Cosmetic Surgery Tips

Breast Reconstruction And Hysterectomy At The Same Time

Breast reconstruction and hysterectomy at the same time are a fairly common procedure. Most women choose to have both of these surgeries at once because they are related, and because they help to treat a number of other issues.

While it’s not uncommon for women to have both of these surgeries, the recovery process can be difficult. Most women need around 6 weeks to recover from their hysterectomy alone, and then another 4-6 weeks for their breast reconstruction surgery.

The best way for you to get through this process is by being prepared with all of your questions and concerns beforehand. You’ll want to make sure that you’re comfortable with your surgeon and how he or she plans on treating your condition before going under general anesthesia for both surgeries at once.

Breast Reconstruction And Hysterectomy At The Same Time

Breast Cancer: Hysterectomy and Removal of Ovaries and Tubes

It is well possible that patients diagnosed with breast cancer have been undertreated in the past.

A study to be published soon shows that breast cancer patients who have a hysterectomy and a bilateral salpingo-oohorectomy (BSO) had a 30% increased chance of survival compared to those who preserved uterus and ovaries.

As gynaecological oncologists we regularly see patients with uterine and ovarian cancer who had breast cancer in the past. Some of those poor breast cancer women even had a hysterectomy and had their ovaries preserved. I asked myself if these women could have not only survived their breast cancer but also prevented another gynaecological cancer if they had their uterus, tubes and ovaries removed?

Together with the Cancer Council Queensland and Queensland University of Technology our unit extracted data of 21,000 women diagnosed with primary breast cancer between 1997 and 2008.

We wanted to explore if the “prophylactic” (surgery not related to the treatment of gyn cancer) removal of uterus, tubes and ovaries had an impact on the incidence of gynaecological cancer and if that impact was strong enough to reflect in survival chances. We were also aware of potential side effects from surgery and early menopause and collected data on stroke, DVT/PE and heart attacks as well.

Overall, 7% of women had a hysterectomy and BSO and most of them were premenopausal at the time of surgery. None of those women who had surgery developed gynaecological cancer. Overall survival was significantly better in the group of women who had a hysterectomy and BSO. Especially women who were premenopausal had a 55% higher chance of survival if they had a hysterectomy and BSO.

We do realise that this study comes with some shortcomings: First, the effect was only valid for women who had a hysterectomy and a BSO. Women who only had a BSO did not reap a benefit. I am unable to explain this effect in detail but the most likely reason is an issue with the coding of surgical procedures in Australian hospitals. In a number of instances it is unclear from the surgical procedure code whether one or both ovaries were removed or if they were preserved.

Secondly, data on hormone receptors are not available. If we were to obtain those results, hormone-receptor status would need to be redone for all 21,000 patients, which would be extremely costly. However, the survival advantage for women who had gynaecological surgery is so great that hormone receptor status alone would not be able to explain the differences in survival.

This study is the first study that has shown that hysterectomy and BSO creates survival benefits for breast cancer patients. In non-breast cancer patients, it is generally advised to preserve the ovaries in order to spare our patients hormone-depletion effects. By contrast, prophylactic surgery is well accepted in patients with genetic mutations, such as BRCA1 or BRCA2 or Lynch.

This study also has shown that current breast cancer treatment more than likely delivers under-treatment. The treatment that these women currently receive can be far more effective. 

I spoke to some breast cancer clinicians and they virtually all agree that a large group of breast cancer patients are hesitant to take their hormone (anti-oestrogen) treatment. Chemotherapy alone is not effective enough to stop all endogenous oestrogen production. Periods may stop but oestrogens are still active and provide fuel for the growth of breast cancer cells.

Further, my colleagues also agree that research into better treatments is financially driven. Pharma companies provide funds to research better treatments. Pharma will not fund surgical treatments because they simply don’t derive a benefit from those. And we all know that our National Funding body, the NHMRC is unable to fund surgical trials even if they believe they are absolutely worthy of funding. Hence, if surgical treatments would outperform medical (pharma) treatments, we simply would not know.

The main consequences of this study are twofold. Some clinicians will see this as a justification for the clinical practice that they already do. There are a large number of doctors who recommended prophylactic hysterectomy and BSO after breast cancer. These doctors will now be reassured and will push even harder for their patients to get into adjuvant surgical menopause.

The other consequence is that these data should be validated by independent data sets. One study should not change the entire treatment of a disease. Confirmatory reports should be requested to confirm those findings.

Fact is that these issues touch a very large patient population and the potential gain of adjuvant surgery is enormous.

Double Mastectomy and Hysterectomy

As breast cancer treatment improves and genetic screening brings ‘compelling’ insight into cancer risk, women face agonizing choices about how far to go in the name of prevention.

It’s a familiar paradox: When we screen more people more often for cancer, we don’t just help by finding life-threatening cancers sooner; we also hurt by giving some people with pre-cancers or low-risk cancers overly aggressive treatments.

When it comes to breast cancer, things are even more complicated. Doctors can screen for cancer. They can also screen for mutations in BRCA genes that put some women at much higher risk. (Women with a BRCA1 mutation have roughly a 60 percent chance of developing breast or ovarian cancerTrusted Source by age 70.)

