Women and men who are diagnosed with breast cancer are generally seen by a team of healthcare providers who treat this specific group of patients. It may include a radiologist, breast surgeon, radiation oncologist, plastic surgeon, or microsurgeon. The patient’s healthcare team may also include a combination of one or more of these specialties. Kim Bowles and I believe it is these physicians who should inform patients newly diagnosed about the surgical choices for breast reconstruction or no reconstruction after mastectomy.
Kim and I met on social media. Although we have never met in person, we have spoken often on the phone and via messages on social media. We are both breast cancer survivors who had to make a choice for breast surgery when a mastectomy was the best oncologic treatment for our respective breast cancers. What we strongly believe in is choice. Kim states,
We are in a position today where we have more choices than we had before.
Kimberly Bowles
Barriers to Choices
We both know barriers exist. These can include:
- Lack of information and choices provided by healthcare teams.
- Financial barriers.
- Access leading to disparities in care.
Lack of Information
Unfortunately, women are not given all their options for breast surgery when they are facing a mastectomy. When I first began my advocacy and Foundation, I was in awe of DIEP flap surgery. That is what I chose. I had the time and information to research a microsurgeon to perform my breast reconstruction.
Throughout the progression of my education as a patient advocate and learning about options, I met Kim. When I read about what happened to her I knew her story became an important component of choice and the information I needed to include in my advocacy. Advocates for reconstruction are allies with advocates for aesthetic flat closure because we both strongly believe in choice and honoring the patient’s personal preference. Kim states this so well in the video.
Financial Barriers and Lack of Access
The Women’s Health and Cancer Rights Act (WHCRA) of 1998 provides financial protection and coverage for women who choose to have reconstruction after mastectomy. However, there are caveats. Some women and men must make appeals to insurance along with their surgeons to provide this coverage. You can read more here to understand the details of the WHCRA.
Functional and aesthetic outcomes of any choice in breast surgery are an important component of optimal patient outcomes. Because travel is sometimes required for surgery because of access to qualified surgeons, this can lead to disparities in care. When a patient cannot find a well-qualified surgeon to perform their surgery, or worse, one who does not honor the patient’s values and preference, the emotional fallout for patients can be huge. Kim discusses this in the video in her own personal experience with flat closure. As she says, when you look in the mirror, your choice should reflect your decision, even as difficult as it was to make.
I was fortunate to find a world class microsurgeon to perform my DIEP flap, but I had many travel expenses not covered by insurance because of access. There was not a surgeon in my area that met the criterion I preferred to perform my breast reconstruction. We made hard financial decisions that year, but I felt fortunate we had the means to travel. This can be a financial barrier for some. Lack of access can also lead to poor patient outcomes when a surgeon may not have the skill level and practice experience to achieve the desired request of the patient.
Optimal Flat Closure is a Choice
The word optimal flat closure comes from the Oncoplastic Breast Consortium of which Kim and I are both advocates for. As part of their mission statement they state:
Our mission is to continuously improve oncoplastic breast surgery by bringing international experts together, promoting high-quality education and performing international multicenter studies.
Oncoplastic Breast Consortium
As part of Kim’s work as Founder of Not Putting on a Shirt, her advice to those who choose optimal flat closure and maximizing your chances of getting a good aesthetic outcome is:
- Most people that choose to go flat are happy with their flat closure.
- Be very clear to your surgeon what your decision is once you have come to terms and peace of mine with it.
- Is your surgeon committed and able to give you your optimal result at your initial surgery?
As Kim points out, priorities are very personal and there is no one right answer for any one person. We discuss the evidence-based information pointing to the true value and a shared decision-making conversation for breast surgery. Both of us feel whatever surgical decisions are made, they will be made as a compromise to facing what no one wants to hear, a breast cancer diagnosis.
We are not here to take away options from patients.
Kimberly Bowles
There is a great deal to learn from the discussion with Kim. I invite you to watch the entire video here. Many thanks to Kim for her time, her advocacy, and work to inform others about choices in breast reconstruction or no reconstruction after mastectomy.
