**Abstract**

In this chapter the recommendations for breast cancer screening, surveillance, and survivorship after breast reconstructive surgery will be discussed. The average risk patient, high risk patient, and the breast cancer survivor after breast reconstruction of any form will be outlined with pertinent challenges, complications, and patient related concerns detailed. The lifestyle changes and psychosocial concerns of patients after breast reconstructive surgery will also be described. The patient's journey is the central theme of this chapter, as are the surgical choices they make and how that might affect their future care.

**Keywords:** screening, surveillance, survivorship, risk assessment, breast cancer

#### **1. Introduction**

When a patient with a breast related concern is faced with challenging discussions regarding breast reconstruction options, there are many variables that must factor into the decision making process. Risk assessment should be performed so that the patient can understand if they are at average risk for breast cancer or at an elevated risk based on quantitative risk assessment models. The indications for surgery should also be fully understood as that can affect the options available to the patient. Any treatments that may be required after surgery should also factor into the decision making process. Once breast reconstruction has been performed it has the potential to alter screening, surveillance, and survivorship recommendations and the patient, the surgical oncologist, and the plastic surgeon must be prepared for those challenges.

In order to facilitate the decision making process all the ramifications of breast reconstruction must be disclosed to the patient and the patient care team. In this chapter the recommendations for breast cancer screening, surveillance, and survivorship will be discussed. The average risk patient, high risk patient, and the breast cancer survivor after breast reconstruction of any form will be outlined with pertinent challenges, complications, and patient related concerns detailed. The lifestyle changes and psychosocial concerns of patients after breast reconstructive surgery will also be described. The patient's journey is the central theme of this chapter, as are the surgical choices they make and how that will affect their future care.

#### **2. The average risk patient**

One in eight women will develop breast cancer. This correlates with an approximately 12% average risk that a woman will develop breast cancer in their lifetime. A woman may decide to proceed with breast reconstruction in varying forms and for many different reasons. In the non-cancer setting breast reconstruction can take the form of breast augmentation, fat grafting, tissue transfers, or silicone injections. These interventions may seem indolent to the patient, but to the surgical oncologist and the breast radiologist even these benign procedures can lead to challenges in future breast cancer screening.

If a patient chooses to undergo a breast procedure of any kind they must be informed that this will lead to changes in the architecture of the breast. Injection of any material into the breast can lead to internal changes and scarring that can be hard to differentiate from a malignant lesion. This finding may then need to be biopsied to determine its true pathological derivation. The anxiety that surrounds a callback for abnormal imaging and the need for a breast biopsy is substantial and should be taken into account. Injection of a foreign material into the breast can lead to pronounced inflammatory changes, including a cellulitis of the breast necessitating treatment with antibiotics and steroids. The treatment of these findings and subsequent breast changes also have consequences to be considered.

A patient who undergoes breast augmentation will still need to undergo screening mammography in order to provide early cancer detection. For the patient with breast implants who needs to undergo routine screening mammography there are some special concerns that should be noted. Patients who have implants are often concerned that the mammogram itself will rupture them, and this is not true. What does need to be considered is that it becomes increasingly more challenging to compress the breast appropriately for the patient with breast implants and all the breast tissue may not be seen clearly. The tissue near the implant will be hard to compress and thus achieve the magnification necessary to see the calcifications or architectural distortion that may indicate an abnormality. Approximately 20% of a patient's breast tissue may not be visualized well after breast augmentation when undergoing screening for breast cancer.

Patients who have a family history of breast cancer who do not meet the criteria of a high risk patient may choose to have a prophylactic mastectomy with reconstruction. That reconstruction could be either implant based or with autologous tissue transfers. Which form of reconstruction is appropriate must be decided on a case by case basis in regards to that patient's particular history and concerns with the surgical oncologist ensuring that the patient understands all the risks associated with these prophylactic procedures. The recommendations for further care in this setting will be discussed in the section related to high risk patients as they would be similar.

The recommendations for screening of the patient at average risk for breast cancer include yearly mammography after the age of 40. This is recommended to continue until the age of 75 or at which time 10 yrs. or less of life expectancy is estimated [1]. The aforementioned breast changes with difficulty in the establishment of a benign or malignant lesion and subsequent need for a tissue diagnosis can lead to mental and physical discomfort in the fear and anxiety that this can provoke, as well as in the procedure itself. Patients should be counseled accordingly prior to breast reconstruction as to the risks involved, and that this may lead to additional breast findings and breast biopsies in the future.
