North East ONCOLOGY News North East Launch of Redesigned ONCOLOGY Cancer Care Ontario Website! News
CCO recently launched their updated Cancer Volume 7 Issue 3 December 2017 Care Ontario website. The site is designed to be mobile-friendly and accessible to everyone, with IN THIS ISSUE improvements to make it easy to search, and New Cancer Care Ontario Website quickly find information you are looking for. New Cancer Care Ontario Website ...... 1 The Resources for Primary Care Providers I am pleased to introduce the new Cancer Care Ontario website, designed to has a more integrated approach to tools and make it easier to find what you are looking for. The website is organized in a way that considers the different types of information that providers or patients and resources across the cancer continuum and can Breast Cancer Weight families most commonly seek. There is a specific section dedicated to primary be accessed at https://www.cancercareontario. Loss Trial ...... 1 ca/en/resources-primary-care-providers care categorized by guideline-based tools, diagnostic assessment, resources for patients, education and news, and quality improvement. This includes information on cancer screening, Genetic Testing - New referral on suspicion, disease pathways, symptom management, follow-up care and palliative care. A Cancer Panels and significant enhancement to the search engine organizes results into categories so that you can find Accessing Genetic what you are looking for quickly to help inform and support your practice. Please take a few minutes www.cancercareontario.ca Services in Northern to go to www.cancercareontario.ca to check out these resources. Ontario ...... 2 Mark Hartman Vice President, Regional Cancer & Clinical Support Services Health Sciences North, Northeast Cancer Centre Regional Vice President, Cancer Care Ontario Post-Mastectomy Breast Reconstruction ...... 3 New Regional Radiation Oncology Lead Launch of Redesigned Breast Cancer Weight Loss Trial I am very pleased to be appointed to the role Prior to that, I grew up in Sudbury completing my Bachelor and CCO Website ...... 4 of Regional Radiation Oncology Lead for the Masters degree in Biochemistry at Laurentian University. I have A novel study titled Breast Cancer Weight Loss (BWEL), also called MAC.20, was North East LHIN. My role in this position is been working as a radiation oncologist at HSN for eight years and I opened for accrual at the Northeast Cancer Centre (NECC) in October 2017. This to ensure that patients in North East Ontario feel very privileged to now have the opportunity to serve my home New Regional Radiation study, coordinated by the Alliance for Clinical Trials in Oncology and the Canadian have access to timely radiotherapy services of community in this new capacity. Oncology Lead ...... 4 Cancer Trials Group, is looking at the impact of a weight loss intervention upon the highest possible quality. We deliver this therapy via our unified invasive breast cancer disease-free survival. program operating out of two northern hospitals (Sudbury and Sault I certainly look forward to working with the medical leaders and Ste. Marie). We strive to minimize patient travel and coordinate providers throughout the North East to ensure that all patients INSERTS: Pre or post-menopausal women with a BMI ≥27 who have been care with northern communities with both OTN consultations as well receive the best possible integration of care through their cancer diagnosed with invasive breast cancer within the past 12 months as follow up care via telemedicine. journey from diagnosis to treatment, ultimately to follow-up care with are eligible to take part in the study. Patients must have completed the primary care provider. • CCO’s Breast chemotherapy and/or radiation therapy and could be on hormonal I obtained my MD from the University of Toronto in 2004 and Reconstruction treatment or bisphosphonates. Women who meet the eligibility criteria will completed my specialty training in radiation oncology in Calgary, Dr. Andrew Pearce Patient Education Tool be randomized to either: Regional Radiation Oncology Lead Alberta in 2009. Head of Service, Radiation Oncology • Quick Reference Northeast Cancer Centre • Arm A- A detailed package of health promotion information, webinars, a newsletter and a health Guide: Post- magazine. Mastectomy Breast Reconstruction • Arm B- The above materials and a two year telephone-based intervention program from the Dana- NORTH EAST ONCOLOGY NEWS Farber Cancer Institute in Boston to promote weight loss; which includes goal setting along with PRODUCTION TEAM North East Oncology News is a triannual publication from the Northeast Cancer Centre providing calorie control supported by structured menus, cookbooks, food scale and protein meal replacements. evidence-based guidance, and clinical