How the coronavirus affects breast reconstruction surgery
The outbreak of COVID-19, the disease caused by the new coronavirus, affects the way hospitals deliver treatment, people interact with their doctors, and people and institutions think about essential care.
Breast reconstruction in this time is an area of confusion for many people. Whether planning on immediate reconstruction with breast surgery, waiting for a revision or a permanent implant, or needing to resolve complications, many women want to know if their procedures are considered “elective” operations that will be delayed during the COVID-19 pandemic.
We are here to help you find answers and support during the COVID-19 outbreak and beyond.
Living Beyond Breast Cancer CEO Jean Sachs, MSS, MLSP, spoke with reconstructive surgeon Clara N. Lee, MD, about how healthcare systems, surgeons, and people seeking treatment are deciding what procedures are being performed and what is being delayed. Watch, listen, or read the transcript below.
Clara N. Lee, MD
Clara N. Lee, MD, is associate professor of plastic and reconstructive surgery at The Ohio State University College of Medicine. She is an associate professor, by courtesy appointment, of health services management and policy in the university’s college of public health.
Jean A. Sachs, MSS, MLSP
Chief Executive Officer, Living Beyond Breast Cancer
Jean began her work with LBBC in 1996 when she became the organization’s first executive director; she was named CEO in 2008. Jean brings a lifetime of women’s advocacy experience to her role as CEO. She lives LBBC’s mission everyday by speaking with newly diagnosed women about their needs and gaps in support. Read more.
Jean Sachs (00:00):
Hi, everyone. It's Jean Sachs, the CEO of Living Beyond Breast Cancer. I hope you're all doing as well as possible, staying safe and staying healthy. As many of you know, we have been interviewing doctors from around the country who are part of Living Beyond Breast Cancer's medical advisory board to get your questions answered and to give you the latest updates in this very fluid situation. Last week we covered breast surgery with Dr. Monique Gary and if you haven't had a chance to listen to that recording, it is on LBBC.ORG.
Today we're going to focus on breast reconstruction and I'm really pleased that we have Dr. Clara Lee, who is an associate professor of plastic and reconstructive surgery at the Ohio State University College of Medicine. Dr. Lee is also a really good friend of Living Beyond Breast Cancer. We've done multiple programs together and she is a real advocate to help women make informed decisions before they embark on their breast reconstruction process.
Welcome, Dr. Lee. It's great to have you.
We have a bunch of questions so we'll jump right in. We know early on, when it was clear that COVID-19 was going to impact health systems around the country, decisions were made that hospitals would stop performing elective surgeries or what they consider non-essential surgeries, so we really want to understand how that has impacted breast reconstruction.
Clara Lee (01:37):
In general, it's pretty variable what institutions are doing. I have found by talking to my colleagues and also reading various communications that it does vary by geographic region and even within an area how a different institution is handling it.
As you may know, the American College of Surgeons came out pretty early with a recommendation to stop elective surgery. More recently, the American Society of Plastic Surgeons made a statement about breast reconstruction that was somewhat open-ended. The challenge for breast reconstruction is it's not super black and white about what is elective and what is not or what is urgent and what is not. It's a bit of a gray area and I think different groups have been tackling it as best they can.
Jean Sachs (02:39):
That means that some breast reconstruction is still happening?
Clara Lee (02:43):
Yeah, for sure. I can give you some examples of what might be considered along the range of possibilities of what is still going on and what's not going on.Would that be helpful?
Jean Sachs (2:59):
Really helpful. Yeah.
Clara Lee (3:00):
Okay, great. I think when the recommendation to postpone elective surgeries came out, a lot of us thought about some of the obvious things on either end of the spectrum, really urgent and really not urgent.
An example of an obvious thing that could wait is a revision of a reconstruction years after someone has had reconstruction or a planned stage of reconstruction that's not the first stage, for example, the nipple reconstruction or the contralateral symmetry procedure — a breast reduction on the other side. Those kinds of things most people, most surgeons, agreed could wait without any impact on the patient's outcome in terms of how their reconstruction looks and feels. Certainly there's impact on how the patient feels like having to wait for surgery with any of these. But in terms of the actual impact on the surgery, those things could wait.
