Sunday, January 13, 2008

Chapter 15 ~ Surgeon

Photo by
Brendon Stuart

Claire did come to the appointment to meet with the surgeon. Rose came too, home from Costa Rica just long enough to play a significant role. And Lawrence, of course. The four of us took up half the seats in the waiting room, where an older woman with no hair—her bald head covered by a blue kerchief—sat at one end and an older man reading a magazine sat at another. Lawrence stood with me at the glass window when I checked in with the secretary, sat next to me on the wicker love seat while we waited our turn. He picked up a magazine about fishing, leafed through it without talking. I looked over a catalog for mail order clothes. Rose and Claire tried gamely to make a few lighthearted comments before we settled into mutually agreeable silence. After five or ten minutes, Dr. Andreas came out to greet us. She was wearing blue hospital scrubs beneath a white doctor’s lab coat. Her dark hair was short and thick, standing straight up off her scalp. Her body was rangy—not slender, not delicate, but able and angular and devoid of fat. She had long, capable fingers. She wore horn-rimmed glasses and exuded competence.

“Are you Jo?” she approached me first, holding out her hand.

“Yes. I brought my troops with me. I hope you don’t mind.” I shook her hand firmly, feeling grateful from the first moment that she didn't have a supercilious air, that we would be able to communicate without wading through excessive pride.

“No problem. The more the merrier. I’m just not sure I’ll have enough seats for everyone in my office. But that’s not a problem, either. We’ll just steal one or two from the office next door. So who do you have here with you?”

“This is my husband, Lawrence,” I held my hand palm up, as if introducing actors on a stage. “And this is my sister, Claire, and my daughter, Rose.” As usual, my presentation of Rose brought a smile of pride to my lips.

“Nice to meet you,” Dr. Andreas nodded her head to each person in turn. “What I’m going to do is take Jo back first for a quick examination and consultation. Then I’ll come out and get the rest of you for the last part of the appointment when some decisions will have to be made.”

“Okay.” I answered, a little disheartened. It seemed my army of bodyguards wasn’t going to be able to guard my body, after all. At the very first threshold, I had to leave them behind.

I followed Dr. Andreas reluctantly through the waiting room door, past the reception station with desks, computers and secretaries on telephones, and down a hall where an older couple was sitting on an upholstered bench beneath a large, abstract painting. The woman was crying softly into her hand. The man had his arm around her shoulders and looked up at nothing, hurt and confused.

“Let’s go in here,” Dr. Andreas said cheerfully, ignoring the couple. She indicated a small examination room and motioned for me to hop up on the elevated bed while she closed the door behind her. “Okay, let’s take a look at that breast.”

I removed my shirt and bra quickly. “Do you want me to lie down?”

“Yes. Why don’t you, just for a moment.” The doctor palpated my left breast quickly, then my right, then both sides of my stomach, before asking me to sit up and checking my upper back, between the shoulder blades. She put her fingers around my ankles, seemed to measure them for swelling, and made some notations on her clipboard.

“Now’s the time to tell me if you have been experiencing any unusual symptoms lately. Have you had any pain in any part of your body? Any swelling?”

“No,” I said uncertainly.

Her question surprised me. It hadn’t occurred to me that the cancer might also be somewhere else. I began putting my bra and shirt back on while I considered. “I had the discharge from my nipple—the lactation—which is what motivated me to get the mammogram. That was unusual. But other than that, hmmm, I’ve just got some regular complaints. My vision is worsening, for instance, I have to wear glasses to read.”

“Anything else?”

“Well, I have this strange thing that happens to my feet sometimes. They hurt when I wake up in the morning. Not after I’ve been standing on them all day, but after I’ve been laying down all night.”

She nodded again. “You need to go to a foot doctor and have them make some orthotics for you—foot supports that you just slip into your shoe. The basic problem is that you haven’t got enough arch support. Anything else?”
“I do get anxiety sometimes.” I felt a bit embarrassed to admit it. “Not often. But I had panic disorder about 5 or 6 years ago pretty big time, and I still have some tranquilizers that I take once in awhile.”

