Reassurance by Sally's doctor is emblematic. Much of the profession has mistakenly confused its best hopes for women with a prognostic and therapeutic competence that does not exist. Regrettably, there has been no significant improvement in the survival of women in 100 years,1,2 despite publication of William Stewart Halsted's 1894 paper3 heralding his results on "operations for the cure of cancer of the breast." For an entire century, the principle of the Halsted mastectomy has been the corner stone for the management of breast malignancy, even though a review of the data reveals that mortality hardly declined between the years of 1925 and 1990.4
Science is nothing if not an attempt to let the evidence speak for itself, assume its own authority, contradict hypotheses once taken for granted, and, if necessary, remake the rules. Medicine, guided by science, takes its lead from that which is proven--if not in laboratories, then in clinical study. Its Hippocratic dictum is to do no harm, but what does this mean?
At a symposium on breast cancer in 1984, pathologist Edwin Fisher5 remarked, "Conceptual aspects of most diseases in medicine--such as breast cancer--have been notoriously rigid. Historically, practitioners have been resistant to change." Surgeon Anaxagoras Papaioannou6,7 comments that "[a] conceptual dichotomy has thus evolved: we accept breast cancer basically as a systemic disease but we persist in treating it primarily as a locoregional problem.... [T]here are some limited, uncontrolled, but intriguing data in women with breast cancer that suggest that the less physicians do, either by surgery, irradiation, or by both, the better the patients do."
After Sally was told she had breast cancer, she was unequivocal about what she wanted from her friends: absolute support for the decisions she was making. I had the impulse to share with her what I knew from 30 years of conversations with my father, whose specialty was breast surgery. But it was too late. She made it clear that to be her friend meant not to question her doctor's opinions. "He's not my congressman," she said, "he's my lifeline." Agitated by fear and muddled by the conflicting opinions of experts, she was focused single-mindedly on heeding her doctor's advice.
Breast cancer is a disease enmeshed in contentious debate. Friction does not revolve solely around techniques, but becomes heated as theoretical models diverge. Inquisitions have been held over contested portraits of reality. As irrefutably as diabetes is a medical rather than surgical problem, breast cancer wobbles across boundaries, straddling internal medicine, surgery, radiology, and oncology. Sally couldn't consider that anything other than surgical intervention would deliver and protect her from harm. In her haste to just want to make it better, she was incapable of considering her options.
Exposing and exploring the premises that have shaped the menu of current choices is itself worthy. How breast cancer is experienced may change as the perception of it shifts. In the summer of 1989 my father traveled to France to witness the early laparoscopic cholecystectomies--removal of the gall bladder via a surgical instrument inserted into small incisions in the belly rather than the former open--abdomen operation. At present, the newer, less invasive surgery has virtually replaced the former operation, reducing patient recuperation time and expense. Continuing with the old operation (except in special circumstances) is now considered unforgivable--no surgeons could justify the more extensive procedure. Yet lumpectomy for breast cancer has still not "caught on." Marc Lippman, a renowned breast cancer researcher, says, "I am puzzled as to what combination of educational, prejudicial, financial, and historical issues have failed to get lumpectomies going.... Most [women] do not choose mastectomies...." Yet they have them anyway. The problem, he said, "is the doctors" (Men York Times. I May 5, 1993).