The Way I See It

When it comes to surgery for cancer, having a “positive margin” is a bad thing.  It means that when the surgeon said he “got it all,” even though he meant it with all of his heart, likely he didn’t.  For a woman undergoing a lumpectomy for breast cancer, that positive margin means a re-excision of the lumpectomy site or alternatively, a mastectomy.  For a woman who has just had a mastectomy, it means that she will likely be seeing me.

I saw a new breast cancer patient on Thursday, a very attractive woman in her early fifties.  She had undergone a mastectomy last March, and had a tissue expander placed at the time to facilitate a later reconstruction with a silicone implant.  The final pathology showed positive lymph nodes on her sentinel node biopsy, and a positive margin where the tumor was close to the chest wall.  She required chemotherapy because of her lymph node involvement, and radiation to her chest wall for the tumor cells that may have been left behind.  She finished her chemotherapy without any difficulty in June.  But instead of coming to me at that time, she elected to complete her reconstruction first.

The first time her expander was replaced with a permanent implant, in August, there were complications which resulted in a failed reconstruction. The plastic surgeon elected to take her back to surgery in November, and replace the implant, and transfer fat cells from her inner thighs to make the reconstructed breast rounder and more perfect.  When the patient saw me on Thursday, she was still not entirely happy with the result, and was looking forward to having additional fat transplanted in the upper inner quadrant.  She guided my hand to the area and said, “See?  The tissue is so THIN right there.”  I stared at her reconstruction in amazement.  It was one of the best I had ever seen.

But yes, there was a problem.  It was not a problem that she had concerned herself with.  The problem was that it was nine months after her mastectomy, and that no one had pointed out to her that a local recurrence of her breast cancer, for which she was certainly at high risk, is a harbinger of metastatic disease and death.  In other words, she had failed to grasp the fact that it was her cancer, and not her breast reconstruction, that she needed to pay attention to.  It took me the better part of an hour and a half to convince her that she should proceed with radiation BEFORE her plastic surgeon achieved the perfection that she sought, and BEFORE her cancer recurred, if it has not already.

I understand the importance of breast reconstruction, and of feeling whole, and feminine again.  But I also understand the evil nature of “the beast.”  I may be a curmudgeon, but I want my ladies to comprehend that it’s not about the boob and the plastic surgeon isn’t going to tell you that—that’s MY job.  First and foremost, pure and simple, it’s about getting rid of the cancer. That’s the only priority.  It’s just the way I see it.


  1. I’m left speechless and saddened that a person could be find appearance more important than not just health, but survival. It must be the logical extension of Beauty above all. I recall a beautiful young man dying of AIDS in the late ’80s who would allow no visitors because he wanted them to remember his pre-disease self, not what he had become, ravaged by AIDS. It was a lonely death. I sincerely hope your patient’s beauty is not fatal.

  2. There are times when plastic surgeons do create miracles and improve lives tremendously. But I have come to be very suspicious of those that promote breast reconstruction.

    Every single woman that I know who has had breast reconstruction has also had “complications”. Some with miserable problems that go on for months. Now I realize that this is a small sample, but it’s shocking to me.

    For a plastic surgeon to promote breast reconstruction in the face of terminal illness…….well, it really makes me wonder about their medical education and understanding of oncology and the basic practice of medicine.

    I admire my mother’s courage. She had a radical mastectomy in 1977 and simply wore a prosthesis for her remaining 28 years of life. And that was no small thing as she was very large-breasted (unlike me!). She was able to do so because the was a pragmatic person and also because my father loved and accepted her the way she was.

  3. When I worked at the Breast Center, none of the plastic surgeons would replace the expander before radiation. I hope you also had a talk with the plastic surgeon.

  4. In this beauty & youth obssessed culture we live in, I am not surprised at her priorities. To her, this has not become a life & death issue. And she has been enabled by her plastic surgeon. Hope your talk has set her on the right path.

  5. Years ago, a young man with testicular cancer was referred to the treatment center where I worked. He had surgery and was needing radiation to complete his treatment. He didn’t call us back. We called and called, sent letters, sent a certified return-receipt letter, and contacted the referring doctor about not being able to reach him but no response.
    When we finally heard from him, he had gone to France to tour for several months with his fiancee and then gotten busy with work when he returned. He was now ready to pursue his radiation treatment….eight months later. Unfortunately, the cancer had already spread and he was now in a fight for his life rather than a more routine situation. So sad and unnecessary .

  6. Perhaps because I work with patients directly out of the operating room, I have some different ways of looking at the subject, and, no doubt, my own personal reaction if I were faced with such a situation kicks in.
    I do totally agree with Miranda that the woman does not have her priorities truly worked out. Perhaps she has been so overwhelmed with her not so good news that she feels if she can grasp at and relate to something that makes her “whole” again, it will somehow make things feel more back to normal – and if one feels back to normal than one must not be “that sick”? That is just my own theory.
    It does seem odd to me that she would have had the reconstruction (done) before doing other therapy recommended for her case.
    BUT, I do not personally think an ethical plastic and reconstructive surgeon pushes anyone into making a hasty decision. Usually care is coordinated between the breast surgeon, the oncologist, the plastics MD and any radiation oncologist involved. I see it written in charts all the time – Explanation to patient of ALL possible options, pros and cons of same.
    It is seeming like this is being pushed or promoted? But the bottom line here is that it is an option that was NOT an option not very long ago – way back when our mothers were faced with this sort of situation, they had NO other options – you could get your mastectomy and you could wear a prostesis if you wanted to, or you could go without. Your choice, but not a great choice if one is an active person – the majority of women I take care of who are dealing with this just want to be all in one piece and not have to worry about putting themselves together each day. And yes, femininity (sp?) plays a role for many and what is wrong with that? If they are doing it for themselves and not to please someone else, I say why not? Also, another very important factor is that until more recently, reconstruction was not paid for nor seen as necessary by insurance companies so if a woman desired one it was out of pocket expense for her and many could not afford it. Then a law was passed saying this HAD to be offered to women as a choice. This is why we see so many more of them these days. I had a scare a few years back and while it did not prove malignant, I already knew that I would have a reconstruction at some point if it came to that. I am way too active to want something loose sliding around in my shirt not to mention that I get hot very easily! Plus, I just know a dog would end up finding and chewing up a prosthesis that wasn’t permanently attached! :>)

    1. Ginni, and some of the others who have talked about the ethics of the plastic surgeon–this particular plastic surgeon is actually quite good, and thoughtful. His experience, unlike my own and many other doctors I know, is that women do better if the tissue expander is replaced with the permanent implant BEFORE the radiation. He likes to cite a paper from MD Anderson where they did it this way and there was no undue delay of radiation. The problem is when they run into a complication–then radiation IS delayed, sometimes by months. I prefer to treat with the tissue expander in place, and slightly over expanded to allow some retraction/shrinkage when the permanent implant is put in. As for myself, I cant say whether I would have reconstruction or not. It’s always an individual decision. M

  7. I am thinking this lady is in denial….If my breast looks perfect then the cancer can’t be there. Denial can last until the last moments of life. Denial can make people make poor decisions. The cosmetic surgeon definitely does not have her overall health in mind. She needs some counselling that her oncologist and perhaps psychologist should be consulted. Sometimes denial is the quiet killer when it doesn’t have to be. So sad….Jean

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