less than one in 400 individuals have one of these significant BRCA mutations. As we learn more about our genetics, there are other genes that can also increase the risk of breast cancer – such as the PALB2, CHEK2, ATM, TP53, PTEN and BRIP1 genes. Studies show there are risk factors that can increase the chances

l PSN: BREAST RECONSTRUCTION 2020

RISK FACTORS FOR BREAST CANCER GENE TESTING A first- or second-degree relative who was diagnosed before they were age 50 with breast cancer

Any male first- or second-degree relative diagnosed with breast cancer

Two or more breast cancers in the same first- or second-degree relative

Two or more relatives on the same side of the family with breast cancer

Breast cancer and ovarian cancer in the same first- or second-degree relative, or in family members on the same side of the family

A family member with a “triple negative” breast cancer diagnosed before age 60

Having a first- or second-degree relative with a known mutation of BRCA

of having one of these genetic mutations. However, even for people with these risk factors, only 15-20 percent will have one of these breast-cancer gene mutations. This may seem complicated, as so much of the information keeps developing and updating every year, which is why it’s important to work with a breast cancer specialist and genetic counselor, so they can help you understand whether you should be tested and what the results mean. People with any of these risk factors can be tested and have the test covered by their medical insurance – because it’s considered preventative care.

How do I get tested? Genetic testing can be ordered by a physician, or through a genetic counselor. After reviewing your family history, the physician or counselor can decide which test would be most appropriate based on the types of cancer in the family.

Sometimes they can see patterns associated with certain syndromes that can have an increased risk of breast cancer, such as Cowden or Li-Fraumeni syndrome. They can also determine who would be best to test first. Sometimes it’s better to get a family member further up the family tree who has had cancer tested first. If they don’t have the genetic mutation, it’s unlikely they passed it on. A genetic counselor or physician will also be key when reviewing genetic test results. The tests are complicated and don’t always give you a simple “yes” or “no” answer. Everyone’s genes are a little different, and we’re still learning the importance of certain genes, so there can be variances that we yet don’t know what to make of. The test result may show a variation of unknown significance that’s still “normal,” and a genetic counselor can explain these results to you.

What if I do have a harmful mutation of BRCA 1 or 2? First, know this does not mean you will get cancer. Although the risk of developing cancer with one of these mutations is higher than in the general population, it isn’t 100 percent. The table below lists the risk for developing breast or ovarian cancer, and this information changes as data continues to come in. There are ways to decrease risks for getting cancer, and close monitoring can be done to catch cancers in an earlier stage. However, the options you choose are incredibly personal. I recently counselled a 17-yearold girl about the BRCA gene mutation and what that meant for her. This is a very different discussion from the one I have with a 60-year-old grandmother who took the test to get information to help her children. Prevention strategies can include a spectrum of options, from more frequent exams, mammograms and MRIs, medications – or surgery to remove the breast tissue and ovaries, which can dramatically reduce the risk of breast and ovarian cancer. It’s important to review these options with a physician, so you can make an informed decision that’s right for you.

RISK OF DEVELOPING CANCER BY THE AGE OF 70 Breast Cancer BRCA 1

BRCA 2

72% (55-85%)

69% (43-84%)

Ovarian Cancer 44%

17%

ASSESSING YOUR RISKS Moderate exercise

DECREASES by 15-25%

Breastfeeding

DECREASES risk of breast cancer

Alcohol

>3 or 4 drinks per week INCREASES risk by 15%

Estrogen/progesterone hormone replacement therapies

Use of HRT INCREASES risk by 25%

Tobacco

INCREASES risk of breast cancer

Obesity

INCREASES risk of breast cancer

Radiation

INCREASES risk of breast cancer

If I don’t have the BRCA mutation, does that mean I can’t get breast cancer? Unfortunately, that’s not true. Up to 95 percent of women with breast cancer and 85 percent of women with ovarian cancer do not have a mutation in the BRCA genes. The lifetime risk for the general population to develop breast cancer is about 13 percent, and 1.3 percent to develop ovarian cancer. However, there are things you can do to decrease your risk of breast cancer.

Knowledge is power Breast cancer can be intimidating, but I hope this discussion has eased your mind. Don’t be afraid to ask your doctor any further questions. Understanding BRCA mutations, diagnostic tests and cancer prevention measures will help you and your family stay well and happy.

