Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.
Friday, October 12, 2007
Since it's Breast Cancer Awareness Month, I should point out that I've done a series here about breast cancer and related issues (one, two, three, four, five; and this about breast lumps.) My "memorable patient" series included this lady with advanced breast cancer; and there was a post about Elizabeth Edwards and her recurrence. I've admitted some outdated views on immediate reconstruction, and lamented my near miss with national notice regarding outpatient mastectomy. None of it does justice, perhaps, to the fact that over my career, by far the greatest number of patients I saw was women with breast problems. In fact, I'd have to say that one factor in my eventual burnout was the increasing number of young women with breast cancer that I was seeing; those office encounters are much worse for the woman and her family, of course. But they took a heavy toll on me as well, time and again, nearly daily.
It was the appearance on NBC news, a couple of nights ago, of a person who has annoyed the hell out of me in the past that reminded me of my recent silence on the subject (which is only because I think I've said most of what I have to say.) This love-ly person is mentioned in one of the above-linked posts. She'd gotten early fame by appearing on various shows claiming that the only reason mastectomy was invented is because men like to mutilate women. Sigh. It's hardly worth responding to something like that. Upping the ante, she also liked to say that if your doctor tells you you need a mastectomy, find another doctor, because no woman ever needs one. Complete and utter bullshit, then and even now. I'd like to believe she wasn't dumb enough actually to have believed it, but was just trying disingenuously to get attention. I do give her credit for having written a quite good "breast book," and I've seen her, more recently, being generally reasonable. But last night she did it again: questioned by Brian Williams about the most important thing a woman can do regarding breast cancer, her answer was always to get a second opinion before embarking on treatment.
I have no problem with the idea of second opinions: when there's any reason at all for uncertainty, I encourage them. ("Always" is a little dogmatic, though.) But what got me was her reasoning. As complicated as the field has become, she said, it's impossible for any one doctor to "keep up." So see two? Like if no one person knows enough to be trusted, getting another will magically fill in the holes? Two wrongs make a... what? I question the math. Anyhow, it's not really a big deal. Getting a second opinion is perfectly sensible, no matter the issue at hand. It's just that, after those years of listening to the woman's crazy rants back then, I have a hard time giving her much credence now. Even when she's right.
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this post comes a week after i had an experience with a second opinion.
i saw a woman with a 3cm mass in a fairly small breast. positive nodes. i gave her the options but suggested modified radical and later reconstruction.
she didn't turn up for her operation. when i inquired, she had gone to the big city (johannesburg). maybe pride, but i had to remind myself that second opinion is a good thing.
It happens to me every so often. I see a lady who needs a MRM (high grade multifocal disease). I spend an hour going through all the options. She agrees with my reasoning. And then I hear a week later she's "gone downtown" to get a second opinion from the "breast expert" at the Cleveland Clinic. And of course she gets her MRM downtown. No biggie. The complexity of breast disease is a little overrated, though. I read journals. I check the NCI once a week. The surgical treatment of breast cancer doesn't change nearly as quickly as the dizzying array of options for neoadjuvant and adjuvant chemotherapy or hormonal therapy. And I always involve a medical oncologist in those decisions anyway.
Oh, I so agree wtih you all. The notion that no woman EVER needs a mastectomy is so wrong. I'm sure you can get negative margins even in a high grade multifocal disease patient, but the result isn't something I"d want to live with. Sometimes a mastectomy with or without revision is much much nicer looking than a mutilated breast.
I agree Buckeye Surgeon (I wanted to abbreviate that BS, but wasn't sure you'd appreciate it). Breast disease is not something that surgically is difficult to treat. The chemo/hormonal therapy does change and there are so many trials out there seem to change daily.
Wow. If my friend had followed this woman's advice and not gotten a mastectomy, she'd be dead. Wonder how this "surgeon" justifies that.
I hope her espousing this erroneous info hasn't caused women to suffer or die that otherwise would have sought/received appropriate treatment.
So weird Doc S.-Your beautiful pic is back on the header. :)
The people I am so happy they go off seeking someone else are those are religious, one might say fanatical about their questioning. Question after question after question.
After a bit you see that they're asking questions but so focused on that they're not listening. They ask the same question, forgetting they've already asked it. They ask questions you anticipated and already answered.
Besides all this rampant advice about questioning your doctors, there needs to be the even stronger advice to focus on what you're being told. It's Ok to ask questions, but listen to the answer before you go on to the next question.
Greg: I've actually written my next post, and it's on that very subject. We agree.
Surgeons who make statements like no woman needs a mastetcomy have fundamental misunderstandings about the global care involving surgical, oncologic, and reconstructive surgery issues.
