New Surgery
Eases the Toll
Of Breast Cancer

By RHONDA L. RUNDLE
July 1, 2008; Page D1

Surgeons are increasingly offering an added benefit to their breast-cancer patients: removing the tumor and cosmetically repairing the breast at the same time.

Women with breast cancer traditionally would see a cancer surgeon to have the diseased tissue removed and later see a plastic surgeon for reconstruction. Now, more cancer surgeons are getting trained in cosmetic techniques that preserve or restore a breast's shape or appearance. This emerging field of "oncoplastic surgery" could allow a patient to minimize the number of times she must go under the knife.

PODCAST

The Cooper Clinic's Dr. Gail Lebovic talks with WSJ's Rhonda Rundle about the oncoplastic surgery and how to determine if you're a good candidate.

The shift comes as traditional plastic surgeons turn increasingly to purely cosmetic procedures, which pay more. Indeed, the number of breast-reconstruction surgeries declined 29% to 57,100 last year from 2000, a development the American Society of Plastic Surgeons attributes in part to poor insurance reimbursement for these procedures.

Breast cancer strikes one out of eight American women at some time in their lives. Making plans for breast reconstruction at the same time as cancer surgery can speed a woman on the path of psychological, as well as physical, recovery. And by combining procedures to reduce the number of operations, it also reduces the risk of complications from successive surgeries.

The combination of cancer surgery with cosmetic techniques is aimed mainly at women with early-stage cancer getting a lumpectomy, a procedure that removes cancerous tissue but leaves the rest of the breast. Oncoplastic surgery also can sometimes benefit patients who need a mastectomy, or total breast removal, by helping to prepare their bodies for subsequent reconstruction.

"There is a growing awareness that we haven't done as good a job as we should" in offering aesthetic options to breast-cancer patients, says Pat Whitworth, director of the Nashville Breast Center in Nashville, Tenn.

In a typical lumpectomy, also called a partial mastectomy, the surgeon makes an incision, scoops out the cancerous tissue and then closes the opening. That can often leave the breast with a disfiguring dent. In oncoplastic surgery, by contrast, a wedge is removed and tissue under the skin is then pulled together to close the defect. That can leave the breast looking smaller, but otherwise normal. Sometimes an oncoplastic approach may be taken by two surgeons teaming up to do cancer removal and repair in the same operation.

"What we're talking about for the most part is how to do a nice lumpectomy," rather than relying on breast reconstruction that uses artificial implants or tissue transplants, says Benjamin Anderson, director of the University of Washington's breast clinic in Seattle.

Sandy Masson, a 48-year-old nurse and director of women's services at Hoag Hospital in Newport Beach, Calif., was diagnosed with breast cancer in April. The first surgeon she consulted recommended a mastectomy, because she had two lumps in different parts of her breast, and she was set to go ahead with it. Ms. Masson, a mother of two young children, says her only thought was: "I want to live; I don't care what I look like."

At the urging of colleagues, Ms. Masson then consulted Melvin Silverstein, an oncoplastic surgeon who had recently moved his practice to Hoag. He told her she could avoid a mastectomy without incurring any increased risk to her survival. Dr. Silverstein says he removed a crescent-shaped chunk of tissue that got both cancerous lumps but spared a substantial portion of the breast. In the same operation, he reduced the size of her other breast to give her a symmetrical appearance.

A week later, Ms. Masson was back to work and is now undergoing chemotherapy. "I'm normal now and not deformed," Ms. Masson said recently, lifting her blouse and bra to display Dr. Silverstein's handiwork.

The number of surgeons using oncoplastic techniques is small but growing, says Diana Rowden, a breast-cancer survivor and vice president of health sciences at Susan G. Komen for the Cure, a Dallas-based advocacy group. There is no professional certification for oncoplastic surgeons, so patients should inquire about a practitioner's training and experience.

The American Society of Breast Surgeons since 2005 has sponsored introductory oncoplastic courses at its annual meeting. In December, the American Society of Breast Disease, a group that includes radiologists and oncologists, held its first School for Oncoplastic Surgery in Texas. The three-day course, to be repeated this year, included a session at the cadaver laboratory at Baylor Medical Center at Frisco, where the surgeons got to practice some techniques. Practitioners say they don't make more money from oncoplastic surgery than from regular cancer surgery, and say the attraction is mainly wanting to do a better job for their patients.

Some cancer surgeons say they are seeking oncoplastic training because of a shortage of reconstructive surgeons, a growing problem especially in rural areas and midsize towns. Plastic surgeons are "bailing out" because "they get paid $1,000 for reconstruction when instead they could do four breast augmentations at $5,000 a pop or more," says Michael Cross, a breast surgeon in Fayetteville, Ark. Reconstructive surgeries also often take more time to perform than purely cosmetic procedures.

"The vast majority of plastic surgeons still do both reconstructive and cosmetic surgery," says Michael McGuire, a spokesman for the American Society of Plastic Surgeons. Still, he blames the decline in reconstructive surgery in recent years on poor insurance reimbursement that "is part of the greater health-care crisis in this country." Federal and state laws require insurance companies to cover breast reconstruction, but the laws don't set payment rates.

Dr. McGuire says he welcomes efforts by cancer surgeons to learn what plastic surgeons can do, but he is skeptical of oncoplastic courses. "To think a surgeon can learn how to do this in a weekend course is unwise," he says. Cancer surgeons say that some techniques aren't difficult and can be quickly adopted. They agree that more intensive training is needed for more complicated procedures, such as reconstruction using artificial implants.

Stephania Timothy, a general surgeon in Wenatchee, Wash., says that after attending a daylong course in New York recently, she was able to start using simple incision techniques that give patients better cosmetic results. She says she plans to improve her skills by practicing at the University of Washington's cadaver laboratory and by pursuing more training.

The Mary Kay Ash Charitable Foundation announced Monday that it will fund a small fellowship program "to train breast surgeons in the emerging field of oncoplastic surgery." The program will be led by Gail Lebovic, a cancer surgeon at the Cooper Clinic in Dallas, who has received specialized training in reconstructive and plastic surgery.

Tanya Elmer says that after she was diagnosed with breast cancer two years ago, she interviewed surgeons who told her they would "get rid of the cancer and then 'you can go to another doctor' " for reconstruction. At the urging of a friend, the 54-year-old homemaker in Flower Mound, Texas, went to see Dr. Lebovic.

Ms. Elmer says her mind was eased when Dr. Lebovic explained how she would both perform the surgery and repair the breast. Ms. Elmer says the advance planning for reconstruction enabled her to complete the treatments after two surgeries, rather than three.

Write to Rhonda L. Rundle at rhonda.rundle@wsj.com