and operational updates of interest with a focus on primary Exercise goals are also set and patients receive a Fitbit and wireless scale, lifestyle workbook, exercise Editor: Mark Hartman care in North East Ontario. Assistant Editor: Dr. Amanda Hey DVDs and/or You-Tube videos. Production Coordinator: Merci Miron-Black References used for this issue of North East Oncology News are available upon request from the Production Assistant: Jody Donivan As site principal investigator, I am excited that the NECC can offer this trial to eligible breast cancer editor. Articles may be reprinted without permission, provided the source is acknowledged. survivors in North East Ontario. This study has been advertised in the media. If you are approached by a patient or family member who may have heard about the study and is interested in knowing more, please 41 Ramsey Lake Road - Sudbury, ON P3E 5J1 Available online at www.hsnsudbury.ca/NECCprimarycareresources Phone: 705-522-6237 - Fax: 705-671-5496 direct them to the NECC Clinical Research office at 1-866-469-0822 ext. 2257. [email protected] Dr. Lacey Pitre Medical Oncologist Northeast Cancer Centre North East ONCOLOGY News
Genetic Testing - New Cancer Panels and Accessing Genetic Post-Mastectomy Breast Reconstruction
Services in Northern Ontario It is estimated that 39% of Canadian women Genetic testing technology is a rapidly advancing field. cancer development. There may also be a lack of diagnosed with breast cancer undergo mastectomy. While genetic testing for individual genes associated established management guidelines or screening Quality of life is often adversely affected. with hereditary cancer predisposition syndromes options available to individuals who are found to has been available for many years, many institutions carry pathogenic variants in genes that are currently are now offering gene panel tests, in which multiple less well-studied. Patient-Centred Care genes are analyzed simultaneously. These panels With improving five-year survival rates for breast cancer, for Education about breast reconstruction is ideally provided may include anywhere from a handful to hundreds Further, because of our incomplete scientific those women undergoing mastectomy, it is important to consider prior to surgery, however if this opportunity didn’t arise, a of genes, and are able to identify sequence changes knowledge and the sheer number of genes included post-mastectomy breast reconstruction (PMBR); to alleviate woman could still benefit from a referral to a plastic surgeon in genes that are associated with increased risks for on such panels, there is a higher likelihood of both practical considerations such as avoiding a prosthesis and with an interest in breast reconstruction after completion of one or more types of cancer. identifying variants of unknown significance (VUS). clothing limitation and improve quality of life (QoL). Importantly, her active treatment to discuss delayed post-mastectomy These variants are changes in the genetic code that while some women undergoing mastectomy have an excellent breast reconstruction (PMBR) options. Primary care Gene panels have a number of advantages. Because are not clearly pathogenic or benign; is the variant QoL; others have adverse effects on psychological well-being providers with knowledge of timing and types of PMBR and many genes are tested at once, the number of follow- expected to alter the function of the gene and result including anxiety, depression and negative effects on body image surveillance recommendations are well positioned to support up tests that are required for a given patient may be in an increased risk for cancer, or is it simply a and sexual function. a breast cancer patient when she is deciding on the optimal minimized. There is also a wide variety of panels to benign genetic variation? For patients receiving this management strategy with her treating oncology team. choose from; health care providers can offer large type of result, many questions remain unanswered, Health Care Provider Education In 2016, Cancer Care Ontario’s (CCO) Program in Evidence- pan-cancer panels that include dozens of genes that but further research over time may provide a clearer Types of Post-Mastectomy Breast Reconstruction are associated with increased risks for a variety of understanding of their individual cancer risks and the Based Care issued a guideline: Breast Cancer Reconstruction There are currently two major surgical approaches to breast cancer types, or targeted panels that focus on genes medical management options available to them. Surgery (Immediate and Delayed) Across Ontario: Patient reconstruction: implant-based reconstruction and autologous that are associated with only one or two types of Indications and Appropriate Surgical Options. It provides clinical