Some women with cancer in one breast who are qualified for a lumpectomy and radiation choose to have a double mastectomy rather than having both breasts removed. Some who test positive for the BRCA gene mutation choose to have healthy breasts and ovaries removed, like star Angelina Jolie did last year.

If doctors find cancer, invasive or non-invasive, there are two breasts to consider. Many patients seem to want aggressive treatments, bartering their breasts for peace of mind.

The question is, do women really get that security?

Life Expectancy After Total Hysterectomy

In California, double mastectomies have become a more popular option to treat patients with cancer in just one breast. In 1998, just 2 percent of those patients underwent a double mastectomy, but in 2011, 12 percent did, according to a recent study published in the Journal of the American Medical Association.

It was the patients with the greatest number of choices who were most likely to take the more aggressive course. Patients who underwent double mastectomy were more likely to be white women under the age of 40 with private insurance. Patients receiving care from a prestigious National Cancer Institute medical center were more likely to have a double mastectomy.

The study found no evidence that the surgery lowered their risk of death compared to more conservative lumpectomy and radiation. Cancer in one breast very rarely spreads to the second, according to Dr. Harold Burstein, a breast cancer specialist at the Dana-Farber Cancer Institute.

In this situation, aggressive care is not, by the numbers, a good trade-off.

Barbara Koenig, a medical ethicist at the University of California, San Francisco (UCSF), was blunt about what these findings should mean to doctors.

“If a patient came to you and said ‘I’m terrified I’m going to get cancer in my leg,’ you wouldn’t remove the leg, you’d give them a psych consult,” she said. “Professional ethics really preclude simply doing things because the patient asks.”

But Burstein left room for the patient to make her own choice.

“Sometimes that makes sense and sometimes it doesn’t,” he said. “The most important thing is to get appropriate treatment for the cancer you know about.”

Genetic Risks Offer a Different Set of Tough Choices

Not all preventative surgeries are the same. Women who elect to have a double mastectomy and/or a hysterectomy when there’s no known cancer but a high genetic risk strike a different bargain.

IIn the United States in 2011, more than one-third of women younger than 40 who tested positive for a high-risk BRCA1 mutation chose to have a double mastectomy. Preventative double mastectomy doesn’t cut the risk of breast cancer to zero, but it does reduce it by 90 to 95 percent, according to the National Cancer InstituteTrusted Source.

The other option is surveillance, which involves examinations and scans once every six months. The “watch and wait” method is more reliable for catching breast cancers than ovarian cancers.

“We present both of these choices to women with BRCA mutations and usually most women know their own mind,” Burstein said.

Many patients, including Jolie, say they feel empowered by their decision to take manage their risks proactively.

“The things that I’m at risk for by going into menopause early are things that to an extent I can prevent in my life, but I can’t prevent ovarian cancer,” said Megghan Shroyer, a Dayton, Ohio, woman who underwent a double mastectomy and radical hysterectomy in 2012 at the age of 28.

“I wouldn’t want to know that my body would be a ticking time bomb, and that’s what it felt like,” Shroyer said.

“I wouldn’t want to know that my body would be a ticking time bomb, and that’s what it felt like.” — Megghan Shroyer

Merilee Kern, 45, learned in 2010 that she had a BRCA1 gene mutation. Although Kern, who lives in San Diego, was newly single and “admittedly horribly vain,” she also opted to a double mastectomy, hysterectomy, and oophorectomy, or removal of the ovaries.

“I’d had a biopsy that turned out to be fine, but there was so much angst and anxiety,” she said. Although the BRCA results caused her even more anxiety and led to a series of major surgeries, she is thankful that she found out.

“It depends how much a gambler you are and under what kind of cloud you want to live your life. For me, I call it the crystal ball. It’s this gift of knowledge,” Kern said.

Some Ethnic Groups Have Higher Risks

Kern’s mother was suffering from cancer when she decided “almost on a whim” to be tested for the cancer-linked gene mutation. Kern’s family had a greater chance of carrying the gene because they are of Eastern European Jewish descent. Two in 100 Ashkenazi Jews carry one of the BRCA mutations, while in the general population, just 1 in 200 people do.

Israeli researchers have argued that all Ashkenazi Jews should be screened for the problem genes. The U.S. Preventive Services Task Force (USPSTF) recommends against BRCA genetic screening for women who don’t have a family history of cancer, even if they belong to particular groups, like Ashkenazi Jews, with higher rates of BRCA mutations.

In a recent study published in the Proceedings of the National Academy of Sciences, researchers reported that Ashkenazi Jewish women who carry the mutation but do not have a family history of cancer still face higher cancer risks than those without the mutation. U.S. screening recommendations would miss those women.

“It depends how much a gambler you are and under what kind of cloud you want to live your life. For me, I call it the crystal ball. It’s this gift of knowledge.” Merilee Kern

UCSF’s Koenig has researched the implications of genetic testing.

“I personally am moving toward the conclusion that there are certain genetic findings that are so compelling that people would want to know,” she said.

It’s a question of finding those people without needlessly frightening others, and ensuring that patients get all of the information they need as they decide how to handle their genetic risks.

“It’s a personal choice, and we like to think that patients make it based on good information and good facts,” Burstein said.

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