**3. The high risk patient**

A patient who's risk for breast cancer has been assessed and whose risk is greater than or equal to 20% is classified as a patient at high risk for breast cancer. These assessments are made based on models such as the Gail Model or Tyrer-Cusick Model of risk assessment. In these models the patient's hormonal history, breast history, and family history of breast and/or ovarian cancer are utilized to estimate that individual's lifetime risk for breast cancer. It can thus be understood that with an elevated risk for breast cancer and with family members who have undergone treatment for breast cancer that the patient may want to do everything they can to prevent this from occurring. High risk screening paradigms as well as prophylactic procedures are then discussed with these patients, as well as genetic testing for predispositions to cancer where appropriate [2].

If an individual who is at elevated risk for breast cancer does not wish to undergo prophylactic/preventive surgery, most often in the form of a bilateral mastectomy, they will be followed closely according to the guidelines documented for that patient population. High risk screening includes two clinical exams yearly as well as annual mammography and annual MRI [2]. Many providers and surgical oncologists will recommend that the patient stagger the recommended breast imaging at six month intervals so that they do not proceed with a year between these imaging modalities and can be seen twice a year with new imaging available at that visit.

When the decision has been made to proceed with prophylactic bilateral mastectomy the patient must first understand that this does not mean that they could never get breast cancer. Surgical intervention has been documented to decrease the risk of breast cancer development by 90%, but that risk is not zero. The patient is then given the option of undergoing immediate breast reconstruction or delayed breast reconstruction. If the patient desires breast reconstruction they then must choose which type of reconstruction they would like to have. Typically the choice is between an implant based reconstruction or autologous tissue transfer.

With an implant based reconstruction the common challenges noted postoperatively include implant rupture (approximately 4% risk in the first 2 years post-operatively and nearly 50% at 10 yrs), capsular contracture, rippling of the skin, and migration/flipping of the implant. In many settings a temporary tissue expander implant is used to stretch the skin post operatively so that an appropriate breast size can be reached, necessitating additional surgery for the final stage of reconstruction. Breast implants are not meant to last the entire life-span of the patient and often need to be replaced after 10 yrs. in vivo. Another more recent concern has been documented in cases of implant associated B-Cell lymphoma, mainly in regard to textured implants placed 8–10 yrs. ago [3].

For the patients who undergo autologous tissue transfers as part of their breast reconstruction, the following should be discussed. It should be noted that the site where the donor tissue is to be removed from is separate and at risk for its own set of complications. The overall failure rate of these reconstructive techniques can be quoted at 1–3% with a wound infection rate estimated at 5–12% [4]. The gravity of these surgeries should be relayed, and the prolonged recovery time explored. These surgeries are often discussed as a one-step surgery, in that there is no required second step to complete the reconstruction, but many patients undergo additional minor procedures to obtain the cosmetic result desired.

After autologous tissue transfer breast reconstruction, it should also be stated that the scarring and internal remodeling of that tissue can take a quite prolonged course and that the patient might note changes to the consistency of that tissue months after surgery. This is most commonly seen in areas of fat necrosis that develop in the autologous tissue, presenting like abnormal chest wall masses that can be quite concerning for a breast malignancy, requiring further diagnostic evaluation and potentially biopsies of that area. In the patient who is at elevated risk for breast cancer the additional changes after autologous tissue transfer reconstruction that may be noted and need further evaluation should be explored in pre-operative discussions to prevent undo anxiety and ensure that they get proper care should a new finding be discovered.

#### **4. The breast cancer survivor**

In the case of the breast cancer survivor the first step in delivery of their care may be recognizing that these patients are facing a traumatic experience and that their ability to make decision may be hampered by anxiety, denial, shock, along with difficulty understanding the complexity of breast cancer care. Additional time to make these life altering decisions can be useful in this instance to allow for time to process the diagnosis and treatment options, to talk to other family members and loved ones who can assist them through this process, and to seek second opinions if desired to ensure the patient understands what they are facing. Additional office visits may be necessary to review the options or talk to additional care givers if the patient is noted to be struggling with the decision on how best to proceed. A patient must be able to develop a sense of trust in their surgical team prior to proceeding and the time necessary to establish this is quite variable.

When the surgical plan for the breast cancer patient is devised, and all the options have been explored, if the patient proceeds with unilateral or bilateral mastectomy with reconstruction there are pre-operative, peri-operative, and post-operative considerations to be disclosed. Pre-operative concerns to be addressed include the timing of surgery, pre-operative risk stratification, as well as a clear delineation of all the risks and benefits to this approach. It should be noted here that according to current guidelines the surgical oncologist is recommended not to encourage prophylactic contralateral mastectomy for the breast cancer patient in the setting of no genetic predisposition to cancer as this greatly increases the surgical risks involved with very little risk reduction, as the risk of contralateral breast cancer is quoted at 0.4% per year [5].

#### **4.1 The pre-operative breast Cancer patient**

Current standard of care dictates that we should pursue surgical intervention within 30 days of the diagnosis of cancer. With the addition of the consultation with the plastic surgeon and the coordination of multiple surgical calendars, this can be quite challenging to obtain. Working together to obtain the earliest surgical date possible becomes incredibly important. Risk stratification in regards to cardiac clearance, pulmonary optimization, and renal status should also be factored into the process for those patients who require it. Any additional imaging, staging studies, genetic testing, and any other pre-operative referrals should be expedited as much as possible. The need for pre-operative systemic therapy must also be taken into consideration when treating a breast cancer patient. In the modern era pre-operative chemotherapy and immunotherapy are commonly used to treat triple negative breast cancer and Her-2

#### *Screening, Surveillance, and Survivorship after Breast Reconstruction DOI: http://dx.doi.org/10.5772/intechopen.112914*

neu targeted therapies are used to treat Her-2 neu (+) breast cancer when appropriate. Neo-adjuvant chemotherapy prior to surgery in this setting is associated with a 60% compete pathological response rate, and the pathological response rate noted is then used to dictate further systemic treatment. The breast care team, with the keystone being the breast cancer care navigator, are integral to ensuring that the pre-operative process is facilitated as much as possible. Working with the patient through each step of the journey so that they are aware of how the process is unfolding is critical during this very stressful point in their life. Clear expectations of what to expect will help the patient immensely as they navigate their care.

