RECENTLY Fay went to Loehmann's with a friend. She wasn't shopping herself, just tagging along for the fun of it. Her friend picked up a blouse and said to her, "Listen, this is just right for my daughter. You're about her size. Would you try it for me?"
"Sure," Fay said, and slipped off her own blouse.
"My god," said the friend, in startled admiration, "look at you!"
She suddenly remembered about Fay's operation.
"Look at her, everybody," the friend said to the dressing-room filled with women, "she's had a mastectomy!"
The point was, of course, that if the friend hadn't announced it, nobody could have told . . .
"You take 100 women with breast cancer," says surgeon Jerome Canter, "about half of them probably will do well no matter what treatment they get -- limited surgery, radiation . . . whatever. About 15 are going to die, no matter what you do. So it's probably important to the other 35 what modality of therapy is utilized. The problem is, nobody can definitively select which patient falls into which group . . . "
Jerome Canter, a Washington surgeon for 20 years, on staff at George Washington University Medical Center, has made an accommodation with the statistics, an accommodation based as much on the quality of life as on life itself. With a plastic surgeon in the operating room, Canter performs modified mastectomies on his breast cancer patients. During the same operation, after Canter has completed the mastectomy, the patient's breast is reconstructed by the plastic surgeon. The breast cancer patient, in most cases, wakes up essentially unmutilated.
Breast cancer continues to increase in almost epidemic proportions. The newest American Cancer Society projection for 1981 is for 110,000 new cases, almost double the 1970 incidence of 69,000.
This is an article partly about the procedure, about the medicine and surgical techniques that make immediate reconstruction possible, and about the philosophy behind it. But it is mostly about three women, of three generations, who opted for it, and about their surgeon, Jerry Canter, who was able to change the way he had been taught to practice his profession, the way he had practiced it for two decades. For a variety of reasons two of the women asked that their identities be disguised. They will be called Edwina and Kelly. The third, Fay, has permitted her real first name to be used.
Fay is 40. She is slim, attractive and admittedly vain. She is utterly without inhibition in discussing herself, her cancer or her reconstructed breast -- or her vanity. She is funny and witty and smart. And she simply cannot understand why more women do not know about, are not clamoring for, this method of treatment.
She discovered a lump in her breast about a year and a half ago -- the lump most women so desperately do not want to find that most will refuse to seek it, despite the well-publicized need for early detection.
She was at the beach, and she recalls, "once I found it, I would self-examine every day, but it didn't go away. It was always still there."
Her own gynecologist (whom she had called long distance for an appointment) sent her to Dr. Canter.
Edwina is 60 but looks perhaps a decade younger. She is a widow with a grown, married daughter (and two grandchildren) in another city. She recently retired from her job as a librarian in a privatge girls' school, and she lives alone in a comfortable condo overlooking the river. She is intelligent and full of a quiet humor. Of Midwestern stock, she is the kind of person people call "salt of the earth."
She is willing to share her experience, she says, "in the spirit of Betty Ford, Happy Rockefeller and Ingrid Bergman," all of whom had more radical operations than hers will be. "They were very brave. It took away a lot of that silly mystery around cancer, especially breast cancer. I want to do what I can."
Fay and Edwina were referred to Dr. Canter by their own gynecologists. Kelly, a free-lance political journalist, sought him out after some careful investigation -- "doctor shopping," she calls it. Kelly is the youngest of the trio of Canter patients who agreed to be interviewed. She is an ardent feminist, a natural skeptic with a finely honed sense of the absurd, a lot of warmth, an occasional flash of pure sentiment. She candidly admits that "attitude" was high on her list of requirements for a doctor.
She is also the only one of the trio on chemotherapy, but her optimism is such that she is currently researching her chances of bearing a child later on when the chemotherapy is finished.
She was 28 when she discovered the lump under her arm. It was about a year ago.
Before she even permitted a biopsy, she read everything she could find, interviewed doctors, demanded information from NIH, the American Cancer Society, anybody, she felt, who would know. She rejected what she didn't want to hear (in-hospital biopsy, for example) and ended up with Jerry Canter.
To ease her own doubts, he helped her find another pathologist and patiently answered such questions as "how do you know the slides weren't switched."
The plastic surgeon who reconstructed Fay and Kelly is Lewis Thompson, who is now associated with Children's Hospital, concentrating on pediatric plastic surgery.
It was Thompson who initially encouraged Canter and several other general surgeons in the area to start performing the general-plastic team reconstructive operations. "He refers to women as 'girls,'" sighs Kelly, "but he's still terrific."
In the past, Dr. Canter's procedure, as was the case with most of his colleagues and still is with many, would have been to admit Fay to the hospital and have her sign a release permitting a mastectomy, should the lump prove malignant. Usually it would have been the radical Halstad procedure in which chest-wall muscle as well as breast tissue is taken. She would find out when she woke up.