“What kind of tranquilizer do you take?”

“Ativan. One milligram.”

“How often?”

“Not very often. Maybe one or two times a month, if even that. Except it’s been more lately.”

“Why more lately?”

“Well…we’ve been having some trouble at home with my son. He’s in Mercy Hospital right now, for the second time in three months, as a matter of fact…In the psychiatric ward.” I couldn’t keep my eyes from tearing up.

“What’s his diagnosis?”

“They don’t say. It might be bipolar. It might be schizophrenia.”

“That’s rough,” she looked at me with sympathy. “I’m sorry to hear you are going through so much. But it looks like you’re in pretty good shape physically, not considering the breast cancer. Let’s go into my office and I’ll show you what I’ve seen on the films. Then we’ll call your family in.”

“Okay.” I took a moment to pull myself together before following Dr. Andreas across the hall. Her office contained a big desk in front of a bookshelf, a wall of windows on one side, two chairs across from the desk, and a light board for viewing x-rays on the same wall as the entry door.

“Here’s your right breast,” she said briskly, pulling a film out of a folder and clipping it to the square plastic screen before switching on the light. “As you can see, there’s a bit of calcification here and there, but nothing to speak of. Overall, your right breast is in good shape. There’s nothing wrong with it.”

What appeared on the screen was a breast in negative. I saw the nipple clearly, and the mounded flesh behind it. Every now and then, a fleck of bright white, like a grain of sand, showed on the dark plastic, as if the negative had been scratched or nicked and the light from behind it was pouring through.

“Now, here’s your left breast.” She took down one film and put up another. This breast was covered with the white flecks. “All this is calcification,” she said, pointing with the tip of her pen at the film. “As you can see, it looks like someone just sprinkled salt all over the breast tissue. You can see by the film that it is quite extensive. There’s no way we could go in and only remove the calcification. It covers two-thirds of your breast. There wouldn’t be anything left. So, in your case, I’m recommending a mastectomy.”

I nodded, stunned.

“Is there anything you want to ask me before we bring in your family?”

I shook my head.

Dr. Andreas went back to the waiting room to get them. She asked a secretary to pull in two more chairs. Claire came in first and sat beside me with her notebook. Lawrence came next and stood behind my chair, with his hands on the rim. Rose entered last and sat near the light board. Dr. Andreas sat behind her big desk.

“Do you want to sit next to your wife?” she asked Lawrence before starting.

“No, I’m fine here.”

“I can move over so you can sit next to Jo,” Claire offered.

“No, I’d rather stand.”

I knew Lawrence was probably annoyed with Claire for taking the seat next to me, but I was glad he didn’t claim it. I was comforted by his physical proximity behind my chair. I put my hand over his behind my shoulder, and leaned my head back into his stomach.

“Well, as I was telling Jo, the type of breast cancer she has does not allow for a lumpectomy, since there is no lump. The cancer, instead, has spread throughout her milk ducts, like a blanket. As you can see on this film, it’s pretty extensive. There’s no way we could remove the cancer and save the breast. For that reason, I’m recommending a total mastectomy.”

Rose looked at the film with detached interest.

“Is that the cancer?” she asked, indicating the white flecks.

“Not exactly. That’s calcification, which is a by-product of the type of cancer we found in the biopsy—ductile carcinoma in situ, or DCIS.”

“So, is it necessary to remove all the calcification?”

“Well it wouldn’t be, if the biopsy had come back benign. Calcification in and of itself is not a danger. But since we know the cancer is there, and calcification is its byproduct, we have to assume that wherever we see the calcifications, the cancer is there, also.”

Claire made notes on her pad. Lawrence and I were silent. I felt removed from the scene, and at the same time, vaguely proud of Rose’s scientific mind.

“So, once you remove the breast, is that the end of the treatment?” Rose wondered.

“That depends. The type of cancer your mother has is not supposed to spread, and if it hasn’t, we’ll remove the breast and that will be the end of it. But sometimes DCIS transforms into another type of cancer that is invasive. The way we test for that is by examining the lymph nodes, which provide a type of drainage system for the breast. We used to just take out a big handful of lymph nodes and send them off to the pathology lab for testing. But that can cause problems later on, like edema. So now we use a relatively new procedure called the sentinal node biopsy.” Dr. Andreas paused for a minute to look around the room, making sure we were still with her.

