Fw: We're on Page 1 of the NYT -- Cancer Patients and Hidden Choices

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From: Zuckerman <dz@...>Subject: We're on Page 1 of the NYT -- Cancer Patients and Hidden Choicesfriends@...Date: Tuesday, December 23, 2008, 11:18 AM

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We were very glad to see this article on the front page of

today’s NYT (see below). We spent a lot

of time with the reporter on this story. We hope that this attention will

help make breast cancer patients more aware of their choices so that they can

make decisions that are best for them, not necessarily best for their plastic

surgeon. And we were glad the article mentioned the high complication

rate with implants – info provided to the FDA but never published (it is

available on our web site, however).

Best wishes,

Zuckerman, Ph.D.

President

National

Research Center for Women & Families

1701 K

Street, NW, Ste. 700

Washington,

DC 20006

(202)

223-4000

www.center4research.org

Combined Federal Campaign #

11967!

HEALTH

| December 23, 2008

The

Price of Beauty: In Breast Reconstruction, Some Hidden Choices

By

NATASHA SINGER

Many patients do not consider

all the options because their doctors are not proficient in the latest

procedures.

December 23, 2008

The

Price of Beauty

Some Hidden Choices

in Breast Reconstruction

By

NATASHA SINGER

For many cancer patients

undergoing mastectomies, reconstructive breast surgery can seem like a first step

to reclaiming their bodies.

But even as promising new

operations are gaining traction at academic medical centers, plastic surgeons

often fail to tell patients about them. One reason is that not all surgeons

have trained to perform the latest procedures. Another reason is money: some

complex surgeries are less profitable for doctors and hospitals, so they

have less of an incentive to offer them, doctors say.

“It is clear that many

reconstruction patients are not being given the full picture of their

options,” said Zuckerman, the president of the National Research Center for

Women and Families, a nonprofit group in Washington.

One patient, Felicia Hodges, a

41-year-old magazine publisher in Newburgh, N.Y.,

chose a double mastectomy after she was

found to have cancer of the right breast in 2004. She consulted a plastic

surgeon, who offered her only reconstruction with breast implants, she said.

Ms. Hodges chose implants filled

with saline, a procedure for which more than a third of reconstruction

patients underwent a follow-up operation, studies show.

Ms. Hodges developed

wound-healing problems that required her surgeon to remove her right implant,

and she was left with a concave chest with a quarter-size hole in it, she

said; she described the experience as “worse than the

mastectomy.”

Then Ms. Hodges discovered a

chat room on the patient-information Web site breastcancer.org,

where women share detailed information about breast

reconstruction beyond what they may have heard from their doctors.

Ms. Hodges learned of newer,

more complex procedures that involve transplanting a wedge of fat and blood

vessels from the abdomen or buttocks, which would be refashioned to form new

breasts.

“It’s unfortunate

that a lot of general surgeons, breast surgeons and plastic surgeons

don’t mention it,” said Ms. Hodges, who underwent one of the

surgeries, known as a GAP flap, last year. A lifelong athlete and a karate

enthusiast, she is now back at her dojo.

To raise awareness of breast

reconstruction and to market it to patients, the American Society of Plastic

Surgeons has adopted the vocabulary of the movement to support a

woman’s freedom to choose an abortion, adjusting it for women with breast cancer. Although women

“don’t choose their diagnosis, they can choose to go

ahead with reconstruction or not, and with the aid of a knowledgeable plastic

surgeon they can choose what their options might be,” Dr. G.

, a plastic surgeon in Galveston, Tex., said in a telephone news conference organized by the plastic surgery society to

mark Breast Cancer Awareness Month in October. “Then they have that

much more power over their lives if they have that power to choose.”

But for many patients, the

options may be limited because their doctors are not proficient in the latest

procedures. Dr. F. McGuire, the president-elect of the American

Society of Plastic Surgeons, said it is not unusual for surgeons to omit

telling patients about operations they do not perform. He compared the rise

of more complex breast reconstruction to the advent in the late 1980s of

minimally invasive laparoscopic surgery of the gallbladder.

“At the time, only a small

percentage of surgeons were doing them and doing them well,” said Dr.

McGuire, who is chief of plastic surgery at St. s Hospital in Santa

, Calif. “If you were not familiar with laparoscopic gallbladder

surgery, you were still doing it the traditional way with an open great big scar across the

abdomen.”

Uneven information about

reconstructive options is a subset of a larger problem, said Dr. Amy K. Alderman, an assistant professor of plastic

surgery at the University of Michigan Medical School in Ann Arbor.

Only one third of women undergoing operations for breast cancer

said their general surgeons had discussed reconstruction at all, according to

a study by Dr. Alderman of 1,844 women in Los Angeles and Detroit that

was published in February in the journal Cancer.

“In the big picture, it

would be great if we could just get doctors to tell people they have an

option of reconstruction,” Dr. Alderman said.

Once patients are so informed,

she added, plastic surgeons should tell them of options beyond implants.

“The next hurdle would be letting them know that using their own tissue

is an option, because my guess is that they are not even getting that far in

the discussion,” Dr. Alderman said.