A native of San Diego, ASPS member Christopher Shale, MD, received his undergraduate degree in Nuclear Engineering at the University of California-Berkely and went on to medical school at Jefferson Medical College. He did General Surgery internship at U.S. Naval Hospital Balboa in San Diego, and after a tour with a Marine helicopter squadron deployed to Iraq, he completed his plastic surgery training at Scott & White Hospital. He’s now a plastic and reconstructive microsurgeon in Utah, specializing in breast and oncologic reconstruction as well as cosmetic surgery.

PSN: BREAST RECONSTRUCTION 2020 l

WELLNESS

ways to maintain your self-care during breast reconstruction By Terri Coutee

The choice to have breast reconstruction when you’re affected by breast cancer can feel like a monumental decision. If you choose to have reconstruction, it requires research to learn all your options, as well as planning, preparation and a healthy dose of self-care and focus on your health during the process. The process can seem less daunting if you treat it as a life event – one in which you can be fully engaged and assert control. As a two-time breast cancer survivor who chose breast reconstruction, I want to share my tips on maintaining your health and self-care during the process.

Research your options

If you choose to have breast reconstruction, you can request an implant filled with saline or silicone that’s inserted into the breast area after mastectomy. Another choice is using your own tissue, which is called autologous breast reconstruction. There are various areas of the body to harvest to create a flap for a new breast. I chose the most common reconstruction, called the DIEP flap, which uses tummy tissue, skin, fat and underlying blood vessels. The third option is a combination of an implant along with autologous or flap reconstruction.

Plan ahead

It’s important to start planning your leave of absence from work for your recovery after surgery. Speak to your plastic surgeon to determine the amount of time you’ll need off from work based on your reconstruction procedure. Perhaps you’re a workfrom-home or full-time mother with children. Arrange for a family member or friends to look after your children while you are in the hospital and/or traveling for your surgery. There’s nothing more comforting than placing the care of your children in trusted hands so that you can focus on your surgery and recovery. You will find your friends and loved ones will want to help, so reach out to them and allow them to assist you. If you have a pet who needs supervision during this time, make arrangements so you feel comfortable knowing they’ll be there during your healing when you return home.

Preparation and recovery

Begin the “nesting” process. Prepare some healthy meals ahead of time and put them in the freezer. Put simple items within arm’s reach in your kitchen, such as a cooking pan for soup, your favorite healthy foods, and cups and glasses. Make sure

l PSN: BREAST RECONSTRUCTION 2020

these food items, as well as the clothes in your closet, are shoulderlevel height and lightweight to ensure safety and proper healing, as you’ll have movement restrictions with your arms for a couple of weeks after breast reconstruction. Let the friends and family who’ve volunteered their help begin a meal train for you. With so many options available now for takeout, delivery and curb-side pickup, this is a great way to make them feel a part of your recovery. One of my favorite tips: Prepare your very own recovery basket for your return home. Find a special place to prepare your basket before your surgery, such as your favorite recliner or overstuffed chair. Create a special basket of your selected favorite items for recovery. Here are some of my favorites: • • • • • • • • • • • • • •

Hand cleanser or wipes Bottled water or your favorite water bottle Eye covers for resting Healthy snack options (e.g., fresh fruit, nutrition bars, pudding, nuts, dried fruit) Lotion and lip balm Back scratcher for reaching Alcohol wipes to strip drains Pre-moistened facial cleansers Earbuds and phone charger Favorite magazines and books Writing tablet with pen TV remote Tablets (e.g., iPad or Kindle) Your favorite cozy, warm blanket and pillow

