BRA Day 2023: Audience Questions 

Triple-positive breast cancers (positive for ER, PR and HER2) are usually treated with both anti-hormonal therapy and anti-HER2 therapy (trastuzumab).  

It depends on the stage and receptor status (ER/PR/HER2) of the ILC. For the most part, ILC is treated similarly as invasive ductal carcinoma (IDC).  

Surgical menopause reduces the risk of ER/PR+ breast cancers. Hormone therapies for increased quality of life increase the risk of ER/PR+ breast cancer.

All women undergoing an axillary procedure can expect some degree of shoulder stiffness, pain, or dysfunction that resolves over time with physiotherapy. The risk is higher in women receiving an axillary lymph node dissection. Rarely, some women have permanent shoulder dysfunction.

It depends on the receptor status.

ER/PR+ HER2- : endocrine therapy and a CDK4/6 inhibitor

Triple negative: capecitabine and immunotherapy trials

HER2+: paclitaxel and anti-HER2 therapy

The choice to undergo breast reconstruction is a very personal choice that is based on information gained during a consultation with a plastic surgeon that specializes in breast reconstruction. Some women choose to have no reconstruction. In this case the surgeon can provide what is called an “aesthetic flat option”, meaning a mastectomy with contouring to try to provide a flat, smooth and even contour.

Breast reconstruction is an option. For many women, reconstruction assists with maintaining or improving a person’s quality of life, following mastectomy or partial mastectomy. Some women make a choice that reconstruction is not a priority. Reconstruction is additional surgery and, in some circumstances, requires surgery to be performed on areas of the body other than the breasts. For women with more advanced disease, a person may choose to manage the breast cancer including any additional medical or radiation treatments before considering reconstruction.

In general, it is easier to produce symmetric and similar results when reconstructing two breasts as opposed to one. In circumstances where one breast is being removed, the reconstructive surgeon will do their best to provide a result that has the closest symmetry as possible. This may require some degree of balancing or shaping of the opposite, unaffected breast.

The decision to remove a “normal” breast for preventative reasons is an important decision that should not be taken lightly. Deciding to have a prophylactic (preventative) mastectomy should only be done after careful consultation with doctors and genetics counsellors that specialize in this area. For women who are considered higher risk (either through genetics testing, strong family history, or disease on the other breast), a choice to undergo preventative mastectomy would generally be supported and offered at hospitals that specialize in the management of breast disease.

We tend to think of breast reconstruction as a post-mastectomy procedure. A lumpectomy still leaves an intact breast. There are ways to correct cosmetic outcome after lumpectomy but they aren’t considered “breast reconstruction.”

For example, we do not put implants in someone who had a lumpectomy because the radiation that is mandatory with lumpectomy will lead to implant complications.

The Goldilocks technique is an option for some women that typically have large breasts and a significant amount of fatty tissue within the breast. In these cases, a mastectomy is preformed to remove the breast tissue, leaving as much fat and skin as possible. This tissue is then used to try to reconstruct and shape a breast mound.

Nipple sparing mastectomy allows for preservation of the nipple and the areola, however the nerves within the breast have been removed. As a result, most women lose sensation to the nipple, including a loss of erectile function. Over time there may be some regeneration of the nerves, but rarely does sensation return to near normal. Surgeons are working today to advance techniques for nerve reconstruction at the time of mastectomy, but results presently have shown limited return of sensation.

This is a reality in many hospitals in Ontario. Many patients often come to Women’s College Hospital for a second opinion because we can accommodate immediate reconstruction.

There’s no right or wrong answer. After weighing the pros and cons, it’s the decision that you feel most at peace with. For some women, it will be a double mastectomy. For others, it will be a unilateral mastectomy.

Recovery after breast reconstruction depends to some degree on the specifics of the type of reconstruction being performed. In general, women undergoing reconstruction with implants have a faster recovery than women having reconstruction with “flaps” or tissue moved from another area of the body. Other factors in recovery can be related to age, general medical health and the type of mastectomy, including whether or not there was surgery to sample or remove lymph nodes. On average, patients return to non physical daily activity within two weeks and may resume full physical activity in 4 to 6 weeks.

