Mammograms and MRI after Breast Reconstruction - Are They Needed?
By: Dr. Minas Chrysopoulo
"Do I still need to have mammograms after my breast reconstruction?" I'm asked this question quite often.
Surprisingly, there is no evidence-based consensus on this among breast cancer physicians.
Some doctors feel that since there is minimal natural breast tissue left behind after a mastectomy (it is impossible to remove all breast cells), there is no need to continue monitoring patients. Others decide on a patient-by-patient basis.
Though the risk is very low, breast cancer can come back after a mastectomy. Breast reconstruction does not increase or decrease the risk of recurrence at all - the recurrence rate is the same whether women have reconstruction or not.
However, since the risk of breast cancer recurrence is a real one, I feel we need to continue some sort of monitoring once the reconstruction process is completed. This is especially the case in nipple-sparing mastectomy patients and patients who carry breast cancer associated gene mutations (eg BRCA).
Self breast exam is a no-brainer. It's relatively easy to perform and it's free.
For implant reconstruction patients it’s easier to feel changes in the skin against the underlying implant. Deep recurrences on the muscle (less common) are also theoretically easier to feel when the implant is placed under the muscle; the pectoralis muscle previously located under the breast tissue (ie at the "deep mastectomy margin") is now displaced superficially and under the skin since it is pushed upwards by the implant placed beneath it.
For patients with silicone implants, the FDA recommends an MRI 3 years after the implants are placed followed by repeat MRIs every 2 years after that. This recommendation was provided when silicone implants were re-introduced to the US market for cosmetic use as a means of checking implant integrity long-term. In the case of breast reconstruction, recurrent cancer is always going to be a more worrying concern for patients than documenting implant integrity. Ironically, when it comes to having the MRI covered by insurance, it is often easier to use the FDA recommendation as the underlying reason for having the test rather than trying to justify a screening test in a mastectomy patient with a benign exam. I don't personally feel routine MRIs are necessary but this approach is an option. While not as sensitive a test, ultrasound is a more cost effective alternative for screening, followed by MRI if the ultrasound shows something abnormal.
Patients who have had a flap reconstruction may also benefit from further imaging studies in addition to self exam.
The most commonly used breast imaging studies are mammograms and MRI. The appearance of a mammogram changes completely after autologous (flap) breast reconstruction. Even if the breast looks natural on the outside, the inside of the breast is completely different since the breast tissue has been replaced by fat.
Some surgeons recommend flap patients have a one-off baseline mammogram, in essence a "flapogram", after reconstruction just to get a new baseline. If the self breast exam reveals anything new of concern then the mammogram can be repeated, often in conjunction with an ultrasound for more information. Now the new mammogram can be compared to the baseline mammogram.
Another option is a one-off baseline MRI after breast reconstruction instead of a mammogram but this is a more expensive approach. MRIs are much more sensitive. Again, if self breast exam reveals a new area of concern in the future, the MRI can be repeated to see if anything has changed.
The counter argument to this approach is that any new breast lumps that appear in the future will likely lead to the recommendation for a biopsy anyway, so what is the point of getting a baseline mammogram or MRI at all?
I understand this point of view but I don't agree with it. Flap reconstructions can develop areas of fat necrosis. This is fat in the reconstructed breast that becomes hard and creates a new mass. While a biopsy may indeed still be recommended, there is a lot to be said for the physician and patient knowing this "lump" has been there all along, is consistent with fat necrosis, and hasn't changed. The additional information and peace of mind a baseline study provides in this situation warrants it in my opinion.