Friday, July 27, 2007
Most of them were crazy, or demented. Sometimes they were brought in by an obviously discomfited relative, a daughter, and there was always something off, something that made it, at a certain level, understandable. "I had no idea. I thought I'd been smelling something, but her whole place was so awful, and she refused any help. She'd get angry when I tried to help. One day she let me help her bathe, and I saw it... Is it bad, doctor? Is there anything you can do?" Parents embarrass their kids all the time; on the soccer field, at birthday parties. This sort of thing is beyond the familiar by a factor of ten, or a hundred. To let a breast cancer advance to that point, one's grip on reality has to have loosened. Lots of people put off seeking medical attention. With breast lumps, I heard many attempts at explanation: I didn't think it was serious; I thought it would go away; I thought it was getting smaller. Even at the point of ulceration, women would claim they just noticed it. The inappropriate smile, the sense of disconnection, a certain dishevelment. Which is why Julia blew my mind.
Dressed like a doily, hair perfectly tinted and permed in tight waves contained like the kids of a strict school-marm, she sat before me and slightly pursed her sticked-lips, which were painted precisely within the lines. She was powdered and rouged, in the manner of the ladies of elegance; subtle, tasteful. No self-mockery, no flags raised; it was by the book, and she exuded a talcumy tastefulness, smelling grandmotherly in the nicest meaning of the term. Completing the picture, she'd been -- and remained -- a bank teller for three decades. A fixture in her slice of the community. "I've found a lump in my breast," she said, quietly, eyes on her hands folded neatly in her lap, not able to meet mine. Embarrassment, not fear, was what I sensed. After perfunctory data-gathering, I showed her into the exam room and gave her a gown.
In the red and seeping crater that occupied almost the entirety of her right breast were layers of kleenex. Cut into little squares, laid orderly one upon the other like baklava from behind the looking glass, the tissues had also been lightly perfumed. By their thickness and leather-like texture, I could tell they'd been there a very long time. As had, of course, the tumor itself. Years, more likely than months.
What were you thinking? How could you let this happen? is what the mind screams. I've seen more than a few like this (though never so tidy) and have never been that blunt. In the case of Julia, after a mental in-drawing of breath, I said simply, "You're probably worried this is cancer, and I'm quite certain it is. But, you know, when they grow large like this there can be some good news. The really aggressive ones spread fast before getting this big, so it sort of declares itself a slow-grower. And we have a good chance of controlling that kind." She nodded in small and quick excursions of her head, assenting in silence to my request to shave a piece of the tumor for testing. Because tumors are devoid of pain nerves, such a maneuver is painless.
What you aim for is local control; a way of treating and extirpating the tumor in such a way as to eliminate the festering and prevent its return. What's done is done: most likely, cure is out of the question -- although as I told Julia, this indolent behavior leaves open the possibility of long-term survival. In elderly ladies, most breast cancer is very sensitive to hormone therapy, which provides a well-tolerated and home-based way to regression of the growth. I've seen large and ulcerated masses shrink and heal over with only such treatment, after which -- unless refused, or prohibited by underlying fraility -- a simple mastectomy has been followed by permanent quiescence, locally. When needed because of medical risk, I've done the operation entirely under local anesthesia. I'm certain that, given the simplicity of the treatment, some of those ladies wondered why they'd waited a lifetime to be seen.
[photo from edinphoto.org.uk]