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A small study released by the University of Michigan finds that mammography screening in women who have undergone a breast reconstructive procedure called TRAM flap
reconstruction may help detect a recurrence of breast
cancer before the tumor grows large enough to be felt by touch. Currently, most physicians
do not routinely screen breast cancer patients who have had their breasts removed with mastectomy because there is little evidence to show that
screening mammography increases the chances of surviving a breast cancer recurrence. While
the new study reveals that mammography can be helpful in certain cases, the new research
also shows that a recurrence of breast cancer is unusual in women who have undergone TRAM
flap breast reconstruction.
TRAM (Transverse Rectus Abdominis Muscle) flap breast reconstruction is a common
procedure that involves using the patient’s own muscle to reconstruct the breast
after a mastectomy. During the four to five hour procedure, the surgeon transfers some of
the patient’s tissue from the back, stomach, or buttocks to the breast area. Though
the recovery is typically slower than breast implant procedures, the breast usually looks
and feels more natural to most women.
Whether routine screening mammography is needed after a mastectomy and breast
reconstruction has been a debated issue for some time. Because the mastectomy removes most
of the breast tissue, many experts believe that mammography is not necessary since a
recurrence is uncommon. Many recurrences will be felt by physicians during clinical
examination , and local recurrence does not usually translate into a poor outcome. In
addition many benign post-operative changes occur and lead to unnecessary worry and
biopsy. Furthermore, opponents of mammographic imaging after mastectomy believe that
screening yields too many "false positive" results that force women to undergo
unnecessary follow-up screening and/or biopsy.
However, some small studies have shown that mammography can be beneficial after
mastectomy. In October 2000, the University of Michigan released two (small) studies that
showed that careful screening may detect early breast cancer recurrences in women
who have had TRAM flap reconstruction. The key is for patients to have screening performed
by radiologists with clear expertise in this type of breast imaging. The latest study is
also released by the University of Michigan and published in the July 2002 issue of Radiology.
In the study, Mark A. Helvie, MD and his colleagues examined 214 mammogram films of 113
women who had undergone TRAM flap breast reconstruction after mastectomy. Seven of the 113
women had had their breasts removed as a preventive measure because they were identified
to be at high risk of developing breast cancer; the remaining women underwent mastectomy
after they were diagnosed with breast cancer.
According to Dr. Helvie and his colleagues, mammography screening revealed
"suspicious or highly suggestive of cancer" in seven patients, six of whom
underwent biopsy. Two of those seven women were found to have a recurrence of breast
cancer. In addition, one of 16 mammograms revealed a "probably benign" reading
that turned out to be cancer.
Based on these data, Dr. Helvie and his colleagues conclude that mammography can be
helpful in identifying early breast cancer in TRAM flap patients before the cancer can be
detected by touch. Typically, the earlier breast cancer is detected, the better the
chances for survival. However, the researchers were also quick to point out that the study
reveals that breast cancer is not common in TRAM flap patients. According to the research,
approximately 1% to 2% of TRAM flap patients are diagnosed with breast cancer each year,
though long-term data are still needed to determine whether the risk increases for these
women later in life.
Dr. Helvie said that most radiology centers do not have much experience screening
women who have undergone TRAM flap reconstruction. Indeed, most physicians do not
recommend screening mammography on mastectomy patients. Many abnormalities found in the
reconstructed breast are palpable (able to be physically felt) and are discovered by a
physical breast exam. Physicians are not certain whether the early discovery of a
recurrence of breast cancer has any significant impact on the overall survival of the
patients. However, once an abnormality is found by physical
exam, physicians will order diagnostic mammography
and/or other breast imaging tests. Biopsy may be performed to determine whether the
abnormality is cancerous.
Though screening mammography is not typically recommended for women who have undergone
mastectomy, imaging after lumpectomy is essential, though
experts debate whether this screening should occur every six months versus every 12
months. (Lumpectomy is a procedure that removes only the breast cancer tumor and a
surrounding margin of normal breast tissue). Screening mammography should also continue on
the unaffected breast after surgery. Self-exams and clinical
breast exams should also continue after surgery and reconstruction.
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