Unidextrous

It'd be darn hard -- probably impossible -- for a one-handed person to be a surgeon. Virtually all technique we use is predicated on the use of two hands: traction, and counter-traction. Hold the scissors with one hand, use forceps in the other. (Or fingers. I love the way the fingers of my left hand seem to know exactly how to noodle the tissues around as I'm scissoring or otherwise instrumenting with my right.) It's nice to be able to switch hands, and I'd say most surgeons do, myself included. But I admit it: I'm better with my right than my left when it comes to the finer stuff.

There's nothing I do with my right hand in surgery that I haven't done with my left: place a stitch, cut, grab; and, of course, we all throw knots happily with either paw. Still, if I really want to be precise, where there's no wiggle room, I use my right hand. A completely ambidextrous surgeon, though not likely to rise above the pack on that alone, has an advantage; at least in terms of annoyances.

The reason I bring it up is that in response to a comment on a recent post, I mentioned the idea of centers of excellence, and a skeptical post I'd written on the subject. In my comment I suggested the time might come when you take your breast to Omaha and your gallbladder to Newark. It could even happen, I said, that you'd take your left breast to Omaha, and your right one to Cleveland. There's the tiniest kernel of truth. Very, very, very tiny, but enough to have produced this here post. As a right-handed person, it's actually a little bit easier to do a right mastectomy than a left.

It's an uncommon situation in which one holds dissecting scissors, which are curved at the tip, in such a way that the curve does not follow the natural arc of one's hand and fingers. (See how awkward it looks?) Without trying to describe the whole operative technique, suffice it to say that the classic approach to mastectomy is the removal of the breast and the lymph nodes under the arm en bloc, meaning in one continuous section. From the "axillary tail" (the upper outer portion) of the breast the dissection is carried into the axilla (underarm) along the axillary vein. With the patient lying on her (sometimes his) back, arm extended, the surgeon is standing to her right. The sweep of the dissection is very natural, holding scissors as they were meant to be held, moving forward in the natural direction for such things. On the left side, there's that awkwardness (even holding the scissors properly); the flow of the operation is against form, like water running uphill.

It's not a big deal, of course. We learn what we need to learn. There's no compromise in quality, no threat to doing the operation properly. It's just that it feels a little better, the one over the other. As a lover of the motion of surgery, the beauty that it can encompass, I simply take note of such things. And move on.

Almost famous

I was nearly famous. Coming this close to being on the PBS News Hour, I was fully prepared to receive love notes and hate mail, and probably would have. The subject was outpatient mastectomy, and I was for it. My patient made it on; I didn't.

Let's get this part out of the way right off the bat: there's no way I would EVER advocate that mastectomy should be considered an outpatient procedure in the sense that insurance companies would urge or require it. The default mode (as we computer-literate folk would say) is and ought always to be that it's done in the hospital. As with many things, I think that when there are options, women having the right to choose is a good thing. Having done many outpatient mastectomies, I can say with complete confidence that it's safe, amazingly well-tolerated, and, for some women, is better in all ways than being in the hospital. Especially in a hospital where the nurses are made to care for too many patients, or to rotate to specialty areas with which they aren't familiar.

First, some housekeeping basics. Clearly, for the woman having immediate reconstruction, outpatient mastectomy is not appropriate. Maybe in the near future I'll say why I have a mild bias in favor of deferring reconstruction ("mild" being the operative word -- it's a complicated matter which I don't want to get into now, but, as I think more about it, will definitely do so later.) And I'm painfully aware of how devastating the idea of mastectomy can be: even mentioning outpatient surgery as an option is something I've done very selectively. It's not for everyone. But physiologically speaking -- referring here to the impact on the body -- there are several operations that I'd consider more "severe," and which are quite often done as outpatient procedures: gallbladder surgery, gastric banding for obesity, various gynecological procedures.

Poking around inside the abdominal cavity has bigger implications than what is essentially a skin operation. OK: "skin operation" is a little glib. But really, the breast is a modified sweat gland. That lovely form, the symbol of femininity and the object of admiration by men and women alike, that most desirable (here I speak as a heterosexual male person and not as a physician!), soft and warm living poetry stinks like a locker room when you cut into it with an electrocautery device. And when you remove it, the operation is mainly on and under skin, leaving muscle -- where most of the pain comes from -- pretty much alone. The old days of removing the pectoralis major and/or minor, along with swaddling the patient in enormous restrictive dressings, are long gone. So, thankfully, are significant blood loss and hours of anesthesia.

