After treatment

After successfully completing breast cancer treatment a feeling of relief and excitement is often felt, but this is often followed by a feeling of anxiety. The biggest stress point for breast cancer survivors is the fear that it will return. This fear of recurrence will stay with survivors, but over time woman who have beaten breast cancer learn to live with that fear.

During breast cancer treatment patients get used to seeing their doctor and nurses on a daily basis, but from one day to another the daily visits stop. This is another point which breast cancer survivors struggle with, the change in daily habits. After successfully completing the treatment procedure, you will no longer need to see your doctor every day. You will instead be scheduled for the follow-up care, which at first will be every 4-6 months. The longer you are breast cancer free, the less often you have your appointments, and after 5 years, the appointment will only be once a year.

It is important to keep in mind that after your treatment is finished it will be difficult to return to how things were before. Breast cancer is a life altering experience, and you will not be the same person after treatment, as you were before. It is therefore often easier to find not to “get back to normal”, but to find what is normal for you now. Breast cancer survivors often have a different look on life; this can continue to change during the recovery.

A new “normal” life may include changes to your eating habits, your sexuality, and your thoughts on pregnancy.


Reconstructive surgery

Breast reconstructive surgery is generally achieved through a number of techniques that attempt to restore a breast to near normal shape, appearance, and size, following a mastectomy or lumpectomy. The surgery will however not give you a breast that looks and feels exactly the same as the breast that was removed.

Breast reconstructive surgery is a type of plastic surgery used to get back the shape of the breast after undergoing a mastectomy, or lumpectomy. The aim of the surgery is to match the existing breast as well as possible. There are generally three types of surgery. The first involves creating a breast through the use of an implant, which is put under the skin and chest muscles. The other two involve using skin, fat, and sometimes muscle from other parts of the body. The type of surgery that best fits you depends on:

  • The amount of breast tissue removed
  • The health of the tissue at the operation site
  • Whether or not you have had radiation therapy to the breast or chest wall
  • Your general health and body build
  • Your wishes and lifestyle

The first, and probably most important step towards breast reconstruction, is to choose a surgeon that you trust, and feel comfortable with. When choosing your surgeon you should look at his background, and how much experience he has in plastic surgery. You should also ask the surgeon about scaring, and the length of recovery.

As mentioned there are three types of breast cancer reconstruction:

  • Reconstruction using an implant
  • Tissue flap: this type of reconstruction involves skin, muscles and tissue from your back or stomach being tunnelled through the chest to create a new breast. The skin, muscle and fat stays connected to the area from which it is taken.
  • Free flap: similar to the tissue flap surgery, this form of reconstructive surgery involves skin, muscles and tissue, but these more often extracted from the buttock and lower stomach. Instead of leaving the tissue connected to the original area, the tissue is separated, and a new blood supply is created for the new breast using microsurgery.

There are two types of reconstruction using an implant. All three types are only suitable for women who have fairly small breasts.

The first type is referred to as subcutaneous (under the skin) surgery. In this type of reconstruction, the surgeon removes all the breast tissue, but leaves the skin and nipple intact. An implant is then placed directly under the skin to replace the removed tissue. Scaring is often visible when using this type of surgery, with the scar sometimes running from the side of the nipple to the side of the breast. The implant is sometimes easy to feel under the skin, giving it a less natural soft texture.

The second type of surgery is called submuscular. This is where the implant is placed underneath the chest muscles. This type of surgery is not suitable for everyone, especially if you:

  • have had radical mastectomy (the chest muscles have been removed)
  • have large breasts (difficult to match the two breasts)
  • have had radiotherapy (your skin and muscles won’t stretch enough for the implant)

The scaring that is left by this form of reconstructive surgery is often side to side, or at an angle following the line of the original mastectomy. A disadvantage of this type of reconstructive surgery is that the shape of the breasts changes, as the overlying muscles contract.

Long term problems
As with all types of surgery, there are complications that can occur. Through advances in modern medicine these complications are less than they used to be. Some examples of complications include: bleeding, seroma (fluid build-up under the scar), and keloid scarring (excessive scar tissue). But there are also possible long-term problems that can occur as a result of breast reconstruction:

  • Capsular Contracture

Whenever a foreign object is inserted into the human body, such as an implant, the immune system responds by forming fibrous tissue around it. Over time, this tissue can contract as part of the natural healing process. Sometimes, when the contraction is severe, tightening, hardening and changes to the shape of the breast might occur. This can create discomfort, and spoil the match to the natural breast. The majority of contractions occur within the first year, but it can sometimes take up to 3 years.

If the contraction is so severe, or creates so much discomfort, the implant might have to be surgically removed, and a replacement inserted simultaneously. The risk of needing surgery to remove the implant as a result of capsular contracture is 10-20%, and is more likely needed if you have had radiotherapy prior to the implant.