That's sort of the extreme where I don't think there's been much controversy, and the other end of the spectrum, where it's absolutely clear that it can't wait, is an urgent complication from breast surgery or breast reconstruction. For example, if a patient recently had a TRAM flap or a DIEP flap and there's issues with the blood vessels that needs to be fixed right away, or if a patient had surgery and is having bleeding or severe infection, those kinds of things are obvious on the other extreme, they do need to happen.
Then there's a whole gray area in between.
Jean Sachs (4:45):
This is when you really want to have good communication with your doctor. Tell us a little bit about how you're communicating with your patients and the reactions you're getting.
Clara Lee (4:57):
The key thing is good communication. The first thing I did, even before the recommendations were made, is personally call my patients who had surgery scheduled soon. My physician’s assistant, who I work with closely, and I sat down with a whole list of patients and we just called them to talk about options. I think that was key, to personally hear from me and to discuss the potential impact.
The reactions I've gotten have changed a little bit over the last couple of weeks and early on people were a little bit like “I didn't know what to expect” and now it's more patients who have surgery scheduled in late April and we're starting to call them. People are more much more aware about the epidemic and the impact on the healthcare system. And so it's a little bit more like, “Oh yeah, I'm not surprised.”
Many of my patients have personally reached out to me, either when I'm calling them or not related to a phone call, and thanked me for being a doctor right now, which really is really touching. Most patients have been quite understanding of the need to reschedule their surgery. And I've emphasized to them that it's for their own safety as well as for the safety of healthcare providers. Other patients who are going to be in the healthcare system and we need to preserve personal protective equipment and healthcare resources.
Jean Sachs (06:42):
And we thank you as well, for all you're doing. At Living Beyond Breast Cancer, we're so grateful.
Let me ask you a specific question. If a woman has had her expanders in and she was getting close to having the exchange surgery, what are you doing in those cases?
Clara Lee (07:01):
We're postponing all of those and that's because there's no real urgency to it. I'd say the main downside of waiting is, as many of you know, the expanders are not comfortable, but there's no real impact on the final outcome of the reconstruction if we wait on that.
Jean Sachs (07:23):
Are women getting the option of immediate breast reconstruction or is everybody being tracked to have delayed reconstruction?
Clara Lee (07:35):
At our institution, we decided as a group that, for the most part, patients would have delayed reconstruction right now during the epidemic. There's a few different reasons for that. Some of us have wondered whether or not we need to do that since the patient is already having surgery. She's having the mastectomy, so it won't add more visits to the hospital for her. It could add some time in the operating room. That's one issue. Then it would, we do know that when you have reconstruction, it does add more postoperative visits. What we're [figuring out], in general, whether or not to hold elective surgery is all of those things. Are we adding more interactions between the patient and the healthcare personnel and the medical system? That's what we take into account.
A more subtle aspect of this question is, what's the chance of something unexpected happening that brings the patient back into the healthcare system again? Especially for our patients who are immunocompromised, the last thing we want is for them to be coming back into the medical system, with potential exposures, more than they need to be.
That's subtle because that has to do with not the definite things that are going to happen, but the chances of something happening, which mostly has to do with the chance of a complication. We factor that into our decision about whether or not to offer immediate reconstruction.
At our institution we're not doing immediate breast reconstruction unless there's a particular circumstance that makes it their one opportunity to have an adequate reconstruction. There are some circumstances, for example, patients who we are pretty sure they're going to need radiation after surgery who can't have autologous or a flap reconstruction. Having immediate reconstruction with an implant may be their one opportunity to have reconstruction.
In those cases where we're doing it and there are a few other cases. In the case of reconstruction after lumpectomy, which is called oncoplastic reconstruction, we had a long discussion about that as well. In that situation, all of those patients are getting radiation after the surgery and it's very tricky to do oncoplastic surgery after radiation. It’s possible, but it's a whole different situation. Because of that, we are proceeding with oncoplastic reconstructions, but only on the side of the cancer, we're not doing the other side until later..
Jean Sachs (10:36):
That was going to be my next question, so thank you. I know this is really hard for everybody right now, but really hard for breast cancer. Newly diagnosed breast cancer patients certainly didn't elect to have breast cancer, so they weren't really electing to have plastic surgery. I just want to reiterate that we're taking options away and that's what's happening.
Clara Lee (10:59):
Yeah. The ability to offer reconstruction to our patients is such an important part of their journey. And for many women, it's a really important part of getting through the process and then healing on the other side. Actively taking that away is really difficult for them. It's difficult for us because we really believe in what we do and yet I really do believe that we're doing the right thing for our patients ultimately. There's the public health, but for our individual patients as well, and that they eventually will get to the same place, but it'll just take longer.
