Faq

For most patients who attend my one-stop clinic, you will be able to get a provisional diagnosis by the end of the clinic consultation (hence the term one-stop). If there is a suspicion of breast cancer, this will be conveyed to the patient.

If you have had a biopsy, it usually takes 5 days for the results to come back. Depending on the case, I can convey that result over the phone or at clinic.

For patients above the age of 40 years old, the cost will include the initial clinic consultation (£150) and the cost of a mammogram on both sides, breast ultrasound and possible biopsy (if required). The cost of these vary between the private hospitals that I work in and can be reviewed in my pricelist section. Please note that for patients below the age of 40, mammograms are not required, only a breast ultrasound.

I will need to review all your clinical documentation including clinic letters, radiology images and results and biopsy results in order to give you advice. This will be charged as an initial consultation (£150).

For newly diagnosed breast cancer patients, I will counsel you about treatment options and this is usually done in the presence of one of my Breast Care Nurses. Your results will be discussed at the weekly Breast Multi-Disciplinary meeting every Wednesday at St Albans City Hospital treatment. For patients who require operations, this can be scheduled within a week and will most likely be performed at Spire Bushey Hospital on a Wednesday evening.

All my breast cancer patients will be introduced to one of my Breast Care Nurses, Bridie or Alina who will help me take care of you. Both are very experienced in providing emotional support and guiding you though your treatment journey. For video explaining the role of Breast Care Nurses, please click here.

This is one of the most common discussions that I have with breast cancer patients whom have just received their diagnosis and it can be difficult to explain due to the large number of factors involved. I will try to simplify this here.

To start, there are only two types of breast operations for breast cancer – breast conserving surgery (removal of a section or sections of the breast) or mastectomy (removing the whole breast). Lumpectomy (also known as wide local excision) operation is the most common form of breast conserving surgery.

For most breast surgeons and breast cancer patients, a lumpectomy is intuitively the preferred operation because:

1. Able to conserve your breast

A lumpectomy is a less radical operation that aims to remove just the tumour while conserving the unaffected breast tissue. Most patients would find a lumpectomy less detrimental to their body image compared to a mastectomy. With new surgical techniques, breast surgeons are able to produce better cosmetic results and reduce breast symmetry. On the other hand, a mastectomy can have a significant impact to a patient’s body image perception.

2. Less aggressive surgery

There is generally not a huge difference in operative time between a mastectomy and a lumpectomy. However post-operatively, mastectomy patients will take a longer recovery time compared to lumpectomy patients due to the larger amount of trauma to the body in the former. Also, for the first few weeks, problems such as seroma (accumulation of fluid under the scar) is very common after a mastectomy and this require needle drainage at clinic. This occurs less often with lumpectomies.

Things you should know before deciding between a lumpectomy and a mastectomy

All breast cancer patients should be given the choice between a lumpectomy or a mastectomy based on their own preference but should consider the following before deciding.

For surgeons, the most important factor to consider in deciding between a mastectomy and a lumpectomy is the size of the breast cancer relative to the size of the breast.

A solitary small breast cancer in a moderately-sized breast

In general, a lumpectomy is suitable if there is only one small-sized solitary breast cancer in a moderate- or large-sized breast. For instance, performing a lumpectomy for 2-3cm breast cancer in a patient with a 32B bra-sized breast is perfectly feasible.

However, the same 2-3cm breast cancer may not be suitable in a woman with a very small-sized breast i.e. 30AA as a lumpectomy will leave very little residual tissue to reconstruct a well-shaped breast and often leads to cosmetically unfavourable results. In such a situation, most surgeon would recommend a simple mastectomy or a mastectomy with reconstruction (depending on the patient’s preference). Conversely, a 4-5cm breast cancer would probably be not suitable in a small or moderately sized breast as there would not be enough remaining breast tissue to reconstruct a breast. Also, there would be a higher risk of finding cancer at the margins of the lumpectomy tissue in this scenario and this would mean more surgery. However, a 4-5cm breast cancer is occurs in a patient with a large-sized breast i.e. 36DD would be amenable to a lumpectomy.

It is often up to your breast surgeon and the multidisciplinary committee to assess and advise patients about which operation is the more appropriate operation.

Multiple small cancers in a relatively large breast

In the past, multiple cancers in one breast would have made a mastectomy mandatory, regardless of breast sizes. However, recent new surgical techniques such as therapeutic mammoplasties have enabled breast conserving surgery to be possible for patients with relatively large-sized breasts. This operation involves removing different sections of the breast which contain breast cancer and then using breast reduction techniques to use the remaining breast tissue to reconstruct a new, well-shaped albeit smaller-sized breast. Therapeutic mammoplasties often lead to breast asymmetry where the resultant operated breast is smaller than the opposite unaffected breast (often refered to as the contralateral breast). Very frequently, a contralateral breast reduction is required to correct this breast asymmetry.  Please refer to my Therapeutic Mammoplasty: Case Study list. 

Reasons for patient opting for a mastectomy instead of a lumpectomy

1. Want to avoid more than one operation – “one and done!”

For patients who have lumpectomies, there is a one in five chance that their post-operative histology report will show that the cancer is close or present at the excision margins. In order to obtain clear cancer margins, these patients will have to undergo a second operation to excise more breast tissue (re-excision) or even a completion mastectomy.

Some patients, especially elderly patients may find this risk of a second operation too daunting. However, if patients undergo a mastectomy at the first operation, that will most likely be the one and only operation as the margins will most likely be clear of cancer.