In the first place, the Halsted mastectomy, routine for more than half a century, has now been virtually abandoned as offering no better chance of survival than lesser surgery.
Then, there were other factors that led Dr. Canter to revamp his long-standing practices: new knowledge about breast cancer and how it spreads; new advances in biopsy and surgical techniques; new insistence by women that they be given a role in the decision-making about their bodies and their lives -- and, not the least, his own anguish at the mutilation and psychological hurt he was inflicting on patients in his efforts to save their lives. He is the kind of doctor who listens, really listens to his patients. His three patients unanimously and independently concluded that "he's different from most."
Now there is virtually no lingering uncertainty. The lump is aspirated in the office, a slide is made and examined immediately by a cytologist -- at GW it is Yolanda Oertel, highly respected in her field. Results come within the hour. In the occasional event that the results are inconclusive, the lump is removed later at the hospital -- on an outpatient basis and under only a local anesthetic.
Canter's patients are offered the double procedure as an alternative and are encouraged to seek other opinions and explore other options before they decide. There is no longer the feeling in the medical community that the operation must always be done at once. Most feel a week or two is not too long a delay. Moreover, breast reconstruction is no longer considered "cosmetic" surgery, and therefore is paid for, at least in part, by most health plans. Canter was one of a small group of physician delegates to the AMA last year who pushed -- successfully -- for AMA endorsement of insurance coverage for breast reconstruction after a mastectomy for cancer.
"I wasn't thinking about anything, really," recalls Fay. "I went for the biopsy with my sister-in-law, who'd had six lumps removed, all benign. Then almost as soon as the lump was removed, the doctor -- and I think he handled it very beautifully -- he said, 'I have some bad news and some good news . . .' And then he said that yes, it was malignant but it was very small and he also thought I would be a good candidate for this procedure that I had never heard of." Fay had no family history of cancer. But she'd been through a difficult divorce and child custody fight and she'd read somewhere about a relationship to inordinate stress . . .
Edwina is on the operating table. The circular light is shining down, just like in "Ben Casey" of "General Hospital," expect the chandelier is a little loose and will cause the surgeons no little annoyance later on. A team of anesthesiologists begins to put her to sleep.
Dr. Canter and plastic surgeon Jack Fisher are discussing how best to make the incision. They mark up Edwina's left brest with a black magic marker, indicating the cut Dr. Canter will make as he performs the mastectomy, approximately the first half of the more-than-three-hour joint procedure. It will be a tricky case because the tumor was above the nipple, making the reconstruction job more difficult because the skin will need to be elevated at the incision. Continued health of the skin is crucial to the success of the reconstruction. It is to cause problems later.
The team at her now-curtained head pronounces her asleep. (The next day, she will devour whatever tidbits a witness can tell her of the operation -- wisecracks, minor graffes, small talk.) There was no cancer in her family background, but she'd been on replacement estrogen since a hysterectomy some 20 years before. She wonders about that.
Dr. Canter is reminded that the third-year medical student, a woman, who is assisting him, spelled hysterectomy "histerectomy" on a recent report. It is unlikely that she will forget again.
Dr. Fisher watches for a few minutes as the operation begins, discusses the relative merits of the thickness of the skin flap and then leaves until it is time for his part in the morning's events. It is mid-October, unseasonably warm outside. Dr. Canter cuts skillfully, easily, carefully, explaining to and quizzing the students and resident as he proceeds. He cuts out several nodes for biopsy, along with the offending malignancy. Edwina is not losing an inordinate amount of blood, fortunate because too much bleeding could foreclose the plan for immediate reconstruction.
Advances in plastic surgery have exploded over the past decade. Once the doctors figured out that the blood supply upon which healthy skin depends is derived principally from blood vessels in the muscles -- a discovery, surprising as it sounds, only a decade or so old -- they found they were able to perform a huge variety of procedures with a vastly enhanced chance for success by moving muscle along with skin. The new techniques range from curing bed sores to greatly simplified breast reconstruction even in women who had radical mastectomies more than a decade before. In some cases now, the nipple can be saved and eventually restored to a reconstructed breast. In other cases vaginal tissue can be used to reconstruct a nipple which will have some sensitivity. "We used to think only about looking well in clothes," a local surgeon said, "but now we think about looking in a mirror as well . . ."
As a group, the plastics aren't crazy about the immediate reconstruction, and Dr. Fisher makes a point of not wanting to sound like he is taking sides, one way or another.
"I will do what the general surgeon wants," he says. "It is a matter between the patient and the general surgeon. With present-day techniques I'm really not worried about when I do it because I feel I have multiple options."