Properly done, mastectomy ought not require blood use, and can be thoroughly carried out in well under an hour. My patients almost always woke up with no pain at all, because I had a way of injecting a long-acting local anesthetic into the field. But even when it wore off, most women were quite surprised at how comfortable they felt. (Nothing in medicine is 100%!) Of those that were hospitalized, the greatest number went home on the first day postop.

You get an idea when you see them: some women would rather not be in the hospital for any of a number of reasons. Privacy. Self-control. Whatever. And there was a time -- which is only marginally better today -- when nurses were so overworked and understaffed that patients didn't always get the sort of care they needed. Drains. Drove me crazy. Leave a drain or two in the area after mastectomy, expect them to be operated properly; otherwise, blood will build up (a "hematoma") and be a source of problems. I wanted them checked frequently and emptied properly; depending on the experience and workload of a given nurse, it might or might not happen. At home, with proper instruction, there was never a problem. So I did more than a few outpatient mastectomies, and neither I nor the women involved had reason to regret them.

In Connecticut, I think it was, a health insurance company is said to have announced it had designated mastectomy as an outpatient procedure. No reason it needed hospitalization; wouldn't pay for it in the hospital unless specifically excepted. People were, justifiably, outraged. There's some controversy as to whether it's actually true that the insurance company made the decision. But it's unquestioned that there has been an uproar, and that Congress has (huzzah) gotten involved, proposing legislation. "Drive-thru mastectomy" is what it came to be called, and it was a rallying cry for many advocacy groups. And, as happens when things get politicized, the truth got sort of swept away.

Once again, I'll say I fully agree: mastectomy has no place on the list of operations mandated as outpatient procedures. (Nor, in my opinion, does the one thing that is generally so mandated, and which is the most egregiously inappropriate: hemorrhoidectomy. Another topic, sometime.) But it absolutely can be done that way.

So, for some reason PBS got wind of it and of all places, it was in the Seattle area that they planned to do a segment on it, on the News Hour. And as luck would have it, the director of the surgery center at which I did most of my outpatient operations was contacted to see if she knew of anyone doing outpatient mastectomy. She gave them my name. I got a call and had a nice conversation with a producer of the show. Great, I thought. I could explain the realities; I made it clear to him that I thought it was very appropriate when the woman preferred it, but in no way should it be required. And, I figured, I'd get a chance to put in a plug for nurses: tell the country what the effect on quality care had been of the steady cuts in hospital reimbursement.

The man seemed quite sympathetic. What he wanted was to follow a woman through the whole thing: show a bit of the operation, film her at home. He needed someone within a fairly short time-frame, and although I saw several women with breast cancer -- as usual -- in the next couple of weeks, none was a candidate. I let the producer know, and asked if he'd like to talk to a patient who'd had it. He would. I contacted a couple of my patients and they were happy to offer themselves. If the piece was produced, I was assured, and if they included my patient, they'd schedule an interview with me, as well.

Time passed, silently vis a vis word from PBS. Until one day I got a call from someone telling me Mr. Producer wanted to let me know the show would be on tonight. What? No me? What about my three minutes of fame? My subsequent offers from Hollywood, the surge in my practice? Well, she said, it's on tonight.

It started well enough. The first patient profiled was mine, who said, among other things, that she'd had dental work that was a bigger deal. Her kids fought over who could empty her drain. She'd do it again in a heartbeat. Best decision she'd made. Like that. Then there were a couple of surgeons saying why it couldn't or shouldn't be done. Patients could never manage the bandages; things could happen that would lead to problems. It's a horrible and insensitive idea. Dangerous. And a couple of patients tearfully saying how they'd been hustled out of the hospital before they were ready. Had I been on, too, I suppose I'd have looked like an idiot. These docs were professors; I was just some country schmoe. And yet, they'd started with my patient saying what a breeze it was. Who, indeed, was the schmoe? If your patients can't handle a bandage, I thought, either you aren't instructing them well, or your bandages are too damn complicated. Bad things happen? Sure they do. But so they can with any outpatient procedure, or with brushing your teeth.

Surgeons -- myself included -- accept change with glacial speed. The things we were taught were pounded in with heavy hammers, and deviation was met with fire and spittle. To consider change is to face a nearly physical reaction and to hear your teachers shouting you down from the grave. It takes a conscious act -- an act of rebellion, really -- to consider the things you do and the instructions you give patients and to examine where they came from and the extent to which they actually make sense. "Don't lift more than ten pounds." Anyone do a study: this group, you lift five pounds; that group, you lift fifteen?

