Wednesday, August 30, 2006
Breast Cancer; prologue
Driving to the hospital on a Saturday morning several years ago, I was listening to NPR, which happened to be airing a discussion about breast cancer. One of the panelists was a woman surgeon with whom I was vaguely familiar; in fact, it's possible she sewed me up once. While training in San Francisco, in an incident well-documented in a certain book I'll not specifically hype (just this once) I suffered an intra-operative cut to my finger, which necessitated a trip to the ER for stitches. At the time, some surgical residents training at Beth Israel in Boston spent time at our trauma center for the unique experience (their boss had trained at UCSF; plus it's well-known there're no training programs in Boston that compare with mine....) I've forgotten the name of woman who sewed me up (and did a fine job), but I know it was one of those residents. And I know that the NPR panelist had done time in that capacity while I was there. I'd been grateful for the repair work. What I heard on the radio pissed me off royally.
"The only reason mastectomy was invented," she proclaimed, "is that men like to mutilate women." I managed to maintain control of my vehicle while screaming at the radio. "You shameless bitch," I shouted. "If you really believe that, you're too stupid to be a surgeon. And if you don't, you're a unprincipled self-promoting whore. Ever hear of penectomy? Know how debilitating prostatectomy can be? The reason mastectomy was invented was that at the time, it was the only thing that had ever cured breast cancer. The reason we do those gross things is that gross is all we have. We're still Neanderthals. You unrepentant hack." Or something subtle like that. I heard her and her shtick several times in several venues over the next couple of years. It made her famous, and probably rich. To her credit, I'll acknowledge she used her fame and fortune to produce an excellent book on breast disease, and eventually dropped the man-hating drivel. I'd Love to tell you her name.
When it comes to cancer treatment, we are indeed Neanderthal, compared to the ideal, and to how it'll surely be in a few decades. It's because of two most major failings: first, we have no way of knowing, for a given individual, how much is enough to cure a cancer (and the converse: we can't tell which tumors aren't going to be cured -- even when they fall into a favorable catergory -- no matter what treatment we apply.) Second: we don't have the proverbial magic bullet -- a therapy that will kill every single cancer cell, and spare everything else. With rare exceptions, non-surgical treatments -- drug therapy and radiation therapy -- can't distinguish between healthy and deadly cells. They work in proportion to the rate of cell division; and cancer cells divide more rapidly than normal ones. But that's why they cause side effects: they kill good cells along with the bad. Just in smaller numbers. And surgery -- like radiation -- only goes where it's aimed, and we have no way of being accurate enough only to remove malignant cells while leaving everything else behind.
We have good data about responses of large numbers of people. But there's a spectrum, of course; which means that we can't avoid the fact that we will over-treat some people, giving them side effects they didn't need (or remove too much or too little), and will under treat others. Some would have been cured had we done less than protocols require: some will die no matter how favorable their situation appears. Before radical mastectomy was invented, by William Halstead in 1889, women who got breast cancer pretty much all died.
Simply stated, the idea of surgical treatment of any cancer, when aiming for cure (as opposed just to biopsy or palliation), is to remove the entire tumor with a rim of healthy tissue around it, allowing enough room to include possible locally migrating cells. And it also means taking adjacent lymph nodes from the region likely to include those to which the tumor might also have spread; hoping, of course, that the surgery is being done before spread has already happened beyond the limits of the operative field. In the time of William Halstead, there weren't mammograms, women didn't do self-exam, and decorum meant that a gentleman (doctor) didn't touch a woman's breasts for routine checkups. So by the time attention was actually given to a breast cancer, it was likely to be huge.
The fact is that radical mastectomy was the first procedure to come along that actually cured breast cancer. It was a huge deal: enormously disfiguring, and significantly debilitating. I'm old enough that I watched a few being done, and even did some. I always found it horrendous. One of the surgeons who taught me had a specially-made, highly polished oak plank with which he levered the patient's torso off the operating table, still asleep at the end of the operation, in order to wrap her round and round with compressive bandages, tightly tethering her arm to her chest in the process. After the wrap -- which by immobilizing the arm ensured a long hard rehab -- we'd lower the woman back down and slide the board out of the bandages. Later, we'd begin daily dressing changes and re-wraps, after inspecting the skin graft for viability and likely avoiding the stunned eyes of the patient. Yes. Skin graft. The operation entailed removing the entire breast along with all its skin, and the two pectoral muscles; and extensive removal of the lymph nodes under the arm. The edges of the wound were too widely separated to re-approximate, so a skin graft was fashioned from somewhere to cover the ribs, which were exposed from the dissection. The effect was indeed mutilating, and the loss of the pectoral muscles, along with the lymph node dissection ensured that the arm was weakened and swollen. But until around the 1970s, the only alternative was death. Rather than some sort of perverse vendetta against women, it was done because at the time of its invention, nothing but radical mastectomy had ever worked on the gross tumors that were typical at the time.
Big changes were occurring by the time I was learning my craft, inspired in large measure by the realization that breast cancers were being discovered smaller and earlier every decade. In France (of course, it would be France) preservation of the breast using radiation treatments was being tried. I saw a woman who'd been among the early subjects: her breast had been cooked hard and brown, and was like a piece of wood on her chest: as different from the other as a rock from a pillow. But she was happy with it -- compared to the alternative, it seemed a fair trade. Surgically, mastectomy was being modified to a less radical form: more skin was left, so it could be closed without a graft. And one or both of the pectoral muscles were being left in place: cosmetically it still left a flat chest, but it was a human one, with contour and function, as opposed to bare ribs. Lymphedema (swelling of the arm) was much less common (but hardly eradicated), as lymph had channels in those retained muscles through which to flow from the arm. With no chain of patients, no long experience with treatment failures, I could be open-minded. But my mentors were of the prior era; for years, they'd seen it as it had been. Big tumors. Local recurrence. One and only one way to treat it. Is it a wonder that they'd be skeptical? Or, more correctly, worried about doing lesser operations when the data were young: when the price of failure was losing someone who might have been saved by the "old ways?" In my transitional time, in my arrival on the scene as things were changing, I could see it their way, without malice. That lady on NPR, she was of my time. Why couldn't she see it, too? Why cast it in such venal terms? But heck with her. It's a complicated and interesting subject. Let's talk some more, later.