Monday, July 30, 2007
The Old Man and the C
I expressed this particular opinion on another medical site, and was -- gently -- told I was an old guy, of a generation that was out of touch. It could be true. But having treated many hundreds of women with breast cancer (I lost count a long time ago) and having been (so I was told) more sensitive to the horror and fear than the "typical" surgeon, I feel qualified to express myself. My thoughts are based in the reality I saw in my practice. So here it is: though not opposed, and having participated in many cases of it, I'm not a big fan of immediate breast reconstruction after mastectomy.
As I recall, the thread in which I commented on that other site was regarding yet another study showing that surgeons had a poor record of offering reconstruction to their mastectomy patients. Of that I was never guilty. I think it's wonderful that it's available. It's a timing thing, to me. To my patients undergoing mastectomy, I always brought up breast reconstruction; among other things, I made sure they understood it was not considered "cosmetic," and was (by law!) covered by insurance. I discussed both immediate and delayed reconstruction, and did not try to talk women out of the former choice if that's what they preferred. But I was glad when they didn't. At the risk of being misunderstood, let me try to explain.
The blanched face, the terrified glaze of the eyes, the tears. The jumbled words cascading past a trembling jaw, the grip of hand upon hand, fingers compressed white and shaking. Witnessing thoughts tumbling almost visibly through the mind, randomly, out of control, one, two, three after another, splashing through pools of panic. Endlessly, I've seen it, over and over, to the point of hating it above all, to the point of looking at my schedule and feeling a physical tightening in my gut when I saw such a consultation there. That's the reality in which such conversations take place. No matter how carefully, how gently or insistently; despite taking time, providing reassurance that we can deal with it, handing out personally-written booklets; my attempt at informing, explaining, supporting the woman and her family to whom I give the news often feels futile, as I try to breach the wall of stunned disarray.
Mastectomy is always a treatment option for breast cancer. As understanding has evolved, it's uncommon that it's the only one. By far the majority of women undergoing treatment for breast cancer have the option of breast preservation, via lumpectomy and radiation therapy. For reasons I've dealt with before (here, plus 1, 2 , 3 , 4 following), some choose -- or need -- mastectomy. More than any other cancer, I'd say, there are branching decision trees to be understood, choices to be made: lumpectomy vs. mastectomy, how and where radiation fits in, when and what kind of chemotherapy is used, the need for lymph node sampling, when and if full axillary dissection would be used instead of or in addition to sentinel node biopsy. And for women who will undergo mastectomy, the issue of prosthesis vs. reconstruction: what type -- among many varieties -- and when. It's a lot to assimilate.
So my first concern is simply about overload: the need to wade through an enormous amount of information and sort it all out, at a time when you are bordering on panic. In the midst of that, adding another very thick layer of fog, requiring visits to a plastic surgeon and the full consideration of several very different options, making a realistic decision about reconstruction seems, sometimes, like piling on. First things first. Let's focus all our energy on getting through the cure. Let's know that this option awaits, and be reassured by it; and get back to it later.
I suppose that sounds condescending. Poor little women, can't handle all that stuff. Hardly. Women are tough as nails. They have to be. And let me say again: I've always brought up, and haven't tried overtly to steer women away from immediate reconstruction. (Does my mind-set affect the outcome? Could be, in some cases.) But condescension (if that's what it is) cuts both ways. At least one famous female surgeon used to go around the country claiming that the only reason mastectomy was invented was because men like to mutilate women. And, by inference, a woman who'd choose it, and not have reconstruction, was somehow succumbing to that mindset. Mastectomy is mutilation. But how one responds to it is -- and ought to be -- very individual. The time, it seems to me, to decide about reconstruction is after the enormous stresses of facing the cancer are dealt with. Many major centers publish with pride that immediate reconstruction is their standard of care, their treatment of choice. I can't help but think that many women are pushed (is that too strong a term?) into it when they'd rather just take their time.
