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Why some women choose to remain flat after mastectomy

It is said that beauty is in the eye of the beholder. And the subjective perception of what constitutes that beauty in any given eye has seemingly limitless influences, varying among cultures, genders and ages - even the sometimes precarious state of one's health.

Cynthia Canevari of Milford, Del., had B-cup breasts for most of her adult life. But when the physical therapist assistant required a mastectomy, she opted for flatness where once a natural curve had overtly proclaimed her femininity and sexuality. Now her T-shirt lies against her chest in much the same way it would if worn by a man. And that is just fine with her.

Her journey with cancer began in 2005, when she discovered an unusual hardness on the left side of her breast during a monthly self-examination. After a surgeon biopsied the breast, Canevari received harsh news: Five tissue samples contained cancerous cells.

"The surgeon said, 'We have to talk about a lumpectomy or a mastectomy.' I looked her right in the eye and said, 'I want a mastectomy, and I want you to take off the other breast too.' It took me no time to think that out. I even remember saying to the surgeon, 'Can't you remove them with a pocket knife and a melon baller right now? I want the cancer gone.' It registered with me that fast that my breasts were not parts of me that I needed to continue living."

Choosing Double Mastectomies
While that aforementioned melon baller was never a viable option, double mastectomy was. Canevari had the biopsied breast removed 20 days after diagnosis, and decided to take time to heal before having an elective second mastectomy a year later. The right breast was cancer-free.

"I had a lot of time to look at myself with one breast - that was horrible for me. Every day when I showered, when I dressed, when I put a prosthetic in a bra, it reminded me that I had cancer," she said. "I looked so displeasing to my own eye; that lack of symmetry made me feel disfigured.

"So you may ask, 'Why didn't you opt to have reconstruction?' The answer is I didn't want to give cancer one more second of my life," Canevari said resolutely. "I knew reconstructive surgery takes a while. . I said, 'No. Enough already.' Reconstructing what cancer had already taken was not a reasonable option for me. Cancer was not going to steal any more of my precious time."

Following the second mastectomy, Canevari had only a twinge of angst, as she tried to figure out how to fit into clothing designed for breasts. "But let me tell you that lasted only a few days. And it was about those practical implications, not the physical, medical or emotional ones," she recalled.

A New Kind of Women's Lib
"What I realized was my femininity does not come from my hair, nor does it come from my breasts," Canevari said. "My femininity comes from my mind; it is who I am inside. When I was going through chemotherapy and didn't have a single hair on my body - none on my head, none on my legs, none on my arms - it was one of the most freeing things that had ever happened to me. It stripped away all of that 'stuff' we hide behind and left the real me exposed - and exposed to the public. I realized, having to look at myself like that, that I like who I am. Having those breasts come off was no big deal. In fact, it was liberating."

Two years later, Canevari also successfully battled bladder cancer. No wonder, then, that she has become a staunch advocate for cancer research funding. As Delaware's lead ambassador for the American Cancer Society Cancer Action Network, Canevari has been to Capitol Hill five times to reinforce her primary message: Don't cut cancer funding.

She not only talks the talk, but she walks the walk of cancer survivorship. "Now 10 years out from breast cancer, I have embraced physical fitness," Canevari said. "When I was first diagnosed, all the studies correlating diet and lack of exercise with breast cancer were not there yet. But now we know that exercise may decrease your recurrence of cancer by 50%. And now we know the foods we eat are connected to body processes. It was an explosion in my mind. I realized that while there are things I cannot control, there are other things that I can control - what I put in, and what I do with, my body."

Today Canevari regularly attends boot camps with a fitness group and runs a monthly 5K. As a result, she has lost 30 pounds, has lowered her blood pressure, and continues to have cancer-free checkups. "Being proactive with my health takes away that feeling of victimization," she explained. "I am not a victim. And I say to our congressman in Washington, 'I've had two cancers, and I am doing my part to keep myself healthy. Now I need you to do your part to make sure the research money is there.'"

SEE ALSO: Breast Cancer Awareness Month

Choosing to Go Flat
According to the nonprofit education organization, only about 20% of patients choose not to undergo breast reconstruction. Susan Hunter, APN, is an oncology nurse practitioner at MD Andersen Cancer Center at Cooper in Camden, N.J., and is part of Canevari's care team. "We see thousands of women with surgical decisions facing them, and the No. 1 factor in rejecting reconstruction is age," she said. "These are usually women who are not looking for a relationship or who are already in a stable, long-term relationship with a partner comfortable with their decision not to reconstruct. But women who are single, dating or looking for a relationship - that's a completely different story."

Canevari said her husband's support was a powerful factor in her choice. "Had Mike not said to me, 'Breasts or not, I love you - do whatever works for you,' I might not have been as secure in my decision."

However, medical reasons underlie some decisions to opt out of reconstructive surgery. "Comorbidities may exist," Hunter said. "Some patients have significant lung issues, autoimmune issues, fear of anesthesia or fear of surgery itself. Some women simply are not healthy enough to undergo some of the surgical options for reconstruction.

"If a patient has any sort of respiratory issue or heart issue, you'd be hard pressed to go forward," Hunter said. "We've also seen some women who have severe keloid scarring, so less surgery is better in these cases. What does it avail a patient to choose reconstruction if cosmetic outcome will not be pleasing?"

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Four cancer survivors training together. From left, Joni Miller, Cynthia Canevari, Joyce Webber and Linda Webb Jenkins. Photo courtesy Cynthia Canevari

Radiation also plays a role in the decision-making process. In a small number of cases, radiation is prescribed after mastectomy. "For instance, if a tumor is close to the chest wall, even though it's been removed, risk of recurrence in that wall is quite high, so radiation would be recommended," Hunter said.

"We have had patients who have had bilateral surgery, gone through expander reconstruction and then have needed the expanders deflated in order to get radiation, with hopes of later being re-inflated. But radiated skin doesn't behave nicely," Hunter said. "It loses its elasticity and we've seen a number of implants rejected in radiated tissue. It makes it very difficult to do further surgeries because the tissue just doesn't heal as well."

For other patients, there is simply fear of having a foreign substance - an implant - in the body.

"We have seen some patients' bodies reject 'other' material. Then there is always a risk of infections and ongoing surgeries," she said.

Guiding Patients
"Just this morning I talked to a patient who had opted against reconstruction," Hunter said. "I asked her why. She said, 'What do I need it for? I'm older and my husband doesn't care. I'm not a vain person, and the absence of breasts does not define me.'"

Hunter said NPs can best help patients facing breast cancer decisions by sharing all options with them. "Above all else, look at each patient within the context of her own culture, and her own goals and expectations in life. Find out what is important to her."

The majority of breast cancer patients Hunter sees are information seekers armed with questions and studies.

"This is their life, after all," Hunter said. "Patients need to do what feels right for them, but they also need to know that if they move forward without reconstruction, they can still initiate the process down the road. Minds can be changed. That is a very comforting notion for some women."

Valerie Neff Newitt is a staff writer. Contact:

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