When I was in training there were a couple of old docs still practicing who'd been trained in the days when any person who'd had major abdominal surgery was required to stay in bed for two weeks. Pneumonia, pulmonary embolus -- they were just part of the deal. Get up, your guts'll fall out. Likewise, women who'd undergone mastectomy were told not to reach, not to lift, not to shower. Why, exactly? I was told -- very strenuously -- as a resident that everyone who underwent splenectomy needed a stomach tube for three days. Why? Because otherwise their stomach would dilate and pop the sutures off the short gastric veins. So that's what I did. Until I thought: wait a minute. I can tie a suture so it doesn't pop off. Do you suppose that it happened to one of his patients (or one of his teacher's -- or his teacher's teacher's) and led to a stone-carved rule?

My instructions to mastectomy patients -- no matter where they found themselves postop -- was to avoid things that hurt, and otherwise to do whatever they wanted. That simple. And, because I used a very small bandage covered in plastic, they could shower whenever they wanted. Yes, there was a drainage tube, connected to a bulb-like collection device. Hang it around your neck in the shower, like soap-on-a-rope, I'd say. And although I've seen the occasional hematoma develop in a hospitalized patient whose drain was ignored, it never happened in my outpatient people.

So what can we learn from all this? First, not everyone who speaks with confidence knows what the hell he/she is talking about. (This, of course, could just as well apply to me.) Second, health insurance companies -- no matter how soothing the music is in their TV ads -- are interested in the bottom line above all else and make decisions that are not necessarily in the interest of their subscribers. Third, doctors do lots of things because they were taught to do so and which have never been subjected to meaningful analysis to see if they actually make sense. Fourth, changing those things is incredibly difficult for lots of complicated reasons. Fifth, if -- and I hope you never are -- you are faced with the need for mastectomy and hate the idea of having to stay in the hospital, and your surgeon offers to do it as an outpatient, feel free!

Almost famous

I was nearly famous. Coming this close to being on the PBS News Hour, I was fully prepared to receive love notes and hate mail, and probably would have. The subject was outpatient mastectomy, and I was for it. My patient made it on. I didn't.

Let's get this part out of the way right off the bat: there's no way I would EVER advocate that mastectomy should be considered an outpatient procedure in the sense that insurance companies would urge or require it. The default mode (as we computer-literate folk would say) is and ought always to be that it's done in the hospital. As with many things, I think that when there are options, women having the right to choose is a good thing. Having done many outpatient mastectomies, I can say with complete confidence that it's safe, amazingly well-tolerated, and, for some women, is better in all ways than being in the hospital. Especially in a hospital where the nurses are made to care for too many patients, or to rotate to specialty areas with which they aren't familiar.

First, some housekeeping basics. Clearly, for the woman having immediate reconstruction, outpatient mastectomy is not appropriate. Maybe in the near future I'll say why I have a mild bias in favor of deferring reconstruction ("mild" being the operative word -- it's a complicated matter which I don't want to get into now, but, as I think more about it, will definitely do so later.) And I'm painfully aware of how devastating the idea of mastectomy can be: even mentioning outpatient surgery as an option is something I've done very selectively. It's not for everyone. But physiologically speaking -- referring here to the impact on the body -- there are several operations that I'd consider more "severe," and which are quite often done as outpatient procedures: gallbladder surgery, gastric banding for obesity, various gynecological procedures.

Poking around inside the abdominal cavity has bigger implications than what is essentially a skin operation. OK: "skin operation" is a little glib. But really, the breast is a modified sweat gland. That lovely form, the symbol of femininity and the object of admiration by men and women alike, that most desirable (here I speak as a heterosexual male person and not as a physician!), soft and warm living poetry stinks like a locker room when you cut into it with an electrocautery device. And when you remove it, the operation is mainly on and under skin, leaving muscle -- where most of the pain comes from -- pretty much alone. The old days of removing the pectoralis major and/or minor, along with swaddling the patient in enormous restrictive dressings, are long gone. So, thankfully, are significant blood loss and hours of anesthesia.

Properly done, mastectomy ought not require blood use, and can be thoroughly carried out in well under an hour. My patients almost always woke up with no pain at all, because I had a way of injecting a long-acting local anesthetic into the field. But even when it wore off, most women were quite surprised at how comfortable they felt. (Nothing in medicine is 100%!) Of those that were hospitalized, the greatest number went home on the first day postop.

