Breast Surgery and Reconstruction During COVID-19
Editor's Note: On April 21, the American Society of Plastic Surgeons released guidelines on how breast reconstruction surgery can begin again. The American Society of Breast Surgeons also issued updated guidelines on treating people with breast cancer during the pandemic. Listen to our update with Drs. Sprunt and Potter, recorded on April 27.
Drs. Elisabeth Potter and Julie Sprunt work as a team to treat breast cancer and then reconstruction a woman’s breast or breasts.
Many people diagnosed with breast cancer are concerned because their breast cancer surgery or reconstruction surgery has been postponed because of the COVID-19 pandemic.
Listen to the podcast to hear Drs. Potter and Sprunt explain:
why many breast cancer surgeries can be safely delayed
the American Society of Breast Surgeons recommendations for treatment during COVID-19
the American Society of Plastic Surgeons recommendations for reconstruction during COVID-19
what they want people who have been diagnosed with breast to know about breast surgery and reconstruction during COVID-19
Dr. Elisabeth Potter is a board-certified plastic surgeon who received her medical degree from Emory University. She completed her plastic surgery residency at the University of Texas Southwestern Medical Center and her reconstructive plastic surgery and microsurgery fellowship at MD Anderson. Dr. Potter specializes in autologous breast reconstruction and has performed more than 750 DIEP flap surgeries.
Dr. Julie Sprunt is a board-certified fellow of the American Academy of Surgeons who specializes in breast surgery, treating all breast conditions. After receiving her medical degree from the University of Texas Health Science Center, she did her residency in general surgery at the University of Texas at Austin and completed a breast surgical oncology fellowship at the University of Southern California.
— Last updated on January 7, 2022, 8:21 PM
Jamie DePolo: Hello, thanks for listening. Today we’re extremely fortunate to be welcoming two guests, Dr. Elisabeth Potter and Dr. Julie Sprunt. Dr. Potter is a board-certified plastic surgeon who received her medical degree from Emory University. She completed her plastic surgery residency at the University of Texas Southwestern Medical Center and her reconstructive plastic surgery and microsurgery fellowship at MD Anderson. Dr. Potter specializes in autologous breast reconstruction and has performed more than 750 DIEP flag surgeries.
Dr. Sprunt is a board-certified fellow of the American Academy of Surgeons who specializes in breast surgery, treating all breast conditions. After receiving her medical degree from the University of Texas Health Science Center, she did her residency in general surgery at the University of Texas at Austin and completed a breast surgical oncology fellowship at the University of Southern California.
Drs. Potter and Sprunt work as a team to treat breast cancer and then reconstruct a woman’s breast or breasts. Today, they join us to talk about the guidelines that have been released on breast surgery and breast reconstruction in response to the COVID-19 pandemic. Drs. Potter and Sprunt, welcome to the podcast.
Dr. Elisabeth Potter: Thank you for having us.
Jamie DePolo: We’re so happy to have you, and I do want to point out to everybody that this is the first time in our podcast history that we’ve had two guests, so that’s very exciting, and I’m really grateful that we’ll be able to give our listeners both of your expert insights.
So to start I want to bring up the word “elective.” Many treatment centers now are canceling or postponing surgeries that they have deemed elective, and I know the American Society of Breast Surgeons has put out recommendations for treatment during this time. Someone who’s been diagnosed with breast cancer probably doesn’t think of surgery to remove the cancer as elective, so Dr. Sprunt, can you explain the Society of Breast Surgeons’ guidelines, and what they mean for us?
Dr. Julie Sprunt: That’s a great question, and it’s important to know that when we, as surgeons, define surgeries as elective, that’s something that we’ve done historically for some time. A lot of that is to appropriately triage patients. Really, when we think of an elective surgery, we say that’s a surgery that is not going to immediately threaten somebody’s life or threaten somebody’s limb, and all surgeries outside of that are considered to be elective.
When we use that word in this time in regards to breast cancer, it’s not that anybody is suggesting that breast cancer surgery is something that somebody can elect to have or not, but it means that there is a large subset of women with breast cancer in whom we can safely use a non-operative treatment strategy so that their surgery does become less urgent. We are fortunate with a lot of different types of breast cancer that we do have a lot of treatment strategies that have been shown to be safe if we use them before surgery, such that we can safely delay many women’s breast cancer operations. Not because they’re elective, but because that is what we are being asked to do when we look at the resources that we currently have in this country as we approach and are going through a national disaster.