“The way that works is in the operating room, we inject a dye into the tissue, and follow it to identify what’s called the sentinal node—which is the first node that the breast drains to. Then we take that node and perform a pathology test right in the operating room to determine if there are any signs of cancer. If there aren’t, we stop there. But if there are, we take out additional lymph nodes which are sent to the lab.”

“So what happens if the lymph nodes have cancer?” I asked her.

“Then, after you recover from surgery, you would go on to chemotherapy and radiation. If your nodes came back positive, you would be referred to a medical oncologist who would manage your care from that point forward—deciding what type of chemotherapy you should have, how much and how often, etc. The thinking is, if the cancer has gotten into the lymph nodes, then it has probably gone somewhere else, too. Chemotherapy isn’t focused on a specific mass or lump. It’s a systemic treatment that is going throughout your body in search of that one cell here or there that may be lying in wait to come back and bite you later on.”

“Okay. So we’re going to hope it hasn’t gotten into the lymph nodes,” Claire offered.

I nodded. “So, how soon do we have to schedule surgery?”

“That depends on a couple of things. Assuming you agree with my recommendation, and approve a mastectomy, the next thing you have to consider is whether or not you want breast reconstruction.”

I looked around, perplexed.

“Some patients opt to have reconstruction during the same surgery in which they have the mastectomy. I’m not a plastic surgeon, and if you decide on that option, I’ll refer you to one to talk about it in depth. But what happens in that case is I go in and do the mastectomy first, then a second team of surgeons comes in to do the reconstruction. That lengthens the time of the surgery from about two or three hours to five or six. Also, the recovery time is lengthened.”

“What is the recovery time for a mastectomy?”

“About two weeks.”

“Two weeks! You’ve got to be kidding me! You think I’m going to be ready to go back to work two weeks after having my breast cut off? I want six weeks.”

Dr. Andreas chuckled. “You can have whatever you want.”

“I want six weeks.”


Everyone was quiet for a moment, marveling at my demand. Then I stumbled forward with the topic at hand. “I was looking at the reconstruction options online last night; they looked pretty scary to me.”

“Well, as I said, I’m not a plastic surgeon. But I know they can do some pretty amazing things.”

“The website I read said they pull the flesh up from your belly, while leaving all of its blood supply still attached, and mound it into a breast shape on your chest wall. That destroys your belly button, which they have to recreate. Your stomach feels like you’ve been hit by a truck afterwards. And you don’t even have a nipple! They have to come back later with a second surgery to put the nipple on.”

Dr. Andreas smiled. “That’s true. I think these days they’re tattooing the nipples on. Some women really like that they get a tummy tuck at the same time that they get a reconstruction, which flattens their belly. But as you’ve pointed out, it’s major surgery—more major, in many ways, than the mastectomy. Another way they do reconstruction is with implants.”

“How does that work?”

“Basically, the surgeon puts a metal container under your skin which is filled with saline solution. Then you go in periodically to have more solution pumped in, which slowly expands the container and stretches your skin. When it reaches the size you want, they do a second surgery to take out the metal container and put in the actual implant. Then they go back again, I believe, to put the nipple on.”

“Do you have any pictures of breast reconstructions?”

“Yes I do.” She reached into her bookshelf and pulled out what looked like a coffee table art book. “You can take that home with you and look it over. You don’t have to make your decision today.”

“When do we have to make it? Isn’t there some urgency about how soon we have surgery?”

“No—not really. We don’t have to do it tomorrow. But we wouldn’t want to wait any longer than, say, a few weeks.”

I leafed through the book halfheartedly, looking at the pictures and leaning back to show them to Lawrence. None of the breasts looked acceptable to me. Many had big scars across the center. Some had stitches all the way around the nipple, making them look as if they had been sewed on by a child. I also knew from previous experience hugging women who’d had implants that many turned hard as wood.

