When her doctor diagnosed breast cancer, this veteran reporter stumbled into the story of her life.”
By BROOKE KROEGER
The image that recurs is of a young artist in a university program, sculpting a life-size clay figure. The sculpture is nearly complete. He studies it again, then takes a piece of wire, holds it taut by wrapping it around the knuckles of both hands and slices off the right breast. He smoothes the surface of the chest where the breast had been and swathes the work in silty wet rags, so the clay will stay moist for the next day. Only he never returns. In this scene, I am the gray lady in wet rags.
My breast was removed because a lumpectomy and radiation failed to eradiate cancer in it, and the cancer recurred. This happens in about 12 percent of all cases. That seems like very few. Until you end up in the 12 percent.
An imperfect mix of scientific inquiry is the basis for all breast cancer treatment in this era, and the decisions a woman makes about whether to lose or keep her breast inevitably involve an abyss of uncertainty. This is why no one facing the decision to have a lumpectomy or a mastectomy is excused from learning everything there is to know before she makes a decision that will profoundly affect her life.
The First Lady was faced with those unhappy choices recently. No one, except for Nancy Reagan, can say for certain what went through her mind before she made the decision to have her breast removed. But it amazed me to learn that though most of her mail honored her courage, she received a number of letters criticizing her choice. How could anyone be criticized in such a situation?
Living with one breast is difficult, a reality I spent a long time denying. The idea of breast reconstruction put me off, though three years after my mastectomy I underwent the procedure. Until then, even when the urge for symmetry would overwhelm me, my impulse was to want my left breast to disappear so that side of my chest would match the blank space with the thin diagonal scar on the right. It disturbed me that my mind leapt to thoughts of disfigurement before I pondered the more logical course of having the breast rebuilt. But I wanted no more anesthetics or knives. And I harbored an irrational fear of what sinister presence the surgeons might find lurking beneath my highly irradiated skin.
Even mastectomy patients have recurrences of the cancer. Again, not very often. But when they do, it is usually a sign that the disease has spread beyond the breast and will mean a countdown to the end.
I am not obsessed with my condition nor my mortality, though it is difficult not to be reminded of both every time I pass a mirror. Still, I am bemused by the steady run of articles in lay magazines that would have you believe no woman need surrender her breast to cancer anymore. I SAID “NO” TO MY DOCTORS trumpted one story. GOOD NEWS FOR WOMEN: NO MORE MASTECTOMIES! another shrieked.
Such stories create the impression that concern about breast cancer has become exclusively cosmetic — a disease that kills 41,000 American women a year. Another 130,000 a year are diagnosed as having it. One in ten American women, at some time in her life, will be told she has breast cancer. A third of those diagnosed will eventually die from it. In some cases, when the cancer is detected early, the survival rate five years after diagnosis is 90 percent and higher. In others, when the disease appears in lymph nodes, it is 67 percent and lower. When the disease has spread to other organs of the body, there is no ultimate cure.
At press time, National Cancer Institute figures showed a sharp 7 percent jump in the breast cancer death rate for young and middle-aged white women after more than a decade of steady decline. It could be a statistical fluke; it could reflect the change in treatment regimens. No one knows for sure.
I have been cautioned not to generalize based on my personal experience. The vast majority of women diagnosed with early breast cancer don't have recurrences. What I have experienced is not the norm, nor is the manner in which I have responded to it, nor is the course of treatment I received. That is not to say that my experience is invalid but that every case is unique — and in that alone they are all the same. This is a very important point.
I was diagnosed with breast cancer in October 1982 at the age of thirty-two. Statistically this puts me in the “under thirty-five” group, the one with the fewest members but with the highest recurrence rate and the lowest chance of staying alive. My tumor was tiny, well under two centimeters, which classified it as “Stage I” cancer. The importance of early diagnosis cannot be overemphasized. There was no indication of disease in my lymph nodes — a sign that the cancer probably had not taken rootin other parts of my body. Several top specialists were consulted. All the risks and possibilities were explained by the surgeon who treated me in my hometown of Kansas City, Missouri. I chose lumpectomy, removal of the tumor and a wedge of normal tissue around it, leaving the breast relatively intact. The surgery ordinarily is coupled with a series of radiation treatments that, at least one major 1985 study has indicated, can be as effective as mastectomy. In the most worrisome cases, where cancer is feared to be growing in other parts of the body or has the potential to grow, chemotherapy is also advised.
My “cosmetic result” was excellent. The only evidence was a thin scar buried in my armpit. But keeping the breast was not my primary motivation for having a lumpectomy. I wanted the quickest possible recovery time, and lumpectomy seemed to offer it. I was the bureau chief for United Press International in Tel Aviv at the time, and the Israelis had invaded Lebanon four months earlier. I was determined to miss the fewest possible workdays, since war in Lebanon was a lot more compelling to me than breast cancer. A postoperative plan was devised and executed at Hadassah Hospital in Jerusalem. Doctors predicted that at the end of the treatment, I would have a 90 percent chance of remaining disease free. The program involved six weeks of utterly painless cobalt treatment that, even with the hour's travel back and forth to Tel Aviv, allowed me to get to work by 9:00 a.m. There was also a gruesome iridium implant that involved threading thirteen polyurethane straws through the cancerous breast, then yanking them out two days later without benefit of painkillers. That was when I first understood the term seeing stars. Each tube contained a measured amount of iridium, a highly radioactive substance. I recall this procedure as forty-eight hours of leperhood. No one, least of all a nurse, wants to enter a room where a breast is getting nuked.
Then came a six-month course of chemotherapy, the nausea that does not relent. Chemotherapy is designed to attack micrometastatic disease that may be brewing elsewhere in the body. If there is no evidence of “micromets,” the chemotherapy could be highly toxic, side-effect-ridden overkill. Or it could be keeping a more ferocious disease at bay.
Two years after diagnosis is the first milestone for a breast cancer patient. Two years without a recurrence gives hope there could be five, and five is as close to an all-clear as a cancer patient gets. For me, two years later in New York, three months into a new marriage and a new job, the cancer recurred in the same breast, not near the original tumor site, practically under the armpit, but more on the surface of the breast above and to the right of the nipple. Maybe it as a brand new disease. Maybe the first treatment had failed. No one can say for certain. The decision at Memorial Sloan Kettering Cancer Center was to classify it as a new primary tumor.
This time I chose simple mastectomy, though for women intent on keeping their breast, some surgeons will go as far as trying to do one or even two more wedge excisions in an effort to obtain a margin of cancer-free tissue on either side of the affected area. Not that I would have considered such a course. But as it happens, doing so would have been a waste of catgut and anesthetics. All of the tissue samples removed from the breast were diseased.
Again, there was nothing in the lymph nodes — good news — but two things were troublesome about the removed tissue: extensive intraductal carcinoma in situ, a precancerous condition in the breast ducts, and lympathic invasion, wherein the tumor locally invades the lympathic vessels. The latter can suggest a more aggressive disease.
So two weeks after surgery, I began a six-month course of a more brutal chemo-cocktail, the high point of which was watching my hair gently disengage from my scalp and end up on my shoulders and notepad in the courtroom of then-U.S. District Court Judge Abraham Sofaer. I am not the first to remark that losing hair is more devastating than losing a breast, even though hair grows back.
At the time, a twelve-member jury was deliberating the outcome of Ariel Sharon v. Time Inc., which I covered for Newsday.My sick days from the surgery through the last injection of the dreaded adriamycin totaled six or seven. I coped very well. But I would be hard pressed to agree to go through chemotherapy again.
My interest in the subject of failed lumpectomies — or “local recurrence” in medical parlance — should then, be obvious. The specialists are very interested in it, too, and made it the subject of an international conference last June. “We're in a time of transition,” said Samuel Hellman, physician-in-chief at Memorial Sloan Kettering and prime initiator of breast conversation in this country. “And when you're in a time of transition, you don't know all the answers.”