There are risks associated with any surgery, and this is no different with breast reconstruction. It is important to have this conversation with your surgeon, as each patient and each reconstructive plan is different. There are risks common to most surgeries including infection, bleeding, scarring and problems with delayed areas of healing. More specific risks such as those related to implants or those related to using your own body’s tissue are procedure dependent.

Implant risks may include infection, rupture of an implant, scar tissue forming around an implant, or in rare cases, systemic effects that can impact a person’s overall health. Implants should be thought of as medical devices and as with any device, are not “once in a lifetime”. There will be times in life where implants will need to be changed or possibly removed.

Tissue flap risks include infection, additional recovery time, additional scars on areas of the body away from the breasts. In rare cases, some or all of the tissue that is being used for reconstruction may not survive and will need to be removed. This would require additional surgery and may impact the eventual reconstructive outcome.

Breast reconstruction involves surgery in the area of the chest wall and usually does not involve surgery in the area of the axilla (armpit). As a result, it is very unusual for reconstruction to cause or exaggerate lymphedema.

Post-op pain and recovery is very dependant on a number of factors including the type of reconstruction, whether this is immediate or delayed reconstruction and the type of mastectomy that was performed. In general, post-operative pain is quite manageable with patients taking pain medication for no more than 2-3 days after surgery.  Of course, this can vary from patient to patient and some people may require some assistance for up to a week.

Post-mastectomy syndrome can occur in 1/3 of patients and is neuropathic pain due to cutting of the nerves that comes out the side of the chest and innervates the breast. When the breast is removed, these nerves have to be cut.

It is important to understand where the surgical scars will be located after your surgery. This will depend on a number of factors including the type of breast surgery being performed (lumpectomy, mastectomy, type of reconstruction). With mastectomy, scars may be placed in a number of locations and this may depend on the degree of disease at the time of surgery, breast size, decision for nipple preservation, patient and surgeon preference). Most surgeons will recommend a protocol after surgery for scar care including scar creams or gels, taping, sun protection along with lasers in cases where this is indicated.

Depends on the tumour size relative to breast size.  If the tumour is small, lumpectomy is fine. If the tumour occupies more than half of the entire breast, there’s no point leaving such a small breast mound and the patient with such asymmetry.

Similarly, if a tumour shrinks significantly after neoadjuvant chemotherapy, we don’t remove the original area of tumour, we just remove the remaining tumour.

Great question!

1. Breast reconstruction is rarely a “one and done” deal. It is common to require more than one surgery to get to the final result.
2. A reconstructed breast may provide a good aesthetic outcome and assist in improving a person’s quality of life, however it will never really “feel” like the original, natural breast. For some women, the breast may feel cool to the touch and will have some degree of altered sensation.
3. Women having reconstruction using breast implants should appreciate that these are medical devices and to some degree, will require long term “maintenance and follow-up”. Breast implants are not once in a lifetime devices.

Breast reconstruction can be performed at the time of mastectomy (immediate reconstruction). The wait time for surgery will be dependent primarily on the indication for surgery. Women with active breast disease will require surgery in a more rapid fashion than those undergoing preventative surgery.

Timing for breast reconstruction performed after mastectomy (delayed reconstruction) is very dependent on resources in your local community. Presently there are significant wait times in most areas of Canada and there is some variability in these times based on where you live. This is a function of resource limitations within hospitals and our existing health care system. Your surgeons and health care teams will be advocating for you to receive your surgery as quickly as possible.

Nipple sparing mastectomy allows for preservation of the nipple and the areola, however the nerves within the breast have been removed. As a result, most women lose sensation to the nipple, including a loss of erectile function. Over time there may be some regeneration of the nerves, but rarely does sensation return to near normal. Surgeons are working today to advance techniques for nerve reconstruction at the time of mastectomy but results presently have shown limited return of sensation.

Any dead tissue needs to be surgically removed as it will not heal.

