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Preparation of the Patient for Breast Surgery
Preparation of the Patient for Breast Surgery c.
D. HAAGENSEN, M.D. *
GREAT care is devoted to the physiological preparation of patients with breast disease for operation, to the excellence of their anesthesia, to the precise execution of the surgical procedure, and to the accuracy of the pathological study of the tissue removed. All this is of course important for the patient's physical welfare. But little or no attention is usually given to the, preparation of the patient's psyche for the surgery that she is about to undergo. This neglect of the mental aspect of the patient's breast disease is an important defect in modern surgical care, and should be corrected. The main reason why the mental preparation of patients for breast surgery is so much neglected is that it can be done only by one personthe senior surgeon in whom the patient places her trust. The physical preparation of the patient for operation can be, and usually is, a cooperative enterprise achieved by several bright young men whom the patient need not know personally. But the detailed explanation of what is to be done at operation, and why, and the inspiring of hope and the quieting of anxiety, must come from the individual whom the patient regards as her surgeon. It makes no difference whether she is a ward or a private patient. The responsible attending surgeon who has the patient's confidence should sit down with her, after he has examined her, and explain her problem to her as simply and as truthfully as possible. This takes time, and most surgeons today carryon their work at such a frantic pace, and attempt to care for so many patients that they have
From the Department of Surgery, College of Physicians and Surgeons, Columbia University, and the Surgical Services of the Presbyterian Hospital and Francis Delafield Hospital, New York.
* Associate Professor of Clinical Surgery, College of Physicians and Surgeons, Columbia University. 535
536
c. D.
Haagensen
no time to prepare their patients mentally for the operations that they perform on them. Most women with breast disease who come to consult a physician today have delayed many months in seeking help. In our Presbyterian Hospital series of cases of breast carcinoma, during the years 1915 to 1942, the average duration of symptoms was 10.7 months. Delay of this length of time is beyond question the most important reason for our comparatively poor results with breast carcinoma. When we get the disease early, radical mastectomy is surprisingly successful, but when the patient comes late, as she so often does, we usually fail to cure her. In my opinion fear is the predominant factor that deters patients from seeking our help early. The fear that often makes cowards of even the most intelligent and educated women who have breast disease is of two varieties. The first is fear of mutilation. The modern woman reads a great deal about cancer, and hears a good deal about it from her friends. Her first thought when she discovers something wrong with her breast is that she has breast cancer. She assumes the worst-that she will lose her breast. It should be apparent to every physician who has had much experience with breast disease that the breasts-both breasts-are vitally important organs to every woman no matter what her age or marital status may be. This fear of breast amputation often strikes so deeply that the woman cannot bring herself to consult a physician for a long time. A second, and almost as important, kind of fear that terrorizes women with breast disease is that they will not be cured of the cancer that they suspectthey have. They have all known friends who were not cured, and many have had relatives who succumbed. We must not overlook the fact that laymen do not have much confidence in our ability to cure cancer. In a recent study carried. out in Manchester, England, by Paterson, it was found. that in answer to the question "can cancer be cured" 50 per cent of those questioned. answered NO. The detailed . answers to this question are shown in Table 1. A similar study carried out by the American Institute of Public Opinion, at Princeton, shown in Table 2, suggests that Americans are better educated-regarding the possibility of the cure of caneervYet these data show clearly enough that a considerable percentageofwornen do not believe that breast cancer can be cured. Many patients with breast disease get very little specific help from their surgeon to relieve these two basic fears-fear of mutilation and fear of death. Their fears are either brushed off with a hasty reassurance, or what is worse, the surgeon attempts to calm the patient by lying to her. A. common practice is to tell the patient that her breast is to be removed because her tumor may become malignant. Neithermethod is
537
Preparation of the Patient for Breast Surgery
likely to succeed. Most patients have enough intelligence to see through this kind of subterfuge. They are then apt to lose confidence in their surgeon, just at the time when they most need to rely upon him. In my experience the best weapon against these fears of breast disease is truth. The truth must of course be told patiently and sympathetically. It is important to emphasize its hopeful aspects. But the word cancer should be used openly and frankly. It has been my own practice to take as much time as is needed after I have completed my examination of the patient, to explain to her in simple terms the diagnostic problem and how we propose to solve it, and what the possibilities in store for her Table 1 CAN CANCER BE CURED?
Paterson and Aitken-Swan Survey, Manchester, 1953 usually } Yes sometimes seldom No, never Do not know
36% 50% 14%
Sample-1200 Table 2
Do You THINK CANCER Is CURABLE? American Institute of Public Opinion Surveys 1940
1950
1953
Yes
56%
60%
No Do not know
27% 17%
23%
65% 20%
17%
15%
are. If the patient in question has a lesion that is probably benign, I tell her so. I always add that my clinical diagnosis is only a good guess, and explain that the microscope is the final arbiter, and that she may in fact have cancer. Plans should be made for any actuality. If the lesion appears to me to be a carcinoma I tell the patient that there is a strong possibility that she has a cancer. I point out that my clinical diagnosis is only a guess, and may be incorrect. I emphasize the fact that the hope of cure is excellent in early breast cancer. If carcinoma is found at operation I tell the patient so without hesitation. When these truths are presented sympathetically to patients it has been my experience that they almost always rise to the occasion and accept them with courage and dignity. Their fears are to some degree
538
c. D. H aaqensen
overcome by facing them. I believe that I usually succeed in gaining the confidence of my patients and in persuading them that they can trust and rely upon me. To some extent, no doubt, they transfer their burden to me. Recently the problem of explaining the rationale of treatment for breast carcinoma to patients who have it has become much more complex because of the development of new and more accurate methods for sorting out the patients whose carcinomas have extended beyond the reach of surgery, and who therefore should be treated by irradiation rather than radical mastectomy. By biopsy of the internal mammary lymph nodes, and the lymph nodes at the apex of the axilla, we are now able to prove that many patients with apparently operable breast carcinoma are in fact incurable by surgery because metastasis to these regions has occurred. When there is no hope of cure by radical mastectomy this operation should never be done. It will do no good-only harm. In preparing patients mentally for what lies ahead of them they must, therefore, today be told that even if cancer is found, the breast is not, under certain circumstances, removed. Instead, treatment with irradiation is given. I do not ordinarily explain to patients why irradiation is preferred. The choice is, after all, an exceedingly technical matter. When I have brought patients to this point in their difficulties they trust me without expecting to be told such details. 'Another important advantage of telling the truth to patients with breast disease is that it makes them face the fact that they may have cancer, and that they must not delay treatment. Patients who are not made to realize this possibility are apt to delay coming into the hospital, or to go shopping around from one surgeon to another while precious weeks and months slip by, and metastasis perhaps occurs. To patients with the breast lesions that are clinically benign I always take time to explain that we are today able to biopsy the tumor; and if it proves on microscopic study to be benign, to remove it, without deforming the breast appreciably or leaving a bad scar. It is an unfortunate fact that the great majority of surgeons make radial incisions for the removal of benign breast tumors, merely because they are traditional. These radial incisions unavoidably leave vicious scars; which remind the patient almost daily for the remainder of her life, of the threat of breast disease. All this anguish can be avoided if the surgeon uses circumareolar incisions to explore lesions in the central portion of the breast, and curved incisions that follow the skin lines for lesions in the periphery of the breast. Such incisions, when closed with fine subcuticular and skin sutures) leave scars that are invisible, or almost so. There is also a tendency among surgeons to remove far more breast tissue than is necessary in excising benign lesions, thus deforming the breast needlessly. These
Preparation of the Patient for Breast Surgery
539
are important aspects of the mental care of the patient with benign breast disease. She must not be needlessly penalized mentally for harmless disease. REFERENCE Paterson, R. and Aitken-Swan, J.: Public Opinion on Cancer. Lancet 2: 857, 1954. 630 W. 168th Street New York 32, N. Y.