Jamie DePolo: Okay, so could you give us some examples? I know I’ve read something where, say, somebody who has a small hormone-receptor-positive cancer, perhaps that can be treated with hormonal therapy now and then surgery can come later once things have perhaps gotten sort of back to normal.
Dr. Julie Sprunt: That’s absolutely right. So what the American Society of Breast Surgeons did is essentially divided breast cancer treatment into three different priorities. And they define that as priority A, B, and C, but essentially saying there are some that, if we do not address those issues surgically on a somewhat urgent basis, that that is immediately life-threatening. A good example of that is a breast abscess that is not amenable to aspiration, and if we don’t drain that abscess you run the risk of a patient becoming septic and dying in a relatively short time span.
The second categorization, or the priority B, are patients in whom delaying surgery beyond 6 to 8 weeks could potentially impact the overall outcome. And those are patients who are coming off of chemotherapy such that we know that outcomes are better if we do surgery within 8 weeks of their last timing of chemotherapy. So there is somewhat of a time-sensitive component to their treatment.
The third priority is priority C, where we say if a patient’s condition is able to remain stable then we can safely delay certain treatments. And a good example of that is exactly what you described: a postmenopausal woman with a strongly hormone-receptor-positive breast cancer, we can safely put those women on a neoadjuvant strategy with either anti-hormone pills or chemotherapy, and we can leave their breast cancer stable. Most breast surgeons are then following women on those treatment strategies to make sure that the breast cancer truly does stay stable, and if that’s the case we can safely delay their surgery.
Jamie DePolo: Okay. I do have one question, too. Somebody was asking about what about having a larger lumpectomy now rather than a mastectomy? Are you seeing that at all, is that something that’s addressed in the guidelines?
Dr. Julie Sprunt: It’s not as well addressed in the guidelines, and that’s where it depends on [us], as surgeons, to communicate with our facilities and our local government to better understand the resources that we have. In some women, it may make the most sense to do a large lumpectomy, even if you anticipate going back to do a mastectomy at a later time. And really, those are such individual case-by-case situations that it would be hard to make a blanket statement in that. Most of us who are still doing mastectomies are doing those in a way that we are sending patients home the same day so that we are limiting our exposure to patients in the hospital who may be exposed to coronavirus, but also, we are limiting the utilization of resources, especially as hospital beds and ventilators become much more pressing.
Jamie DePolo: Okay. Now, Dr. Potter, what about breast reconstruction surgeries? I know the American Society of Plastic Surgeons has also issued guidelines, and it sounds like delayed reconstruction should just be that, delayed, but that some immediate reconstruction procedures are going forward. And I guess I should explain, or I can have you explain, what immediate reconstruction is just in case some people are not familiar with that.
Dr. Elisabeth Potter: Absolutely. So the statement provided by the American Society of Plastic Surgeons was really to help guide decision making around breast cancer reconstruction in the face of the COVID-19 pandemic. I think it’s important to understand that many factors play a role in these complex decisions including, as Dr. Sprunt said, your community, your hospital resources, your local and regional regulations.
I think that one of the main points, obviously, that the American Society of Plastic Surgeons made was that delayed reconstructions should be delayed. That includes revisions to reconstructions that have already been done, and in my practice that also includes delayed DIEP flap reconstructions. So oftentimes in my practice, and I practice with Dr. Sprunt, we place tissue expanders for women who have an invasive cancer, and I wait until the cancer treatment has been completed before performing a DIEP flap reconstruction or a reconstruction using a woman’s own tissue.
There’s a complex series of reasons why we do that, but basically I want all the pathology back, the margins back, and I don’t want it to stand in the way of chemotherapy or radiation. So for a lot of my patients, they have a tissue expander in place and are waiting for their DIEP flap. That, in this situation, is considered an elective surgery.
So then we get to immediate reconstruction, so what about the women who have the need to undergo a mastectomy? In general, the American Society of Plastic Surgeons has said, “Please err on the side of caution and delay reconstruction if possible.” But that decision is very patient specific. So, I think what they’ve asked us to do, is to, on a case-by-case basis, evaluate the patient’s comorbidities, their medical problems, their likelihood of having a complication, and do all of this in light of our community resources.