tissue reconstruction. Skin-sparing, nipple or areola-sparing cancer. These tests are available from many genetic As trends in genetic testing move increasingly toward guidance with respect to patient suitability, timing of procedure and mastectomies may be offered for women undergoing prophylactic laboratories in Ontario, as well as in other Canadian the use of gene panels, complex genetic information optimal PMBR techniques. It is also intended to inform decisions mastectomies, or for those with DCIS. For women who cannot provinces and the United States. is being uncovered more rapidly than ever. at the policy and administrative level to improve the QoL of women have their nipple preserved, nipple areolar reconstruction Comprehensive genetic counselling is important for with breast cancer across Ontario. The guideline is available at may be an option. There are no absolute contraindications to While gene panels are an efficient way of investigating individuals considering genetic testing, and whether https://www.cancercareontario.ca/en/guidelines-advice/types-of- breast reconstruction however some relative contraindications the possibility of a hereditary cancer syndrome within or not to move forward with testing is always a cancer/31721 include smoking, radiation, prior donor-site surgeries, medical a family, there are many important factors to consider personal decision. Patients in Northern Ontario may comorbidities and advanced cancer stage. Patient Education and Preoperative Evaluation prior to pursuing testing. The cancer risks associated be referred to their nearest Genetics clinic within the Patient education should be initiated at the time that mastectomy with mutations in well-known genes like BRCA1 and Northern Regional Genetics Program is offered by the general surgeon, and include early consultation For more information on the timing and methods of PMBR, please BRCA2 have long been established, but such risks (www.nrgp.on.ca) if they are interested in discussing with a plastic surgeon if appropriate and desired. If chemotherapy see the enclosed Quick Reference Guide: Post-Mastectomy are not as clearly defined for many other genes that their genetic testing options. and/or radiation therapy are potentially to be required, ideally the Breast Reconstruction or refer to the Breast Cancer Well Follow- are included on current cancer panels. These genes medical and/or radiation oncologist are included in the preoperative Up Care: a Guide for Primary Care Providers in North East may have only recently been identified, or there may Carleigh Robertson evaluation through formal consultation or a multidisciplinary Ontario, available at: https://wellfollowup.hsnsudbury.ca/breast/ be conflicting evidence about their association with Genetic Counsellor Other-Interventions Health Sciences North cancer conference. CCO has developed a one-page overview for patients titled: Breast Cancer Reconstruction Surgery. Please see Accessing Services insert. Routine screening for breast cancer recurrence following post-mastectomy Timing of Post-Mastectomy Breast Reconstruction Clinic Location Phone breast reconstruction (PMBR) Timing can be immediate (at the same time as mastectomy) or There is insufficient evidence to support delayed. In Ontario between 2004 and 2010 it is estimated that the use of post-mastectomy surveillance North Bay Parry Sound District Health North Bay Parry Sound District Health Unit only 7.6% of women undergoing mastectomy received immediate 705-474-1400 ext. 2305 mammography in the reconstructed Unit Genetics Program (North Bay) PMBR. More recent data indicates rates in Toronto are nearer to breast. Women should be followed with 30% but Northern Ontario rates remain around 5% for immediate clinical examination of the chest wall and Algoma Public Health reconstruction. Algoma Public Health Genetics Program 705-942-4646 ext. 3123 reconstructed breast as per the regular (Sault Ste. Marie) breast cancer follow-up regimen. To address the latter, CCO’s Breast Cancer Treatment Pathway Sudbury Outpatient Centre Health Sciences North Genetic Map for ductal carcinoma in situ (DCIS) and operable invasive Health Sciences North 705-675-4786 Counselling Services breast cancer now includes a possible plastic surgeon consultation Dr. Amanda Fortin (Sudbury) prior to mastectomy. CCO’s Breast Cancer Treatment Pathway Plastic Surgeon Health Sciences North Porpupine Health Unit Porcupine Health Unit Map is available at: https://www.cancercareontario.ca/en/ 705-267-1181 ext. 3210 pathway-maps/breast-cancer Genetic Department (Timmins) North East ONCOLOGY News
Genetic Testing - New Cancer Panels and Accessing Genetic Post-Mastectomy Breast Reconstruction