2. Avoiding radiotherapy

More information on whole breast radiotherapy and its side effects, please click here. The main drawbacks to radiotherapy are:

Effects on the skin, breast, heart and lung

Radiotherapy can cause redness and swelling of the breast and chest-wall skin which gives the appearance of sunburn (radiation dermatitis) which eventually settles down after radiotherapy. For a small proportion of patients, breast radiotherapy can lead to hardening of the breast which can sometimes lead to chronic pain.

Many years later, radiotherapy can cause scarring of the lung and heart (for left breast cancer patients). In majority of patients, these radiation-related scarring is unlikely to cause any long-term side effects to patient who do not have lung or heart conditions. However, these risks become significant in elderly patients and in patients who have pre-existing heart conditions such as coronary heart disease, previous heart attacks and heart failure or lung conditions such a COPD, bronchiectasis and lung fibrosis. Radiotherapy is likely to worsen these conditions. For these patients, these risks should be discussed with your surgeon before deciding on the operation. Occasionally, for such patients, a mastectomy should be recommended for these patients so that they can avoid radiotherapy.

Daily travel for radiotherapy

Whole Breast Radiotherapy involves daily visits and treatment for at least 15 days in a row, though recently new shorter regimes have been developed. Daily radiotherapy may be especially challenging for patients who are elderly and immobile or patients without appropriate transport to attend their radiotherapy sessions. Under these special circumstances, your breast surgeon may agree to do a mastectomy to avoid radiotherapy.

3. Patient Personal Preference

Sometimes fit and young breast patients may still request for a mastectomy for personal reasons, even though they are suitable for a lumpectomy. Often it is to avoid radiotherapy but more often because there is a misconception that a mastectomy is the more effective operation (report). In some patients, this decision is partly due to information gathered in the media i.e. the Angelina Jolie effect but for others, there is a psychological reassurance that after a mastectomy, there is no residual breast tissue that could become cancerous later on.

Even though, I will happily conform to the patient’s request for a mastectomy, it is imperative that they know that having a mastectomy does not increase the overall survival rate from breast cancer compared to a lumpectomy and radiotherapy and this has been proven in many studies.

4. Previous history radiotherapy

This applies to patients who have develop recurrent breast cancer in the same breast (ipsilateral recurrence). If the previous breast cancer was treated by lumpectomy and radiotherapy and a local recurrence develops several years later, it is likely that the next operation will be a mastectomy. This is because if a lumpectomy is performed for a recurrence, radiotherapy cannot be readministered for a second time. Repeated radiation to the same tissue will lead to significant complications. Please note that omitting radiotherapy after a lumpectomy for recurrence will likely lead to further local recurrence in future.

A mastectomy is also recommended for breast cancer patients who have had previous mantle radiotherapy for lymphoma treatment.

5. Other reason why some patient should have a mastectomy instead of a lumpectomy:

Inflammatory breast cancer (info)

Inflammatory breast cancers are a rare and aggressive type of breast cancer that spreads out through the lymphatics in the breast and the skin. It is associated with a high risk of recurrence and most breast surgeons would recommend a mastectomy to reduce that risk.

High risk of more breast cancers in future i.e. BRCA gene mutation carrier

Breast cancer patients with a strong family history of breast cancer and gene mutation carriers have a high risk of developing another breast cancer in same (ipsilateral) breast and also in the other (contralateral) breast in future. Even though a lumpectomy is still acceptable in this scenario, gene mutation carriers can consider undergoing double mastectomy as this will reduce their lifetime risk of developing anymore breast cancers to less than 1 percent.

Misconceptions about having a mastectomy

1. Will having a mastectomy allow me to live longer from my breast cancer ?

Patients need to be aware that many studies have repeated proven that a mastectomy does not improve breast cancer prognosis compared to a lumpectomy + radiotherapy.

2. If I have a lumpectomy, I then must have subsequent radiotherapy?

Recently, some studies have found that some breast cancer patients are able to be treated using lumpectomy only with subsequent radiotherapy if they fulfil certain strict criteria i.e. if their risk of recurrence is low. For more information, please read FAQ 2.

3. If I have a mastectomy, my risk of local breast cancer recurrence will reduce to zero?

Breast cancer can still develop local recurrence in the mastectomy scar or under the skin which is why patients still need to perform regular self-examination after treatment.  Local recurrence refers to breast cancer returning in the part of the body i.e. breast or chest wall (as oppose to distant recurrence which refers to cancer returning to another part body i.e.  metastasis in the bone, liver, lung brain).

All patients who are due to undergo a mastectomy should be offered a breast reconstruction. This is a highly complexed subject in which I spend a considerable amount of time counselling patients about.

Breast reconstruction practices vary greatly between different countries, regions, hospitals and even between surgeons in the same department but in this section, I will concentrate on what is perceived to be the most common practices in the UK.

Before we start, it is important that you familiarise with the basics about breast reconstructions though these external information resources which I have rated as the most comprehensive website:

“Types of Breast Reconstruction” by Breast Cancer Now – reviewed on March 2018 issue.

“Should I have breast reconstruction surgery?” by MacMillan Cancer Support – reviewed on 30 Nov 2018

From my professional opinion, these are the points that are relevant when I counsel patients on breast reconstructions.

1. “Should I have a breast reconstruction?”