I think that the overall message is that we should be good stewards of the supplies that we have right now. Does this mean that we’re not doing any type of breast reconstruction? No, in my case it means that in some cases we are placing tissue expanders, and, as Dr. Sprunt mentioned, for those women who are in that window after neoadjuvant chemotherapy and perhaps have a nipple-sparing mastectomy in which, if we don’t place an expander, the outcome could be compromised, I’m willing to say I think that that is necessary to do to help achieve a good outcome for this woman.
But all of this is in flux, and we are trying to be responsive to the needs of the community and to the needs of our hospitals.
Jamie DePolo: Okay, and there’s no issue — if somebody has tissue expanders in now and is kind of waiting for reconstruction — there’s no issue with waiting 6 months or… I guess what I’m asking in my naiveté, is there a limit on how long tissue expanders can stay in, or doesn’t that matter?
Dr. Elisabeth Potter: That’s a great question, and I think that 6 months is the perfect amount of time to start with. The FDA in the last year has put forward 6 months as an appropriate time to have a tissue expander in place, but honestly many women have tissue expanders in place for a year. And that allows for us to complete radiation and a waiting period and then do a reconstruction afterwards.
So, I’d like to make the point that for many women, even before COVID-19, I was recommending placing a tissue expander and then doing a delayed reconstruction. So I think that hopefully that gives some women peace of mind. Perhaps we’re going to be waiting a little bit longer, and you’re not going to have the surgery on the date that we had planned, but we are still going to get there.
Jamie DePolo: Okay, thank you. And I’m also wondering, what if somebody is having complications from breast reconstruction — capsular contraction, really noticeable asymmetry, something like that — is that able to be fixed now or is it better to wait? I realize it’s a balancing act, because as you both have said, you’re going to have to be mindful of the community resources, but you also don’t want to expose patients to something that could compromise their health.
Dr. Elisabeth Potter: Yeah, I think that absolutely, issues of asymmetry currently can wait. Those are things that we are not going to operate on at this time. Now I will say that there are some physical therapies that can help with asymmetry and capsular contracture, and there are still therapists who are doing online therapy that can help with that. So if you are having a complication that is causing asymmetry or contracture, talk to your plastic surgeon. There may be some other modalities that we can employ while we’re waiting. But surgery for asymmetry is not going to happen in front of surgery for cancer.
Now, I will say that sometimes an infection can present as asymmetry, so if you notice a change in your breast, let your plastic surgeon know. Let your breast surgeon know. We’ll want to be apprised of everything that’s going on, because we’re still going to do the right thing. We’re going to do the operations that need to be done.
Jamie DePolo: Okay, and Dr. Potter, I want to ask you, in talking with your patients, I know some people — because this is big surgery — they need to gear themselves up and sort of mentally and emotionally prepare, “I’m going to have the surgery, I’m going to be in the hospital.” And now, say, somebody’s had this schedule — and I’m using this as an example, somebody in our Discussion Boards was talking about, “You know, I was supposed to have it this week. I got myself all ready emotionally, physically, and now it’s delayed and I don’t know when it’s going to be, and I don’t know if I can get myself all ready again.” Are you having those discussions with your patients, and what are you telling them?
Dr. Elisabeth Potter: I am. For me, I’ve called these patients personally and talked to them and I’m just honest. I think that’s just the most important thing to be right now. I think that when I’m talking to patients about these unfortunate circumstances we find ourselves in, we’re just having to respond in the best way that we possibly can. And for the most part, I think that patients are responding really well. I recognize how very hard it is to have a mastectomy and to be planning for reconstruction and to have that delayed. And this journey is already so emotionally and physically taxing even without this new challenge.
But you know, we can do it. I know that doctors like myself and Dr. Sprunt all around the country are ready to operate when it is time, and we will do that in the safest way possible. It’s hard to wait. But right now that’s what we need to do.
Jamie DePolo: Okay. And Dr. Sprunt, from your viewpoint and in talking to your patients, it may be a little bit different because you’re going to actually be removing the cancer, and I imagine that’s got to be a little bit frightening to some people when they hear, “No, you have to wait.” How are you talking to your patients about this?
Dr. Julie Sprunt: You know, in any of these situations, and when I look at taking care of any of our patients, I wish that medicine was perfectly black and white, and in all honestly it is not. I am very lucky in talking to a lot of my patients that their treatment will be the same whether COVID was going on or not. I’m still seeing young women who are diagnosed with triple-negative and HER2-positive breast cancers, and those women oftentimes benefit from chemotherapy before surgery. So fortunately the plan is the same.
