Category: Surgery

Ya, no … That is pretty much what I thought when the resident on call suggested a catheter with a pee bag attached to my leg for the next week or so.

I don’t think she really heard me right. I said I was having difficulty urinating, but I am still doing it! There is still pee coming out of me … perhaps not as much as should be.

Over the phone she diagnosed me with post-operative urinary retention. It is not uncommon. Actually, a quick Google search shows that it is the most common side effect for anesthesia. I was hoping to be given some anti-spasm drugs (like you sometime get with a urinary track infection), no such luck. The problem is that the involuntary muscles aren’t working properly. The way the resident explained it, is that my bladder is still ‘asleep’  – it has not yet woken up from the anesthesia.

Sensing my non-compliance, she asked if I was OK with the plan. I said no, how about we watch and wait – cause I am passing some urine, I’m not completely blocked – it is just taking time and not flowing properly. I don’t completely trust the resident’s opinion. I want to hear it from someone with more experience. I have an appointment with my surgeon (whom I trust) tomorrow at 10am. So, the resident and I negotiated a plan. I would watch and wait, but if I have a window of 6-8 hours where I don’t pass any urine or if I feel my bladder is full/distended, then I’m to go to urgent care and ask for a catheter and leg bag. I must give the resident credit for detecting by the sound of my voice that I had no intention of just going in and getting the catheter and bag. We spent a good few minutes discussing the watch and wait option, so I know what signs mean I need to go and get it deal with.

Now that I’ve had a little more time to process the idea, I can deal with it. If my surgeon says I need it, I will get it tomorrow, and deal with it while travelling (oh joy). The resident said that it would stay in for a week, and then they would do some test to see if my bladder was working properly (voiding properly) such that it could be removed.

On the pain front, I’ve started to wean off the pain meds. I’m on a lower dose, less frequently, and so far it is working out OK. I caught myself last night unconsciously doing my normal inspection/feel of my breasts, I accidentally squeezed one of them a little. Hurt like …

… won’t be doing that again anytime too soon!

 

Never in my life did I even imagine that I would be naked in a home photo studio in Berkeley California (well, maybe not actually Berkeley, rather Albany, which felt a lot like Berkeley) … anyways, it isn’t something I ever thought that I would do, and yet I did it. Cancer has certainly meant I’ve found myself doing a lot of those “never” things.

I had been pondering the idea since I first learned about Camera’s Over Cancer – I had even booked a session with them – but was discouraged by it. I didn’t want to buy clothing just for a photo shoot, and I am not the type of person who has a closet full of boudoir appropriate outfits. I was also challenged with getting to their studio (which interestingly enough is out in Oakland, and actually closer than where I went today).

At the BCC conference, there was an exhibit of photos on each table. The photos where really classy pictures that celebrated women’s breasts. The photos were taken as part of a project by Laura Turbow called For Luli (you can read about it here). Her photos really spoke to me, so I emailed her about a possible session. As I was unable to drive earlier, or get a ride, we ended up booking for today – the only possible time to take the photos before surgery. It was rather fortunate that her schedule and my schedule aligned. To be honest, I was much more nervous about my ability to drive then about having photos taken. It is the first time I’ve drive on my own up through Oakland to Berkeley. I was rather intimidated by the need to drive on that particular highway, which is often full of traffic. It turned out to not be so bad! So, today, I found myself in Laura’s studio, just north of Berkeley California, posing for a classy set of photos that celebrate my breasts. I really enjoyed the process, and I’m really looking forward to seeing the photos. When I get them, I’ll share a few of the ‘general public friendly’ photos here. I recommend the session for anyone who wants to capture their pre-surgery selves.

And now I need to get back to my pre-surgery preparations. I’m getting some food ready for when I can eat when I get home, and I need to shower before trying to get a little bit of sleep. I will need to shower again in the morning before driving up to Stanford for a 6 am start. Surgery isn’t until 1:40 pm, but there are several pre-surgery procedures that need to be done first. Specifically, injection of some nuclear isotope into each breast that helps to identify the sentinel node, and the insertion of wires to guide the surgeon to the exact location of each of the tumors, neither of which sounds at all like fun. I do hope the plan to use the paravertebral nerve blocks is still in place. That will make my morning go a whole lot smoother!