“Do you have any pictures of women who decided not to get a reconstruction? Who just have one breast?” I asked tentatively.

“Yes, I think there’s one in the back of the book, there. That woman was planning to get a reconstruction later, in a second surgery, so the surgeon left a lot of skin.” The picture in the back of the book showed a dumpy-looking woman with one sagging breast. On the other side of her chest was a diagonal scar over a fleshy pouch of skin. It looked repulsive. I frowned.

“I saw a picture a long time ago of a woman who didn’t have a reconstruction after having a mastectomy. She had only one breast, and a tattoo over her mastectomy scar. She had her head thrown back, and her arms lifted at her sides, like this, very joyfully.” I posed briefly. “I remember thinking it was a really beautiful picture. Have you ever seen that one?”

“I have seen pictures of tattoos over mastectomy scars, but I don’t remember seeing anything specifically like that.”

“Oh,” I was disappointed. “Well, do I have to decide now if I want a reconstruction? Can’t I just have the mastectomy first, and then decide later if I want the other stuff?”

“Yes. You could decline now, and then decide five years down the line that you’ve changed your mind—you want a reconstruction. Federal law says your insurance company has to pay for it if you ever decide you want it.”

I looked hopefully around the room. “When do you want the decision?”

“Well, you don’t have to decide right now, in the office. But the sooner the better, of course. Scheduling surgery can be a problem. And if you decide to go for the reconstruction at the same time, that means we’ll have two surgeons’ schedules to coordinate along with the availability of the operating room, which can make it somewhat tricky, and sometimes push the date out pretty far.”

“I have a question,” Rose interrupted. “You mentioned you can’t start chemotherapy until you’ve recovered from surgery. Doesn’t that mean that if you had a reconstruction, and then found cancer in your lymph nodes, that you wouldn’t be able to begin treatment for several weeks?”

“That’s a good point,” Dr. Andreas said. “Recovery from reconstruction typically takes five to six weeks, and if chemotherapy was indicated, it would have to be delayed.”

“That sounds like it could be dangerous,” Rose said.

“Well, if I don’t have to make a final decision now. If I can always change my mind and decide to get a reconstruction later, I think I’ll just skip it for the moment.”

“That sounds like a reasonable decision,” Claire echoed.

“Wait a minute,” Lawrence spoke up for the first time. “Dr. Andreas said we don’t need to decide anything now. Let’s not rush into anything. Let’s go home and think it over. We can always call her back tomorrow.”

Dr. Andreas nodded.

“Okay,” I said hesitantly. What was Lawrence’s reluctance, I wondered? Was he beginning to worry about how I would look without a breast? Did he care whether or not I got a reconstruction? Was he going to love me less—find me less sexually attractive—after I was disfigured?

“Well, I know how hard it is to schedule surgery,” Claire said, “so why don’t we get a few dates from you to consider before we go?”

“Okay,” Dr. Andreas looked at her computer screen. “Let’s see, just considering my own schedule, it looks like the earliest we could do it would be August 25—that’s in two-and-a-half weeks. I’ve also got openings August 28, August 30, September 1 and September 7…

Claire made several notes on her pad. I picked up the book of photographs of breast reconstructions. We all stood and shuffled out. I shook Dr. Andreas’ hand once again before leaving. “I guess we’ll talk about it together at home and call you tomorrow.”

“That sounds like a good plan.” She sounded reassuring.

I worried during the car ride about Lawrence’s objection, but didn’t bring the topic up until we got home and safely settled in the living room. Claire and Rose sat on one couch. Lawrence sat on the other, and I sat on the floor by the coffee table.

“If it were me,” Rose started, “I’d definitely get the reconstruction because I’m still young and my breasts are part of my sexuality. But I don’t think you should have it done, Mom. It sounds dangerous.” Claire nodded in agreement.

Her comment was not comforting. Did she imagine that I didn’t care about sex? “My breasts are part of my sexuality too, Rose,” I said irritably.

“Well, I know, but…I mean, you’re already married. You’re not dating.”

“That doesn’t mean I don’t want to look good.” I said peevishly. This conversation wasn’t helpful. Rose’s comments were leading me in a direction I didn’t want to go.