The conversations I’m having where the plan is different is in women who have a very usually favorable type of breast cancer, one that’s strongly hormone-receptor-positive, HER2-negative. And in those women, we are very lucky to have data that shows that we have a lot of safe options, to put them on pills, some of those women do still need chemotherapy, and we can do that before a surgery.
It doesn’t change the fact that there is still a lot of gray in this situation. And I tell all of my patients, I truly do take 10 steps back and do exactly what Dr. Potter and I have always done, and say, “Listen, if you were our mom, sister, or daughter…” And we have sisters that we love, and we have moms that we love. I have a daughter, and I really do think if she was sitting here in this situation, what would I want her to do? Knowing that she has a lot of safe options, and together I’m developing plans with patients that are considering the national crisis and our local resources, what is the best way to treat your breast cancer in a way that is not going to compromise your outcome but may actually allow us to save resources that we desperately need right now?
And so fortunately, I still am able to operate on those that I need to take to the operating room, but many of my patients can be safely temporized using a neoadjuvant strategy.
Jamie DePolo: Okay, thank you. To kind of wrap up a little bit, Dr. Potter, I would ask you, from the reconstruction standpoint, what are the three things you want a woman who’s been diagnosed with breast cancer to know right now in this time of COVID pandemic?
Dr. Elisabeth Potter: I think the most important thing that I would say is something I say to my patients a lot, which is that we don’t control what happens to us all the time but we get to control our response, and that’s really being tested right now. We don’t control the fact that we’re in this situation, but we’re going to do the right thing. We will get to the breast reconstruction when it’s time. I promise you that there are hundreds of breast reconstructive surgeons around the country who are ready and waiting to do your surgery and will be thrilled to do it when it’s the right time. But we have to be respectful of the crisis that our nation is presented with.
I think I also want patients to know that we recognize, I recognize that this is a frightening time. I don’t want anyone who is going through breast cancer and wondering, am I being left behind? Does anyone remember me? I see you, and I’m thinking about you and I am planning for your surgery. We just aren’t operating right now.
And then lastly, I think in a kind of a philosophical way, I think a lot of doctors like myself and Dr. Sprunt are at our best when we’re confronted with a challenge. And this is not going to be an exception, so stick with us, we’ll get through it.
Jamie DePolo: Thank you, and Dr. Sprunt, I would pose this same question to you, from a breast surgeon’s standpoint, what are the three things you want a woman who’s been diagnosed with breast cancer to know right now?
Dr. Julie Sprunt: The irony is, and it was very unplanned, my response is very similar to Dr. Potter’s, in fact.
Number one, we see you during this time. It is not lost on me that every night when I am watching the nightly news and updating myself on this awful crisis, that all of our country is focused on COVID-19 right now. And if you’re being diagnosed with breast cancer right now, it’s adding an already extremely stressful breast cancer diagnosis to an extremely stressful environment. And I can understand how, as we all focus on COVID-19, you might feel like the attention that your personal crisis deserves isn’t being addressed or able to be valued in the same way. And I just want you to know that for those of us who are still looking in your eyes, taking care of your breast cancer, we see you. And there is nothing and no treatment strategy that we are going to bring to the table that we don’t think is safe.
Also, if you need surgery for your breast cancer and we don’t think it can be safely temporized, we are still operating on those patients. And it’s going to be stressful as there are different stories and different, “who did what and where.” We are spending every day thinking of how we can best handle this situation for our patients who have breast cancer. And so truly, we see you and we are fighting that fight. And not only that, we are preparing for when we get through this, because we will get through this. And we are making sure that when the operating rooms do open up, our patients with breast cancer are at the front of that line to be able to use resources that they so graciously allowed us to spare at a time when we could safely spare it during their breast cancer care.
So just know, I think that you are safe during this time. I think there are a lot of options for our patients with breast cancer, and if the best option is to go to the operating room, we still can and will do that. And again, that really depends on local resources, but there are a lot of non-operative, safe treatment strategies that, fortunately, our breast cancer patients can benefit from during this time.
Jamie DePolo: Thank you so much. I think that will really help a lot of people. Thank you both so much. I, myself, am not facing breast cancer surgery, but I feel reassured, so I thank you so much for all your information and insights.
Dr. Elisabeth Potter: Thank you so much for letting us speak to these women.
Dr. Julie Sprunt: It is a tough time for us all, and I just hope, most importantly, as we have always done as a country and as a nation, we will get through this and we will be better on the other side.