When a breast cancer patient receives her diagnosis and is told she needs to have a mastectomy, generally there are 3 choices to make:

• To have a simple mastectomy without reconstruction
• To have a skin/nipple spring mastectomy and immediate breast reconstruction
• To have a simple mastectomy first, followed by a delayed reconstruction several months later

The most important point to remember that the decision whether to have a breast reconstruction and when to have it is entirely based on your needs and preference. There is no right or wrong answer to this question. The only criteria to consider is that you do need to be physically fit enough to have a reconstruction. The questions that you will need to ask yourselves are:

• How do you think a mastectomy will impact your psychological and emotional well-being.

For a woman, a simple mastectomy is a very radical change to her body image and may change her view of herself. Some mastectomy patients are able to cope with this change because they look completely normal in her clothes and even in a bra. This is because a breast prosthesis can be inserted into a pocket in specially designed post-mastectomy bra. A breast prosthesis is made from soft silicone gel, can be made-to-measure or selected from a wide variety in retail stores. This usually provides an exact fit and is comfortable. This works well and is convenient for many mastectomy patients

However, some mastectomy patients will find the loss of the breast difficult to cope with this change. This is because of the visual change that they see when they look at themselves topless in the mirror. A one-sided flat chest and scar can be a constant reminder of the breast cancer and its personal cost. There is also the change in sensation of not having a breast on one side as well as the weight asymmetry form the other breast which is present all the time. Some patients may find the breast prosthesis difficult to manage especially those where the opposite (contralateral) breast is large.  A simple mastectomy may sometimes affect their relationship with their partner.  Patients finding difficulty to coping with these changes should consider having a breast reconstruction.

• How quickly do you want to recover from breast cancer treatment?

This very much depends on the patient’s life priorities. A simple mastectomy without reconstruction is a relatively quick and simple operation with significant lower of complication risks compared to one having a reconstruction. This option is especially suited for patients who want to complete their treatment quickly and with as little risk of complication as possible. Simple mastectomies are especially suited for older patients with other health problems and whose main priority is to complete their breast cancer treatment quickly and safely. Younger women with busy careers or heavy family commitments whose priority is to promptly get back into their daily routines may also consider this option.

Conversely, mastectomy and breast reconstructions are much longer operations with a longer recovery time and higher risk of complications such as post-operative pain, implant infection, donor-site would infection/breakdown and seroma. These complications will inevitably lead to more hospital visits. Also, some reconstructions may result with cosmetic imperfections that may require more surgery over several months to achieve better results. These scenarios can be distressing to patients, prolong their overall recovery and are time-consuming. Patients undergoing breast reconstruction need to be physically and emotionally resilient consider this before committing to a breast reconstruction.

2. Which breast reconstruction should I have?

Most patients have the option of both implant-based and autologous reconstructions. Overall, neither one of these are more superior than the other.  A brief summary of both reconstructions is listed below:

Implant Reconstructions

Autologous Reconstructions (i.e. DIEP, TUG, SGAP. Excludes LD flaps)

• Patient preference factors:

Implant reconstructions are short operations and patients recover more quickly than autologous reconstructions. Despite that, some patients are averse to the idea of having a silicone implant. Conversely, autologous reconstructions are extremely long and invasive operations which may involve removal of a short section of a rib and a long scar across the abdomen (for DIEPs). This causes difficulty in recovery and mobility for several weeks post-op. However, it is noteworthy that autologous reconstructions feel more natural to patients as fatty tissue has the same consistency as breast tissue. Also, once patients have recovered, autologous reconstructions are robust and will maintain its shape over a time as long as the patient maintains their weight.

• Clinical factors:

Body shape and size

Patients who are thin and do not possess enough fatty tissue and skin at the donor sites ( in the lower abdomen, thigh or buttocks) are probably not suited for autologous reconstruction and should have implant reconstructions instead.

Patients who are too overweight, smokers and those cardiovascular disease s i.e. angina, have poorer blood circulation and this precludes an autologous reconstruction.

Locally advanced or inflammatory breast cancer

Locally advanced breast cancers are cancers which are attached to the skin or muscle or have spread to the lymph nodes while inflammatory breast cancer is a rare and very aggressive form of breast cancer which disseminates through skin lymphatics. Both these conditions exclude an implant reconstruction. Locally advanced breast cancer may be amenable to immediate reconstruction but in my opinion, it is safer for both locally advanced and inflammatory breast cancers to be treated with a simple mastectomy first and then followed by a delayed autologous reconstruction once she has completed her cancer treatment.

Radiotherapy

Radiotherapy leads to significant scar tissue formation which leads to hardening, pain and deformity of the breast reconstruction as well as capsular contracture (40% at 5 years). Even though, majority of my patients with irradiated- implant reconstructions have remained cosmetically favourable, I have a handful of cases who developed significant wound problems, grade 4 capsular contractures and even implant loss as a long term result of radiotherapy. Some have required implant removal and conversion to a simple mastectomy several years later.

Autologous breast reconstructions are generally more robust to radiotherapy and most will remain soft and cosmetically favourable many years after radiotherapy.

3. Are young breast cancer patients usually recommended to have breast reconstructions.

In general, younger patients tend to prefer having breast reconstructions compared to older patients but this should not influence your decision as the decision should be based solely on you needs and priorities. Even if you opt for a simple mastectomy without reconstruction, people around you will not know that as you will still look normal in your clothes if you have a perfectly fitted breast prosthesis.

From my experience, there is no age distinction between patients who decide for or against a breast reconstruction as long as they are physically fit and committed to have the operation. For instance, my oldest patient whom I have performed a reconstruction on was a fit 78 year old lady while recently, I had a 38 year old patient who decided on mastectomy without a reconstruction because she wanted to get back to looking after her kids ASAP. Once again, the decision is all based on your needs and priorities.

