I was a 27-year-old surgical intern at New York Hospital in 1976 when I took care of my first patient who died from breast cancer. Mrs. M. was a 40-year-old woman with two young children and a loving husband. About eight weeks before I met her, she had noticed that her left breast had become swollen, red, and somewhat tender. Her skin felt firm and the texture was like the skin of an orange. She'd had mastitis when breastfeeding a few years before and thought that this was the same thing, but she didn't have a fever and she didn't feel sick the way she had then. She saw her GP, who prescribed antibiotics for an infection, bought larger bras since the size of her left breast had increased, and used warm soaks on that breast, but nothing improved. She then saw her gynecologist, who referred her for a mammogram; the mammogram showed thickened skin in the left breast but no other abnormality. The gynecologist called a breast surgeon for an early appointment for the woman. The surgeon performed a biopsy and found a breast malignancy that appeared on his experienced clinical exam to have spread throughout much of the breast and lymph nodes. He had seen only two cases like this before and both patients had died quickly.
I was the surgical intern who was responsible for the first in hospital interview and examination of this patient , who was to have surgery the next day. I took a careful history and did a gentle exam. I made sure that all of the required tests were ordered for a pre-op patient.
In 1976 the life of a house officer, as interns and residents were called, was not for the frail. We worked 36 hours on and 12 hours off with free one-and-a-half day weekends every two weeks. The night before Mrs. M's surgery was my night "off." I remember that I signed out to the incoming team at 9 pm, then went to visit Mrs. M. Visiting hours had ended and she was there alone. My years of hospital work as a nurse's aide had given me an understanding of patient anxiety that other young doctors at my stage did not generally have. I knew that she would be frightened about all of it: how she would be treated in the operating room, the removal of her breast, the diagnosis of breast cancer, the reaction of her husband, friends, and family to the news. I also knew what the surgeon suspected and she did not yet know -- that she might die from this cancer.
I stayed for an hour, admiring pictures of her children and talking about her garden in Long Island that gave her such pleasure. Before I left, I asked if I could call her husband and have him bring some things to the hospital the next day. I made the call from her room and asked if he would bring her own pillow, some family pictures, and some photographs of her garden. I handed the receiver to her so he could give his wife a goodnight phone kiss.
Mrs. M had a radical mastectomy with removal of many lymph nodes from the left armpit the next morning. The news was bad. She had stage 4 breast cancer, with 30 out of 30 lymph nodes positive. She had a rare kind of breast cancer that didn't have a name yet but was being discussed at meetings because it looked and acted differently. The women who had this cancer were often younger at diagnosis and almost all of them died. When the diagnosis was made the cancer was always advanced.
Mrs. M was strong and healthy otherwise. She was ready to fight her cancer with all the chemotherapy and radiation treatments that were suggested. Each time she was admitted to the hospital for some complication of the terrible chemotherapy complications of those times -- wiped-out white cells and red cells requiring blood transfusions, wiped-out immune system with pneumonia and blood stream infections -- she called me and I would see her daily.
Mrs. M died 4 months from the day I met her, with metastatic disease in the brain and lungs, and pneumonia that could no longer be treated. I was with her when she died on the 17th floor of the hospital, in the last room on on the left.
Today her cancer has a name: inflammatory breast cancer.
It's a rare but aggressive form of breast cancer. While it accounts for 2 to 6 percent of all breast cancers, the 5-year overall survival rate is 40 percent, as compared to nearly 90 percent for all types of breast cancer combined. The key to survival is an early and accurate diagnosis and being in the care of healthcare providers who specialize in inflammatory breast cancer. Today there are centers devoted to the scientific study of this cancer and to the cutting edge care of these patients. And there is hope, because the money raised by breast cancer awareness groups has given scientists and physicians the labs and tools they need to discover why this cancer is so aggressive, why it is different from other breast cancers, what treatment protocols work best, and whether there are gene markers that will identify women at risk or will change the type of treatment program that will work best for each woman.
I teach my patients to look at their breasts (as well as palpate them) as part of their breast self-exam, reminding them that they should not assume that pain or redness that persists for a week is something simple. I tell them to look for changes in the texture of the skin and for nipple retraction, both hallmarks of inflammatory breast cancer, and I tell them to see a doctor right away, as this rare form of breast cancer still is diagnosed later than it should be.
The 17th floor of New York Hospital is no longer used for surgical patients. I do not have patients in the hospital on this floor. But once a year I visit it anyway, take a walk to the door of the last room on the left, and remember Mrs. M, her heroic struggle to live for her children and her family, and how little we in medicine could do for her at that time.
Cross-posted at Women's Voices for Change.