You get an idea when you see them: some women would rather not be in the hospital for any of a number of reasons. Privacy. Self-control. Whatever. And there was a time -- which is only marginally better today -- when nurses were so overworked and understaffed that patients didn't always get the sort of care they needed. Drains. Drove me crazy. Leave a drain or two in the area after mastectomy, expect them to be operated properly; otherwise, blood will build up (a "hematoma") and be a source of problems. I wanted them checked frequently and emptied properly; depending on the experience and workload of a given nurse, it might or might not happen. At home, with proper instruction, there was never a problem. So I did more than a few outpatient mastectomies, and neither I nor the women involved had reason to regret them.

In Connecticut, I think it was, a health insurance company is said to have announced it had designated mastectomy as an outpatient procedure. No reason it needed hospitalization; wouldn't pay for it in the hospital unless specifically excepted. People were, justifiably, outraged. There's some controversy as to whether it's actually true that the insurance company made the decision. But it's unquestioned that there has been an uproar, and that Congress has (huzzah) gotten involved, proposing legislation. "Drive-thru mastectomy" is what it came to be called, and it was a rallying cry for many advocacy groups. And, as happens when things get politicized, the truth got sort of swept away.

Once again, I'll say I fully agree: mastectomy has no place on the list of operations mandated as outpatient procedures. (Nor, in my opinion, does the one thing that is generally so mandated, and which is the most egregiously inappropriate: hemorrhoidectomy. Another topic, sometime.) But it absolutely can be done that way.

So, for some reason PBS got wind of it and of all places, it was in the Seattle area that they planned to do a segment on it, on the News Hour. And as luck would have it, the director of the surgery center at which I did most of my outpatient operations was contacted to see if she knew of anyone doing outpatient mastectomy. She gave them my name. I got a call and had a nice conversation with a producer of the show. Great, I thought. I could explain the realities; I made it clear to him that I thought it was very appropriate when the woman preferred it, but in no way should it be required. And, I figured, I'd get a chance to put in a plug for nurses: tell the country what the effect on quality care had been of the steady cuts in hospital reimbursement.

The man seemed quite sympathetic. What he wanted was to follow a woman through the whole thing: show a bit of the operation, film her at home. He needed someone within a fairly short time-frame, and although I saw several women with breast cancer -- as usual -- in the next couple of weeks, none was a candidate. I let the producer know, and asked if he'd like to talk to a patient who'd had it. He would. I contacted a couple of my patients and they were happy to offer themselves. If the piece was produced, I was assured, and if they included my patient, they'd schedule an interview with me, as well.

Time passed, silently vis a vis word from PBS. Until one day I got a call from someone telling me Mr. Producer wanted to let me know the show would be on tonight. What? No me? What about my three minutes of fame? My subsequent offers from Hollywood, the surge in my practice? Well, she said, it's on tonight.

It started well enough. The first patient profiled was mine, who said, among other things, that she'd had dental work that was a bigger deal. Her kids fought over who could empty her drain. She'd do it again in a heartbeat. Best decision she'd made. Like that. Then there were a couple of surgeons saying why it couldn't or shouldn't be done. Patients could never manage the bandages; things could happen that would lead to problems. It's a horrible and insensitive idea. Dangerous. And a couple of patients tearfully saying how they'd been hustled out of the hospital before they were ready. Had I been on, too, I suppose I'd have looked like an idiot. These docs were professors; I was just some country schmoe. And yet, they'd started with my patient saying what a breeze it was. Who, indeed, was the schmoe? If your patients can't handle a bandage, I thought, either you aren't instructing them well, or your bandages are too damn complicated. Bad things happen? Sure they do. But so they can with any outpatient procedure, or with brushing your teeth.

Surgeons -- myself included -- accept change with glacial speed. The things we were taught were pounded in with heavy hammers, and deviation was met with fire and spittle. To consider change is to face a nearly physical reaction and to hear your teachers shouting you down from the grave. It takes a conscious act -- an act of rebellion, really -- to consider the things you do and the instructions you give patients and to examine where they came from and the extent to which they actually make sense. "Don't lift more than ten pounds." Anyone do a study: this group, you lift five pounds; that group, you lift fifteen?