One of my concerns with surgery is that I’m highly sensitive to adhesives, even steri-strips cause my skin to blister. If any tape or adhesive based dressing is used, it will blister within a few hours – making me very uncomfortable but also hindering my body’s ability to heal. Fortunately, they don’t need to use adhesives, they just need to be reminded to not use them (they use special surgical glue to close the incision). My husband came up with the idea of adding a note in permanent marker on my belly (actually just under my breasts) … so I’ll have him write “no tape” as a reminder to not put anything sticky on my skin!

I’ve been reading up a bit on the expected pathology reports for post-mastecotomy after neoadjuvant chemotherapy (that is, what should I be hoping for in the pathology after chemo – and what does that mean?).

To start with my new term for the day is “pathological complete response” or pCR – this indicates the degree to which the chemotherapy treatment has killed the cancer. According to Cortazer et al (2014), you are considered to have a pathological complete response if:

• absense of invasive cancer or in-situ cancer in breast or the axillary nodes (ypT0 ypN0)
• absence of invasive cancer in breast or axillary notes but in-situ is present (ypT0/is ypN0)
• absence of invasive cancer in breast but in-situ and nodal involvement (ypT0/is)

Note that definitions for pCR are not consistent – so each study defines it for their own analysis. For those in the analysis with the same type of tumor I have (based upon my most aggressive tumor which is IDC ER/PR+ HER2- grade 3) the pathological complete response rate is 16.2 % (95% Confidence interval – so 13-4-19.3). This means that I can expect about a 16% chance of having a complete pathological complete response. This takes into account everyone with the same type of cancer, but doesn’t separate out those who had clinical indications of node involvement prior to surgery/chemo. Of those who had no clinical indication of nodal involvement regardless of cancer type the numbers are 18.8 % (95% CI 17.9-19.8). So I’m hoping for the higher number, since I don’t have any indicators of node involvement.

The research says that for the type of tumor that I have, if I have a pathological complete response then it is a good indicator of my overall survival.  The studies don’t say anything about survival if you don’t achieve pathological complete response. The purpose of the two studies I looked at was to determine when/if pathological complete response was a good indicator of disease free survival. The answer for my type of cancer is yes – if the pathology comes back with pCR then that is a good indicator of disease free survival.

Note that it takes along time for a study to be published – so this study published in 2014 is based upon patients that were treated between 1990 – 2011.

The second study that uses more categorization and is more detailed. It gives me a higher likelihood of achieving pCR (11.2 % ypT0 ypN0, 15.4% ypT0/is ypN0, 17.6% ypT0/is ypN0/+). The one quote which is interesting is “subgroups with highly proliferating tumors, pCR can discriminate between patients with good and poor prognosis accurately” (von Minckwitz et al., 2012, p.1802).

So, I now know what I should be hoping for when the pathology comes back after my bilateral mastectomy surgery.

The one thing this exercise is telling me is that I really want to know the pathology from my bilateral mastectomy before I commit to the DIEP flap surgery. This has me leaning towards a skin sparing mastectomy with immediate reconstruction with tissue expanders. This means that if I want the DIEP surgery later, I can have it. Or I can have the expanders removed and skin cleaned up if I don’t want it. It leaves the doors open for reconstruction or not – and the decision will likely depend on prognosis. If I’m going to live a long healthy life post breast cancer, then the DIEP surgery is a worth-while investment in my time and physical energy. If the prognosis is not so great, then I’d rather be done with the surgeries and get on with living.