Services in Northern Ontario It is estimated that 39% of Canadian women Genetic testing technology is a rapidly advancing field. cancer development. There may also be a lack of diagnosed with breast cancer undergo mastectomy. While genetic testing for individual genes associated established management guidelines or screening Quality of life is often adversely affected. with hereditary cancer predisposition syndromes options available to individuals who are found to has been available for many years, many institutions carry pathogenic variants in genes that are currently are now offering gene panel tests, in which multiple less well-studied. Patient-Centred Care genes are analyzed simultaneously. These panels With improving five-year survival rates for breast cancer, for Education about breast reconstruction is ideally provided may include anywhere from a handful to hundreds Further, because of our incomplete scientific those women undergoing mastectomy, it is important to consider prior to surgery, however if this opportunity didn’t arise, a of genes, and are able to identify sequence changes knowledge and the sheer number of genes included post-mastectomy breast reconstruction (PMBR); to alleviate woman could still benefit from a referral to a plastic surgeon in genes that are associated with increased risks for on such panels, there is a higher likelihood of both practical considerations such as avoiding a prosthesis and with an interest in breast reconstruction after completion of one or more types of cancer. identifying variants of unknown significance (VUS). clothing limitation and improve quality of life (QoL). Importantly, her active treatment to discuss delayed post-mastectomy These variants are changes in the genetic code that while some women undergoing mastectomy have an excellent breast reconstruction (PMBR) options. Primary care Gene panels have a number of advantages. Because are not clearly pathogenic or benign; is the variant QoL; others have adverse effects on psychological well-being providers with knowledge of timing and types of PMBR and many genes are tested at once, the number of follow- expected to alter the function of the gene and result including anxiety, depression and negative effects on body image surveillance recommendations are well positioned to support up tests that are required for a given patient may be in an increased risk for cancer, or is it simply a and sexual function. a breast cancer patient when she is deciding on the optimal minimized. There is also a wide variety of panels to benign genetic variation? For patients receiving this management strategy with her treating oncology team. choose from; health care providers can offer large type of result, many questions remain unanswered, Health Care Provider Education In 2016, Cancer Care Ontario’s (CCO) Program in Evidence- pan-cancer panels that include dozens of genes that but further research over time may provide a clearer Types of Post-Mastectomy Breast Reconstruction are associated with increased risks for a variety of understanding of their individual cancer risks and the Based Care issued a guideline: Breast Cancer Reconstruction There are currently two major surgical approaches to breast cancer types, or targeted panels that focus on genes medical management options available to them. Surgery (Immediate and Delayed) Across Ontario: Patient reconstruction: implant-based reconstruction and autologous that are associated with only one or two types of Indications and Appropriate Surgical Options. It provides clinical tissue reconstruction. Skin-sparing, nipple or areola-sparing cancer. These tests are available from many genetic As trends in genetic testing move increasingly toward guidance with respect to patient suitability, timing of procedure and mastectomies may be offered for women undergoing prophylactic laboratories in Ontario, as well as in other Canadian the use of gene panels, complex genetic information optimal PMBR techniques. It is also intended to inform decisions mastectomies, or for those with DCIS. For women who cannot provinces and the United States. is being uncovered more rapidly than ever. at the policy and administrative level to improve the QoL of women have their nipple preserved, nipple areolar reconstruction Comprehensive genetic counselling is important for with breast cancer across Ontario. The guideline is available at may be an option. There are no absolute contraindications to While gene panels are an efficient way of investigating individuals considering genetic testing, and whether https://www.cancercareontario.ca/en/guidelines-advice/types-of- breast reconstruction however some relative contraindications the possibility of a hereditary cancer syndrome within or not to move forward with testing is always a cancer/31721 include smoking, radiation, prior donor-site surgeries, medical a family, there are many important factors to consider personal decision. Patients