Posted by: notdeaddinosaur | September 25, 2013

A Pendulum Too Far: Breast Cancer Treatment Then and Now

Once upon a time, women with suspicious breast masses were put under general anesthesia for surgery not knowing whether they were going to wake up with or without their breast. If the biopsy showed cancer, the surgeon went right ahead with the mastectomy. No time to lose; it’s cancer, you know. Breast reconstruction? Don’t be silly. No one does that. You should feel lucky to be alive!

Can you imagine? Doctors making decisions for patients without consulting them, assuming they know best “what women want.”

Thanks to advances in technology allowing ultrasonically guided outpatient biopsies, and our understanding of the biology of cancer, management of breast lumps is very different today. No more signing a “blank check” surgical consent. Waiting a week (or a month) doesn’t materially affect treatment or outcome. And immediate reconstruction is now the rule, complete with mandated insurance coverage. 

Wonderful. 

But have they gone too far in the other direction?

I’ve had patients with breast cancer who, for their own reasons, are not interested in breast reconstruction. Some want reconstruction so they can look normal in clothes, but don’t care about a nipple (surgically reconstructed or tattooed.) Surprising numbers of these women tell me with dismay of confronting the disapproval of their other doctors. You don’t want reconstruction? Don’t be silly. It’s covered by insurance. Everyone does it. What’s wrong with you?

Can you imagine? Doctors assuming they know best what their patients want, without listening when women actually tell them things they don’t expect to hear.

And it’s not just surgeons. I got a letter from an oncologist seeing a patient three years after completing treatment that included this:

She did not pursue getting fitted for a mastectomy bra and prosthesis when I gave her a prescription three years ago.

Yeah; so? I thought as I read, assuming he was just being informative. Further down, though, the peeved tone comes through more strongly:

I strongly recommended that she be fitted for a mastectomy bra and prosthesis, and gave her written information regarding insurance reimbursement, local fitting stores, and another prescription. She does not appear interested in Plastic Surgery evaluation.

Honestly, dude. Back off!


Responses

  1. Thank you. I actually wanted immediate reconstruction at the time of my mastectomy. And with the hard work of both my surgeon and my oncologist I was able to have the kind of reconstruction that I was most interested in. It wasn’t clear at my diagnosis if that would be possible. However, I really wanted to have bilateral mastectomies and reconstruction, but was deferred by both doctors. They were hesitant to remove a healthy breast. As a result, at nine years past treatment, I am still waiting for the other shoe to drop. It may never happen, but it could and that is a problem for me. But you know, it’s not just surgeons and oncologists who do this. Just about every specialist out there does this. And it isn’t even this blatant, a lot of it is down right sneaky. Like not mentioning information that may have me consider doing other than what they want me to do. Quite often, it is better to listen to their counsil, but I do wish they’d show me the respect to give me all the information.

  2. “Once upon a time” is actually not that long ago. What you describe was the standard in the late 1970’s when I was training. Nobody having a biopsy knew when they were put to sleep if they’d wake up with or without a breast. Things have certainly improved since the.

  3. Thankfully, I got no such nonsense from any of my doctors when I decided to have a prophylactic (BRCA2) bilateral mastectomy without reconstruction 7 years ago. As I said to one of my docs, “The way I see it, breasts have 2 functions: food and fun. Reconstructed breasts will do neither.” All medical decisions are personal but this one is even more so.


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