#### **4.2 The peri-operative breast cancer patient**

Peri-operatively the expected hospital course, pain management, wound care, drain care, recovery experience, and post-operative limitations should be clearly delineated. If able the psychological aspects of losing a breast, or both breasts, should be approached with the patient as well. Many institutions have a policy in place where a patient is discharged to home on the day of their procedure if they are undergoing implant based reconstruction. In this setting it can be incredibly helpful to have a staff member call the patient the day after the procedure to ensure no complications have been noted post-operatively. Clear instructions on what to expect as well as what to look out for are usually provided by the physician or surgical facility of choice to assist with this. If the patient undergoes a period of 23 hour post-operative observation many of these concerns can be evaluated and readdressed prior to their discharge the following morning. After autologous tissue reconstruction patients are often admitted to the hospital with lengths of stay approximating three to five days.

Pain management is another critical component of the peri-operative discussion. Many great strides in multi-modal pain management have been documented and should be applied where appropriate. Multi-modal pain management can include Tylenol, NSAIDS, and muscle relaxants; in addition to local nerve blocks to lesson or alleviate the need for post-operative narcotics. Many patients voice anxiety concerning the level of pain that they are going to experience after surgery and they can be comforted that a pain management approach that attempts to control pain from many different angles will be used.

Drain care, post-operative wound care, and any specific limitations should also be addressed in the peri-operative phase. What the recovery period after unilateral or bilateral mastectomy may look like is another essential component of these discussions. A recovery period of approximately 30 days is not unreasonable. Drains that remain in place for 2–3 weeks is not uncommon. Bathing restrictions while the drains are present is often noted as well as lifting restrictions for up to four to six weeks postoperatively. There are often physicians who prescribe antibiotics post-operatively for the time frame in which the drains remain in place as well. Working with the nursing staff who provides this information to the patient to ensure that it is correct and that the patient is able to assimilate this information is essential to decreasing the incidence of post-operative complications noted, such as; hematoma/seroma formation, infection, and other wound related complications, while ensuring their compliance with the instructions.

After discussions in the pre and peri-operative phase of the breast cancer patient's surgical care it may be noted that they might benefit from additional assistance. A psychologist or social worker may need to be involved if the patient requires additional resources to cope with the psychosocial aspects of their health. A physical therapist may be required to assist with return to full range of motion as the patient recovers. For the elderly or infirm a subacute nursing facility may be necessary to assist with their daily activities until they improve and are able to return to their baseline health status. A holistic approach to the individual patient and their care is necessary to achieve the best outcome and can require a multidisciplinary approach.

#### **4.3 The post-operative breast cancer patient**

The breast cancer patient's journey into survivorship often is felt to begin in the post-operative period. For the patient who chooses to undergo mastectomy with reconstruction that journey begins with accepting an entirely new body image; and for a woman, the loss of an organ very deeply tied into their gender identity, sexuality, and maternal nature. From a technical perspective long term complications after mastectomy and reconstruction include numbness to the skin of the mastectomy flaps, loss of the nipple areolar complex in many cases, post-operative pain, and lymphedema. If adjuvant radiation is required after mastectomy with reconstruction this can increase the risk of lymphedema noted as well as the previously described risks of capsular contracture and skin rippling after implant reconstruction. In general the skin sparred at time of mastectomy can become darker, thicker, and have decreased wound healing capabilities. All these aspects can be combined into a cosmetic result that is less pleasing then imagined prior. The risk of a patient's breast cancer diagnosis necessitating adjuvant radiation should thus be broached to allow for complete disclosure, often leading to a recommendation for delayed reconstruction should that risk be high.

In the post-operative period there also remains a risk that the patient will develop a wound infection or wound dehiscence, leading to implant removal for those patients who chose to undergo an implant based reconstruction. For the patient who undergoes a nipple sparing mastectomy there is a noted risk of loss of the nipple areolar complex. The mastectomy flaps themselves are at risk of ischemia and thus tissue loss that may require debridement, skin grafting, or other procedures not excluding removal of the implant to allow for wound closure and another attempt at delayed reconstruction. In the patient who undergoes autologous tissue transfer reconstruction, as noted prior, the wound related challenges discussed also apply to the site of tissue harvest. If abdominal muscle is taken at time of autologous tissue transfer this infers an associated risk of abdominal wall hernia formation that should be taken into consideration.

In the peri-operative to immediately post-operative period after autologous tissue reconstruction there is a risk that the whole tissue graft will be lost should a postoperative complication occur, such as venous outflow obstruction or arterial occlusion. In certain settings leeches can be and have been applied to the reconstructed breast flap in an attempt to alleviate venous congestion and preserve graft function. This would be quite a troubling and unexpected event to the patient who is unaware that this is a potential outcome. In the setting of autologous tissue transfer reconstruction it can be also noted that areas of fat necrosis can develop that can be quite large and concerning. Tissue contracture may occur to a degree that necessitates fat grafting or other surgical approaches to filling the defect that remains. Multiple procedures may be necessary to achieve the final outcome desired and close clinical follow up is often required during this period to ensure optimal outcomes and that a recurrent cancer does not develop.