in Northern Ontario may comorbidities and advanced cancer stage. Patient Education and Preoperative Evaluation prior to pursuing testing. The cancer risks associated be referred to their nearest Genetics clinic within the Patient education should be initiated at the time that mastectomy with mutations in well-known genes like BRCA1 and Northern Regional Genetics Program is offered by the general surgeon, and include early consultation For more information on the timing and methods of PMBR, please BRCA2 have long been established, but such risks (www.nrgp.on.ca) if they are interested in discussing with a plastic surgeon if appropriate and desired. If chemotherapy see the enclosed Quick Reference Guide: Post-Mastectomy are not as clearly defined for many other genes that their genetic testing options. and/or radiation therapy are potentially to be required, ideally the Breast Reconstruction or refer to the Breast Cancer Well Follow- are included on current cancer panels. These genes medical and/or radiation oncologist are included in the preoperative Up Care: a Guide for Primary Care Providers in North East may have only recently been identified, or there may Carleigh Robertson evaluation through formal consultation or a multidisciplinary Ontario, available at: https://wellfollowup.hsnsudbury.ca/breast/ be conflicting evidence about their association with Genetic Counsellor Other-Interventions Health Sciences North cancer conference. CCO has developed a one-page overview for patients titled: Breast Cancer Reconstruction Surgery. Please see Accessing Services insert. Routine screening for breast cancer recurrence following post-mastectomy Timing of Post-Mastectomy Breast Reconstruction Clinic Location Phone breast reconstruction (PMBR) Timing can be immediate (at the same time as mastectomy) or There is insufficient evidence to support delayed. In Ontario between 2004 and 2010 it is estimated that the use of post-mastectomy surveillance North Bay Parry Sound District Health North Bay Parry Sound District Health Unit only 7.6% of women undergoing mastectomy received immediate 705-474-1400 ext. 2305 mammography in the reconstructed Unit Genetics Program (North Bay) PMBR. More recent data indicates rates in Toronto are nearer to breast. Women should be followed with 30% but Northern Ontario rates remain around 5% for immediate clinical examination of the chest wall and Algoma Public Health reconstruction. Algoma Public Health Genetics Program 705-942-4646 ext. 3123 reconstructed breast as per the regular (Sault Ste. Marie) breast cancer follow-up regimen. To address the latter, CCO’s Breast Cancer Treatment Pathway Sudbury Outpatient Centre Health Sciences North Genetic Map for ductal carcinoma in situ (DCIS) and operable invasive Health Sciences North 705-675-4786 Counselling Services breast cancer now includes a possible plastic surgeon consultation Dr. Amanda Fortin (Sudbury) prior to mastectomy. CCO’s Breast Cancer Treatment Pathway Plastic Surgeon Health Sciences North Porpupine Health Unit Porcupine Health Unit Map is available at: https://www.cancercareontario.ca/en/ 705-267-1181 ext. 3210 pathway-maps/breast-cancer Genetic Department (Timmins) North East ONCOLOGY News North East Launch of Redesigned ONCOLOGY Cancer Care Ontario Website! News
CCO recently launched their updated Cancer Volume 7 Issue 3 December 2017 Care Ontario website. The site is designed to be mobile-friendly and accessible to everyone, with IN THIS ISSUE improvements to make it easy to search, and New Cancer Care Ontario Website quickly find information you are looking for. New Cancer Care Ontario Website ...... 1 The Resources for Primary Care Providers I am pleased to introduce the new Cancer Care Ontario website, designed to has a more integrated approach to tools and make it easier to find what you are looking for. The website is organized in a way that considers the different types of information that providers or patients and resources across the cancer continuum and can Breast Cancer Weight families most commonly seek. There is a specific section dedicated to primary be accessed at https://www.cancercareontario. Loss Trial ...... 1 ca/en/resources-primary-care-providers care categorized by guideline-based tools, diagnostic assessment, resources for patients, education and news, and quality improvement. This includes information on cancer screening, Genetic Testing - New referral on suspicion, disease pathways, symptom management, follow-up care and palliative care. A Cancer Panels and significant enhancement to the search engine organizes results into categories so that you can find Accessing Genetic what you are looking for quickly to help inform and support your practice. Please take a few minutes www.cancercareontario.ca Services in Northern to go to www.cancercareontario.ca to check out these resources. Ontario ...... 