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The Lititz mother of three immediately opted for a double, or bilateral, mastectomy followed by breast reconstruction.
For Shaffer, a nurse practitioner who counsels other women about chest health, it wasn't about mourning the loss of her genetic breasts. It was about avoiding future complications, embracing life and a new norm.
"I did not even give it a second thought, not a blink of an eye, unless someone could tell me why I specifically shouldn't have done it."
No one did, including her husband.
"He just wanted me healthy."
She also has no regrets about reconstruction.
"My concern was just being able to look in the mirror every day. I just wanted to be back to normal, or the new normal, and be able to walk out on the street and nobody (was) going to know what happened to me."
Like Shaffer, Michele Young, 37, of Elizabethtown, had cancer detected in one breast. But after Young, who has an extensive family history of the disease, learned she carried a genetic mutation which increases the risk of breast cancer, she had a bilateral mastectomy, as an added precaution, followed by reconstruction.
She, too, said she has no regrets.
"Twenty years ago people used to think (that) was crazy, 'Oh, you're taking a normal breast, no way,' but now women don't want to have problems in the future," said Young's plastic surgeon, Dr. David Warsaw of the Cosmetic Surgery Center.
In fact, a 2007 University of Minnesota study found that the percentage of U.S. women with cancer in one breast who chose a double mastectomy more than doubled over five years, from 4.2 percent in 1998 to 11 percent in 2003.
But then, what about life after breasts?
Reconstruction has been available for decades and has become more sophisticated, plastic surgeons say, but the surgery may be underutilized.
According to the American Society of Plastic Surgeons, about 57,000 women had reconstructive breast surgery in 2007, actually a drop from the 78,000 reported in 2000 — perhaps due to the improved availability of breast conservation therapies, more effective cancer eradication through radiation as well as declining insurance reimbursement for surgeons.
"Breasts are an important part of our society and culture," said Dr. Richard Levin of Lancaster Plastic Surgery. "No one wants to be stigmatized by cancer or what happened to them.
"Body image is important. No one wants to be incomplete. … "
Although reconstruction may not create an exact replica of the original breast, surgery may help restore that sense of completion for women, he said.
"I like to tell everybody that only God makes a real breast, so you're not going to have the same sensation, exactly the same look, and even if you're doing a bilateral (reconstruction) there's always going to be some difference," said Shaffer's plastic surgeon, Dr. Kenneth Arthur of the Cosmetic Surgery Center of Lancaster.
Still, with plastic surgery, it's as much artistry as surgery, plastic surgeons say.
"This isn't just an operation, it's an art form," said area plastic surgeon Dr. Wendell Funk. "You want it to look as good as possible."
Awareness of and proactive attention to women's breast health flourishes. Women are inundated with choices, which can be overwhelming.
"Some patients come in and there's a lot of anxiousness, a lot of nervousness, understandably so because they've just been told they have cancer," Funk said. "Sometimes they feel rushed into making a decision."
One role of the plastic surgeon, he said, is to help each patient fully assess preferences, options, expectations and time frame.
"I think that (reconstruction) is the process (people) don't hear (about)," Shaffer said. "Everybody talks about identifying breast cancer, how to do breast exams, getting mammograms, but it's the afterward piece that's not well talked about.
"This is the life-after side."
•••
The American Cancer Society estimates that 270,000 women will be diagnosed with breast cancer this year.
For those able to have breast conserving surgery, such as a lumpectomy, or radiation treatments, there may be no significant deformity.
But in 2006, about 66,000 U.S. women had mastectomies, based on the latest federal government figures.
Breast reconstruction is a very personal choice, which may depend on the cancer treatment — concern about risks — even cost, say plastic surgeons.
There are two basic options — implants or tissue flaps — and surgery can be done either immediately after a mastectomy or be delayed.
Implants, filled with saline or silicone gel, can be inserted into the chest wall. Tissue flaps, tissues from the woman's body (usually from the tummy area), can be grafted onto the chest.
The ACS has reported that women who have a post-mastectomy breast reconstruction — the procedure can now be done on women into their 70s — benefit psychologically.