D. HAAGENSEN, M.D. *
GREAT care is devoted to the physiological preparation of patients with breast disease for operation, to the excellence of their anesthesia, to the precise execution of the surgical procedure, and to the accuracy of the pathological study of the tissue removed. All this is of course important for the patient's physical welfare. But little or no attention is usually given to the, preparation of the patient's psyche for the surgery that she is about to undergo. This neglect of the mental aspect of the patient's breast disease is an important defect in modern surgical care, and should be corrected. The main reason why the mental preparation of patients for breast surgery is so much neglected is that it can be done only by one personthe senior surgeon in whom the patient places her trust. The physical preparation of the patient for operation can be, and usually is, a cooperative enterprise achieved by several bright young men whom the patient need not know personally. But the detailed explanation of what is to be done at operation, and why, and the inspiring of hope and the quieting of anxiety, must come from the individual whom the patient regards as her surgeon. It makes no difference whether she is a ward or a private patient. The responsible attending surgeon who has the patient's confidence should sit down with her, after he has examined her, and explain her problem to her as simply and as truthfully as possible. This takes time, and most surgeons today carryon their work at such a frantic pace, and attempt to care for so many patients that they have
From the Department of Surgery, College of Physicians and Surgeons, Columbia University, and the Surgical Services of the Presbyterian Hospital and Francis Delafield Hospital, New York.
* Associate Professor of Clinical Surgery, College of Physicians and Surgeons, Columbia University. 535
536
c. D.
Haagensen
no time to prepare their patients mentally for the operations that they perform on them. Most women with breast disease who come to consult a physician today have delayed many months in seeking help. In our Presbyterian Hospital series of cases of breast carcinoma, during the years 1915 to 1942, the average duration of symptoms was 10.7 months. Delay of this length of time is beyond question the most important reason for our comparatively poor results with breast carcinoma. When we get the disease early, radical mastectomy is surprisingly successful, but when the patient comes late, as she so often does, we usually fail to cure her. In my opinion fear is the predominant factor that deters patients from seeking our help early. The fear that often makes cowards of even the most intelligent and educated women who have breast disease is of two varieties. The first is fear of mutilation. The modern woman reads a great deal about cancer, and hears a good deal about it from her friends. Her first thought when she discovers something wrong with her breast is that she has breast cancer. She assumes the worst-that she will lose her breast. It should be apparent to every physician who has had much experience with breast disease that the breasts-both breasts-are vitally important organs to every woman no matter what her age or marital status may be. This fear of breast amputation often strikes so deeply that the woman cannot bring herself to consult a physician for a long time. A second, and almost as important, kind of fear that terrorizes women with breast disease is that they will not be cured of the cancer that they suspectthey have. They have all known friends who were not cured, and many have had relatives who succumbed. We must not overlook the fact that laymen do not have much confidence in our ability to cure cancer. In a recent study carried. out in Manchester, England, by Paterson, it was found. that in answer to the question "can cancer be cured" 50 per cent of those questioned. answered NO. The detailed . answers to this question are shown in Table 1. A similar study carried out by the American Institute of Public Opinion, at Princeton, shown in Table 2, suggests that Americans are better educated-regarding the possibility of the cure of caneervYet these data show clearly enough that a considerable percentageofwornen do not believe that breast cancer can be cured. Many patients with breast disease get very little specific help from their surgeon to relieve these two basic fears-fear of mutilation and fear of death. Their fears are either brushed off with a hasty reassurance, or what is worse, the surgeon attempts to calm the patient by lying to her. A. common practice is to tell the patient that her breast is to be removed because her tumor may become malignant. Neithermethod is
537
Preparation of the Patient for Breast Surgery
likely to succeed. Most patients have enough intelligence to see through this kind of subterfuge. They are then apt to lose confidence in their surgeon, just at the time when they most need to rely upon him. In my experience the best weapon against these fears of breast disease is truth. The truth must of course be told patiently and sympathetically. It is important to emphasize its hopeful aspects. But the word cancer should be used openly and frankly. It has been my own practice to take as much time as is needed after I have completed my examination of the patient, to explain to her in simple terms the diagnostic problem and how we propose to solve it, and what the possibilities in store for her Table 1 CAN CANCER BE CURED?
