When Rose Kushner discovered a lump in her left breast one Saturday night seven years ago, she called 19 doctors before she found one who would remove only the lump without insisting she agree to an immediate amputation of the breast.
The tumor was cancerous and the breast came off, but to this day, Kushner, a Kensington resident who now is considered a national lay expert on breast cancer, insists that the waiting period between the biopsy and the mastectomy allowed her time to consult other doctors and discover a less disfiguring operation than the then-standard Halsted radical mastectomy. The Halsted procedure removes, in addition to the breast, much of the chest and underarm muscle.
"I went down the list of doctors in the Yellow Pages and when I told them what I wanted to do, most of them hung up on me," said Kushner, an energetic woman who has since written a book on the subject and heads a breast-cancer advisory center. "But I had worked at Johns Hopkins and heard all the horror stories about patients waking up with various parts of their bodies missing. I was not going to be one of them without at least finding out what else could be done."
Since 1974 when Kushner had her mastectomy, much has changed in the treatement of breast cancer. The Halsted method is no longer the standard operation in many parts of the country. Partial mastectomies and different treatments are being tried, and most doctors seem to agree that there is little danger of the cancer spreading if a woman waits two weeks between the time of lump removal and breast amputation. The National Cancer Institute (NCI) also has recommended that doctors perform two-step mastectomies: biopsy, discuss alternatives with patient, then surgery.
But despite these advances and the NCI recommendation, there are still a number of women, according to Lois Callahan of the American Cancer Society, who go in for the initial biopsy--the tumor is diagnosed as cancerous while the patient still is under anesthesia--and who wake up with the breast amputated. This is the one-step mastectomy.
Legislation introduced in the Maryland General Assembly this session would have have prohibited the one-step surgery for the estimated 2,400 women in the state the cancer society says will be diagnosed as new breast cancer patients this year. But after an extended fight, in which the bill's proponents lost at every step, the measure failed without ever getting out of committee.
The legislation's failure, say its backers, was as much an example of the dwindling strength of women in the legislature as it was an example of the influence the medical lobby wields in the General Assembly.
The state medical society, the Medical and Chirurgical Faculty of Maryland, lobbied heavily against the bill and the chairman of the committee that oversaw the measure, Torrey C. Brown, is a physician. After debate at a public hearing, a number of the women delegates on the Environmental Matters Committee, the body assigned to consider the bill, complained that many of the male legislators made sarcastic remarks about the gender nature of the bill. According to several present at the hearing, among other questions, some male legislators wanted to know why breast cancer should be treated any differently than prostate cancer, a common form of cancer in males.
Only one man on the committee, Del. Gerald Winegrad (D-Anne Arundel) supported the bill. Judith Toth (D-Montgomery) was the only woman out of seven to oppose it. Catherine Riley (D-Harford) was absent for the vote.
"The bill was a useless battle from the beginning," said Del. Paula Hollinger (D-Baltimore County), a member of the House Environmental Matters Committee, where the bill was assigned. "The main opposition to the bill were all the physicians in the state and the chairman of the committee is a physician.
"There were a lot of disparaging remarks from the men on the committee who viewed this as an issue differently than the women did. They don't have to worry if I have to have a mastectomy," Hollinger concluded.
The society argued that although the state's physicians heartily endorse the bill's intent of ensuring that patients be informed of all alternatives, the legislation would draw the courts into the medical domain, and would unfairly single out one type of cancer treatment for regulation.
Under the bill, introduced by Del. Joan Pitkin (D-Prince George's), a physician, after performing a biopsy, would be required to describe alternative treatments available to the patient. Massachusetts and California have passed similar laws.
In addition to opposing the legislative sanctions, the society argued that proper disciplinary measures already exist within the state's Commission on Medical Discipline. If a doctor failed to properly inform a patient about the possible types of surgery or outcome of treatment, a patient could file a complaint and the doctor's license could be revoked, according to Dr. Jose Martinez, chairman of the society's legislative committee. Before a biopsy is performed, every patient signs an informed consent form that should outline what procedures may be taken, Martinez added.
Proponents of the bill, however, argued that the treatment of breast cancer and whether a woman had a one-step or two-step mastectomy varied widely throughout the state as evidenced both by physicians' testimony and by experiences of patients. Informed consent forms also differ from hospital to hospital, they said, introducing forms from a number of hospitals as evidence.
The waiting period, the largely female group of backers argued, would allow women the time both to become psychologically prepared for the operation and to seek out other medical advice.
"It's a terrible time and all you hear is the word cancer when you're first told," Juanita Raafat said after testifying at the public hearing. A nurse and a Columbia resident who had a mastectomy in May 1979, Raafat insisted on a two-step mastectomy. "I knew what to do because I was a nurse . . . but there are a lot of women who are not getting the chance to get a second opinion or to think about what's going to happen to them. Just psychologically, they need the time.
"You can't understand it until it happens to you. It's a shock. It's like getting hit over the head by a two-by-four."
The final bill, which was amended to remove the provision for disciplinary action and instead instructed the state health department to print breast cancer informational pamphlets, failed on an 11-6 vote. The chairman of the committee, Brown, instead will write to the health department and express the committee's concern about two-step mastectomies.
Pitkin said she plans to introduce the bill again next year, but expects another tough battle. Most controversial bills, she added, usually must be introduced at least two or three times before they have any serious chance of approval.
"There is so much opposition to this bill from the medical community," Pitkin said. "They feel it's a foot in the door towards the beginning of more regulation of medical practices."