4. Should I have the breast reconstruction as an immediate or delayed procedure?

For implant reconstructions, the best cosmetic results are achieved in the immediate setting as the breast surgeon can perform a skin and nipple sparing mastectomy at the first operation. In a simple mastectomy, this excess skin is removed. Hence, a delayed implant reconstruction is technically challenging as there is very little skin remaining after a simple mastectomy.

For patients with locally advanced breast cancer, I usually recommend that they have a simple mastectomy first, complete their chemotherapy and radiotherapy, and then have a delayed autologous reconstruction. From experience, this appears a much smoother and less distressing pathway as patients can focus on their cancer treatment first (which is more important) and then take time to have their reconstruction and recover from it.

5. Does a breast reconstruction affect my breast cancer survival?

No, there is no evidence that patients who breast reconstructions affect patient prognosis whether it is an implant or autologous or whether it is performed as an immediate or delayed reconstruction.

6. Can I preserve my nipple in a reconstruction?

For implant reconstructions, it is feasible to preserve the nipple, but this depends on how close the cancer is to the nipple. If the cancer is too close to the nipple, then the nipple will need to be removed. Also, there is a technical risk that leaving the nipple and areola behind may leave residual breast tissue that may later develop another new breast cancer many years later. This especially applies to gene mutation carriers where the risk of further breast cancer is very high.

In an autologous reconstruction, it is technically difficult to preserve the nipple. However, some plastic surgeons may be able to accommodate this on the patients request by altering their technique, but this depends on the size and shape of the patient’s breast.

It is worth noting that the nipple and areolar is not usually preserved in a simple mastectomy

6. What is Breast-Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL)?

Recent findings have suggested that a very small proportion of women with breast implant can develop BIA-ALCL. This is a rare form of lymphoma (cancer of the lymphatic system) that develops in the scar capsule of the implant. The recent reports say it occurs in 1 in 5,000 women with breast implants and hence is rare. It presents as a sudden painless swelling of the reconstructed breast many years after the reconstruction due to accumulation or fluid. If this occurs, please arrange to see a breast or plastic surgeon.

Association of Breast Surgery position on BIA-ALCL is explained here.

7. What is Breast-Implant Related Illness?

This is a new condition that has been reported by a small proportion of women who have had silicone breast implants for breast augmentation and reconstruction. Symptoms are non-specific such as lethargy, joint pains, anxiety and chronic pains and has been associated with other conditions such as hair loss, brain fog, general fatigue, fibromyalgia, ME, irritable bowel syndrome, skin conditions, lupus, rheumatoid, SLE, Reynaud’s.

At the time of writing this section, even though there have been reports in the scientific literature highlighting this condition, there has not been any robust study that strongly suggest that silicone implants are causing this condition. Currently, there are no restrictions on the use of breast implants.  Please section on the Association of Breast Surgery website.

For patients with DCIS:

Recent studies have identified patients with DCIS who can undergo lumpectomies without undergoing subsequent radiotherapy if the risk of breast cancer recurrence is very low (more info). This includes patients whose final histology shows a small sized low- or intermediate grade DCIS. This practice will need to be carefully discussed with a clinical oncologist

For patients with invasive breast cancer

Currently, treating invasive breast cancer with a lumpectomy without subsequent radiotherapy is not conventional practice. However, breast cancer patients in the UK who are keen on avoiding radiotherapy will need to be to be enrolled into the PRIMETIME study and discuss this carefully with your clinical oncologist.

Why would some patients prefer to avoid radiotherapy?

Patients who undergo lumpectomies or other forms of breast conserving surgery are generally advised to have whole breast radiotherapy and this was validated in the Oxford Overview. For more information on whole breast radiotherapy and its side effects, please click here. More information on whole breast radiotherapy and its side effects, please click here. The main drawbacks to radiotherapy are:

Effects on the skin, breast, heart and lung

Radiotherapy can cause redness and swelling of the breast and chest-wall skin which gives the appearance of sunburn (radiation dermatitis) which eventually settles down after radiotherapy. For a small proportion of patients, breast radiotherapy can lead to hardening of the breast which can sometimes lead to chronic pain.

Many years later, radiotherapy can cause scarring of the lung and heart (for left breast cancer patients). In majority of patients, these radiation-related scarring is unlikely to cause any long-term side effects to patient who do not have lung or heart conditions. However, these risks become significant in elderly patients and in patients who have pre-existing heart conditions such as coronary heart disease, previous heart attacks and heart failure or lung conditions such a COPD, bronchiectasis and lung fibrosis. Radiotherapy is likely to worsen these conditions. For these patients, these risks should be discussed with your surgeon before deciding on the operation. Occasionally, for such patients, a mastectomy should be recommended for these patients so that they can avoid radiotherapy.

Daily travel for radiotherapy

Whole Breast Radiotherapy involves daily visits and treatment for at least 15 days in a row, though recently new shorter regimes have been developed. Daily radiotherapy may be especially challenging for patients who are elderly and immobile or patients without appropriate transport to attend their radiotherapy sessions. Under these special circumstances, your breast surgeon may agree to do a mastectomy to avoid radiotherapy.

For basic information about the SNB procedure, please visit:

“Surgery to the lymph nodes for breast cancer” – MacMillan Cancer Support (31/10/2018)

The most common site where invasive breast cancer spreads to is the lymph nodes in the armpit (axilla). A positive SNB means that the cancer has spread to the axillary lymph nodes. We aim to remove 1-3 lymph nodes in an SNB procedure and occasionally one or more of those lymph nodes may contain breast cancer. The likelihood of finding a positive sentinel node depends on patient age, size, grade, receptor and HER2 status of the breast cancer.