Depending on the method, breast reconstruction is a very big deal. The operation can take several hours, and may subsequently require a couple of much smaller touch-ups. Clear-headed choice is mandatory. And here's a related issue: lying in an operating room for another four hours -- turning a forty-five minute operation into a five hour one -- anesthetized, then having one's body deal with all the required healing, while asking the body also to deal with as yet not-fully-treated cancer seems physiologically iffy. I know of one study that found no average delay in starting chemotherapy for women undergoing immediate reconstruction, and that's good. What haven't happened yet -- and likely won't, for practical reasons -- are studies that randomize women into immediate versus delayed reconstruction and follow for several years to evaluate any effect on long-term cure, segregated by stage at diagnosis. It'd be important, I'd think. Related are the delays from diagnosis to treatment that come with the need for arranging the consults and coordinating operating time. Maybe centers who promote immediate reconstruction have streamlined that part.
I don't for a second minimize the psychological effect of mastectomy. I've seen it. I know it. I've practiced through the times when reconstruction was not available; when it was technically disappointing, and when it became cosmetically fabulous; when it was done only later; and now, when it's done at the time of the mastectomy. In the pre-immediate days, I've had many patients who were very relieved to know reconstruction could be done yet who, when the time came, said they were surprised at how comfortable they were with their status and chose not to have reconstruction. (Prosthetics have also come a long way: some adhere directly to the chest so they don't need a special bra; they have lifelike texture and coloration; their nipples show through flimsy bras, if you like that sort of thing.) The numbers weren't small. From that fact, I infer that many women, under the stress of the initial diagnosis, are "encouraged" into a very big surgical deal when, given time, they'd have opted out. One can argue both ways whether that's a good or a bad thing.
Psychological well-being and body image are the bottom line issues (assuming -- which we can't quite -- no impact on survival). Studies make it clear that reconstruction serves the purpose very well, and argue for immediate reconstruction. Yet it's not simple: the "baseline" evaluations of immediate reconstruction were done in women not yet treated, who had no basis for knowing what mastectomy would be like for them; those of the women who underwent delayed reconstruction had already had mastectomy. The measured improvements were less in those with delayed surgery; but they'd had time to adjust and, in effect, raise that baseline.
I'm no crusader here. I neither expect nor desire to change minds. Recognizing that it's not clear-cut, rather than pushing a particular approach, I favor being sensitive to the individual; having feelers out to intuit what the woman sitting in front of me needs. But it appears that there's now a trend in a single direction, and that it's generated in academic centers -- the very places where, in all things, more is more. (If there's a more complicated means to an end, they find and promote it. Kidding [?]) Based on my experience, it's a steamroller for at least some women, generating what may be unnecessary anxiety and commitment to a very laborious and expensive process; forcing a quick decision at a time of great vulnerability.
When I've been asked my opinion, I've given it. When from behind those glazed eyes, from obviously overwhelmed minds the words are formed, "What do you think, doctor? Should I have reconstruction right away?" I've usually said something like this: "I have no problem with it if that's what you want to do. But if you don't want to have to decide now, you will always have the option, any time, down the road. Let's set up a consultation with a plastic surgeon if you like, to hear what's involved. But for now, let's go about curing breast cancer. Let's get all that over with, and when you're recovered, feeling good, strong, we'll take that one on and sort through the options." It's self-selecting, I'm sure: if they're asking, they're hesitant. But generally, when they hear that, a quantum of tension is dissipated, the grip relaxes, and you can sense a bit of relief fill the room.
Addendum: I'm well aware that most plastic surgeons prefer immediate reconstruction, because they don't have to deal with scar tissue. It's easier. Many claim better cosmetic results (I've seen it both ways, and -- at least with tissue-transfer techniques such as TRAM flap -- can't tell the difference. Both look great, usually.) Frankly, I think their ease is part of the push for immediate reconstruction, and I'm not sure it ought to be. Patient satisfaction is another issue, and like the whole subject is iffy and tricky and subject to claims of being patronizing. Recognizing the impossibility of accurately measuring such a thing and to subject it to a meaningful prospective study, I've heard opinions expressed on both sides of the issue by plastic surgeons. Some say that comparing a reconstructed breast to the "real" one -- which is what happens with immediate reconstruction -- has a higher chance of disappointment than when it's compared to having lived with mastectomy for a time. I'd welcome comments from my occasional plastic surgeon readers. And here is an example of what we're talking about, from the right side of the bell curve: