BRA Day 2026: the question worth asking before a mastectomy

This 21 October was BRA Day, Breast Reconstruction Awareness Day. It began in Toronto in 2011 and is marked every third Wednesday of October, within breast cancer month. It is worth saying at the outset what it is and what it is not, because it is often misread: it is not a campaign for women to have reconstruction.

It is a campaign for them to know.

The aim is not that every woman with breast cancer should have reconstruction. It is that every woman with breast cancer should have had the chance to discuss it with a plastic surgeon before deciding.

The difference between those two sentences is the whole point. Whether or not to have reconstruction is a personal decision, and there are women who decide against it and are entirely within their rights and at peace. What should not happen — and happens every day in Peru — is finding out the option existed two years after the mastectomy, having already grieved the loss believing there was nothing to be done.

Why the time to ask is beforehand

This is the medical part that is hardest to convey and the one that changes most: reconstruction is planned with the mastectomy, not after it.

When the cancer surgeon and the plastic surgeon talk before going into theatre, possibilities open up that no longer exist afterwards. The main one is preserving the skin: in a mastectomy planned alongside reconstruction the skin envelope can be preserved — and in selected cases the nipple-areola complex — and reconstruction carried out in the same operation. The starting point is different, and the number of operations required is usually smaller.

When reconstruction is considered years later, the starting point is skin that has already closed, sometimes irradiated and contracted. It is still perfectly possible — delayed reconstruction is an operation we perform often and with good results — but the road is longer.

What shapes the decision

• Whether there will be radiotherapy. This weighs most. Radiotherapy over an implant increases the risk of capsular contracture and of losing the result, and that may argue for delaying reconstruction or choosing the patient's own tissue instead of an implant.
• The type of mastectomy. Skin-sparing is not the same as one where the extent of the tumour requires the skin to be removed.
• The tissue available. Abdominal or back flaps give more natural results and tolerate radiation better, but you need somewhere to take them from and a larger operation.
• Where you are in cancer treatment. Cancer treatment always comes first. Reconstruction fits around it and never the other way round.

In Peru it is part of treatment, not an aesthetic extra

Law 31336, the National Cancer Law, published in August 2021, and its regulations, approved by Supreme Decree 004-2022-SA in March 2022 and since amended, establish cover for cancer treatment under a model of integrated care that includes continuity of treatment, rehabilitation and complementary interventions according to medical assessment. That is the framework in which breast reconstruction is understood as part of cancer treatment, and not as a separate cosmetic operation.

That said, with the same honesty: having legal backing and having access are not the same thing. Services with multidisciplinary teams are concentrated in Lima, demand outstrips capacity, and each insurer and each institution has its own process and its own timescales. Asking early guarantees nothing, but not asking guarantees being left out.

What to ask in the consultation

If a mastectomy is on the horizon — yours or that of someone you are supporting — these are the questions worth writing down and taking with you:

1. Am I a candidate for immediate reconstruction, in the same operation? It is the first question and the one that opens or closes most doors.
2. Am I expected to have radiotherapy? If the answer is yes or "perhaps", the strategy changes and it is better to know beforehand.
3. Can the skin be preserved, and the nipple and areola? It depends on the tumour, but it is a question to ask rather than wait to be answered.
4. Which techniques are reasonable in my case, and why? Implant, expander, own tissue or a combination. Ask for the why, not just the what.
5. How many operations does each route involve? Almost no reconstruction is finished in a single operation, and knowing that from the start avoids disappointment.
6. What does my insurance cover and what process do I need to start? The sooner the paperwork begins, the less likely the cancer timetable is to overtake it.

And one more, which is not clinical: can I speak to a plastic surgeon before the mastectomy? In many cases you only have to ask.

What is not promised

Reconstruction does not give you back the breast that was there. It gives back a shape, a volume and a clothed symmetry that for most patients completely changes their relationship with their own body, and that is a great deal; but sensation does not return as it was, there are scars and more than one operation is almost always needed.

Nor is it compulsory. A woman who decides, informed and unhurried, not to have reconstruction has made a decision as valid as the opposite one. BRA Day is not there to push anyone in either direction: it is there so that the decision is hers and not the silence's.

If you are at that point, or supporting someone who is, that conversation can be asked for now.