Paterson and Aitken-Swan Survey, Manchester, 1953 usually } Yes sometimes seldom No, never Do not know
36% 50% 14%
Sample-1200 Table 2
Do You THINK CANCER Is CURABLE? American Institute of Public Opinion Surveys 1940
1950
1953
Yes
56%
60%
No Do not know
27% 17%
23%
65% 20%
17%
15%
are. If the patient in question has a lesion that is probably benign, I tell her so. I always add that my clinical diagnosis is only a good guess, and explain that the microscope is the final arbiter, and that she may in fact have cancer. Plans should be made for any actuality. If the lesion appears to me to be a carcinoma I tell the patient that there is a strong possibility that she has a cancer. I point out that my clinical diagnosis is only a guess, and may be incorrect. I emphasize the fact that the hope of cure is excellent in early breast cancer. If carcinoma is found at operation I tell the patient so without hesitation. When these truths are presented sympathetically to patients it has been my experience that they almost always rise to the occasion and accept them with courage and dignity. Their fears are to some degree
538
c. D. H aaqensen
overcome by facing them. I believe that I usually succeed in gaining the confidence of my patients and in persuading them that they can trust and rely upon me. To some extent, no doubt, they transfer their burden to me. Recently the problem of explaining the rationale of treatment for breast carcinoma to patients who have it has become much more complex because of the development of new and more accurate methods for sorting out the patients whose carcinomas have extended beyond the reach of surgery, and who therefore should be treated by irradiation rather than radical mastectomy. By biopsy of the internal mammary lymph nodes, and the lymph nodes at the apex of the axilla, we are now able to prove that many patients with apparently operable breast carcinoma are in fact incurable by surgery because metastasis to these regions has occurred. When there is no hope of cure by radical mastectomy this operation should never be done. It will do no good-only harm. In preparing patients mentally for what lies ahead of them they must, therefore, today be told that even if cancer is found, the breast is not, under certain circumstances, removed. Instead, treatment with irradiation is given. I do not ordinarily explain to patients why irradiation is preferred. The choice is, after all, an exceedingly technical matter. When I have brought patients to this point in their difficulties they trust me without expecting to be told such details. 'Another important advantage of telling the truth to patients with breast disease is that it makes them face the fact that they may have cancer, and that they must not delay treatment. Patients who are not made to realize this possibility are apt to delay coming into the hospital, or to go shopping around from one surgeon to another while precious weeks and months slip by, and metastasis perhaps occurs. To patients with the breast lesions that are clinically benign I always take time to explain that we are today able to biopsy the tumor; and if it proves on microscopic study to be benign, to remove it, without deforming the breast appreciably or leaving a bad scar. It is an unfortunate fact that the great majority of surgeons make radial incisions for the removal of benign breast tumors, merely because they are traditional. These radial incisions unavoidably leave vicious scars; which remind the patient almost daily for the remainder of her life, of the threat of breast disease. All this anguish can be avoided if the surgeon uses circumareolar incisions to explore lesions in the central portion of the breast, and curved incisions that follow the skin lines for lesions in the periphery of the breast. Such incisions, when closed with fine subcuticular and skin sutures) leave scars that are invisible, or almost so. There is also a tendency among surgeons to remove far more breast tissue than is necessary in excising benign lesions, thus deforming the breast needlessly. These
Preparation of the Patient for Breast Surgery
539
are important aspects of the mental care of the patient with benign breast disease. She must not be needlessly penalized mentally for harmless disease. REFERENCE Paterson, R. and Aitken-Swan, J.: Public Opinion on Cancer. Lancet 2: 857, 1954. 630 W. 168th Street New York 32, N. Y.