“If you do forgo the reconstruction, I think you should sign up for the Sept. 1 date,” Claire said, as if we were scheduling a celebration. “That’s Labor Day Weekend, so we will all be off work and can come to the hospital to support you.”

I frowned. “What do you think, Lawrence?” I asked fretfully. “Why didn’t you want to sign up for surgery in the doctor’s office? Are you thinking I should get a reconstruction?”

Everyone turned to see what he would say.

“No. Not at all. I’m not thinking anything. I’m just thinking you shouldn’t rush into a decision. You should make an appointment with the plastic surgeon so you can talk about it with someone who knows. You should be making your decision after you get all the information, not before.”

His answer alarmed me. I didn’t believe he was stating his real concern. I worried he didn’t want a wife with only one breast. Perhaps he was already feeling some revulsion…I knew I would agree to have a breast put on, if it was important to him, but I feared I would resent him for leading me to that decision, and might eventually come to hate the dead wooden knob on my chest.

“But I don’t want to talk to the plastic surgeons,” I answered pathetically, almost pleading. “I already know what they’re going to say. They’re going to say it’s all good—all fantastic. But you’ve seen the pictures. Do you like the way the breasts look in this book?” I held it out toward him, an offering.

“Look. I don’t want to talk about this now.” He looked at me directly, with significance, and I could see that what he was saying took effort. “I think this is something we should talk about in private.”

“Oh.” I was surprised. “I’m sorry.” I knew Lawrence was a more private person than I, but hadn’t realized he would consider this a private decision. “I guess you’re right. We should be talking about this alone,” I said apologetically, looking first at Claire, then at Rose, while silently asking their understanding.

Claire immediately folded shut her notebook. “Well, this is as good a time as any for me to be getting home,” she said.

“Thanks for coming with us,” I said sincerely, giving her a hug. “I’ll call you tomorrow.” She nodded. I walked her to the door, and ushered Rose out of the living room.

“Okay. We’re alone now,” I turned to Lawrence with trepidation. “Tell me what you are thinking.”

“I’m not thinking anything specific. It’s like I said before. I think you should talk to the plastic surgeon first.”

“Are you thinking you want me to have a reconstruction? Do you like the way the pictures look in this book?”

“No,” he scoffed. “I think they look scary. They look like Frankentits.”

Relief surged through me. “Are you worried you won’t find me sexually attractive if I have only one breast? Is that it?”

“Well frankly,” he pulled me toward him, “if the truth be told, neither of us is as good looking as we used to be.”

I smiled. “So what is this insistence on talking to the plastic surgeon?”

“I’m not insisting. I’m just saying it makes sense to get all the information.”

“But I have all the information I need. I don’t want a reconstruction; I’m sure of it. I’m afraid of having surgery as it is. The mastectomy is going to take two or three hours—that’s plenty. There’s no way I want to be put under for five or six hours, for one thing. I don’t trust them not to make a mistake.”

“I agree with you there.”

“And even if I wasn’t worried about surgery, I don’t think the results are worth it. They just don’t seem to know how to make breasts very well, yet. I’ve hugged women whose tits feel like cement. I don’t want a hard, lifeless bump on my chest.”

“Me neither. I think that would be creepy.”

“So do you mind if I call Dr. Andreas and schedule the surgery? There’s no point in going to talk to a plastic surgeon. That’s just going to delay things.”

“I guess. If you’re sure you don’t want that information.”

“I’m sure. My mind is already made up. And the good thing is, I can always change it later. If I decide, after the surgery, that I really miss having a breast, I can always go back and have one constructed. That’s what she told us.”

“Okay. That’s true. Go ahead and call her, then.”

“What date should I ask for? Labor Day weekend?”

“No. If it was me, I’d want her to do it tomorrow. Just call and ask for the soonest date she has open.”

“Are you sure? Are we ready?”

“We’re as ready as we’re ever going to be. Call and ask for the first date available. You should get that thing taken off before it does any more harm.”

Read the next chapter HERE, or buy a paperback copy of the whole novel HERE.

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