Jean Sachs (11:41):
When we move past this crisis and, and women are able to come back for a delayed reconstruction, should they anticipate any problems with their health insurance coverage?
Clara Lee (11:53):
Oh, good question. I don't think so because we routinely do delayed reconstruction anyway. This would just be another version of delayed reconstruction, so I don't think so. I think the potential issue is in scheduling.
After the epidemic subsides and we're able to do elective surgery again, there will definitely be a backlog of urgent cases and a backlog of elective surgeries. It's going to take a while to get back on top of those.
Jean Sachs (12:27):
That's a really good point. We will have to keep reminding people that we'll have to be patient and doctors will have to make decisions in this triage way that you've been making decisions.
Clara Lee (12:39):
Exactly. There'll be a whole new wave of triage them.
Jean Sachs (12:44)
You've talked a lot about how you've been supporting your patients. I'm really impressed that you've made phone calls and your physician assistant have been making phone calls. Are there other ways you've been supporting patients or if there is a woman or women out there listening who feel unsupported, do you have some suggestions of things they could be doing?
Clara Lee (13:04):
Being informed about the impact of breast reconstruction and the potential impact of waiting for your breast reconstruction can only help. I think it always helps to be informed and ways you can do that are through something like Living Beyond Breast Cancer, which has so many resources. Also, talking to your surgeon or to other clinicians, asking them questions.
I have had patients ask me, “If I wait, what will my incision look like when we do the reconstruction months from now? And how is that different than if we were doing it now?” I love it when patients ask those questions. They need to. In other words, if your provider is not telling you those things and you're wondering about it, certainly ask, but then also try to read. That would be the first thing I would say: inform yourself.
The other thing is, our institution has been really deliberate about making telemedicine visits and video visits possible for our patients. We always offer the option, but not everyone feels comfortable doing it that way. If your surgeon hasn't offered that, definitely ask, because I think most institutions are.
Say you have had your surgery delayed and you have a concern about how it's going to affect the reconstruction. You can still talk to the plastic surgeon even though you haven't had the surgery yet. Ask them for more information or ask them about a concern you have. In other words, staying informed and staying in touch with your providers.
Jean Sachs (14:46):
Are you doing any second opinions for people who are trying to decide what kind of reconstruction to have? Is that happening?
Clara Lee (14:55):
In general we’re seeing fewer of those kinds of visits, non-essential consultations. But yeah, I saw a patient yesterday that was a second opinion, so we're still seeing them. I saw that patient in person. It's certainly possible that even clinic visits, consultations will start becoming more and more limited. but it really, we don't know. It depends how the epidemic progresses. And I think it varies by location in the country.
Jean Sachs (15:30):
Yeah, that's very true.
I think you made a really good point. I know in talking to so many newly diagnosed women over the years that making the decision about breast reconstruction is often very rushed because they want to get everything moving and this does give an opportunity for women to be more thoughtful about what they might want: if they even want reconstruction or how they want to do it. I think that you make a good point: use this as an opportunity to get more informed. Living Beyond Breast Cancer can connect people to other women who have had a variety of different kinds of reconstruction. I appreciate you bringing that up.
I think we covered all the questions I had. Do you think we missed anything that you want to make sure patients are aware of?
Clara Lee (16:21):
If there is a silver lining in some of this, it might be for oncoplastic surgery. What we're doing, at least here, we're doing the oncoplastic side now, but we're not doing the other side. For example, if a woman is having a breast reduction approach to her lumpectomy, we usually do the whole thing. In theory, that can bring up symmetry issues later. Like after you've had radiation. there might be differences in the two sides. So one potential silver lining is that we now can do the other side after there have been changes and there might be better symmetry. I tried to think in the positive of the possible good things that might come out of this.
Jean Sachs (17:08):
Yeah, we have to all find the silver linings.
Thank you so much, Dr. Lee. This is really helpful and I know will be extremely helpful to people who are in the middle of making these decisions and they're there all over the country as we know.
Thank you to everyone for listening. Remember, Living Beyond Breast Cancer has a lot of resources on our website. We also have closed Facebook pages, so if you want to connect with other women or call our helpline, we want to hear from you. Stay strong, stay safe, and we will continue to do everything we can to provide you with the information you need to make informed decisions. Take care.