In Flattening Breast Cancer by Removing the Breasts: Protecting a Woman’s Right to Choose Reconstruction of an Aesthetic Flat Chest After a Mastectomy, Amelia Landenberger centers the experiences of women who carry a genetic predisposition for breast cancer (namely the BRCA1 gene). The article argues that these women should have the option of aesthetic flat chest reconstruction, along with other breast reconstruction options.1 To vindicate this option as a legal right, Landenberger argues for a broad interpretation of the Women’s Health and Cancer Rights Act of 1998 (WHCRA). The WHCRA is an under-researched federal statute that prevents insurance companies from denying coverage for breast reconstruction after mastectomies. Landenberger maintains it should be read to require coverage for aesthetic flat chest reconstruction when preferred by a patient. Landeberger’s article contributes to the sphere of equality scholarship by centering the experiences of a little-understood group—those who carry the BRAC1 gene—and by bringing to light a little-understood problem, namely difficulty accessing aesthetic flat chest reconstruction.
Landenberger’s article is illuminating in several important respects. First, Landenberger centers the experiences of high-risk women, who are termed “previvors,” for a practical reason, namely because, when they choose mastectomies as a preventative measure, such women have a full-range of options available for reconstruction (whereas the reconstruction options of some breast cancer patients may be more limited). (Pp. 1201-02.) Nonetheless, this approach is a powerful one. Landenberger explains the astronomical risks that these previvors have of becoming afflicted with breast cancer—a 55% to 72% chance, and she further describes the liminal space that such women occupy—the space between sickness and wellness. She also relates that, for many such women, breast cancer is “not merely a hypothetical future,” but it is also “a part of their past,” as many have lost mothers, grandmothers, and/or aunts to breast cancer. (P. 1204.)
Landenberger also includes powerful testimony from previvors throughout the article. Taylor Harris, one previvor quoted in the article, describes her conflicted feelings and grief after having undergone a preventative mastectomy: “I’m looking for space, as a previvor, to mourn. A space where I can stop and consider that my scars are signs of relief but also collateral damage from a choice I made. I am fortunate and disappointed, indebted and sad.” (P. 1205.)
I am a two-time breast cancer survivor myself and therefore know a great deal (too much, in fact) about the experience of being faced with various harsh treatment options and of the challenges of going through treatment. I also have friends and colleagues who have a genetic predisposition for breast cancer. Nonetheless, Landenberger’s depiction of the experiences of previvors opened up a whole new world of experience and understanding to me.
Landenberger’s legal argument is that patients receiving breast reconstruction should be informed of the option of aesthetic flat chest reconstruction and that insurance companies should be required to cover the procedure under the WHCRA. WHCRA is light on definitions, and Landenberger creatively mines criminal law for authority that flat chests are also considered breasts and, therefore, that flat chest reconstruction should be understood as breast reconstruction for purposes of the WHCRA. Landenberger importantly explains that reconstruction is needed to achieve a flat chest. (P. 1220.) Previously, I had assumed that a flat chest would result if a patient simply opted out of reconstruction, not knowing that reconstruction is required to achieve that result and that there is this grey area relating to coverage for this procedure under the WHCRA.
Another important contribution that Landenberger’s article makes is its elucidation of the difficulties that many previvors and breast cancer patients face in accessing aesthetic flat closure. As she explains, often patients are not told it is an option and they may face pushback when they request it based on their own research. She posits that these reactions and omissions are due to many surgeons not knowing how to create such a result in some cases and, in other cases, to stereotypes about what women should look like or want, as well as paternalism. I found this aspect of the article extremely insightful. When undergoing breast cancer treatment and reconstruction myself, especially the first time, I often experienced paternalistic attitudes from doctors, which I have written about (although I was one of the lucky patients Landenberger describes who can afford to see a variety of doctors before choosing one (P. 1232), so I ultimately ended up with great doctors). Therefore, I was all too familiar with the fact that breast cancer patients frequently have difficulty having their wishes regarding treatment and reconstruction heard and acknowledged. As one doctor Landenberg quotes explains, “‘What it feels like to the woman has been a kind of blind spot in breast surgery.’” (P. 1222.) It had not occurred to me that these difficulties extend to, and even appear to be exacerbated for, women who choose aesthetic flat closure after mastectomies.
In short, the article does an excellent job of bringing several little-known issues relating to WHCRA and breast cancer treatment to the forefront.
- While Landenberger acknowledges that trans women and trans men also experience breast cancer (and presumably non-binary persons as well), she states that she does not focus on them in this piece due to a lack of available research on trans persons’ perspectives and the challenges that they face. (P. 1201.) Following Landenberger’s lead, I similarly refer to “women.” However, I hope that more information on trans persons’ perspectives on these issues will become available soon.