Reference

Cortazar, P., Zhang, L., Untch, M., Mehta, K., Costantino, J. P., Wolmark, N., . . . Valagussa, P. (2014). Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis. The Lancet. Retrieved from http://www.rits.onc.jhmi.edu/dbb/custom/A1/files/12/pCR_Cortazar.pdf

von Minckwitz, G., Untch, M., Blohmer, J. U., Costa, S. D., Eidtmann, H., Fasching, P. A., . . . Loibl, S. (2012). Definition and impact of pathologic complete response on prognosis after neoadjuvant chemotherapy in various intrinsic breast cancer subtypes. J Clin Oncol, 30(15), 1796-1804. doi:10.1200/JCO.2011.38.8595

 

In preparation for my consult with plastic surgery this week, I’ve been doing some reading on patient satisfaction after breast reconstruction. I began by asking the medical information officers at Bay Area Cancer Connections for a link to a few articles. From there, the academic in me took over, and I search and read a variety of articles regarding post reconstruction patient satisfaction.

First off, I should start by pointing out an important blog post written by Nancy on why post-cancer breast reconstruction is not a boob job. When looking at patient satisfaction, I focused on post-cancer reconstruction which is a lot more complex than cosmetic reconstruction.

I should also point out the my literature review focused on autologous reconstruction, in particular on DIEP flat reconstruction – as this is what I currently believe I’m most interested in. I’ll have a better sense after the consult, as I don’t yet know that I’m a candidate (although I think I am).

Important terms:

• Autologous reconstruction is reconstruction that involves the patients own tissue (e.g. DIEP flap, TRAM flap).
• Prophylactic mastectomy (PMX) is the removal of the healthy breast to reduce the likelihood of re-occurrence of breast cancer. PMX is also performed on women who after unilateral mastectomy dislike the lack of symmetry.

In my literature review, some interesting things emerged:

• In a great general article on breast reconstruction Serletti et al (2011) indicate that “studies suggest that generic counseling increases the likelihood of choosing prophylactic mastectomy, despite the fact that BRCA accounts for only 5 to 10 percent of all breast cancers” (Serletti et al, 2011, p.124e). In other words, seeing a generic counsellor likely increases prophylactic mastectomy. Now, given that you typically are referred to a genetic counsellor if you have a family history and/or are diagnosed under 45 years of age, I’m not completely surprised by this.
• The biggest factor in determining timing for reconstruction should be whether or not radiation therapy is required, as “several studies have identified postreconstruction radiation therapy as an independent risk factor for volume loss, fat necrosis, and poor cosmetics”  (Serletti et al, 2011, p.129e). That being said, women are generally happier (sooner) with immediate reconstruction. That is, Zhong et al, 2012 highlight that post-surgery happiness is the same, however, the time post-mastectomy pre-reconstruction women are less happy. However, the reason for delayed reconstruction is usually cancer treatment, so I’m not surprised they would be less happy!
• The rates of implant-based surgeries in the US has dramatically increased (as compared to autologous reconstructions option) (Albornoz et al, 2013) despite literature that indicates that patients longer term satisfaction is greater with autologous reconstruction (Yuch et al, 2010). This in part may be attributed to the increased surgeon compensation rates, but also the availability of operating room time. Autologous surgeries take significantly more time to perform and the hourly rate of compensation by insurance companies in the US is lower than for implant-based surgeries (Albornoz et al, 2013) . One of the studies I read said that university hospitals did not show this same increase in implant surgeries – highlighting the economic reason for the increase (I can’t find the reference now).
• “The strongest predictors of implant reconstruction were procedures performed after 2002, Medicare recipients, bilateral mastectomy defects, and patients operated on in the West and Midwest regions” (Albornoz et al, 2013, p.21).
• “It is now mandatory for partitioners caring for women with breast cancer to inform them about reconstruction” (Albornoz et al, 2013, p.20).
• “Studies suggest the increase in bilateral mastectomies is attributable not to the changing incidence of bilateral breast cancer but rather to the growing use of contralateral prophylactic mastectomy” (Albornoz et al, 2013, p.21-22).
• In a Canadian study that looked at patient outcomes after autologous reconstruction patients scores on breast, sexual well being, and psychosocial well being improved after surgery (measured at 3-weeks and 3-months). The only negative finding was that at 3-months patients scored lower on abdominal well-being – that is, even after 3-months patients felt a decrease in their abdominal health. Note that the surgeries in question were predominantly DIEP flap which did not involve muscle from the donor site (Zhong et al, 2012).
• Both Zhong et al (2012) and Yueh et al (2010) indicate that women undergoing DIEP surgery travelled further for treatment. This is likely because it requires specially trained surgeons (surgeons trained in microsurgery) and as a result the surgery is only available in major centers (more commonly offered in academic settings – in part also because surgeons are not compensates as much for autologous surgery as they are for implant surgery).
• Institutions that do more flap surgery have better flap surgery outcomes (significantly). Specifically, “in centers with a high volume of microsurgical procedures and experienced surgeons, the number of total flap losses tends to be low, an dis consistent with our flap loss rate of 1.8% in the DIEP flap group” (Momoh et al, 2012, p.22). I’ve seen numbers as high at 10% for flap loss rate.
• Patients who have reconstruction have increased body image afterwards (Gopie et el, 2014) – not a comparative study – so doesn’t say anything about body image of patients who don’t have reconstruction – does breast cancer create a more positive body image regardless of type of post mastectomy surgery choice?
• In Canada the barriers to immediate reconstruction for flap surgeries include availability of operating rooms and experienced surgeons. Socioeconomics play a role in whether Canadians get access to immediate flap reconstruction. Women travel to special centers to access immediate flap reconstruction (Zhong et al, 2014).
• With abdominal flap reconstruction, patients are not necessarily satisfied with the abdominal outcomes. This highlights the need to better set patient expectations regarding not just the breast outcomes but also the abdominal surgery outcomes (Niddam et al, 2014).
• In looking at a large insurance claims database, Jagsi et al (2014) note that 76% of patients who underwent bilateral mastectomy opted for reconstruction. They also note that those who underwent radio therapy were less likely to undergo reconstruction. That being said, I wonder if the radiotherapy numbers include lumpectomies (which they would), such that reconstruction is less likely to be necessary.
• In a study looking at risk factors associated with blood transfusions and DIEP surgery, Fischer et al (2014) looked at neo-adjuvant chemotherapy but did not indicate that it was a risk factor. Those who have blood transfusions are more likely to have complications (no mention of causality in the study – so it could also be said that those who have complications are more likely to have blood transfusions). One thing that is useful to look at if you are having the longer bilateral mastectomy with reconstruction surgery is giving your own blood in advance of the surgery, so that you can have it available for transfusion. I’m not sure if this is even possible when you have neo-adjuvant chemo.
• Lundberg et al (2014) reviewed the literature and provided a view that DIEP surgery is only cost effective in patients who have been treated with radiotherapy (and are therefore not candidates for implants). They point out that the studies done so far use “bad science” (I don’t agree – this article reads as somewhat biased itself). They do say that if you are a smoker, you should stop smoking 4-weeks before DIEP flat surgery in order to significantly reduce complications. They also point out the BMI over 30 is a risk factor. What is interesting here is that you need to have enough body fat to have enough fat at the donor site, but too much fat reduces the likelihood of successful outcome. It will be interesting to see what the plastics folks say for me.
• Lundberg et al (2014) recommend “angiography … preoperatively to find out if the flap has perforators and can provide the anatomical prerequisites for the operation to be successful” (p. 108)
• Those undergoing nipple sparing surgeries are more likely (>88%) to have immediate reconstruction (Albornoz et al, 2013).
• Serletti et al (2011) highlight that many patients “begin by saying they do not want implant reconstruction” (p.125e).

One of the challenges with using literature to help inform your decision is that it is all based upon the past. As was highlighted by Lundbert et al. (2014), the techniques and tools (e.g. implants) used today are not the same as those used 5 and 10 years ago. As a result, the studies involving longer term outcomes are not truly representative. In many ways the surgery will be a gamble – the decision may be based upon the best information available at the time, but there is always the random chance variable that we just don’t know. In many ways, my surgery choice needs to be in part based upon my gut feel – the same as my decision for neo-adjuvant chemotherapy. I have to choose based upon what ‘feels’ right for me, after collecting all the evidence I can.

In looking at the literature I am most concerned about studies regarding the cost/benefit analysis of the different reconstruction types. There is a significant trend towards implant based reconstruction. This can be attributed to the change in technology being used (a new type of silicon implant was approved in 2006), but also because it requires less time in surgery, and it therefore easier to schedule. In addition, the autologous surgeries require specially trained plastic surgeons – which means women need to travel to major centers in order to have this type of surgery (makes me glad that I’m being treated at Stanford!). My concern is that the cost/benefit studies will be used by insurance companies to deny women specific types of surgery. Although the Women’s Health and Cancer Right Act of 1998 requires that insurance companies cover reconstruction, I’m not sure how comprehensive that coverage is and whether insurance companies can limit it to types of reconstruction?

OK, I have a few more articles to read, but I’m not getting much new information – which means I’m reaching saturation on this particular literature review.

If you want a copy of a particular article and don’t have access, send me an email.

References

Albornoz, C. R., Bach, P. B., Mehrara, B. J., Disa, J. J., Pusic, A. L., McCarthy, C. M., . . . Matros, E. (2013). A paradigm shift in U.S. Breast reconstruction: increasing implant rates. Plast Reconstr Surg, 131(1), 15-23. doi:10.1097/PRS.0b013e3182729cde

Gopie, J. P., ter Kuile, M. M., Timman, R., Mureau, M. A., & Tibben, A. (2014). Impact of delayed implant and DIEP flap breast reconstruction on body image and sexual satisfaction: a prospective follow-up study. Psychooncology, 23(1), 100-107. doi:10.1002/pon.3377

Jagsi, R., Jiang, J., Momoh, A. O., Alderman, A., Giordano, S. H., Buchholz, T. A., . . . Smith, B. D. (2014). Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States. J Clin Oncol, 32(9), 919-926. doi:10.1200/JCO.2013.52.2284

Lundberg, J., Thorarinsson, A., Karlsson, P., Ringberg, A., Frisell, J., Hatschek, T., . . . Elander, A. (2014). When is the deep inferior epigastric artery flap indicated for breast reconstruction in patients not treated with radiotherapy? Ann Plast Surg, 73(1), 105-113. doi:10.1097/SAP.0b013e31826cafd0

Momoh, A. O., Colakoglu, S., Westvik, T. S., Curtis, M. S., Yueh, J. H., de Blacam, C., . . . Lee, B. T. (2012). Analysis of complications and patient satisfaction in pedicled transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flap breast reconstruction. Ann Plast Surg, 69(1), 19-23. doi:10.1097/SAP.0b013e318221b578

Niddam, J., Bosc, R., Lange, F., Chader, H., Hersant, B., Bigorie, V., . . . Meningaud, J. P. (2014). DIEP flap for breast reconstruction: retrospective evaluation of patient satisfaction on abdominal results. J Plast Reconstr Aesthet Surg, 67(6), 789-796. doi:10.1016/j.bjps.2014.02.008

Serletti, J. M., Fosnot, J., Nelson, J. A., Disa, J. J., & Bucky, L. P. (2011). Breast reconstruction after breast cancer. Plast Reconstr Surg, 127(6), 124e-135e. doi:10.1097/PRS.0b013e318213a2e6

Yueh, J. H., Slavin, S. A., Adesiyun, T., Nyame, T. T., Gautam, S., Morris, D. J., . . . Lee, B. T. (2010). Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg, 125(6), 1585-1595. doi:10.1097/PRS.0b013e3181cb6351

Zhong, T., Fernandes, K. A., Saskin, R., Sutradhar, R., Platt, J., Beber, B. A., . . . Baxter, N. N. (2014). Barriers to immediate breast reconstruction in the Canadian universal health care system. J Clin Oncol, 32(20), 2133-2141. doi:10.1200/JCO.2013.53.0774

Zhong, T., McCarthy, C., Min, S., Zhang, J., Beber, B., Pusic, A. L., & Hofer, S. O. (2012). Patient satisfaction and health-related quality of life after autologous tissue breast reconstruction: a prospective analysis of early postoperative outcomes. Cancer, 118(6), 1701-1709. doi:10.1002/cncr.26417