If you are about to have a SNB operation and would like to know the likelihood of finding a positive SNB, visit this reputable website.

A positive SNB means:

• You may need chemotherapy
• if you have had a mastectomy, you will likely still need chest wall radiotherapy
• you will need more axillary treatment i.e. axillary clearance or radiotherapy?

Conventional practice in the UK states that a positive SNB means that patients are required to undergo another operation called an axillary node clearance (ANC). This is a radical operation to remove all the lymph nodes in the axilla to remove any more lymph nodes that may contain cancer. However, ANC procedures are associated with a risk of arm lymphoedema (at least 30% lifetime risk), permanent numbness to the medial part of arm and frozen shoulder. Recent study (AMAROS trial) recommends axillary radiotherapy instead of ANC with equal safety and efficacy.

Records have shown that for most patients with small breast cancers with a positive SNB, the subsequent ANC usual yields no further cancer in the lymph nodes. Also, large recent studies suggest that the ANC do not confer any improvement in breast cancer overall survival. This was originally suggested in a US study (ACOSOG Z0011 study) but that study had some design flaws and hence its recommendations could not be implemented as conventional practice. However, in the UK, positive SNB patients who are keen on omitting ANC may be able to enrol themselves into a national UK study called POSNOC study (POsitive Sentinel NOde: adjuvant therapy alone versus adjuvant therapy plus Clearance or axillary radiotherapy). Please visit this website to see if you fulfil the criteria to be enrolled into this study.

Patients who are keen to enrol need to be registered with a trial centre which include the Breast Care Unit at St Albans City Hospital.

For many years, conventional approach to patients diagnosed with early breast cancer is surgery first followed by adjuvant treatments including chemotherapy and radiotherapy.

Recent developments now suggest that certain types of breast cancer should be treated with primary chemotherapy.

Primary chemotherapy refers to treating the cancer with chemotherapy first as oppose to surgery first. Even though primary chemotherapy has been in practice for many decades, recent studies have shown that is it particularly favourable in these types of breast cancers.

• Triple negative (ER-negative, PR-negative, HER2-negative) breast cancers
• HER2- positive breast cancers (regardless of ER and PR status)

Primary chemotherapy can also be used for ER-positive, PR-positive, HER-2 negative breast cancers but are not as effective in the breast cancers mentioned above.

Primary chemotherapy is a safe and effective approach and are only recommended to patients who are anticipated have chemotherapy as part of their breast cancer treatment at the outset. It provides several advantages:

• Downsize the breast cancers to allow breast conserving surgery (lumpectomy)

This is particularly important for patients with large sized breast cancers (more than 4 cm) in whom surgery before chemotherapy will inevitably mean a mastectomy. Primary chemotherapy can shrink the cancer to a size where a lumpectomy is achievable.

• Allow medical oncologist to choose the most effective chemotherapy drugs

During primary chemotherapy, the medical oncologist will monitor the responsiveness of the breast cancers monitoring the size of the cancer by clinical examination and breast ultrasound. If the cancer does not appear to be responding a particular chemotherapy drug, the medical oncologist then changes to another chemotherapy drug. This monitoring and changing of chemotherapy drugs cannot be done after surgery as there is no longer there for monitoring.

• Check for Pathological Complete Response and decide need for further chemotherapy

Complete pathological response (pathCR) is clinical term where the cancer has been completely removed by chemotherapy when surgery has been performed and no cancer is found in the final histology result. PathCR means that the chemotherapy has been extremely effective and this has been shown to be a marker of good prognosis (articles for triple negative BC and HER2-positive breast cancers).

A recent review of 121 patients in my NHS and private practice, the pathCR rates are as follows:

Triple negative breast cancer                         : 40%

HER2- positive breast cancer                          : 62%

ER-positive, HER2-negative breast cancer     : 15%

In current practice, PathCR is used as an indication whether further chemotherapy is required. When surgery is performed after primary chemotherapy and residual cancer is found, it means pathCR has not been achieved. Recent studies have shown that these patient would benefit from further chemotherapy with new generation chemotherapy drugs (Kadcyla for HER2-positive BC, and Capecitabine for Triple Negative BC)

The scientific evidence on these different subtypes of breast cancer suggests that primary chemotherapy a very effective and safe way of treating these types of breast cancer.

Newly diagnosed breast cancer patients are generally advised to have their operation as soon as possible. In the NHS, there Cancer Waiting Times target states that you should start your treatment (operation in most cases) within 31 days from the day you receive your diagnosis. However, this is a blanket rule that the NHS has applied to all cancers and does not take into account the breast cancers nor its different subtypes.

Breast cancer progression depends very much on histology details i.e.  the type, size, grade, lymph node involvement, Oestrogen Receptor, Progesterone Receptor and HER-2 results. In general:

• DCIS are preinvasive breast cancer and is the earliest stage of breast cancer. By definition, does not spread into surrounding tissues nor do they spread into lymph nodes. It takes many months or years before DCIS progresses to invasive cancer. Once DCIS has progressed into invasive cancer, technically the risk of cancer spreading into surrounding tissues and lymph nodes increases. Patients with who have been diagnosed with DCIS only (with no invasive cancer in the biopsy report) can wait 31 days to have their operations or even a bit longer. However, I would not advise patients to wait longer than 3 months to have their operation for DCIS.

