Decisions

Here is the promised post on decisions:

After acquiring the information from MDA this week, I've pretty much limited my surgical options down to two options. The first option is breast conserving surgery (lumpectomy), and the second option is bilateral mastectomy with SGAP reconstruction. There are many pros and cons to both options. Both have more cons than pros. I spent some time earlier writing this out on paper to try to come up with lists of the pros and cons for each to use as a decision making tool. Below is a description of each option, followed by the pros and cons of each. If you have any opinions you'd like to share, please feel free to email, call or comment.

Breast Conserving Surgery (aka lumpectomy)
This is a simple outpatient surgery where the surgeon makes an incision near the tumor site and removes the tumor along with a small margin of cancer free cells around the edges. Once the tumor is removed, a pathologist reviews the tumor and insures the margins are clear. If the margins are not clear, an additional surgery is required to achieve this. The breast is then radiated to insure that any remaining cancer cells are eliminated. The 5 year mortality risk for this surgery and mastectomy are the same; however, the chance for recurrence is slightly higher (15% vs 5% for mastectomy). Post surgery, you would require more frequent mammograms and ultrasounds than the normal population (most likely every 6 months rather than once a year). My biggest fear with this surgery is that they will not be able to adequately screen me afterwards. I plan to call MD Anderson and talk to the radiologist who I mentioned in the proceeding post and ask how well he feels he can screen me should I choose this option.

Skin Sparing Bilateral Mastectomy with SGAP Reconstruction
Skin sparing bilateral mastectomy is a surgery where they remove the breast tissue and nipples from both breasts. They make the incision around the nipple area and sew the skin back together, leaving two scars where the nipples used to be. Before they sew the incisions, they typically place expanders (saline or air filled bags that can be expanded) in place to stretch the skin. In my case they would put these in place, and prior to radiation they would deflate them. After radiation, they would reinflate these and continue to inflate them until the skin is stretched enough for reconstruction. It would be 4-5 months after radiation before reconstruction can even be considered. A hospital stay and several weeks recovery time are required. This surgery also involves having drains put in that stay in for several weeks. These drains have to be emptied at home each day.

The SGAP reconstruction consists of taking skin and fat from the hip to create the breast mound. The expanders are removed and the fat is put into the breast to create the shape. The patch of skin they take is shaped like a football and sewn cross the center of the breast like a patch. In order to get blood to the skin patches, they have to microsurgically attach the blood vessels of the patch of skin to nearby blood vessels. This is a tedious task. One breast usually takes 8 hours to complete. Several days of hospital care are required. Recovery can take many weeks. A second surgery is usually needed for each breast to correct any problems. A third surgery is required to create a nipple. There is a risk of necrosis occurring if the skin patch does not take. Risk of infection is also an issue. This procedure appears to be a rare one and not many surgeons are very experienced. Even at MD Anderson, their best surgeon has only done 20 in their career. I was told they have more experienced surgeons in New Orleans at the Microsurgical Center. I plan to call them and get more information and see if this is true.

So here is what I have for pros and cons on each:

Lumpectomy

Pros:
Outpatient Easy Surgery
Little to no recovery time
No hospital time
No drains
Maintain feeling in breasts

Cons:
Have to go back to MD Anderson (I wouldn't feel confident having it done here)
Screening Concerns
Higher chance of recurrence(15% vs 5% for mastectomy)
Future possibility of many biopsies should they find any little thing on my screenings
Possibility of second surgery should they not get clear margins
One Scar
Possibility of slight breast asymmetry
Worry that they will miss something on a screening
Costs associated with travel

Bilateral Mastectomy with SGAP Reconstruction
Pros:
Lower risk of recurrence (5% vs 15% for lumpectomy)
No future screening necessary
Less worrying about recurrence

Cons:
Have to wait until after radiation for reconstruction
Have to use prosthesis or go flat chested during this time
Multiple scars
Multiple surgeries
Multiple recoveries
Risk of necrosis(which would lead to more scars and more surgeries and more recoveries)
Have to travel to New Orleans
Costs associated with travel and lodging
More invasive surgery
No feeling in breasts
Mastectomy requires physical therapy afterwards to achieve range of arm movement
Risk of infection on all surgeries

So now you see what I'm facing. I have two options, both with more cons than pros. The question is, do I go through hell for an additional year for the 10% lower chance of recurrence, or do I take the quick and easy way out and just hope they can screen me effectively and find anything should it come back? What do you think you'd do and why?