He reiterates one of the plastic surgeon's reservations, one which is repeated, again and again, by other plastic and general surgeons. Basically, it is this: If a woman is allowed to live with the mastectomy for a while, she'll be more appreciative of the eventual reconstruction.
Says Fisher, "I find sometimes, it's good for the woman to have a perception of what her mastectomy has produced . . . sometimes after immediate breast reconstruction a woman can look down and say, 'That doesn't look like my breast. What's going on?' So in those patients it is very important to sit down with them and say to them, 'No one can make you a perfectly normal-looking breast again. Our goal is to make you look good in clothes or a bathing suit or a low-cut gown so you're comfortable.' But there are some who would wake up after the surgery and say, 'This doesn't look right . . .'"
In a just-released national survey on breast cancer prepared for the National Cancer Institute, the largest percentage of women who said they would not want breast reconstruction -- 34 percent -- gave having "to go through another operation" as their main reason. The survey did not include questions on immediate reconstruction.
"My god," snaps Kelly, "if I thought I'd have to go through that whole business twice, wake up throwing up twice, why I'd never do it. That," she pronounces, "is just appalling." Nor does Dr. Canter have much use for that argument. He simply does not consider it a rational reason for delaying the reconstruction.
Nor does he consider age or even poor prognosis valid arguments against it.
"We all give lip service to quality of life," he says. "Now suppose you take an older woman and suppose statistically she's got a lousy prognosis. I mean, look, we don't hesitate to put a limb on a 70-year-old amputee who is probably hobbling only to the bathroom, but we go to all the expense of getting a limb on him and rehabilitating him . . . I mean what is the difference in terms of attempting to improve the quality of life? . . . What's the point of waiting three or six or nine months to 'see how she does' before you reconstruct? And don't forget you're talking about another hospitalization, another anesthetic, another operative procedure . . ."
It is almost two hours since Edwina was wheeled into the operating room. The breast tissue, looking exactly like what it is -- raw meat -- is on a side table being examined by a pathologist.
Now it is Jack Fisher's inning. The first thing he does is demand that the music from WASH-FM which is piped into the operating suite (and was deliberately turned off by Canter) be turned louder.
Fisher is 33. He digs Barry Manilow and Eddie Gallaher while he works.
The ambiance in the operating room has changed now, too. Bye-bye "Ben Casey"; hello "M*A*S*H." Dr. Canter is a perfectionist, an operating nurse confides, and demands perfection from those assissting. He is known, she whispers, for a tongue occasionally as biting as a cautery when somebody doesn't do something right. There is a great deal of affection and respect for him, but things are more relaxed with Jack Fisher.
Not that he doesn't demand perfection, too, but he jokes a lot. Even clowns a bit. He seems conscious of being on stage. He talks about his grandfather-the-tailor and how he's following in his footsteps. But he also worries over the health of Edwina's skin flaps. The anesthesiologists, who are monitoring Edwina's functions under the anesthetic, are beginning to watch the clock. It is a long operation.
Fisher, who trained at GW and at Emory University Medical School in Atlanta, a major center for breast reconstructive surgery, is used to long hours of microsurgery -- sometimes 13 at a stretch. The anesthesiologists keep reminding him that Edwina has been under a long time, more than three hours now. With all his jocularity, he moves swiftly and competently.
Fisher is creating a pocket for the silicon gel and saline solution prosthesis, which he will insert under the muscle. This particular model permits the surgeon to adjust size to match the other breast. It looks like nothing so much as a midsummer sea nettle washed up on the beach. Skillfully, it is tucked into a muscular pocket (designed by Fisher so that the artificial breast cannot slip out of place, as earlier models tended to do), the carefully sculpted flaps are closed and, to the obvious relief of the doctors minding the anesthetic, the operation is complete after the last-minute injection of a substance that shows where blood supply in the skin may be poor. i
Edwina is already stirring, even before the dressing is completely wrapped.
Later she will recall waking up with people around her, but a nurse tells her that is nonsense. She is relieved to find out from a witness that she did, indeed, begin to waken still on the operating table. It has been a long four hours.
Dr. Thomas Lee, associate professor of surgery at Georgetown University Medical Center, has been performing mastectomies with immediate reconstruction for several years. Georgetown is also one of six centers (including NIH) offering one of the newest experimental techniques -- an intramammary irridium implant, which involves removing the lump only, and subsequent X-ray treatment along with a 48-hour radioactive implant at the tumor site. About half the patients at Georgetown, says Dr. Lee, are having reconstruction either with the mastectomy or within two weeks. About a quarter are in the experimental program and the rest are having mastectomines without reconstruction.
He does not judge the plastics' preference for waiting, nor does it influence his decisions. But he is sympathetic. "People tend to look at the plastic surgeon as some sort of artist, that if a nose is off-center they can just paint it right. It's not quite like that, and when you remove a breast and put in a prosthesis, there's no way to get an exact match."
