Breast cancer – how to tell and treatment

Twenty-five years ago there would be no discussion about the correct treatment for a woman having an early carcinoma of the breast. She would be submitted to a radical mastectomy with remo­val of the whole of the breast, pectoralis major and minor and with complete clearance of the axillary contents. This operation had been accepted for something like half a century. Yet the fact remained that the overall 5-year survival of all patients submitted to this treatment was only in the region of 50%.

Surgeons and radiothe­rapists began to seek other techniques or treatment and they showed that simple mastectomy combined with radiotherapy gave at least as good results as radical mastectomy. There was controversy as to whether radiotherapy should be given pre- or post-operatively and debate as to whether or not removal of the ovaries or irradia­tion to the ovaries was advisable. There are a number of important reasons why this subject has been the source of such debate. Pro­bably the most important is that advocates in the past have based their enthusiastic arguments not on controlled clinical trials, but on consideration solely of the 5-year survival rate of their preferred technique.

Fortunately surgeons are now submitting themselves to the rigid discipline of controlled clinical trials.

A recent survey of current practice carried out by means of a question­naire to 440 surgeons indicated a swing away from radical mastecto­my towards a more conservative approach, so that many surgeons now carry out simple removal of the breast together with axillary clearance.

Treatment of advanced breast cancer

Radiation therapy is va­luable for localized irremovable disease. Thus an extensive malig­nant tumour, beyond the stage of. surgical excision, will often regress with radiotherapy and it is our practice wherever possible in such circumstances then to carry out a toilet mastectomy. Localized re­currence after mastectomy or localized metastases, again, can often be satisfactorily treated by radiation therapy and this applies parti­cularly to painful spinal metastases and to pathological fractures which should first be stabilized by means of an intramedullary nail. Palliation of osseous metastases with radiation treatment can be achieved in something like 70% to 80% of patients.

Should the doctor tell? One of the most painful dilemmas is whether or not to tell a patient that he or she has a fatal or in­curable illness. Here two experienced doctors state opposing views. Each doctor spoke without knowledge of what the other had said.

Should the incurably ill patient be told the facts about his illness?

“Yes,” says Dr. X. “During the many years that I have practis­ed medicine I have repeatedly been told that a seriously ill patient who hears the truth about his condition may become suicidal or men­tally unstable. I have been telling patients the truth for a long time but I have never seen either of these things happen. I am reminded of a patient who, on learning that he had lung cancer, warned me not to tell his wife. “She would throw herself out of the window,” he said. When the wife did find out about it, she rushed to our clinic and said, “I hope you’re keeping this a secret from my hus­band. He would take poison if he knew the truth.” Of course, nei­ther committed suicide. They were in love and they greatly com­forted each other during the four years that the husband lived. The only patients I’ve heard about who have committed suicide are those who were not told the truth but suspected the worst.

Breast cancer

A man or woman who is seriously ill is more afraid of the un­known. One can easily tell a patient, “You have a little arthritis,” when he actually has bone cancer. A man who has leucaemia may be told only that he is anaemic. But there is no way you can soothe away — or lie about the fact that these patients see themselves getting progressively worse. I find that the truth somehow en­ables the patient to feel a certain satisfaction; relieved of his gnaw­ing suspicion, he is able to accept the fact that he is ill — a state of mind that has obvious medical advantages.

How you tell is very important. Many doctors conceal the truth simply because they find it difficult to disclose unfortunate facts and at the same time impart hope and courage Hope is essential but it cannot be false hope. It must move in the direction of truth.

You cannot tell a patient about his illness in three or five mi­nutes. All the humanity of tht doctor is called upon. Sensitivity, kindness, compassion and, I believe, honesty are needed to encou­rage patients and give them support in times of pain and depres­sion.

The information must be cushioned, I agree that the word “can­cer” fills up with terror. But patients need to be told about the enormous advances including atomic research being made in medical science. They need to know, for example, that pernicious anaemia used to be 100 per cent fatal, but now nobody dies of it.

When patients are told the truth a kind of protective strength en­folds them. If one should face death it’s better to do it without a blindfold.”

“No,” says Dr. Y. “At present I know a young man suffering from cancer who knows “what he is in for” — his doctor has told him about it in detail. Although he is a courageous person, the know­ledge of his condition has thrown him into despair. The doctor in charge of this case said to me: ” I would give anything if I could inject him with a little optimism.” You can’t do much for a patient who has no fight left in him, I recall a scene in a hospital corridor years ago when I was a young doctor. An old man was being wheel­ed from one treatment centre to another. He was suffering from inoperable cancer but he didn’t know it. Although he had been in pain for sometime, he kept smiling. Suddenly someone walked up and said: “Is this the cancer patient?” and dropped a set of charts on the stretcher. The old man read the truth in the nurse’s fright­ened face. He wept bitterly. From then on, the spirit drained out of him. He told no more jokes. He turned his face to the wall, pas­sively waiting to die.

There is no question that someone should be told when a pa­tient has a fatal illness. That person is not necessarily the patient’s husband or wife. Often it is a good idea to tell two members of the family. Then they can lean on each other for comfort without intruding on the patient.

The most important attributes of a doctor’s relationship with a dying person should be confidence, willingness to talk and frequent personal contact. I remember the statement of a heart specialist be­ing a friend of mine. “Instill a cheerful outlook. Tolerable comfort is nearly always possible. Remember that life is sweet.”

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