• Aggressive breast cancers such as Grade 3 cancers, triple negative, metaplastic cancers and inflammatory breast cancers progress very quickly and generally should be treated with surgery as soon as possible unless the recommendation is to start with chemotherapy first.

• Small (<5cm), Grade 1 or 2 ER+ve HER2-negative breast cancers are moderately growing breast cancers. Though these cancers will not grow or spread as fast as Grade 3 or triple negative breast cancers, it is advisable for patients to have their operations within the 31-day rule.

Patient Information on Implant-based & Mesh Reconstructions
(last updated Dec 2021)

A) Reasons for breast reconstruction
Breast Reconstructions are mainly for patients who have mastectomies either as part of their breast cancer treatment or for reducing breast cancer risk. Our aim is to provide a semblance of breast symmetry while the patient is in a bra and/or clothes. It is rare that a breast reconstruction looks or feels exactly like a real/original breast.

B) Types of reconstruction
There are many different types of breast reconstructions, which are described in the “ Breast Reconstruction- Breast Cancer Care ” booklet provided by your breast care nurse. It is important that your read this carefully before agreeing to which type of reconstruction we perform on you.

The type of reconstruction heavily depends on patient suitability, benefits and risks. You may prefer one type of breast reconstruction but occasionally you may not fulfil certain conditions to allow that type of reconstruction to be feasible. The choice of reconstruction must be carefully discussed with your plastic and/or breast surgeon before consenting to the operation.

C) Incision placement
There are numerous sites to place the surgical incision to perform your mastectomy and reconstruction as listed in the diagram. Even though, you may prefer one incision over another, some incisions may not be technically suitable for you as it may compromise the ability of the surgeon to perform a safe mastectomy and reconstruction operation.

In most cases, the surgeon will assess during the operation and decide on which is the most suitable incision to make in order to perform the mastectomy and breast reconstruction most effectively. If you have a preference as to which incision you prefer, please discuss this with your surgeon before the day of surgery.

D) Implant and Acellular Dermal Matrix (ADM) Mesh Reconstructions

1. Implant
There are numerous types of breast implants that can be used for breast reconstructions that are described in the Breast Cancer Care- Breast Reconstruction Booklet.

In this breast unit, the routine is to use an inflatable (expander) implants, also known as a Becker’s implant. This is used so that the implant can be left uninflated or partially inflated immediately after the operation. The benefit to this is that it allows the blood supply to the skin envelope to improve in the few days after surgery by not allowing the implant to apply too much tension onto the skin envelope. As such, you implant reconstruction may look deflated and cosmetically unfavourable for a few weeks until the Beckers implant is inflated. Your surgeon will decide when the most appropriate time to inflate your implant when he sees you at the outpatient clinic. The port (button which is placed under your skin to allow saline injection) is usually sited just below your operated breast or below you armpit. Some patients do occasionally report of pain in the area where the port sited.

Once the Becker’s implant inflation is complete and your surgeon and you are satisfied with the appearance of the reconstructed breast, the port is usually removed usually many months after the first operation. The procedure involves making a small incision over the port either by local or general anaesthesia and this is usually performed several months later. Some patients can opt to leave the port in indefinitely. Occasionally, for various reasons, the Beckers implant may be exchanged for a fixed volume (pure silicone) implant.

Occasionally, your surgeon may discuss about the option of inserting a fixed volume (non inflatable) silicone implant , also known as direct-to-implant reconstruction. The benefit of this approach is that it saves the patient the need to remove the Becker’s port and the whole reconstruction process can be achieved in one operation. However, direct-to-implant approach is associated with a higher complication risk i.e. nipple/skin necrosis (tissue death) and wound complications (wound infection and breakdown). If you would want to pursue this approach, please discuss it with you surgeon before the day of the operation.

2. Meshes (ADM and synthetic)
The aim of the mesh is to cover the lower part of the implant in a breast reconstruction. The benefits of a lower pole mesh are:

i. it provides more space in the lower part of the breast pocket and allows
larger implants to be inserted

ii. allows the reproduction of ptosis appearance (tear-drop shape)

iii. prevents contact between skin and implant which can potentially lead to the implant eroding through the skin.

There are many meshes in the market. The two types most commonly used in this unit are:

2a. Acellular Dermal Matrix (ADM)
ADMs are expensive medical materials that are made from made skins of calves and pigs that has been processed and sterilized to remove all cells. This process reduces the risk of disease and of your body rejecting it. The most common ADM brands that we use is made from pig-skin with the trade names Strattice, Artia, Surgimend and Braxon. Once it has been inserted during the operation, the ADM eventually merges into your overlying skin envelop and will remain permanently that way.

There are two ways on inserting the ADM mesh:

a. Sub-pectoral (Under Muscle) Approach
In this approach, the implant is placed under the pectoralis major muscle. The ADM mesh is sutured to the lower edge of the pact major muscle, draped over the implant and the other edge sutured to the lower edge of the skin enveloped (inframammary fascia). This method will involve more tissue dissection bleeding and it will leave the shoulder movement slightly weaker. However, it is associated with better would healing rates and is useful in certain circumstances i.e. patients who needs radiotherapy after surgery or in patients in whom wound healing may be impaired i.e. smokers, elderly patients, diabetics, significant cardiovascular diseases.

b. Pre-pectoral (In front of muscle) Approach
This is a new approach to implant reconstructions where the implant is placed in front of the pectoralis major muscle. The muscle is not lifted/dissected at all. The ADM mesh is then used to cover the implant to prevent contact with the skin envelop. The benefit to the is that it involves less tissue dissection and hence minimizes bleeding, post-operative pain and weakness to the shoulder joint movements. The theoretical drawback is that the wound healing may not be as good as in the subpectoral approach and there is an increased risk of nipple necrosis (death of nipple tissue).