2 Mark Hartman Vice President, Regional Cancer & Clinical Support Services Health Sciences North, Northeast Cancer Centre Regional Vice President, Cancer Care Ontario Post-Mastectomy Breast Reconstruction ...... 3 New Regional Radiation Oncology Lead Launch of Redesigned Breast Cancer Weight Loss Trial I am very pleased to be appointed to the role Prior to that, I grew up in Sudbury completing my Bachelor and CCO Website ...... 4 of Regional Radiation Oncology Lead for the Masters degree in Biochemistry at Laurentian University. I have A novel study titled Breast Cancer Weight Loss (BWEL), also called MAC.20, was North East LHIN. My role in this position is been working as a radiation oncologist at HSN for eight years and I opened for accrual at the Northeast Cancer Centre (NECC) in October 2017. This to ensure that patients in North East Ontario feel very privileged to now have the opportunity to serve my home New Regional Radiation study, coordinated by the Alliance for Clinical Trials in Oncology and the Canadian have access to timely radiotherapy services of community in this new capacity. Oncology Lead ...... 4 Cancer Trials Group, is looking at the impact of a weight loss intervention upon the highest possible quality. We deliver this therapy via our unified invasive breast cancer disease-free survival. program operating out of two northern hospitals (Sudbury and Sault I certainly look forward to working with the medical leaders and Ste. Marie). We strive to minimize patient travel and coordinate providers throughout the North East to ensure that all patients INSERTS: Pre or post-menopausal women with a BMI ≥27 who have been care with northern communities with both OTN consultations as well receive the best possible integration of care through their cancer diagnosed with invasive breast cancer within the past 12 months as follow up care via telemedicine. journey from diagnosis to treatment, ultimately to follow-up care with are eligible to take part in the study. Patients must have completed the primary care provider. • CCO’s Breast chemotherapy and/or radiation therapy and could be on hormonal I obtained my MD from the University of Toronto in 2004 and Reconstruction treatment or bisphosphonates. Women who meet the eligibility criteria will completed my specialty training in radiation oncology in Calgary, Dr. Andrew Pearce Patient Education Tool be randomized to either: Regional Radiation Oncology Lead Alberta in 2009. Head of Service, Radiation Oncology • Quick Reference Northeast Cancer Centre • Arm A- A detailed package of health promotion information, webinars, a newsletter and a health Guide: Post- magazine. Mastectomy Breast Reconstruction • Arm B- The above materials and a two year telephone-based intervention program from the Dana- NORTH EAST ONCOLOGY NEWS Farber Cancer Institute in Boston to promote weight loss; which includes goal setting along with PRODUCTION TEAM North East Oncology News is a triannual publication from the Northeast Cancer Centre providing calorie control supported by structured menus, cookbooks, food scale and protein meal replacements. evidence-based guidance, and clinical and operational updates of interest with a focus on primary Exercise goals are also set and patients receive a Fitbit and wireless scale, lifestyle workbook, exercise Editor: Mark Hartman care in North East Ontario. Assistant Editor: Dr. Amanda Hey DVDs and/or You-Tube videos. Production Coordinator: Merci Miron-Black References used for this issue of North East Oncology News are available upon request from the Production Assistant: Jody Donivan As site principal investigator, I am excited that the NECC can offer this trial to eligible breast cancer editor. Articles may be reprinted without permission, provided the source is acknowledged. survivors in North East Ontario. This study has been advertised in the media. If you are approached by a patient or family member who may have heard about the study and is interested in knowing more, please 41 Ramsey Lake Road - Sudbury, ON P3E 5J1 Available online at www.hsnsudbury.ca/NECCprimarycareresources Phone: 705-522-6237 - Fax: 705-671-5496 direct them to the NECC Clinical Research office at 1-866-469-0822 ext. 2257. [email protected] Dr. Lacey Pitre Medical Oncologist Northeast Cancer Centre
Breast Cancer Reconstruction Surgery