The positives were the driving force behind the 1998 Women's Health and Cancer Rights Act, which mandated that insurance carriers offering mastectomy coverage also cover reconstruction. Later legislation imposed penalties for those out of compliance, and it now offers a broader coverage to include breast symmetry.
WHCRA does not prohibit deductibles or co-payments, but they must be consistent with those charged for other plan benefits.
Reconstructive surgery costs vary with procedure, surgeon and even area.
According to www.plasticsurgeryportal.com, part of the SignatureSpecialists Network of professional health care Web sites, the national average cost (primarily surgery, not global fee) is $7,000; $5,000 minimum and $9,000 maximum.
Despite continuing changes in legislation, insurance reimbursement rates also vary considerably, even state by state. According to the ASPS, surgeons have continued to lose ground on the issue of reimbursement.
"This has been one of the factors, of course, in my opinion, in the decreased rate of reconstruction for all surgical procedures across the United States, including breast surgery," Levin said.
"I do think that reconstruction is a top insurance priority, particularly breast reconstruction."
•••
Plastic surgeons expect to field questions from women considering breast reconstruction.
What will their breasts look and feel like? Will they be bigger, smaller, the same? Will there be a lot of scarring?
"I was confident I was going to be cancer-free," Shaffer said. "But what was I going to look like?"
Many patients ask if they're going to look the same in a bra, if they will still be attractive and feminine, said Funk, who always appreciates consulting with both husbands and wives.
Funk said surgical incisions have become increasingly smaller over the years, making scarring less apparent.
Shaffer and Young said their scars continue to fade with time.
Patients may have the option to change their breast size (augment or reduce). Shaffer and Young remain about the same.
But while reconstruction restores shape, the surgery can not recreate tactile sensation, and the end result can be firmer.
"They're perky," Young said.
Shaffer said she no longer has to wear a bra.
Overall, both women are pleased with their reconstructions.
"I worried about it, about what people would think, and if they would look at me any differently," Young said.
"Sure, (my breasts) are a little different, but I'm alive."
More about reconstruction
Breast reconstruction has become increasingly more sophisticated and fine-tuned over the years, plastic surgeons say.
Here is a basic, simplified guide:
• TYPES
Essentially, there are two choices: implants, the most common, and tissue flaps.
Implants: Breast-shaped pouches in a silicone shell filled with saline or silicone gel, implants are put under the skin. Implants that have the capacity to be filled with saline after insertion are called tissue expanders (like a balloon) and stretch or expand the skin.
They can remain or be removed after several months and be replaced with a more permanent implant.
Gel implants are generally softer than saline, Funk said.
Tissue flaps: The breast is created using some of the woman's own tissues, most often from the tummy area. Some say tissue grafts create breasts that are softer and more natural, but the surgery also causes two sets of scars.
"There are pros and cons to each method depending on body size, patient medical history, personal preference … ," Warsaw said. "A lot of planning and discussion goes into it."
Cost and time commitment can also be a consideration.
Tissue flaps are much more expensive than implants (almost double the cost, plastic surgeons say), and require a more involved surgery, up to five or six hours, and a longer hospital stay. However, women who utilize tissue expander implants may require more than one surgery.
Occasionally, small implants may be incorporated into tissue flap surgery, Funk said.
• WHEN
Immediate breast reconstruction is done at the same time as the mastectomy. Delayed reconstruction can be done months or even years later.
In cases of immediate implant insertion, the mastectomy incision can be utilized to make a pocket, usually underneath the chest wall. The cost of IR is generally lower since there is one less operation and a shorter hospital stay.
In delayed reconstruction, the mastectomy scar may be reopened for the implant.
Hospital stays range from one to four days.
There may be an additional surgery in the case of tissue expanders, and steps may be delayed if there is radiation treatment.
• PROCEDURE
Reconstruction also involves creating symmetry between breasts. In addition, patients may opt to have a nipple and the surrounding areola reconstructed utilizing other body tissue. "Tattooing" the new nipple and areola is done to match the color of the opposite nipple and areola as closely as possible.
Sources: Cosmetic Surgery Center; Lancaster Plastic Surgery; www.cancer.org (American Cancer Society); www.plasticsurgery.org (American Society of Plastic Surgeons); Dr. Wendell Funk
