Cancer exists on a continuum, with endogenous (internal) causes on one end and exogenous (external) causes on the other. Surgeons are the mechanics and oncologists are the pest controllers. Today the focus is on chemotherapy as a form of pest management; tomorrow there is a promise of medicine being equipped to enhance our self-capacities and eliminate virulence through engineering molecular environments.
Others believe that it is the ambient and ubiquitous burden of toxins in the soup in which we swim daily that foments these changes within. Rather than breast cancer being a local problem, it is a global one. it tends not to have a single regional locus, but becomes universal within the organism; it is more like a virus than a fracture. Struggling against disease with hope is itself believed by many to be therapeutic, but there is not enough known to issue universal prescriptions. Over the centuries, even some of our greatest spiritual teachers have died of cancer.
Surgeon Richard Selzer54 commented that after he wrote a medical essay titled "The Exact Location of the Soul," readers wrote to him, pumping him for more specific information. Upon reflection he answered that if he were to fix the soul in a location, it would be in the wound, that place of tender suffering. Buddhists claim that life is an evolutionary exercise in learning lessons dressed in suffering. One antidote to suffering is glad acceptance--not wishing for things to be other than they are. This entails transcendence of future-oriented desires and instead focuses on experiencing each moment as bliss: exquisitely full, complete, sufficient. The emphasis shifts to the quality rather than the duration of life--more on living better, and less on living longer. Some studies suggest that women who exhibit optimistic determination fare better than do those who are either helpless and hopeless, or those who are anxiously preoccupied.55 Hope can mean tenaciously affirming that life makes sense while encountering the universality of our inevitable death. The best we can do is live well each day, paradoxically accepting what is as we strive valiantly to change.
Harriet Beinfield has practiced acupuncture and Chinese herbal medicine for 24 years at Chinese Medicine Works in San Francisco, Calif. She is the co-author, with Efrem Korngold, of Between Heaven and Earth: A Guide to Chinese
Medicine Malcolm S Beinfield is an associate clinical professor in the Department of Surgery at Yale University School of Medicine and on the staff of the Yale Comprehensive Cancer Center. He has practiced surgery for 45 years and has pub fished numerous articles on clinical breast cancer research.
The authors wish to thank Nat Berlin, MD, for his valuable comments during review of this manuscript.
1. The NCI Consensus Conference concluded that "Breast conservation treatment is an appropriate method of primary therapy for the majority of women with Stage I and 11 breast cancer and is preferable because it provides survival equivalent to total mastectomy and axillary dissection while preserving the breast.... Breast conserving treatment Idefined as lumpectomy and axillary dissection followed by irradiation! is preferable because it provides survival equivalent to total mastectomy and axillary dissection while preserving the breast" (NIH Consensus Development Panel. Consensus development conference on the treatment of early-stage breast cancer.J Natl Cancer/nst. 1992:11:1-S).
2. Greater cohesion and homogeneity of the pro&scion were also achieved by the deliberate segregation of Jews, Catholics, women, blacks, and the foreign-born. consolidating the rise of a genteel Protestant medical aristocracy. Medical school admission and operating privileges at hospitals were granted to a closed fraternity of surgeons, qualified more by social caste than by professional achievement Discrimination underlay the building of hospitals with names like Saint Vincent, Saint Mary, Saint Joseph, Beth Israel, Mount Zion, Mount Sinai-places that welcomed Catholic and Jewish patients and doctors.10(pp173-177)
3, Establishing Johns Hopkins as the model for all others to follow was consolidated by the Flexner Report of 1910, which Arced the massive closure of schools that did not conform to the new standards. By 1936, S91 million was steered primaniv from the Rockefeller General Education Board into a select group of schools, Johns Hopkins being among the seven that received more than two thirds of the funds.10(p121)
4. Curiously, his parents were both the offspring of business partners (his father was a Halsted and his mother was a Haines) and cousins (his mother and father were the children of sisters) (Rutgow 1, William Halsted, his family, and 'queer business methods.' Arch Surg. 1996;131:125),
5. In London, Charles Moore formulated the principles of mastectomy in 1867; Joseph Pancoast, prom Philadelphia, recommended removal of the breast and glands all in one piece as early as 1844; Richard von Volkmann in Germany and Theodor Billroth in Vienna both removed the entire breast in the 1870s: and William Handley in London and Willie Meyer were contemporaries of Halsted, who supported his efforts with their own.
