SECTION I

AT FIRST

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In this day and age, with the high degree of emphasis placed on physical beauty, health, and sexuality, particularly in the Western world, the finding of a breast lump is one of the most dreaded events a woman can experience at any age but particularly in the prime of her life, and worse even at a young age.

The thoughts first engendered by this finding are reflections of the traditional fear of cancer compounded by the stories heard, the news and books read, the movies or video programs seen, frequently depicting the worst possible scenarios associated with the diagnosis of breast cancer. These media never dwell upon the many who, having been diagnosed and treated for breast cancer, are cured and go on with the rest of their life. We are given scenarios of the fear and suffering, not the successes.

While not minimizing the potential seriousness, with emphasis on "potential," of the finding of a breast lump, I must immediately qualify such a finding by reminding the reader of the fact that the breast is frequently, to a greater or lesser extent, a "lumpy" organ and that fortunately many of its lumps are benign and physiological. That does not mean that such a lump may be safely overlooked but that immediate panic is not necessarily justified. It is also a fact that with the present and constantly improving diagnostic technology it has become possible to detect breast cancers of minuscule size and at a stage of development at which immediate and appropriate treatment is associated with a very high rate of permanent CURE. Indeed, over the past several years the mortality from breast cancer finally stabilized and then declined while it had been rising for a long time in the past. At present questions are even raised about the true significance of the very tiny cancerous or pre- cancerous lesions detected by the ever increasing improvement of the mammographic images obtained by the ever increasing technological precision of the diagnostic equipment: should every single one of these increasingly smaller lesions be followed by biopsy and / or excision?

Surgery for breast cancer has become progressively less extensive and even in circumstances under which the breast has to be removed by mastectomy, the surgical technique of breast reconstruction has evolved to the point where physical appearance can be restored to a degree that also restores the self-image of the woman who has had to undergo that type of cancer surgery. On the other hand, a growing proportion of the women with breast cancer do not have to lose the affected breast because the increasingly early detection of cancers generally smaller than in the past, makes it possible to preserve it, thus avoiding the disfigurement of mastectomy. Furthermore, while the addition of radiation therapy to breast-conserving surgery, as an integral part of the initial treatment, has resulted in long-term outcomes identical to those of the previous standard mastectomy, it is not without certain long delayed after-effects including the rare development of other malignancies related to the radiation.

Finally, chemotherapy and/or hormonal therapy administered as part of the initial management (adjuvant systemic therapy) of breast cancer, when indicated, have improved both the survival and the cure rate for this malignancy. For the women for whom it is indicated the contemplation of having to undergo months of administration of these medications after the initial more or less extensive surgery and radiation therapy for some, is certainly disruptive and many of the media depictions and publicized personal stories have emphasized the frightening and uncomfortable aspects of this category of treatments. It is therefore not unexpected that its application is contemplated with dread. Yet, just as progress in the techniques of surgery, radiation, plastic reconstruction and chemotherapy has improved the quality of their results, new developments have improved the supportive measures designed not only to relieve but also to prevent the uncomfortable side effects of this chemotherapy, to the point that they seldom cause any serious disruption of the life and wellbeing of its recipients. Again, as with radiation therapy, certain long delayed complications are increasingly being recognized.

I have also found that the most devastating side effect of chemotherapy is not the nausea, the fatigue, the metabolic or hormonal changes, but it is the difficult-to-hide loss of hair. While that is the least medically important one and while it is temporary, it is, for a woman, other than the loss of a breast, the side effect that is associated with the greatest emotional impact, one that cannot be minimized and that has to be acknowledged and dealt with: the further disruption of the self-image.

In this section the story titled "This is New York" depicts one person's way of dealing with that feature of her disrupted physical appearance. Her story is unique and personal and only serves to illustrate the fact that each individual finds his or her way of dealing with that problem. It is frequently the attitude of those surrounding and interacting with the main character of this personal drama, that requires correction, guidance, and help, help that often comes from the patient herself.

The effects of the entire complex system including the diagnosis, the treatment, the profound and invisible physiological changes it produces as well as the emotional impact of it all on the woman herself, on those closest to her and on her sexuality, are frequently unmentioned and overlooked in her day-to-day care because they either are not physically obvious to the observing physician, because the patient feels...