I'm Aware

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 I've admitted some outdated views on immediate reconstruction, and lamented my near miss with national notice regarding outpatient mastectomy.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.

Disconnect

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]

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.

Memorable Patients: part seven

I first met her when I consulted on her hospitalized son, who'd been in and out several times with transient abdominal pain. He'd already been through various tests and consultations, each time improving before a diagnosis was established. When I was asked to see him he was once again on the mend, but I concluded that he likely had the uncommon condition of recurrent appendicitis, and proposed surgery. Taking out his appendix, which I did shortly thereafter, permanently cured him, and the pathologist confirmed the diagnosis. Mrs. Davidson told me she knew God had sent me to them, and thanked me prayerfully. As her son recovered, she prayed with him as well.


When next we met a few years later, she was the patient, having discovered a lump in her breast. With a fine-needle aspiration I confirmed the diagnosis of cancer, and before long we were together in the operating room. Based on my physical exam, I expected to find some lymph nodes containing tumor; but when I got into her axilla, I was surprised -- sickened, really -- by how many. There's a clear correlation between failure to cure and the number of lymph nodes under the arm. Whether removing those nodes is therapeutic or merely diagnostic is a matter of disagreement: in other words, does removing them improve prognosis in any way other than telling us what we're up against? Regardless of further therapy, is it good to remove all the nodes you can? I think so, until clearly shown to be otherwise. When the cancer has marched its way all through the axilla, the odds are very strong that it's gone beyond as well; but in the absence of proof of spread outside the axilla, it's still theoretically possible that removing all the tumor in the breast and under the arm will be curative. Theoretically. That's what I did for Mrs. Davidson, and of the fifty or so lymph nodes found in the tissues I dissected out, thirty-two had tumor in them. I think that's the record, in my practice. Her risk of relapse somewhere in her body was dauntingly high.

At each stage of the game, Mrs. Davidson prayed, and her faith seemed to carry her. The lump would be OK, she felt, and when it wasn't she knew God would be with her. But when she got the news about the lymph nodes, and the implication for cure, and when she heard the recommendation of her oncologist, she fell apart.

Not far down the road from my area of practice, there was an on-going study of women with advanced breast cancer: removing and preserving bone-marrow stem cells, giving massive doses of chemotherapy and radiation -- enough permanently to kill the production capabilities of the marrow -- followed by returning to the patient her saved marrow cells to regrow her blood-making ability. It was tough stuff, taking the women to the brink in a most literal sense, suitable -- if at all -- only for those with very poor prospects. (The therapy has fallen into disrepute, in a pretty messy set of circumstances featuring another patient of mine who'd come to me with widespread recurrence.) With cancer all over the body, it was a desperate "hail Mary" of a treatment. In a situation like Mrs. Davidson's, it made more sense, at least from some points of view: take a woman with a very high statistical chance of having cancer somewhere, but undetectable, in her body, throw the therapeutic book at her on the theory that the best chance to cure lay in getting those cells when they were at their fewest in number. (Which is also part of the rationale of removing all the involved nodes.) That's what her oncologist recommended, and I concurred.

For Mrs. Davidson, it was hell on earth. Unable to eat, nauseated, dependent entirely on intravenous feedings, bleeding what little blood she had, fighting infections -- she was as miserable as it gets. Per protocol, she remained hospitalized for the entire treatment and well after the stem-cell reinfusion. Her husband, who worked at a coffee shop I frequented, told me on many occasions that she'd said she wanted to die, that she'd begged them to stop treatment. He wouldn't let her; he wanted her around. But she sank deeper and deeper into depression; how could God do this to her, she asked, after everything she'd done for God?

Her anger and depression outlasted her therapy. After her release from the hospital, I saw her fairly regularly, even though she'd healed her surgery: she just wanted to come in and ventilate. As hard as it was for her, it was frustrating for me: surgeons like to fix things, and I had little to offer except an ear. Seeing her continuing to lose weight, to descend into darkness, I finally suggested anti-depressants, which she accepted with a "why-bother" shrug. In the periods between visits, which eventually tapered off, I frequently saw her husband at the coffee-shop. He was nearing the end of his rope as well. She remained despondent, he said, despite the passage of time with no sign of cancer.

I've generally observed that when people have deep religious faith of any sort, in most cases it helps them cope with bad news: "God's will." Despite her attitude when I cared for her son, in Mrs. Davidson's own crisis it seems to have done the opposite. Funny thing is it's over fifteen years since all this happened, and she's doing great. Her depression is long gone, she's active, and there's not been any evidence of disease since her operation. In our relationship, I never initiated discussion of her faith, and I don't know where it ended up in her life. In medicine, nothing is 100%. She seems to have beaten very long odds. How? Maybe I actually got to her at the moment before any distant spread, and my operation cured her. Maybe the hyper-intense therapy did exactly what it was intended to do. Maybe she'll recur still, and we just bought her some time. Or maybe....

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.