6. Halsted demonstrated the use of cocaine as local anesthesia to Koller's friend, Anton Wolfler, who had been the Viennese surgical giant Theodor Billroth's first assistant. Later, Wolfler published on the subject (Penfield W. Halsted of Johns Hopkins. JAMA. 1969;210112l:2214-2218). (Reprint of Halsted's letter to Osler, dated August 23,1918.)
7. In a private letter to Osler, Halsted wrote that three of his associates "acquired the cocaine habit in the course of our experiments on ourselves--injecting nerves. They all died without recovering Prom the habit" (/AMA. 1969:2101121:2217).
8. A lump was the initial symptom in 83% of the women, which by the time of hospitaCzation had become a large mass for many. Ulceration, sometimes extensive. was seen in 68%: only 7% of the women came to the hospital within 6 months of the symptoms. Seventy-one percent delayed for more than 12 months. In 24% of the women, more than 3 years elapsed; in 12%, more than 5 years. The longest delay was 16 years. This contrasts with later practices, in which patients present within 6 months to 1 year after symptoms are noticed. A high percentage of the Middlesex women therefore had advanced disease (Bloom H. Richardson W. Harries E. Natural history of untreated breast cancer 11805-19331, Br Med / Jul
1962:219). According to Diana Fischer, research scientist at Yale School of Medicine, the 50 women who received mastectomies reported upon in Halsted's study between 1889 to 1894, when compared with the 250 cases at Middlesex Hospital in London between 1805 to 1930, showed no statistically significant survival difference between the surgically managed and untreated women (written communication, March 1996).
9. Farber D. Biologic variations of tumors. Presented at the American Cancer Society; October 11-13, 1991; Pasadena, CaCf (referring to Bloom H. Richardson W. Harries E. Natural history of untreated breast cancer 11805-19331. Br Med J July 28, 1962:213-221).
10. "For virtually all patients who have had a mastectomy, recurrent breast cancer is not a curable disease" (Loprinzi C. It is now the age to define the appropriate follow-up of primary breast cancer patients.JClin OncoL 1994;12(5):881. Editorial).
11. If in 10 years there are 1000 cells within a tumor, in 20 years there are I million; in 30 years, I billion; and in 40 years, I trillion. The human body contains about 11 trillion cells. Death usually results when 10% of the body is replaced by cancer cells. The doubling time of breast cancer cells varies greatly from 9 to 900 days, with an average being 100 to 185 days (spran IS, Spratt JA, Grouth Rates in Cancer of the Breast. 3rd ed. Philadelphia, Pa: WB Saunders; 1988:270-302).
12. Love comments elsewhere: "I think that any breast cancer large enough to be detected has already spread.... The danger of cancer depends on the balance between the cancer and the ability of your body's immune system to fight it" (Dr Susan Love's Breast Book Reading, Mass: Addison-Wesley; 1990:212).
13. "Whether lymph node metastases in the axilla or internal mammary drainage basins are removed, radiated, or merely observed, survival is absolutely equivalent" (Cady B. Dilemmas in breast disease. BreastJ 1995:1121:121-124).
14. The National Lymphedema Network, based in San Francisco, and Stanford University are each testing an early therapy for the problem using massage, special armbands, and lifestyle modifications, though elimination ofthe procedure would I absolutely cure the side effects of lymph node dissection.
15. High-dose chemotherapy with autologous bone marrow transplantation and/or blood cell transplantation for the treatment of metastatic breast cancer. Executive Briefing, Emerging Care Research Institute (ECRI), February 1995. ECRI is an independent technology assessment organization located in Plymouth Meeting, Pa. An article about ECRI appears inJAMA (1995;274113]:999-1001).
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