Dr. Lee has also found that age is no predictor of whether or not reconstruction is elected. "I had a 64-year-old patient, dripping jewels, a socialite type, who said to me, 'Okay, you can take by b--b off if you want, but I want a new one before I leave the hospital."
Dr. John Little, Georgetown Medical Center plastic surgeon who is working with several general surgeons doing the two-in-one operations, concedes that it is easier for the plastic surgeon if the reconstruction is delayed but that the techniques to do it at once are certainly available. Although personally he feels this procedure "is headed toward becoming the standard way," it is still, he believes, investigatory, and he does not fault general surgeons for being reluctant to do it. "Women should not be made to feel their doctors are behind the times," he says.
"If it's good," he says, "it will evolve. If problems develop, then it won't. You can't expect a change overnight." He confirms that there does appear to be less depression in the women who have had the procedure.
Meanwhile, he is concerned that women may demand it prematurely, even in cases where it may not be appropriate. "It's the one positive thing in a negative experience and there is a tendency to hang onto it," he says. "The patient who has just found out she has cancer has a thousand things flooding her mind and this adds one other big decision-making burden on her."
Dr. Thompson told Kelly that the new breast would "be a mound, not a breast." She is quite satisfied with it.
Dr. Thompson told Fay the new breast would "probably be smaller" than the old. "So," she says she asked him, "how come it's bigger?" He just shrugged. Never mind, she is delighted with it. Only weeks after the operation she was back on the beach (out of the sun, though) and she says "it was like I was some kind of guru. Every woman on the beach came over to look at me. Every one of those women was terrified of breast cancer, they'd had an aunt . . . or a grandmother . . . they were just terrified. None of them had ever heard of this . . . It was reassuring to them."
Edwina was still self-conscious about hers when, after only a few weeks out of the hospital -- last week, in fact -- the implant began to push out. This is a complication which occurs, one doctor estimates, in perhaps 10 percent of the cases, or less. It is common to both delayed and immediate reconstruction. Some plastic surgeons feel it may be, at least fractionally, more common with immediate reconstruction.
It was, not surprisingly, frightening to Edwina at first. It is not considered an emergency situation, but needs immediate attention. The implant must now stay out for several months until all possibility of infection is gone. If Edwina decides to have it redone, chances are, doctors say, it could be a much simpler procedure unless more surgery involving muscles is needed. Edwina is a little disappointed. A little uncertain about the future.
Fay, an avid golfer, found stiffness and pain something of a problem for a while. She needed help in changing her grip and her swing, for one thing. "It is a hard convalescence. You do need patience," she says. Last summer she won a golf tournament.
The American Cancer Society is in the process of forming a group called RENU, which will provide support for women who have had reconstruction and will train those who so desire to counsel other women who are considering it -- either with a mastectomy or later. "We need to help create awareness about reconstruction options," says Lois Callahan of ACS.
Fay attended a class -- a support and exercise group -- for women with mastectomies given by the Rockville Jewish Commmunity Center.
She was the only one who had been reconstructed in this manner and, as each woman told her story, Fay found she was the only one who could admit to no depression. She also derived a great deal of support from her family -- her husband, his three children from an earlier marriage, her two from her earlier marriage and their daughter.
She pushes the operation with the zeal of the newly converted. "I just think I was lucky I had a choice. I think I'm more vain than I ever was because it's very important to me to look good. I don't hide the fact that I've had a mastectomy. I have this need to tell people that there's this operation that's available. I just feel like so many people don't know that it exists."
There's no breast cancer in Kelly's family. But she'd been on the pill since she was 20.
Kelly has had a great deal of support and understanding from her husbnd. "But of course, there have been times when I've gotten depressed," she says. "And we cried the whole night we found out. We kept waking up and hugging each other and crying and crying. There was no end to the grief at first . . . "
Jerry Canter's pre-med training was as an English major at Princeton. He attended GW Medical School. He is genuinely saddened by the cursory exposure to the classics and the humanities of today's medical students, buried as they are by the avalanche of physiological and biochemical discoveries. He cares about the philosophy of medicine. He cares about people. He is 49. Of his four sons, one seems to have an interest in medicine which he is enthusiastically encouraging. His wife is a Ph.D. biochemist at the National Institutes of Health.
"I went in to thank him," says Fay, "and he was so sad. He said he kept thinking of all the women he'd 'multilated' and I said, 'You can't feel bad about that. Think of all the patients who died before they discovered penicillin.' So I ended up comforting him."
"You know," muses Kelly, "there are certain things that are so jarring that any human being has to work very hrd to get used to. But this isn't so hard to get used to. It was nice to have it there when they took the bandage off. I'm sure it made it a lot easier. You know, everything you do to make yourself normal, to make your life normal, is that much less you have to overcome . . . "