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Fri, 6 Oct 2006 12:58:13 EDT

Oct. 6, 2006. 06:48 AM

LIFE WRITER

Only about one out of 10 women in Ontario who could benefit from breast reconstruction after mastectomies are having the procedure that can help them look and feel normal, say two prominent Toronto doctors — one who underwent the surgery to rebuild her breasts and another who performed the surgery.

This compares with a U.S. average of almost 17 per cent in 2002, with the rate in some major American urban areas, including Detroit, rising as high as one in four.

Both the high-profile patient — TV celebrity Dr. Marla Shapiro — and University Health Network plastic surgeon Joan Lipa, who specializes in cancer reconstruction, are hoping the rate of breast reconstruction in Ontario can be raised.

Shapiro is championing the establishment of a chair in breast reconstruction surgery and is working to raise funds for its creation. A dedicated chair, she says, will help lessen the waiting time and make more women aware that the surgery is available, effective and paid for by OHIP.

"There aren't enough doctors who are trained, dedicated, and have the ability to do this," explains Shapiro. "And should you do a delayed reconstruction, meaning you have mastectomy and then want to have a reconstruction later, the wait is tremendous."

Lipa says for immediate reconstruction, the time until consultation is anywhere from a couple of weeks to even couple of months if the woman is going through chemotherapy, and then anywhere from within a month to schedule surgery (if there is no chemo or if chemo is done) or longer if treatments like chemo need to be completed. Lipa says it usually takes a couple of months to get a consultation appointment with her and then a year before surgery is scheduled.

As for women who have delayed reconstruction — whether for medical reasons like radiation or because their mastectomies were prophylactic or because they weren't concerned about esthetics while initially struggling with cancer, Lipa says, "It could take longer than a year to get in for a consultation and another year after that for the surgery."

Because Shapiro was a candidate for immediate reconstruction, the procedure for rebuilding her breasts was initiated simultaneously with removing them.

The saga of the celebrity TV doctor's year-long journey through diagnosis, lumpectomy, chemotherapy, a double mastectomy and breast reconstruction, is recounted in her new book, Life in the Balance.

"I felt stunned," writes Shapiro about being told she had breast cancer in August 2004, "but as if this really were not me at all. Surely it must be someone else's breasts ... "

Shapiro, a family doctor with unparalleled connections inside the medical community, was hardly a typical breast cancer patient — even though the disease and its impact don't discriminate.

And yet, with all Shapiro's insider knowledge of the system and how to make it work — her routine breast exams were performed by breast surgeon Dr. David McCready ("as a fellow physician he tolerated my visits") — she expresses dismay and resentment about how her cancer was not diagnosed before it became invasive.

"With breasts as dense as mine, and even without a family history of breast cancer, I should have been offered an MRI as an additional routine screening tool. I could feel the anger welling up in me at this thought ... We knew that the mammogram had missed my cancer when it was there one year earlier."

Despite being reassured that excision of the invasive ductal carcinoma, removal of a few sentinel nodes and subsequent chemotherapy would deal effectively with the disease, Shapiro opted, as many women do, to undergo a double mastectomy and had it scheduled for when her chemo ended.

"Dr. McCready was very reluctant to do a mastectomy," recalls Shapiro. "He thought that the burden of my disease could be handled with a lumpectomy."

Nevertheless, Shapiro wanted the peace of mind mastectomies would bring her (as do many breast cancer patients). Six months after the cancer had been diagnosed and four weeks after completing chemotherapy, she was wheeled into the operating room to have both breasts removed.

Just before the surgery, Lipa used an indelible marker to create a "roadmap" for reconstruction.

During the surgery, tissue expanders with some fluid were inserted under the muscle to stretch the muscle and skin to eventually accommodate implants.

Another approach to breast reconstruction is "flap" surgery which uses the body's own tissue, sometimes including muscle tissue, typically from the abdomen but sometimes from the back or buttocks.

"I just didn't have enough places to harvest," explains Shapiro, "so I was going to be a silicone implant, or a saline implant."

But, she says, "I knew right away that I wanted reconstruction. I knew that I wanted to look like me."

She says, "Would I have taken off the breasts without the reconstruction? Yes, I would have. I made that decision based on my pathology, what my risk factors were, my concerns about mammography and MRI with my breast density, the fact that my mammogram the year before had missed the breast cancer when it was clearly there — there were a lot of reasons we made the decision.

"The fact that I could have reconstruction — I don't think I realized how important it was to me until a week, two weeks, three weeks after the mastectomy."

Not having breasts, says Shapiro, "creeps into your image every day and it creeps into your self-esteem.

"And that's for someone who is," she pauses and adds, with a laugh, "nasty. I'm a nasty person. I'm a strong person. You know what I'm saying? I've got a lot that defines me. I've got a full, wonderful life. I've got a lot of self-esteem. I know who I am. My breasts do not define me in any way. But you know what? Even for a woman like me, without your breasts, it sure does impact on your self-esteem."