  • Flap Failure

The main problem with using tissue to replace the removed breast is that the flap might die. This is less likely to happen if Tissue Flap is used. When undergoing a Free Flap surgery, a new blood line has to be created. This is a difficult procedure, and therefore about 1 in 10 flaps develop some problem with the blood supply within the first 48hrs after surgery. About 3-5% Free Flap surgeries fail completely. When this happens the flap will have to be removed, and 6-12 months are needed to recover before a new try can be made.

Breast form

Women, who have lost a breast to breast cancer can use breast forms to simulate the look and feel of a natural breast. The breast forms are a good alternative for women who do not want to undergo breast reconstructive surgery. Breast forms are a type of prosthesis, which can either be worn inside a bra, or attached to the body. They simulate the weight, bounce, feel, movement, and the natural look of the female breast. The modern breast forms are designed by computers and can be attached to the chest. These can be worn with strapless dresses and lingerie, while showering and sleeping. Breast forms can also sometimes cause skin irritation, if this happens you can buy special bras with sewn in pockets, or have your own bras adapted for the pockets.

There is a waiting period between a mastectomy and the fitting of a breast form. The site of the surgery should heal first before you can be fitted for a permanent form. Your doctor will let you know when this is. There is no real suggested waiting period, as the healing process is different for everybody. Besides the fact that your tissue needs to heal before you can get a form fitted, the chemotherapy you undergo may also leave you too sensitive for the constant movement of a form.

It is important to read your insurance policy when purchasing breast forms, as some health insurance agencies might cover the costs of your purchases. It is also good to ask your doctor for prescriptions for you forms and bras. What you should keep in mind though is that once you have submitted a claim for your form, your insurance agency might not cover you for any future breast reconstruction surgery, should you wish to undergo it.


Sexuality and pregnancy

When diagnosed with cancer, the last thing you might be thinking about is sex. But the issue will eventually arise, during or after your treatment. You will want to start going back to your ‘normal’ life, which for many women means resuming sexual intimacy with their partner.

An intimate connection with your partner can be a source of support during your treatment. But breast cancer treatment does have some sexual side effects, which can make resuming sex difficult. Because breast cancer treatment is focused on the upper body, there are fewer side effects than with other types of cancer, such as bladder, ovarian or vaginal cancer. The most likely as a result of breast cancer treatment is due to chemotherapy.

Many women experience a loss of libido during and after chemotherapy. The side effect of the treatment, such as fatigue, nausea, hair loss, and weight changes, can make women feel unattractive. But this side effect soon fades after the treatment ends, but it may take time to rebuild your self-confidence, especially after a mastectomy.

Chemotherapy can cause a sudden loss of oestrogen production in your ovaries. This in turn can lead to symptoms of menopause, such as thinning of vagina, and vaginal dryness, both can cause pain during penetration. You should ask your doctor about the side effects of chemotherapy, because it can sometimes cause permanent damage to your ovary.

When it comes to breast cancer surgery, there isn’t a clear link between surgery and decreased sexual function, although women who undergo a mastectomy may lose sensation in their breast area. What is often observed is that women who have lost an entire breast (or both breasts) can have a decreased libido. This can be a result of a poor self image.

Hormone therapy can also have a negative influence on sexual intimacy. When a woman has a hormone-sensitive cancer, and receives medications that can be effective in shrinking and killing cancer, she can experience menopausal signs and symptoms. But this usually wears off after treatment is finished. But what you should keep in mind is that hormone therapy usually lasts approximately 5 years.

Pregnancy
Even though most of the women who have developed, and beaten breast cancer have already moved past the child bearing stage in their life, in some instances breast cancer strikes at a time when having a child is a priority. These women often have two major concerns regarding pregnancy:

  1. If I’m pregnant before, or during treatment, will the therapy have a negative influence on my pregnancy?
  2. Will the treatment I have had negatively influence my ability to conceive a healthy child?

In women who are pregnant, or who have just given birth, breast cancer often occurs between the ages of 32 and 38. If a women does become pregnant it will be difficult to diagnose her with breast cancer in the later stages of her pregnancy, or after birth, due to the fact that her breasts will be swollen and tender. This can make lumps difficult to detect, and delay the diagnosis. To detect breast cancer, pregnant and nursing women should administer self breast exams, and undergo clinical breast exams during their routine prenatal and postnatal examinations.

If breast cancer is detected during pregnancy, a number of factors should be taken into account, including: size and location of the tumor, how far along is the pregnancy, and has the cancer spread. Treatment during pregnancy aims to achieve the same goals as treatment on women who aren’t pregnant, keep the cancer from spreading. If the breast cancer is so far along that the woman require therapy (radiation, chemotherapy, etc.), she is asked to consider ending the pregnancy because of possible damage to the fetus. Although this does make the treatment process easier, it is not proven that it improves the chances of survival.

But before radiation therapy, chemotherapy, or any other form of therapy is considered, women with breast cancer undergo surgery. The surgery itself will carry little risk for the fetus, the anesthesia on the other hand may pose as a risk. The doctors will work together to decide what the safest time is during the pregnancy to perform an operation.

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