About 66,000 women in the United

States had mastectomies in 2006, the latest figures available,

according to the federal government. And about 57,000 women had

reconstructive breast surgery last year, according to estimates from the

plastic surgery society.

For many of these women, the

operations were more about feeling whole again than about restoring their

appearance.

Implant surgery is the most

popular reconstruction method in the United States.

Often performed immediately after a mastectomy, it initially involves the

least surgery — usually a short procedure to insert a temporary

balloonlike device called an expander — and the shortest recovery time.

But implants come with the

likelihood of future operations. Within four years of implant reconstruction,

more than one third of reconstruction patients in clinical studies had

undergone a second operation, primarily to fix problems like ruptures and

infections, and a few for cosmetic reasons, according to studies submitted by implant makers to the Food and Drug Administration. (Reconstructive

patients are more likely to develop complications after

implant surgery than cosmetic patients with healthy breast tissue.)

Complication rates for newer

flap procedures like the one Ms. Hodges had have not been well studied,

though many surgeons say they are less likely to require follow-up

operations. The most common flap procedure, named a TRAM flap, for the rectus

abdominis muscle, cuts away a portion of abdominal fat, as well as underlying

muscle containing blood vessels, and uses the tissue to rebuild a breast. The

vessels provide a blood supply for the new breast mound. The procedure promises a more lifelike

look and feel, but it carries a risk of a weaker abdominal wall and hernia.

Another flap method, the DIEP

free flap, is the newest and most intricate, named for the abdomen’s

deep inferior epigastric perforator vessels. It involves moving abdominal fat

and blood vessels, but no muscle. The DIEP flap theoretically holds out the

promise of a reduced likelihood of abdominal problems. But Dr. Alderman

cautioned that researchers have not yet conducted rigorous national studies

that would establish a complication rate. Sometimes the flaps fail and need

to be surgically removed.

All breast reconstructions

involve a tradeoff, said Dr. L. Spear, the chief of plastic surgery at town

University Hospital in Washington. “The implants have a lower investment in

the short term and a longer-term higher risk of

having to redo it,” said Dr. Spear, who is a paid consultant to the

implant maker Allergan. “The flaps have a bigger investment in the

short run, but you are less likely to revise it in the long run.”

Dr. Spear said plastic surgeons

sometimes fail to mention the flap options for the simple reason that implant

surgery can be more profitable. “It’s really embarrassing to say

so, but, from a purely selfish point of view, if you are looking at insurance

reimbursement for TRAM and DIEP flaps, it’s a loss leader,” Dr.

Spear said. “They really require so much time and effort that a surgeon

thinks, ‘Man, I can’t afford to do this.’ ”

Nevertheless, town, long

a center of expertise for implant reconstruction, recently hired a plastic

surgeon who specializes in the more complicated tissue flaps.

A typical surgeon in Manhattan

charges insurers about $7,000 for a one-hour implant reconstruction, but for

a DIEP procedure that takes 6 to 12 hours, the going rate is $15,500.

Although health insurers are

required by federal law to cover reconstructive breast surgery after

mastectomies, the government does not set private insurance rates. Flap

reconstruction typically requires a higher out-of-pocket co-payment than

implant surgery.

“In certain geographical

areas where it is badly reimbursed, it’s a disincentive for plastic

surgeons even to do the work,” said Dr. A. D’Amico, a

past president of the American Society of Plastic Surgeons, speaking of the

flap procedures.

Dr. R. Colen, the

chairman of plastic surgery at Hackensack University Medical Center in New

Jersey, said plastic surgeons might also not inform patients

about the flap procedures because they lacked the advanced training in

microvascular surgery needed to perform them.

“A lot of patients are

offered implants because the surgeon does not know how to do the flap, and

then the implant fails and they need the flap anyway,” Dr. Colen said.

To counter doctors who might

routinely steer patients to implants, Dr. Colen started a program at his

hospital in which women can meet directly with an impartial physician’s

assistant, who goes over the benefits and drawbacks of reconstruction

methods.

“We sort of wanted to take

the flow of the patient out of the control of the physician and put it in the

hands of a medical person who has no personal or financial interest,”

Dr. Colen said.

Dotti , a retired nurse

in Crossville, Tenn., said

the plastic surgeon who performed her breast reconstruction after a

mastectomy offered her only an implant. “That was his procedure,”

said Ms. . Her first implant developed hardened scar tissue and

required replacement. Her replacement implant ruptured. Now she is going to

have an operation to replace the second implant, she said.

The DIEP flap was developed by

Dr. J. , a plastic surgeon in New York, New

Orleans and ton, S.C., in 1992. Now surgeons at hospitals including the University of Pennsylvania Health System in Philadelphia and Beth Israel Deaconess Medical Center in Boston specialize in the procedure.

Dr. and Dr. L.

Levine, who operate together in Manhattan,

often recommend a prospective patient talk at length with patients of theirs

who have had a successful flap procedure, like Ms. Hodges, the magazine

publisher and karate student, as well as with those whose first flap

reconstructions failed and required a second procedure.

“Patients should not

necessarily accept the first thing they hear as the end-all, because that is

not necessarily the full story,” Dr. said.