Focus on your health

It’s important to focus on your health before, during and after your breast reconstruction. This will depend on your level of activity and if you’re in treatment before surgery. It’s not too late to begin a simple walking regiment, lift light weights or do basic squats to prepare your body for surgery. This will also help with your recovery. When surgery is over and you begin your healing process, start slowly – and only with approval and instructions from your plastic surgeon. You should begin moving the day after surgery. Gradually work up to more activity to regain trust in your newly reconstructed body. Celebrate each small milestone and improvement. You’re worth the self-care and planning it takes during your breast reconstruction. Think of this as your part in taking control of an often-overwhelming time in your life. You will look back on this and feel a sense of accomplishment and pride for all you’ve been through. You might also be able to pay it forward and share your self-care tips with someone else after breast reconstruction. Happy healing – and let me know if I can help! Terri Coutee is a two-time breast cancer survivor who underwent a successful DIEP flap breast reconstruction. She shares her personal story and evidence-based content from diagnosis through breast reconstruction on her blog DiepcJourney. Terri is a strong proponent of shared decisionmaking and the founder of the nonprofit DiepCFoundation.org, providing resources and support to empower breast cancer patients to make an informed decision about all their options for breast reconstruction.

CORPORATE SPONSORS SUPPORT

BRA Day Efforts

esearch shows that far too many women diagnosed with breast cancer still don’t know about their reconstruction options following a mastectomy. Launched by ASPS and The PSF in 2012, the Breast Reconstruction Awareness USA Campaign is instrumental in providing these women with both education and information about their reconstructive options as they undergo breast cancer treatment. Breast reconstruction can help women rebuild their self-esteem and improve their quality of life following breast cancer surgery. Plastic surgeons play an important role in a breast cancer patient’s recovery process – and the annual Breast Reconstruction Awareness Day movement gives those surgeons an opportunity to empower cancer patients, celebrate survivors and help women make an informed decision at the time of diagnosis. The ninth annual Breast Reconstruction Awareness Day will take place on Oct. 21, 2020. The Breast Reconstruction Awareness Campaign would not be possible without the generous support of our dedicated corporate sponsors. Thanks to their commitment, the campaign continues to provide education and resources about reconstructive surgery and raise awareness to close the loop on breast cancer – both on Breast Reconstruction Awareness Day and throughout the year. 2020 SPONSORS Three companies have generously lent their support to the 2020 Breast Reconstruction Awareness Campaign. This year’s Diamond Sponsor is Allergan Aesthetics, an AbbVie company, one of the country’s leading supplier of medical products for the global aesthetic medicine market. Mentor Worldwide LLC, a Silver Sponsor this year, has been a longtime supporter of the Breast Reconstruction Awareness Campaign. Both companies have launched multiple reconstruction solutions and are committed to continued innovation that will provide surgeons with the tools to improve patient outcomes in breast reconstruction. Integra Foundations joins the Breast Reconstruction Awareness Campaign this year as a Bronze Sponsor. Every corporate partner contributes annually to the campaign’s success and continues to make a difference in empowering women facing a breast cancer diagnosis, as well as providing them with reconstructive education. Donations from sponsors are applied directly to programs that support related research and awareness efforts, and provide charitable care. ASPS and The PSF sincerely thank the 2020 Breast Reconstruction Awareness campaign’s generous sponsors for their continued support and dedication to women’s health, patient education and innovation.

an AbbVie Company

For more information on the Breast Reconstruction Awareness Campaign corporate sponsors, visit breastreconUSA.org.

PSN: BREAST RECONSTRUCTION 2020 l

Collecting information on breast implant procedures and devices allows plastic surgeons and breast implant manufacturers to identify trends and other information that can be used to improve the safety of breast implants for current and future patients.

Our Goals

Acquire accurate and meaningful data during clinical workflow, including rates of reoperation and implant failure.

Identify

Collect

safety signals early and

data that includes incidence of

provide optimal safety.

complications requiring reoperation.

Allow

Establish

for innovative and safe products to

a framework for more

enter and remain on the U.S. market.

in-depth studies.

Contribute your data today.

ThePSF.org/NBIR

Breast Reconstruction 2020

Articles inside

Answers to common questions about the breast cancer gene

Four ways to maintain self-care during reconstruction

Industry support is vital to Breast Reconstruction Awareness efforts

Is ‘seasoned’ age a valid concern in breast reconstruction?

Breast reconstruction during COVID-19

Young scientist empowers women through her BRCA journey

Survivor helps uninsured women find closure after breast cancer

Survivor helps spearhead community-based fundraisers for reconstruction

Plastic surgeon’s mission trips restore hope – and lives – in Ghana

Preserving and restoring sensation after surgery

ASPS president shares lessons learned during cancer journey

Get involved: Breast Reconstruction Awareness Day