For some breast cancer survivors, reconstruction not part of their plans
After watching her maternal grandmother and maternal aunt die from breast cancer, Amanda Marshall made a pact with her mother.
“We always promised that if we were ever diagnosed, we would opt to just remove everything,” Marshall said. “To eradicate every trace of the disease.”
Marshall was vigilant about getting yearly mammograms from a young age. Three years ago, her mammogram revealed a spot in one of her breasts just after her 38th birthday.
Biopsy results indicated it was ductal carcinoma in situ, or DCIS, often referred to as stage 0. Doctors caught it early, but given her family history, Marshall wanted to keep her pact with her mother — which meant opting for a double mastectomy.
She drove an hour and a half to Pittsburgh from her town of Home, Indiana County, to meet with Dr. Emilia Diego, a breast surgeon at Magee-Womens Hospital of UPMC. After thoroughly reviewing all of her surgical options, and after a lot of long, hard contemplation, Marshall decided that following her mastectomy she would “go flat” — a term used by post-mastectomy patients who forgo reconstructive surgery.
“I didn't want reconstruction for so many reasons,” Marshall said. “You have a longer hospital stay, multiple surgeries, risk of infection. One option is silicone implants, but I knew I didn't want anything foreign in my body. I was already dealing with cancer, so I didn't want to put anything else in there that's not supposed to be there.”
While breast cancer rates have decreased since 2000, nearly 250,000 new cases of invasive breast cancer are diagnosed in women every year. Surgeons say it is important for women to be aware of all treatment and surgical alternatives.
“Patients are becoming more informed about their options,” said Dr. Michael Cowher, a surgeon and Quality Assurance Director for Breast Surgical Oncology at Allegheny Health Network. “They do their own research online and often come in very informed, whereas 15 or 20 years ago people mostly just did whatever their doctor told them to do.
“When it comes to going flat, it is acceptable for women to take time with the decision, Cowher said.
“If you're not sure, you don't burn any bridges by waiting,” he said. “Have your mastectomy, treat your cancer, heal. If in a year you decide you do want reconstruction, you can always come back for it later.”
Diego said the shift in patient awareness is a good thing but worries that elective double mastectomies could become “trendy” because celebrities like Angelina Jolie have opted for them. She points out that among patients eligible for lumpectomies or breast preservation, survival rates are the same for those who undergo optional full mastectomies as they are for those who opt for more conservative surgeries.
Some breast cancer survivors view reconstruction as an essential part of their healing process and undergo it immediately following a mastectomy. Others opt to wait until they've completed their cancer treatment and arefully healed to decide whether they want additional surgery for reconstruction. And others, like Marshall, opt to skip it entirely.
“Every day, people have tonsillectomies, appendectomies and thyroidectomies, and no one thinks twice about it because it's just part of your body that's diseased that you need to get rid of,” Marshall said. “To me, losing a breast or both breasts isn't any different. The only difference is that the world has deemed breasts a necessity for women.”
Diego said she tells patients reconstruction is an option, not a requirement.
“It's not a mandatory part of their care,” she said. “It's a very personal choice.”
Marshall has two children who were 7 and 9 at the time of her surgery, and she wanted to prioritize minimizing their time apart.
“It's a very difficult thing to go through,” she said. “I just wanted to get home and recover.”
Marshall stayed in the hospital overnight after her surgery and went home the next day. Follow-up tests showed no signs of cancer, so she didn't have to undergo radiation therapy or any additional treatment. But life without breasts required adjustments.
“It's almost a grieving process,” she said, “because there's a part of you that's suddenly gone, and it's not a part of you you don't see — it's a part of you that's very visible.”
Marshall sometimes wears a prosthesis in the form of artificial breasts worn inside a bra. She said she likes that option because a variety of shapes and sizes are available, and she can choose when to wear it based on the occasion and her clothing.
“My husband's support helped so much,” she said. “From the start he told me that he would rather have me than my breasts and said he'd support me no matter what choice I made. It did take some time to adjust, but he was there every step of the way, reminding me that my breasts didn't make me who I am.”
Marshall said she's proud of the example she's setting for her kids.
“I wanted my son to see that a woman isn't defined by her breasts,” she said. “I am still a mother, a wife and a sister, even without breasts. And I wanted my daughter to know that true beauty isn't defined by physical appearance. It's in your heart, in your soul.”
Kristina Marusic is a Tribune-Review contributing writer.