2b. Synthetic
These are non-biological meshes in that they are not derived from animal material but instead manufactured materials. The most commonly used synthetic mesh in this unit is the Tiloop Mesh. This is a sheet of netting made from lightweight polypropylene impregnated with Titanium which helps reduce inflammation. Like ADM, synthetic mesh eventually merges with the skin.

Both ADM and synthetic meshes are clinically safe to use in breast cancer patients. Whether an ADM or synthetic mesh is used depends on your surgeon’s or your preference. This will be discussed with you before the day of surgery,

E) Implant vs. free flap reconstruction: Potential advantages and disadvantages
Advantages of implant surgery over flap:
• shorter, less complex surgery
• faster recovery time
• shorter and fewer surgical wounds

Disadvantages of implant surgery over flap:
• implant-based reconstructions may require multiple operations
• multiple clinic visits to receive tissue expander injections
• less likely to feel, look, or move like a natural breast
• implants can get infected and if persists, may lead to implant removal.
• subject to future problems such as rupture, deflation, capsular contracture
• opposite healthy breast often needs surgery to match the implant
• generally not a good option if skin has undergone radiation as the wound
complication risks are high.
• most implants may eventually require further operations for capsular contracture, asymmetry and rupture.

Specific types of reconstruction are discussed in more detail below.

F) Implant with ADM vs Implant-assisted Latissimus-Dorsi (LD) Reconstructions
Please read the section on LD flap Section in the Breast Reconstruction Booklet from Breast Cancer Care.

There are several disadvantages of Implant-assisted LD reconstructions over the Implant with ADM reconstructions. The main complication is significant donor site (operated area at the back) morbidity: the LD flap operation leaves a large scar at the back and involves surgical dissection of a large surface area of the back muscle. Potential problems include
i. wound infection, seroma, chronic scar pain
ii. weakness is shoulder and arm movement on the operated side
iii. muscle contraction of the reconstruction breast with arms movements

In addition to the above, implant-assisted LD reconstructions also retains all the other complication risk described in section G. In general, we would reserve this procedure for patients with the following conditions:
• previous breast or chest wall radiotherapy
• previously failed implant–only or autologous reconstructions in whom there are few reconstructive options left available.

G) What to expect in the first few weeks after surgery

1) Pain and discomfort
Most patients undergoing this operation will have manageable pain but occasionally some patient may experience severe pain. We will aim to control this pain with painkillers as soon as possible and before you are discharged home. Be prepared to be administered painkillers such as Codeine Phosphate, Cocodamol, Tramadol and Morphine oral solution and you will likely be discharged home with these. These painkillers can lead to confusion, drowsiness, nausea and vomiting and constipation. Also, you should be prepared to take use some laxatives such as Lactulose, Senna or Movicol if you become constipated.

2) Drains
Patients will be discharged home with at least one drain left attached. This is to prevent tissue fluid and blood collection and aid wound healing.

3) Difficulty in moving and getting mobile
Patients will find difficulty standing, walking, bathing and doing simple everyday tasks because of post-operative discomfort. It is advisable that there is someone (i.e. spouse, children, friend) to observe or assist in you in these activities for the first two weeks. We would advise patient to continue being mobile after your operation to avoid developing deep venous thrombosis (clots in the leg veins) and continue performing the shoulder exercises as advised by your breast care nurse.
Patients are discouraged to drive for at least the first two weeks and should do return to driving only after discussing with your surgeon or breast care nurse.
Patients are advised not to perform strenuous exercise such as gym and weight lifting for the first month after surgery.

4) Unable to return to work
It is advisable that you should take at least two weeks off work and then develop phase return after that. For sick leave medical certificate, please request that from your GP or you can request a certifying letter from you surgeon.

5) Attend repeated clinic appointments
We will try to minimise the number of clinic follow-up appointments. However, if you develop any complication, be prepared to attend many frequent clinic appointments with your surgeon/breast care nurse until the complication has resolved.

6) Surgical complications
It is not unusual for most breast reconstruction cases to develop an immediate or long term wound complication. These are described in Section G.

7) Photo taking
Upon obtaining your consent, we may take photos of both breasts before and after the operation for medical records, medical teaching/presentation and for discussion with other staff members. These digital photos will be kept in the Breast Care Unit Department computer and are password secured.

H) Complication Risk of implant based-reconstruction

Immediate (First 4 weeks)
1) Bleeding after surgery (1 in 100 cases)
Your surgeon will endeavor to ensure that all blood vessels are sealed before the operation is finished. Unfortunately, there are rare occasions where some vessels may rebleed after the operation due to rising blood pressure. This may affect the cosmetic results. If severely acute, your surgeon may have to take you back to the operating theatre to stop the bleeding under general anaesthesia.

2) Wound infection (10%)
This commonly occurs within the first week after surgery as the skin envelop is till trying to recover from surgery. Please inform your breast care nurse / surgeon as soon as you see the following symptoms on the reconstructed breast: redness, pain, swelling, heat in the skin. This risk is higher in diabetics, patients who have had previous radiotherapy, smokers, significant co-existing heart and respiratory problems and on long-term steroid treatment.
3) Implant infection (5%)
This usually follows a wound infection and has the same symptoms. Most implant infection can be treated with antibiotics but in rare cases, this may not be effective. In severe cases, the implant will need to be removed to stop the infection and this involves another general anaesthetic operation.
Once the implant has been removed, it will be necessary to wait for several weeks or months before reinserting the fresh new implant so that the infection can be fully removed. In most of such cases some cases, it may not be possible to insert the same Beckers implant, may need more than one operation and use different types of inflatable implant such as tissue expanders before achieving a satisfactory cosmetic result. In some cases, subsequent implant reinsertion may not achieve the same cosmetic results as the achieved in the first reconstruction operation.