What is Breast Cancer • Talk to your health care team breast, such as lumps or skin Reconstruction Surgery? about the best timing for your changes. • In order to surgically treat breast breast reconstruction. Can everyone have breast cancer or to prevent cancer if What is used to rebuild the reconstruction surgery? you have a high risk of getting breast? • Breast reconstruction may not breast cancer, your surgeon 1. Saline or silicone implants be possible for everyone. For may recommend a mastectomy, example, breast reconstruction • There are a lot of factors which is the removal of your is not recommended if you are a involved in choosing an implant. breast. smoker, have a medical You may need a temporary • Breast reconstruction is surgery condition such as obesity or saline filled tissue expander first to rebuild your breast after a diabetes, or your cancer is at an that is filled over time and then mastectomy. advanced stage. replaced with a permanent • These things can put you at a Timing of Breast Reconstruction implant at a second stage. You greater risk of serious problems Surgery might be able to have a after surgery. • For some people, breast permanent implant right away. • These factors, as well as your reconstruction can be done at Implants come in many shapes surgeon’s preference and your the same time as your and sizes. preference may also affect the mastectomy. This is called 2. Your own body tissue type of reconstruction that is immediate reconstruction. • Tissue from your body best for you. Breast reconstruction can also (autologous tissue) is taken from be done at a later time. This is Who should I talk to about breast your stomach, back, thighs or called delayed reconstruction. reconstruction surgery options? buttock to rebuild your breast. • Immediate reconstruction is not • Your health care team can give always possible. Here are some 3. Implants and body tissue you the best information about reasons why immediate • Implants and/or body tissue may your breast reconstruction reconstruction may not work for be used for either immediate or options based on your personal you: delayed reconstruction. medical situation. You have inflammatory In some cases, it may be possible to • It is important that you breast cancer keep your breast skin (skin-sparing understand and feel comfortable Cancer is found in your mastectomy), or your skin, nipple with your options for breast lymph nodes and areola (nipple-sparing reconstruction. If you have You may choose to delay mastectomy) if you are having concerns of questions, talk to a breast reconstruction immediate reconstruction, but this member of your health care surgery until fully recovered should be discussed further with team. from mastectomy or other your surgeon. Additional Resources: personal issues • Canadian Cancer Society: You need radiation treatment Is follow-up required? http://www.cancer.ca/en/cancer- quickly after your You need to follow-up with your information/cancer- mastectomy surgery health care team and have regular type/breast/supportive-care/ • If you have radiation to the check-ups with a physical • Canadian Breast Cancer breast you may need to wait at examination of your chest wall and Foundation: http://www.bra- least 1 year after your breast is breasts. day.com/breast-reconstruction/ removed before having delayed • breast reconstruction. This may You may need imaging if you reduce your risk of serious have changes or unusual problems after surgery. symptoms in your reconstructed
QUICK REFERENCE GUIDE: POST-MASTECTOMY BREAST RECONSTRUCTION
Post-mastectomy breast reconstruction may be an option for a woman receiving a mastectomy for breast cancer and occasionally for those women with severe asymmetry after lumpectomy and radiation.
The goals of breast reconstruction are to: • Give the breasts a balanced look in a bra. • Restore breast contour. • Avoid the inconvenience of an external prosthesis. Reconstruction timing and technique selection is based on the assessment of the cancer treatment, the woman’s body habitus, obesity, smoking history, comorbidities and patient concerns. Smoking is a relative contraindication to breast reconstruction, so women who smoke should quit prior to the procedure. TIMING OF BREAST RECONSTRUCTION Immediate breast reconstruction occurs at the same time as mastectomy. • Immediate reconstruction with autologous tissue or implants can be considered if there is a low risk of the woman requiring radiation therapy after mastectomy (e.g. no close surgical margins or positive lymph nodes). • Immediate reconstruction is contraindicated in inflammatory breast cancer. Delayed breast reconstruction can occur sometime following completion of cancer therapy. • If radiation therapy is required, a delayed approach after radiation therapy is preferred. Immediate placement of an implant in patients requiring post-operative radiation therapy has increased rates (up to 60%) of capsular contracture, malposition, poor cosmesis and implant exposure. Education about breast reconstruction is ideally provided prior to surgery, however if this opportunity didn’t arise, a woman could still benefit from a referral to a breast plastic surgeon after completion of her active treatment. There is no time limit on reconstruction.