When breast reconstruction or partial mastectomy has been performed on a single breast, it is very common to consider a balancing operation on the opposite breast. This is, of course, dependent on a patient’s individual goals and needs. Balancing options may include reducing a large opposite breast, lifting a breast to make the shape more equal to the reconstructed side, or in some cases, augmenting the opposite breast with either implants or fat.

There are various options for managing a breast that has undergone a previous lumpectomy. These will be dependent on the specifics of the situation, but may include scar revision, fat grafting or the addition of tissue from areas near the breast (local flaps). It is best to discuss these options with a plastic surgeon that performs reconstructive breast surgery.

Every patient has the right to seek a second opinion on surgery, if they so desire.

It is a discussion between the patient and their plastic surgeon, and how far they are moving away.

If you have had a previous tummy tuck, or for that matter, any previous abdominal surgery, you may not be a candidate for abdominal based reconstructions such as the DIEP or TRAM flap surgeries. There are almost always other options available such as implant reconstruction or flap surgery from other areas including the back, buttocks or thighs.

Usually, nipple-preserving mastectomy gives the more natural look. If you are unhappy with a nipple-sparing mastectomy cosmetic outcome, you can always discuss with your plastic surgeon how it can be improved.

There are many factors that can impact the subtle shaping of a breast mound including the type of reconstruction, the type of mastectomy, the amount of fatty tissue under the skin that remains after a mastectomy, previous surgeries, a person’s natural anatomy and whether or not radiation has been performed. Breast reconstruction is best thought of as a “work in progress.” There are always things that can be done to improve or refine an outcome and address issues such as irregularities, contour indentations, asymmetry or issues with the shape of the breast. Most of the time, this will require surgery, so it is best to weigh the benefits and risks in discussion with your surgeon.

This is because studies have shown that patients ambulate and recover better at home.

Nipple sparing mastectomy allows for preservation of the nipple and the areola, however the nerves within the breast have been removed. As a result, most women lose sensation to the nipple, including a loss of erectile function. Over time there may be some regeneration of the nerves, but rarely does sensation return to near normal. Surgeons are working today to advance techniques for nerve reconstruction at the time of mastectomy, but results presently have shown limited return of sensation.

This is currently only offered in select centers in the US. It will probably be several more years before it comes to Canada and it is actually covered by OHIP. Those nerve grafts can cost tens of thousands of dollars.

Yes. In Ontario (and all of Canada), reconstructive breast surgery is an insured service at any time after mastectomy.

If a person is healthy and a good candidate for surgery and if their disease is stable, breast reconstruction can be performed at any time following mastectomy.

Start by having a conversation with a plastic surgeon who performs breast reconstruction. If it is your choice and preference to “go flat”, the surgeon can explain the process of implant removal along with the removal of any excess skin to obtain a result that is aesthetically pleasing, smooth and flat.

It is a personal decision but concerns include asymmetry, using a prosthesis.

Going Flat Photos & Resources – Mastectomy, Revision, Explant – NPOAS (notputtingonashirt.org)

You should discuss how to achieve a flat aesthetic closure and how to minimize dog ears. We tell patients that a flat closure may not be achievable at the first surgery and may need a second procedure to correct any dog ears.

It is all covered by OHIP.

Fat grafting is an excellent adjunct to reconstructive breast surgery. Fat can be used to fill indentations, improve the overall contour of the breast mound, make the breast have a more overall natural appearance and cover over visible edges or ripples associated with breast implants. The procedure involves finding an area on the body with some excess fat, harvesting the fat using liposuction techniques, preparing the fat in small syringes and then injecting the fat into the desired areas just like injecting a filler.

The benefit is that this is natural tissue and can be performed with a fairly minimal surgical procedure.

It will take 1-2 hours.

Aesthetic flat closure is now endorsed by the American Society of Breast Surgeons and we are teaching aesthetic flat closure.

Yes, it is possible. Typically, it is preceded by informed decision-making with your surgeon.

You should reach out to your plastic surgeon to discuss removal, and to decide if that is how you would like to proceed.

The radiation probably is a causative factor for the pain and not necessarily the implant. It’s true that there is more pain with UTM but you’re not having this pain on the opposite side.