Local recurrence rates (that may be up to 19% in some instances) with lumpectomy is a risk most women aren't willing to accept, irrespective of whether or not disease related mortality is equivalent.
XRT (as currently practiced)carries signifigant morbidity and inconvenience for most patients. It not infrequently makes it difficult (or even impossible) to perform good reconstructive procedures. A MRM or simple mastetcomy with reconstruction will often be more favorable then a scarred/radiated lumpectomy salvage.
Greg p- I think I was that pt with my urologist group last year. I was so taken aback by it all, not feeling well, in pain, afraid, etc. Bottom line for various reasons and not all medical, I was filled with anxiety. I have always been the go to strong person for a lot of people...even amidst great stress, but last year I crumbled like a little girl.
If a person is filled with anxiety...it's not that they aren't listening ...they can't process and retain what your are saying. That was my experience anyway.
I am grateful that he has been such a compassionate, dependable, skilled and dedicated doctor always on top of my case. The surgeon who would have done the surgery that worked out of the larger facility was also great with me.
Dr S.-I get my next renal scan this coming Wednesday and uro doc and I are optimistic about a good report!
I would NOT want to go to a doctor who did not want me there.
The women with metastatic disease in my group of women under 40 with breast cancer call October "amateur month."
I'm curious: do you think the prognosis of younger women is worse than older women? What age is the cut -off for this worse prognosis? Is it related to the aggressiveness of the tumors, or that some of them are not hormone responsive?
Do you recommend different treatment for this patient population based only on their age? If so, what exactly? For example, would you recommend mastectomy instead of lumpectomy? More aggressive chemo?
The worse prognosis for younger women is that they tend to get cancers with more unfavorable markers, with respect to hormone receptivity, her2neu, etc. Given the same markers women of differing ages tend to have similar prognosis. So it's not the age per se but the tumor charateristics. In general the difference is pre- vs post-menopausal, as opposed to a specific age. So the answer to you last question is, no, recommendations aren't made based on age, but on the tumor characteristics that are determined.
Something I've often wondered about: Is there any particular medical reason to "support *breast* cancer research" as opposed to "support cancer research" generally?
I certainly can see a lot of social reasons why focusing on a particular sort of cancer can make fund raising more successful. People are probably going to be more generous and involved with something that affects them personally. It's a very common type of cancer, and I would say that the sisterhood aspect draws people together. And for whatever reasons, I understand that you may feel like that's the area where you would like to prioritize you donations.
But is there really any difference, in terms of the people working in the labs to develop drugs or what have you, between breast cancer and skin cancer or colon cancer, for instance? It would seem like a potential treatment for one kind of cancer would be just as likely to work on a wide variety of other sorts of cancers.
Not all tumors are the same, as some of the posts here talk about, but since we seem to be still wrestling with and refining the basic idea of finding something that kills the tumor cells, but not the healthy cells, are we in a position to try to specialize so much?
Or is it all really the same behind the scenes and the charities are actually funding a broad array of research that will just as likely come up with prostate cancer treatments?
PB: that's an excellent question. The answer, I'd say, is "yes and no." Understand I'm neither a researcher nor an expert on cancer biology; but I'd say a couple of things. First, whereas it's true that the "concept" of cancer -- ie, that it's one's own cells that have begun to behave abnormally, dividing more rapidly than normal and taking on the ability to invade and spread -- it's not true that all cancers are the same. Some produce specific proteins, some don't; some are sensitive to some kinds of drugs, others aren't. What causes one kind may not be true of another; ie, things which initiate the DNA changes, such as smoking, in some are not as impactful in others. Some hormones affect some cancers, others affect others, many are entirely unaffected. So there are differences in the millieu in which a given type of cancer forms, differences in response to treatments, differences in which treatments are most effective; all of which means there are reasons to focus on specific cancers in labs.
On the other hand, there are lines of research that, if successful, may apply to all or most forms of cancer. Ways of getting one's immune system to recognize and kill cancer cells; vaccines; ways to repair the DNA alterations of the malignant cells. If and when such things become reality, it will fundamentally change cancer therapy, and very much to the good. Meanwhile, there remains need for "specialized" research.
Thanks very much, Dr. Schwab, for that answer. Like I said, it's something I've long wondered about.
I've spent hours over the last several days reading your surgery blog, and it's been absolutely fascinating. I'll be looking for a copy of your book.
I've even been over to your other blog a little. You remind me of a guy I went to college with. He was kind of a tree-hugger. We used to have periodic friendly arguments about this and that. I don't think either of us changed our views much, but I think we came to understand the other viewpoint a little better, and it was surprising what we did agree about.
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