A breast surgeon reflects on the complex decisions facing her patients at a difficult time
13 Oct 2016
I recently told a 30-year-old woman she probably has breast cancer. I say woman, but she looked like a young girl to me. Even as I approach 50, I feel young and that there is a long future ahead.
This wasn’t the first time I’ve had to give devastating news to a patient, and it won’t be the last. My colleagues around the country will all have had similar experiences. A breast cancer diagnosis, any cancer diagnosis, is never good; but in the young, especially when they have small children, it seems particularly unjust and all the clinical team is affected by it. Your definition of ‘young’ will to some extent depend on your own age, your parents’ ages, but 30 is young in any doctor’s view.
I explained to my patient that she would have to come back in a week’s time once we’d received the pathology results and we’d had our multi-disciplinary team meeting to discuss the diagnosis. Time and time again I am told that the waiting for results is the worst bit. It’s excruciating and this is when the worst-case scenarios are imagined.
Already, and understandably, I could see her mind racing ahead wanting answers to questions. Is it growing? Is it spreading? When and how will you treat it? Will I die?
The prevalence of breast cancer and the profile it has in the media means most women have some idea of what treatments to expect: surgery, reconstruction, radiotherapy (which usually means travelling to the nearest big city every day), chemotherapy (and therefore losing your hair).
In addition to those concerns there is the practical stuff ... How will this affect my job? Will I be able to work? What about the holiday we have booked? Will I be able to collect the children from school? What about the family wedding next month?
There is no doubt that a cancer diagnosis causes huge emotional and practical upheaval in someone’s life and in that of their loved ones.
Although most patients feel some relief when the diagnosis is confirmed and a plan is in place, reflecting a sense of them taking back some control, before that plan is confirmed there are often many decisions to make.
Patients may have to consider whether they would prefer to have chemotherapy before surgery, to try to shrink the tumour, and potentially avoid a mastectomy (an operation to remove the breast); or to have the lump removed (lumpectomy). Radiotherapy - x-ray treatment - can affect the skin texture and the appearance of a reconstructed breast - another consideration. Then there may be a discussion about what type of reconstruction they would want: a ‘straightforward’ implant, or a bigger procedure, using skin or muscle from another part of the body, causing scarring elsewhere and a longer recovery.
We quite rightly present the options to our patients and involve them in decision making, but there is no denying this isn’t easy and can add to the stress at an already difficult time.
The clinical decisions and treatment recommendations will be based on the size and grade of the cancer and the tumour’s biological factors. We’ll provide our patients with written information from Breast Cancer Now and MacMillan to give them time to think through their options. They will also be offered time with a specialist breast cancer nurse to discuss the possible treatments again.
It is not unusual for patients to be troubled by competing priorities - between the idea that surviving the cancer is paramount - and the desire to preserve or rebuild the breast.
In addition to the treatment decisions, if you receive a breast cancer diagnosis before starting a family, this presents another complex set of issues and there are several options to consider: from ovarian preservation, to IVF, to dealing with the possibility of infertility.
While the prognosis after a cancer diagnosis depends on various factors, including the size and grade of the tumour, the good news is that nowadays for a lot of women there is a realistic chance of them being cured. All women over 50 are offered breast cancer screening on the NHS and this has contributed to survival rates increasing by 35% since the 1970s1. NHS patients now also have access to a team of specialists who work together to decide the best treatment option for them.
In total, around 50,000 women are diagnosed with breast cancer each year and more than 80% are still alive five years later2. Almost half (47%) of female breast cancer deaths in the UK each year are in older women aged 75 and above (2012-2014)3. Mortality rates for female breast cancer in the UK are highest in females aged 90+ (2012-2014). Very sadly, around 11,500 women and 80 men die from breast cancer each year4.
From my perspective, it is a privilege to be a breast cancer surgeon. It is also hugely rewarding to know you have made a positive contribution at this crucial time in a woman’s life. My patients may go through a very difficult time, but with help and support they often show great fortitude and resilience. Once they’ve finished their treatment many return to work and lead full and active lives.
Miss Claire Murphy is a Consultant Oncoplastic Breast Surgeon in Airedale, North Yorkshire.
The month of October is breast cancer awareness month. For more information visit Breast Cancer Care.