TYPES OF BREAST RECONSTRUCTION FOLLOWING MASTECTOMY Breast implant: e.g. tissue expander placement at the time of mastectomy followed by implant placement; or immediate implant placement with or without dermal allograft. • Tissue expanders require weekly or every one to two week visits to the plastic surgeon’s clinic for installation of saline into the tissue expander to stretch it out to the size of the final implant. • After approximately three months the tissue expander/ port is removed. A different implant (saline or silicone) may be inserted and any revisions done at this time. Autologous tissue transplantation: e.g. pedicled or free transverse rectus abdominis myocutaneous (TRAM) flap, microsurgical flaps from the abdomen, back, buttocks and thighs. • Autologous tissue often feels natural to the touch; however as in any approach, the reconstructed area has no sensation. • TRAM flaps may result in some weakening of the abdominal wall with a risk of hernia and limitations in lifting heavier objects and doing sit-ups. • Autologous reconstruction has a risk of having fat necrosis which can feel like lumps. This happens when the fat is not well vascularized and it turns into scar tissue. Both autologous tissue transplantation and breast implant: e.g. latissimus dorsi flap as a single stage procedure that combines the autologous ‘flap’ from the back to cover the breast implant. • This procedure is most commonly performed if a mastectomy is followed by radiation and the patient does not meet the criteria for a TRAM or other autologous tissue flap. Nipple reconstruction: • Nipple reconstruction is often done in two steps; the first is to create a nipple bump and the second to give colour with a tattoo. • This step is done after the breast mound creation is complete so the position can be determined. • It is usually done under local anaesthetic.
Adapted from the Breast Cancer Well Follow-Up Care - A Guide for Primary Care Providers in North East Ontario 2015 available in hard copy, pdf or as a mobile website at https://wellfollowup.hsnsudbury.ca/breast.
November 2017
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QUICK REFERENCE GUIDE: POST-MASTECTOMY BREAST RECONSTRUCTION
THE PROS AND CONS OF POST-MASTECTOMY BREAST RECONSTRUCTION TECHNIQUES*
IMPLANT/ AUTOLOGOUS LATISSIMUS DORSI/EXPANDER EXPANDER TISSUE (TRAM/DIEP)
2 separate shorter surgeries 1 longer procedure Usually single procedure Surgery (2 hrs) (4-10 hrs) (3-4 hrs)
Day surgery (overnight stay if 1-2 night stay for first procedure, day Hospitalization Average 3 days immediate) surgery for second procedure
4-6 weeks following tissue Recovery 8-12 weeks 8 weeks expander insertion
Mastectomy scar & scar at donor site Mastectomy scar & scar at donor site Scars Mastectomy scar only (abdomen) (back)
Shape & Feel No natural sag, firm over time Very natural feel, soft More natural than implant alone
More changes needed to match Fewer changes needed to match other Fewer changes needed to match other Opposite Breast implant side side
Decreased strength with repetitive Breast feels more firm (capsular 5% risk of microsurgical failure with overhead activities. Seroma or hematoma Complications contracture), rupture may complete flap loss; 5% risk of in back at donor site. Still has implant require replacement (10%) abdominal weakness, bulge, hernia risks/complications *Adapted from: Canadian Cancer Society/ Canadian Breast Cancer Foundation at http://support.cbcf.org/get-information/breast-reconstruction/types-breast-reconstruction/
ARE BREAST IMPLANTS SAFE? Both saline and silicone gel implants are safe and available for use in Canada. However, there is a chance that implants can become infected, rupture, or your body can form a capsule of scarred and firm tissue around the implant. Implants don’t get “rejected” but may have to be removed in the case of severe infection. Although in the past there were concerns that silicone gel may be associated with breast cancer and rare autoimmune disorders, researchers have not found significant evidence to support this cause-and-effect relationship. After a temporary ban on the use of silicone implants for breast augmentation by the United States Federal Drug Administration (FDA) in the 90s, the use of silicone implants was approved in Canada in October 2006. The newer generation silicone implants contain thicker silicone gel that is more cohesive and in turn are more “form-stable”.i
In 2017, the FDA designated breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) as a rare T-cell lymphoma that can develop following breast implants.ii Data is still evolving, so the true incidence is not known but it seems to be associated with textured implants. The most common presentation is a late onset persistent seroma, often presenting 10 years after implant placement. These women should be seen by a plastic surgeon if possible and the seroma fluid sent for lymphoma testing (CD30 immunohistochemistry).
i http://support.cbcf.org/get-information/breast-reconstruction/types-breast-reconstruction/
ii https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239995.htm
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