When I was in training there were a couple of old docs still practicing who'd been trained in the days when any person who'd had major abdominal surgery was required to stay in bed for two weeks. Pneumonia, pulmonary embolus -- they were just part of the deal. Get up, your guts'll fall out. Likewise, women who'd undergone mastectomy were told not to reach, not to lift, not to shower. Why, exactly? I was told -- very strenuously -- as a resident that everyone who underwent splenectomy needed a stomach tube for three days. Why? Because otherwise their stomach would dilate and pop the sutures off the short gastric veins. So that's what I did. Until I thought: wait a minute. I can tie a suture so it doesn't pop off. Do you suppose that it happened to one of his patients (or one of his teacher's -- or his teacher's teacher's) and led to a stone-carved rule?

My instructions to mastectomy patients -- no matter where they found themselves postop -- was to avoid things that hurt, and otherwise to do whatever they wanted. That simple. And, because I used a very small bandage covered in plastic, they could shower whenever they wanted. Yes, there was a drainage tube, connected to a bulb-like collection device. Hang it around your neck in the shower, like soap-on-a-rope, I'd say. And although I've seen the occasional hematoma develop in a hospitalized patient whose drain was ignored, it never happened in my outpatient people.

So what can we learn from all this? First, not everyone who speaks with confidence knows what the hell he/she is talking about. (This, of course, could just as well apply to me.) Second, health insurance companies -- no matter how soothing the music is in their TV ads -- are interested in the bottom line above all else and make decisions that are not necessarily in the interest of their subscribers. Third, doctors do lots of things because they were taught to do so and which have never been subjected to meaningful analysis to see if they actually make sense. Fourth, changing those things is incredibly difficult for lots of complicated reasons. Fifth, if -- and I hope you never are -- you are faced with the need for mastectomy and hate the idea of having to stay in the hospital, and your surgeon offers to do it as an outpatient, feel free!

Breast Cancer Women

Something you may not know, and won't get by looking at most renditions of them, is that the legendary Amazon warrior women are said to have cut off their breasts. One, more accurately. In order to shoot their arrows with their bows, the left breast (assuming right-handedness) was removed. (The linked article above has it wrong, I think.) Pantomime it on yourself: the left breast would be in the way, particularly if bare-breasted, as they were, so it is said. And here's the kicker: it's in the name. Amazon. A (for absent); Mazon (same root as mastectomy: referring to the breast.) Of course, none of this is confirmable, but it is an accurate account of the legend. And so I told it to Gloria and her husband, competitive archers.

Women are tougher than men, no doubt in my mind, having operated on both more than a few times. The fact emerged first in medical school, when a fellow (male) student fainted dead away as we heard a lecture on blood types. A lecture, not even a lab! And about types; not even the gooey stuff itself! The prof was unsurprised: "Happens all the time," he said. "Always the men. Ladies live with blood. It's no big deal to them." Bunch 'a wimps, we.

Don't get me wrong: I'm well aware how devastating the idea of cancer can be, and how mutilating many operations are -- mentally as well as physically. And yet it's been a source of inspiration over the years to witness how well most women are able to adjust to mastectomy: with bravery, with calm, with humor. I learned many years ago, when inspecting a surgical wound, not to say "beautiful," no matter the operative type. And yet I've heard lots of patients, when they looked at their mastectomy scar, say "gee, that's not as bad as I expected." And many, for various reasons, chose not to have reconstruction later, when they'd initially figured they would.

This is not a treatise on the benignancy of mastectomy, nor a suggestion that women who have a hard time with it are somehow deficient. I'm just saying -- because it's been a source of amazement to me -- that for some women, it turns out to be ok. More ok than they'd expected it to be. On the day of her surgery, I pulled back the covers on one lady to discover that she'd crocheted a quite impressive nipple/areola in brown and pink yarn and placed it on her chest; delighting in my surprise.

So, back to Gloria. A very athletic woman, tall and muscular, she and her husband sat in my office hearing the results of her biopsy. In addition to all the usual fears, they were concerned about their archery careers. They competed at a very high level, and had tournaments coming up. How soon, they wanted to know, would she be able to pull a bow? That was as high on their list as any other issue, and I was glad to hear it: desire to get back into life is important, whatever the operation. I hadn't known about this avocation of theirs, and it gave me my one and only chance to tell the Amazon story. And yes, it was her left breast, and she was right-handed. She loved it.

There was no question in her mind which option to choose: it was mastectomy for her, and she recovered like the athlete she was, proudly arching (or whatever they call it) and telling the legend to her competitors in short order. As I recall, her husband got her some sort of Xena paraphernalia to wear, as well. Sometimes, things have a way of working out.

[Addendum, 5/2014: I was sent this link to some very inspirational quote by celebrities who've dealt with breast cancer.]

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.