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.
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.”