You have quite correctly answered your own question. The most important factor is a person’s general health and candidacy for elective surgery. There is no age cut-off, but as people get older, it is wise to carefully weigh the benefits and risks of elective surgery.

From the sounds of things, what you are describing is actually quite common. A reconstructed breast will often hold its shape and size much better than a natural breast. It is normal for breasts to change through life and most women’s breasts change shape and often get larger with age. Your non-reconstructed breast is behaving in a normal way! If it is problematic, you can consider having a lift and reduction of the larger breast to obtain better balance. Ask your family physician to make a referral to a plastic surgeon that does this type of work.

This is a common problem and is not really related to the reconstruction. The sensations that you describe are caused by the removal of the nerves within the breast at the time of mastectomy. As the nerves try to regenerate, they can cause unpleasant sensations such as tingling, irritability, electric shocks or shooting pains. These often get better with time. There are also some medications that can assist with this irritability, and it may be worth discussing this with your primary care physician.

Yes. If the reconstruction is with implants, then the implants can be made smaller. If it was performed with your own tissue, then usually the breasts can be reduced with either liposuction or tissue reduction techniques.

It is important to note that the body (including the reconstructed breasts) continue to age following your surgery. If your reconstruction involves implants, then it is likely that you will require further surgery later in life to change or replace an implant. Breast implants are not once in a lifetime devices.

Yes. If you are a healthy candidate for elective surgery, balancing procedures can be performed at any time. As of today, balancing procedures to try to match a reconstructed breast are OHIP insured procedures.

This will be specific to your body, your general health and the type of surgery that you undergo. Post reconstruction physiotherapy is often very helpful in speeding up your recovery, maintaining good range of motion and regaining strength. Other therapies such as ultrasound, manual lymphatic drainage and scar management may also be advisable.

Reconstructive surgery is an insured service in Ontario.  Of course, there is a fine line between what is reconstructive versus what might be considered aesthetic or non-medically necessary.  For the most part, all surgeries related to reconstruction post-mastectomy or lumpectomy are insured services, although there may be exceptions.

The risk of cancer after having a mastectomy and reconstruction is already low because there is little breast tissue remaining.

For any type of reconstruction (DIEP or implant), it can be difficult to detect a recurrence behind the reconstruction on the chest wall. A lat or DIEP flap does not make detecting recurrence any easier than implant reconstruction.

After a double mastectomy, there is already very little tissue remaining. The best way to survey is with annual physical examinations.

The small amount of tissue left behind a nipple-sparing mastectomy is so small that it does not justifying getting an annual MRI.

Clinical palpation of the nipple-areolar complex annually is sufficient.

Both nipple sparing and complete mastectomy will reduce the risk of contralateral breast cancer by 90-95% with no difference between the two. However, I stress that in average risk women, the risk of getting a contralateral breast cancer is really low (only 0.37% per year or 10% over the next 25 years).

We only recommend annual physical after mastectomy, regardless whether it is flat or with implant reconstruction. The reality is that 90-95% of the breast tissue has been removed, the remaining 5% is not discernable on a mammogram or MRI.

We do not recommend MRI during breastfeeding because the breasts will show so much enhancement just from the breastfeeding. It will be very difficult to tell enhancement from breastfeeding versus a tumour.

Yes, genetic testing for the BRCA1 and BRCA2 genes (as well as other hereditary breast cancer genes) is definitely available after a mastectomy. Your cancer treatment doesn’t change this test. With germline genetic testing, we are not looking at the cancer itself. Instead we are testing whether someone was born with a genetic change (called a mutation) that made them predisposed to develop breast cancer in their lifetime. Testing is typically done on a blood sample or a saliva sample. OHIP may cover the cost, but it depends a bit on your personal cancer history (for example, how old you were when you were diagnosed with breast cancer) and your family history of cancer. Recently, the criteria have expanded so that many more breast cancer patients are eligible to have their genetic testing paid for – but not quite all.  You can check with your family doctor, or some information can be found here: Cancer Care Ontario.