4. Seroma
This is accumulation of tissue liquid under the skin. This is common after any operation and can occasionally cause discomfort. When you are seen at your follow-up clinic, this seroma liquid can be removed by needle drainage at clinic.

Long-term Complications (After the first month of surgery)

1) Scars and scar pain
No matter which type of surgery you decide to have, you will have scars on the skin and also underneath the skin in the soft tissue where operating has taken place. Scars do fade and shrink over time in most women, but they don’t go away completely. Scars can occasionally cause hardness of tissue and pain.

2. Capsular contracture
Once a breast implant is in place, scar tissue forms around it, creating what’s called a scar capsule. These tissue capsules usually are soft or slightly firm and not noticeable. But in a small number of women, this capsule can become thick and cause pain and distortion of the shape of the breast. This occurs several years after the reconstruction and is called capsular contracture. Radiotherapy after an implant reconstruction will increase the risk of a Capsular Contracture forming. (40% risk at 5 years after surgery and radiotherapy).
Physiotherapy and scar massage therapy can help reduce this. In some cases, this requires another operation to remove the scar tissue and replace the implant.

3. Wound and Tissue breakdown
Sometimes the surgical wound or breast skin tissue may break down because of pressure from the implant or expander leading to small ulcer or opening of wounds. This may because network of vessels that supply blood to the skin could have been slightly damaged during surgery or radiation or may be more common in diabetics and smokers. This is why we strongly recommend you stop smoking for several weeks before your operation.
If tissue breakdown happens, you may need a prolonged period of wound dressing and frequent clinic appointments. Occasionally, we may need another small operation to remove dead skin/ tissue to improve wound healing or even skin grafting(taking skin or tissue from another place on your body) to cover or fill in the affected area. In wound breakdowns, there is also a increased risk that the implant may get contamination and get infected leading to implant removal.

4. Pain around implant
Some women feel pain or discomfort from the tissue expander, the implant, or scar tissue putting pressure on a nerve or other sensitive area. This may be due to a nerve damage that may occur during the operation or due to capsular contracture (described above).

Your doctor may prescribe a program of exercise, stretching, and massage, and possibly anti-inflammatory medicines, to relieve mild pain. Occasionally, this may be relieved by some injection of local anaesthetic and steroids by your surgeon at clinic follow-up appointments.

5. “Dynamic distortion,” or distortion with movement
A breast reconstructed with an implant may move in unnatural ways as you flex your chest muscle (pectoralis muscle). Because the skin tends to scar down to the underlying muscle, any movement may cause distortion in the shape of the breast. Although this isn’t dangerous, some women find it uncomfortable or distressing — especially if it wasn’t discussed as a possibility before surgery.
6. Implant migration
There is a small risk that your implant might migrate and move from its original position over time (tends to move upwards and towards the arm). If that happens, you may be able to massage it back into place or your surgeon might give you a Bandeux strap to wear at home to keep the implant in place. If there is significant implant migration, your surgeon may recommend another operation to reposition the implant.

7. Implant Palpability and Rippling
Occasionally, there may be a small area of the muscle or mesh which may thin out and lead to the implant directly in contact with the skin. This may lead to the implant being easily palpable. Also, over time the implant may adhere to the implant leading the rippling (small shallow folds on the skin) which may appear in certain positions. Speak to your surgeon about this if it happens.

8. Implant rupture and Gel Bleed
There is a small risk that your implant might leak after many years (usually more than 10 years). You may suspect an implant leak if there is a sudden change of shape, shrinkage of your size of the reconstructed breast or a lump on the reconstructed breast. If these occur, make an appointment to see a breast or plastic surgeon. Sometimes, there may not be a localized leak but implant may undergo ‘gel bleed’ where some silicone crosses the wall of the implant and accumulate around the implant, in the absence of a rupture.
An implant rupture requires another operation to replace the implant. This is because accumulation of silicone in the surrounding tissues and lymph nodes can lead to pain and swelling.

9. Anaplastic Large Cell Lymphoma (ALCL)
Recent findings have suggested that a very small proportion of women with breast implant can develop ALCL. It is a form of lymphoma (cancer of the lymphatic system) that develops on the scar capsule of the implant. The recent reports say it occurs in 1 in 24,000 women with breast implants and hence is rare. It presents as a sudden painless swelling of the reconstructed breast many years after the reconstruction. If this occurs, please arrange to see a breast or plastic surgeon.

I) Expectations of breast reconstruction
Keep your expectations realistic when anticipating the outcome of your surgery. Breast reconstruction surgery offers many benefits, but it won’t make you look or feel exactly like you did before your mastectomy.
What breast reconstruction can do:
• Give you a breast contour
• Provide improved symmetry to your breasts so that they look similar under clothing or a bathing suit
• Help you avoid the need for an external prosthesis

What breast reconstruction may not do:
• Improve your self-esteem and body image
• Partially erase the physical reminders of your disease

What breast reconstruction may not do:
• Make you look exactly the same as before
• Give your reconstructed breast the same sensations as your normal breast