Friday, March 23, 2007
Thinking About Elizabeth
Reading about Elizabeth Edwards' breast cancer recurrence brings my own patients to mind. On any given day in my practice, the greatest number of office visits were women (and the occasional man) with breast problems. The majority of those who saw me for cancer appear to have been cured, but many weren't. It took a long time for me not to see them as personal failures, and in some sense I think I still do. For everyone involved, there's enough pain to go around. My patients came to me wanting cure, expecting it. My hope was to be a part of that. Yet no matter how expeditiously, how skillfully I did my job, cure did not always result. That it wasn't my fault (had I delayed diagnosis, done the wrong operation, failed to coordinate surgery with other needed treatments, it would have been) didn't change the fact that I saw myself -- and assumed the patient did, too -- as having let them down.
When such a public figure deals with serious illness, people learn a lot. One important fact that I've heard countless times in the past couple of days is that breast cancer that has spread to bone is still breast cancer, not bone cancer. We name cancers by their organ of origin, and it's important because breast cancer, for example, behaves as breast cancer no matter where it ends up. In other words, the response of a type of cancer to particular treatment depends more on what kind of tumor it is, than on where it's found. Mrs. Edwards' treatment options depend on the type of breast cancer she has (there are several variants, with different general behaviors and responses to drugs: in particular, some respond to hormone manipulations and others don't). Cancers, however, can change: it's a laboratory of "unnatural" selection. Any cancer is made up of millions of cells, not all of which are equally responsive to particular treatment. You may wipe out all those that are, leaving others that aren't. That's one reason why most treatments combine several drugs.
I suppose it's just semantics, but I object slightly to the notion that her cancer has "returned." It never left. And that gets back to my opening statement about guilt. Our ability to cure cancer depends on a fortuitous coming together of happenstance and science. If the woman looking back at me with fear in her eyes has had her cancer discovered before it's spread from her breast, or if the cells that have escaped are few in number and sensitive to the drugs she'll get, she will be cured. If that's not the case, then treatment will most likely prolong life -- often very significantly -- but it won't wipe out the tumor. It will stay there, somewhere.
On NBC news last night, when Brian Williams reported on Elizabeth Edwards, he said (probably not an exact quote) "her cancer is back, and it's malignant." By definition, cancer is malignant. The ability to spread is, more than any other criterion, what distinguishes a malignant tumor from a benign one. "Tumor" means a group of cells -- the patient's own formerly normal cells -- that have undergone a change such that they grow at a faster rate than necessary to replace the natural turnover of their cell type. Skin cells, for example, die off at a certain rate: that's why we flake. New cells are constantly formed to replace them. If a cell changes -- mutates -- randomly, or as a result of sun exposure, or for whatever reason, in such a way as to increase the rate of division, all its "daughter" cells will carry on that change. A tumor is the result. If slow-growing, without the ability to insinuate itself into surrounding tissues -- getting into blood vessels or lymphatics, or locally infiltrating like a weed -- we call it a benign tumor. If it includes those dangerous abilities, it's malignant.
The important thing is this: it's all about timing. No one really knows -- particularly for any given person's tumor -- how much time is needed from the time the first cell or cells change to the point at which they slip beyond local control. But most people agree -- for "solid" tumors anyway (as opposed to tumors of the blood cells) -- that that window exists. You read reports that mammograms don't save lives, that breast self-exam doesn't help. In this, I'm a denier. I can rationalize that there's poor standardization of those studies among various types of mammograms and of the quality of interpretation; I can say self-exam is done better by some than others. Whatever the reason, I've never been convinced by those nay-saying studies. I've had too many patients who came to me because they found a lump, or because their routine mammogram discovered something, and who went on to be cured, for me ever to tell women to abandon regular self-exam and screening Xrays. And I've wondered from the beginning whether Elizabeth Edwards put off seeking attention because she had other things on her mind.