Mammograms after Mastectomy and Breast Reconstruction - Are They Really Needed?
Posted Jun 18 2009 12:38pm
"Do I still need to have mammograms after my mastectomy and breast reconstruction?"
I'm asked this question quite often.
The truth is there's a lot of ongoing debate about this.
Some doctors feel that since there is no "natural" breast tissue left, there is no need to continue monitoring patients. I disagree with this strongly.
Breast cancer can come back after mastectomy - there's a 6.7% chance in fact. Breast reconstruction does not increase or decrease the risk of recurrence at all - the recurrence rate is the same whether women have reconstruction or not.
Since the risk of breast cancer recurrence is a real one, surely we need to continue some sort of monitoring?
Self breast exam is a no-brainer. It's relatively easy to perform and it's dirt-cheap (free). The issue of mammograms is less clear-cut.
The appearance of the mammogram changes completely after breast reconstruction. Even if the breast looks very natural and similar to the way it did before the mastectomy on the outside, the inside of the breast is completely different.
Let's take the following example: a woman who undergoes a skin-sparing mastectomy and tissue (flap) reconstruction like a DIEP flap may look like she has natural breasts that have merely been "lifted" . In reality her breast tissue has been completely replaced by tummy fat. Fat and breast tissue look completely different on mammograms so the post-reconstruction mammograms cannot be compared to any taken before the mastectomy. You're essentially starting from scratch as far as the mammograms go.
Some surgeons feel that patients should have 1 mammogram after the reconstruction has been completed just to get a new "baseline". If the regular self breast exams reveal anything new of concern then the mammogram can be repeated. At least now the new mammogram can be compared to the baseline mammogram.
Other breast surgeons take it a step further and recommend a baseline MRI once the reconstruction is completed instead of a mammogram. MRIs are much more sensitive (sometimes over sensitive though) and the information they provide is also more specific. Again, if self breast exam reveals a new area of concern in the future the MRI can be repeated to see if anything has changed.
The issues with MRIs are (1) the additional cost compared to a mammogram, and (2) sometimes they see things that really aren't there - for example, something that is benign is interpreted as worrisome. This in turn leads to further investigations and biopsies that may never have really been needed.
Yet one more viewpoint is that any new breast lumps that appear in the future are going to require a biopsy anyway so what is the point of getting a "baseline" MRI or mammogram at all? Tissue (flap) breast reconstructions can occasionally develop something called "fat necrosis". These are areas of fat in the new breast that become hard and create "lumps". While a biopsy may indeed be planned anyway, there is a lot to be said for the physician and patient knowing this "lump" has been there all along (on the MRI) and the chance of this representing a new cancer is extremely low. The additional peace of mind and information a baseline MRI provides in this situation alone warrants the test in some physicians' opinions.
What do I recommend? At least a mammogram 6 months after the breast reconstruction is completed to get a new baseline and regular self breast exams.