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Ensuring Your Breast Cancer Patient Is Referred for Reconstruction Consultation

November 11, 2010 | AONN+ Blog | Breast Cancer
Featuring:
Lillie D. Shockney, RN, BS, MAS, HON-ONN-CG
Lillie D. Shockney, RN, BS, MAS, HON-ONN-CG
Editor-in-Chief, JONS; Co-Founder, AONN+; University Distinguished Service Professor of Breast Cancer, Administrative Director, The Johns Hopkins Breast Center; Director, Johns Hopkins Cancer Survivorship Programs; Professor of Surgery and Oncology, JHU School of Medicine; Co-Creator, Work Stride-Managing Cancer at Work

Though most women diagnosed with breast cancer are good candidates for breast conservation therapy, there remains a portion of women diagnosed who need to undergo mastectomy. These include women with: the presence of multicentric disease; a large tumor contained within small breast tissue volume; previous radiated breast; or inflammatory breast cancer. There are also women who make a personal decision that they prefer to have mastectomy rather than lumpectomy surgery. Something that has been recently written about and warrants discussion (or in this case blogging) is the importance of ensuring that your patient has all the information she needs to decide the type of surgery she wants to have performed (if a candidate for either lumpectomy or mastectomy) and the opportunity to consider reconstruction. Reconstruction is rarely incorporated into the decision-making process for surgical breast cancer treatment.1 Despite the increase of breast reconstruction procedures being performed in 2008, nearly 70% of women who were eligible for a reconstruction procedure were not informed about this plastic surgery option.2 

In a survey of recently diagnosed women who had surgery performed by a general breast surgeon, those who discussed reconstruction with their surgeon were four times more likely to receive a mastectomy compared with those who did not. Younger women had a higher probability to have a discussion about reconstruction options than older women.1 This all highlights the importance of a multidisciplinary care model to facilitate an informed surgical treatment decision-making process with the patient. 

As nurse navigators, we have a critical role in facilitating a referral for discussion with a plastic surgeon. Unless the patient has significant comorbid conditions that prevent her from being able to have general anesthesia safely, then all comers should have a consultation with a reconstruction surgeon. Age in and of itself should not be a factor. Most importantly, inconvenience on the part of the breast surgeon shouldn't be either. ([AU: Please provide a reference for this statement.]A primary reason for not making the referral was the complexity of having to arrange operating room time with another surgeon; therefore, it is easier for the breast surgeon to do the mastectomy without reconstruction as a solo procedure.) 

Initiating the discussion with the patient is essential. It is not unusual, however, for a patient to decline initially. If prodded to explain why, a common answer is that the patient “doesn't want to ask for anything beyond saving her life.” Other responses include concern that reconstruction will delay starting chemotherapy (it shouldn't); the patient doesn't want to bother with it now (then when?); the patient assumes what it would look like (show her photographs of fresh postoperative women through to 2 to 3 years after surgery); the patient is unfamiliar with the various forms of reconstruction, and only has heard about the bad publicity implants got a decade ago and her neighbor's problems with hernia repairs post-TRAM flap surgery (DIEP flap and S-GAP have solved those problems). 

Your role as a navigator is not just to navigate one patient, but also to put together, from an operations management perspective, a way to streamline coordination of care for all patients. This is an excellent opportunity to work with your surgical faculty and develop relationships with plastic surgeons who can make themselves available quickly for add-on consultations. You can also use this opportunity to facilitate working out the bugs that result from the challenge of surgeons performing their procedures simultaneously. Your patient will thank you later for restoring her cleavage and mammary folds. 

References

  1. Alderman AK, Hawley ST, Waljee J, et al. Understanding the impact of breast reconstruction on the surgical decision-making process for breast cancer. Cancer. 2008;112:489-494.
  2. 2009 Report of the 2008 Statistics of Plastic Surgery. Arlington Heights, IL: American Society of Plastic Surgeons; 2009.
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