To B or Not to B

Last fall, I was invited to give a talk to a group of breast cancer survivors known as the Firefly Sisterhood. Prior to the presentation I met with a very nice woman who was organizing it, also a survivor herself; of course, we got to talking about all things breast cancer related, including the current state of health care during a global pandemic. That topic included how difficult it had been for patients to schedule appointments and surgical procedures, including the operations related to breast cancer treatment and reconstruction. Stories of last minute cancellations and multiple delayed surgeries were almost the norm.

This got me thinking once again and reflecting back on that complex decision for any woman facing breast cancer: the surgical approach, and whether or not to reconstruct. While I recognize this is an entirely personal decision with no one right answer, I was surprised early on by how many people, including family, friends, and even doctors assumed I would want bilateral mastectomy with immediate reconstruction. I had to do a lot of research on my own to realize there was more than one option and that there was no cancer benefit to removing the opposite breast in absence of a genetic mutation. After I chose right simple mastectomy, some even went so far as to ask me when was I having my next operation. I didn’t even understand the question at first, until it dawned on me that again, the assumption was reconstruction. I tried to laugh and make light of it; “Well, hopefully never, actually, for me, I opted out of all that.”

Yet it’s surprising how little we talk about the alternatives. When reading and gathering information on the internet, one would assume (very broadly speaking) that women who choose no reconstruction fall into two general categories: (1) Ultra feminist types: burn the bra! Who needs these things! Plastic surgeons are sexist! (2) Little old lady types: what’s the point, at my age, this old body is just falling apart anyway, no need to even keep up the pretense here. I had a harder time, honestly, because I fell into neither category. When I first paused, and pondered, I couldn’t articulate why I decided against it; it felt like a knee jerk, “not for me” type of gut reaction. And I stuck with that immediate response; I never even met with a plastic surgeon. But later on, with less anxiety, thinking it through, I believe there were really two reasons: (1) the end result and (2) avoiding unnecessary risk.

I’ve seen many women in my clinic panel who survived breast cancer and did go on to have reconstruction. I’ve been surprised sometimes, during the physical exam, when I lower the gown and I’ve temporarily forgotten about this particular aspect of their medical history. At times, I have found myself thinking, That’s a breast? Oh wait, I guess that’s why they call it a breast “mound.” Because sometimes, the resemblance to an actual breast–the shape, the feel, the look, the lack of a nipple–well, in some cases, it takes a bit of a stretch of the imagination to be honest. And from a medical standpoint, this breast mound is going to be numb, no sensation, no intact erogenous zone; in my mind, no purpose other than filling out a silhouette in clothing. Instead, I came up with my own solution for that–the athletic bra with removable pads. In fact, I wish more women knew about that option; I’ve heard that a silicone prosthesis inside a specialized bra can be heavy, uncomfortable, and cause excessive sweating. For a woman who is a B cup, the athletic bra works amazingly well, using an extra pad or two to create symmetry, and it is soft, so comfortable to wear.

On the other hand, it seems some women pursue bilateral mastectomy to reduce the perceived cancer risk in the opposite breast–even though multiple studies enrolling thousands of patients have shown this is not the case. Other women want to make it easier to achieve symmetry with the plastic surgery approach. Well, to me, in these cases not only are you removing a perfectly healthy breast, risking surgical complications for no cancer benefit, but you are giving up the only functional side in terms of sensation, innervation, erogenous zone and so on. For younger women of child bearing age, it also means giving up potential breastfeeding. I sincerely hope that women are completely informed as to what they are gaining but also what they are losing in this process. Because as far as erogenous zone or nursing a baby, well, it’s kind of like donating a kidney for transplant: you really only need one, for all practical purposes.

The other reason–unnecessary risk–well, that was directly related to my training as a physician. Breast reconstruction involves multiple surgeries and many steps, each one carrying its own risks. Perhaps I have seen too many complications over the years, from something that was perceived to be a “minor” intervention. The bile leak after gallbladder surgery performed for unclear reasons, to treat vague abdominal symptoms. The blood clot after a knee replacement. I have even seen, just once, a perforation from a routine colonoscopy. Studies suggest that physicians tend to recall more vividly an unexpected complication compared to a positive outcome.

Unfortunately, there is no procedure, no operation, no medication, no diagnostic test that is zero risk, other than a placebo. Doctors will know this, and may be unable to separate that from their own medical decision making regarding their own case management. This is probably another reason doctors make terrible patients for certain things such as routine screening. They see both the advantages and disadvantages of ordering more tests.

Looking at the calendar, it’s been almost six years since my operation. While it seems so long ago, it’s still fairly recent. I try and think back, when was the last time my appearance changed that drastically? Was it pregnancy? Dying my hair red in college? Certainly since 2016 I have needed to draw on some inner reserves, those that have to do with appearance, self image, body confidence, whatever we call it these days. And I considered the following from 1 Peter 3:

3 Your beauty should not come from outward adornment, such as elaborate hairstyles and the wearing of gold jewelry or fine clothes. 4 Rather, it should be that of your inner self, the unfading beauty of a gentle and quiet spirit, which is of great worth in God’s sight.

These verses from scripture remind us to focus on the inner self and not worry so much about the outward appearance. And as far as the question I posed: one can be a “B” even while missing one “B”. And for me, it’s nice not to rely on silicone, either inside or outside the body. I write about this topic only to raise awareness and promote the idea that when it comes to breast cancer surgery, multiple options exist; women should be given all the information available, and feel empowered by having choices. Because in this situation, as in most of life, one size certainly does not fit all.