Prostheses After Cancer Surgery: Questions and Planning

"Prosthesis" is one word covering very different devices. After cancer surgery it might mean a breast form you put on in the morning. It might mean an artificial eye. It might mean a plate that closes a hole in the roof of the mouth, or an artificial leg. Each has a different fitter, a different wait, and different rules about who pays.

This page covers what is documented for each, and what to ask before the first fitting.

The National Cancer Institute is clear that all three are real choices. Some women "choose not to have their breasts reconstructed after a mastectomy, instead preferring a flat closure."

For the rest, NCI writes that "Women who delay reconstruction (or choose not to undergo the procedure at all) can use external breast prostheses, or breast forms, to give the appearance of breasts."

Timing matters. Reconstruction can happen "at the time of the mastectomy, called immediate reconstruction." Or it can happen "after the mastectomy incisions have healed and treatment has been completed, called delayed reconstruction."

Radiation changes that calculation. NCI notes that "Radiation therapy can sometimes cause wound healing problems or infections in reconstructed breasts." Some women therefore delay reconstruction until radiation is finished. NCI adds that "immediate reconstruction with an implant is usually still an option for women who will need radiation therapy." Ask your surgeon which applies to your plan.

One more fact people are rarely told up front. NCI states that "Any type of reconstruction increases the number of side effects a woman may experience compared with those after a mastectomy alone." NCI also notes that physical therapy can help "improve or maintain shoulder range of motion or help recover from weakness."

This is where money and law meet, and the law is specific.

The Women's Health and Cancer Rights Act of 1998 applies to group health plans that cover mastectomy. NCI describes it as a federal law requiring those plans "to also pay for reconstructive surgery after mastectomy."

The Department of Labor spells out what must be covered. Plans must pay for "all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses, and treatment of physical complications of the mastectomy, including lymphedema."

Read that list again. It includes prostheses. It includes surgery on the other breast for symmetry. It includes lymphedema care.

Three details are worth knowing:

• Plans may still charge deductibles and coinsurance. But that is allowed only "if the deductibles and coinsurance are consistent with those established for other benefits under the plan or coverage."
• The law is not limited to cancer. DOL states that "Despite its name, nothing in the law limits WHCRA rights to cancer patients."
• Some plans sit outside it. If your coverage comes from a "church plan" or "governmental plan," DOL advises you to "check with your plan administrator."

On Medicare, the split runs by setting. Part A "covers surgically implanted breast prostheses after a mastectomy if the surgery takes place in an inpatient setting." Part B "covers the surgery if it takes place in an outpatient setting." Part B also covers "some external breast prostheses (including a post-surgical bra) after a mastectomy."

Your share: "After you meet the Part B deductible, you pay 20% of the Medicare-approved amount for the doctor's services and the external breast prostheses."

Enucleation is surgery "to remove the eye and part of the optic nerve." NCI says it is done when vision cannot be saved. It is used when the tumor is large, has reached the optic nerve, or is raising the pressure inside the eye.

On what follows, NCI is brief but useful: "After surgery, the patient is usually fitted for an artificial eye to match the size and color of the other eye."

Ask two things. Who does that fitting at your center, and how long after surgery does it usually happen?

The specialist here is a prosthodontist, and NCI names them as part of the head and neck cancer team. These devices replace teeth, jaw, or palate after surgery.

Two facts from NCI's oral complications summary should shape your timing.

First, get the dental work done early. NCI advises a full oral health exam "at least a month before cancer treatment begins." That exam checks for dentures that fit poorly. It also checks for decay, gum disease, sores, and jaw movement.

Second, a device that fit before radiation may not be safe after it. NCI describes breakdown of bone in an area that received radiation. Among the listed ways to prevent it, NCI advises wearing "removable dentures or devices as little as possible." If you wear a removable device and are having radiation to the head or neck, ask whether that applies to you.

Bodies change after surgery, and prostheses do not.

MedlinePlus is direct about limb prostheses. "It will take time for your prosthesis to be made. When you have it, getting used to it will also take time." The same guidance says to inspect the residual limb every day, using a mirror if needed. Wash it daily with mild soap and water, and do not soak it.

That daily inspection habit is the single most useful thing on this page. Skin under any device is skin you cannot see while the device is on.

If the skin under a prosthesis breaks down, call before you put the device back on. MedlinePlus lists these signs for any surgical wound:

• "There is more redness, pain, swelling, or bleeding at the wound site."
• "The wound is larger or deeper, or it looks dried out or dark."
• "The drainage coming from or around the wound increases or becomes thick, tan, green, or yellow, or smells bad (which indicates pus)."
• "Your temperature is 100.4°F (38°C) or higher."

MedlinePlus also warns against common home remedies. "Do not use skin cleansers, alcohol, peroxide, iodine, or soap with antibacterial chemicals. These can damage the wound tissue and slow healing." Use "a normal saline solution (salt water) or mild soapy water" instead, and clean your hands before changing a dressing.

• When can fitting safely begin after my surgery, and after radiation?
• Is this device temporary or permanent? What replaces it, and when?
• How many do I get in a year, and how are replacements approved?
• Which part of my insurance pays for this, and what will I owe?
• What should the skin under it look like after a normal day of wear?
• How long should I wear it at first, and how do I build up?
• Who do I call about the fit, and who do I call about the surgical site? These are often different people.

Bring the answers home in writing. The person who fits a device is usually not the person who treated your cancer. The two offices may not share notes.

• Breast Reconstruction After Mastectomy — National Cancer Institute
• Women's Health and Cancer Rights Act FAQs — US Department of Labor
• Breast Prostheses Coverage — Medicare.gov
• Intraocular (Uveal) Melanoma Treatment (PDQ), Patient Version — National Cancer Institute
• Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ) — National Cancer Institute
• Head and Neck Cancers — National Cancer Institute
• Leg Amputation, Discharge Instructions — MedlinePlus
• Surgical Wound Care, Open — MedlinePlus