Hearing the words "you have breast cancer" is an overwhelming and commonly devastating experience. When this happens, most women experience the usual stages of a crisis: shock, denial, anger, understanding, and, ultimately, acceptance. But there's no one universal way that all women react to the news and to the surgery they will need to remove the source of this disease.
Once a woman overcomes the immediate fear of losing her life, her next fear usually is losing part or all of her breast. It's important to understand how closely her perception of her body image and self-image is tied to her breasts. For many women, fear of how others will perceive their altered body image is difficult to handle. There are women alive and thriving today who underwent a Halsted (total) radical mastectomy, a very debilitating surgery that remained the standard of care until just 20 years ago. This legacy still feeds some women's images and fears of bodily mutilation.
Physicians may be surprised at how differently women react when they are told they need breast cancer surgery. One woman may say, "Take them both off. They don't mean anything to me. They've never given me any pleasure." Another may say, "Will I have a scar on my breast after the lumpectomy? Will it be visible in the mirror when I look at myself?" Two different responses, yet both women may have the exact same stage of disease and the same treatment plan: lumpectomy with radiation.
I often ask patients, "Tell me about the first time you were fitted for a training bra: good experience or bad? How important are your breasts when you are intimate with your partner? If you were asked to rank your physical attributes, where do your breasts fall in that ranking?" Answers to these questions can give me, a health care provider, valuable insight into how well a woman is likely to cope with the surgery she is about to undergo. Understanding a woman's emotional state before surgery may help in treating the woman after surgery. By anticipating reactions, you will be more successful treating the whole person and not just the disease.
Society teaches us from a young age the importance of cleavage and mammary folds. I have a photograph of a 10-year-old girl wearing a T-shirt that says boldly across the chest, "Watch this space" . . . and we do. On the Johns Hopkins Breast Center's Ask an Expert Web site, I get e-mails from young girls aged 13 to 22 who are concerned that their breasts aren't growing as quickly as their friends', their breasts don't look symmetrical, or their nipples aren't normal-looking. Young people spend a fortune on bras designed to increase their bust size and depth of cleavage, even though it's only an illusion. Girls wear shoestring bikini tops and may actually expose 80 percent of their breast tissue, but until we see the nipple and areola we don't actually think we have seen a woman's breasts.
A woman's personal treatment preference of lumpectomy with radiation, versus mastectomy, versus mastectomy with reconstruction is often driven by her feelings about her breasts. If she gets educated about available therapies and is assured that all three options are equal from a treatment perspective, her choice will usually be driven by emotions.
When I faced my own diagnosis of breast cancer, I was no different from most patients. Having had 44Ds, I quickly discovered that part of my self-image was sitting on my chest. I faced mastectomy without the option for reconstruction twice, at ages 38 and 40. If it weren't for my husband teaching me that I needed to look at the surgery in a different way -- as transformation -- I don't know how I would have handled it psychologically. He said the surgery would transform me from a victim into a breast cancer survivor.
After my surgery, I focused on being optimistic and thankful that my life was being spared. I also learned that a woman's femininity is as much in her mind as it is in her silhouette. It is truly not based on breast ducts, lobules, and breast fat cells. Having had the privilege of choosing reconstruction 10 years later, however, reaffirmed that my psychological well-being, though healthy, could be improved by restoring what I had lost to cancer a decade earlier.
The important message here is that the relationship a woman has with her breasts influences her decision-making about her breast cancer treatment, her emotional well-being during and after treatment, and, for that matter, how much she may fear getting this disease to begin with. Culturally and as a society, we need to take a different approach when teaching our children and grandchildren about self-image. Self-image should be tied to self-respect, the values we teach, and the feminine strength that womanhood should represent.
I urge those of you who are facing a recent diagnosis of breast cancer to inform your surgical oncologist and oncology nurse about your relationship with your breasts. Participate in the decision-making. Be sure that the type of surgery you choose also addresses your psychological well-being. We each have the right to choose, but choices should not be made in haste but after careful thought, education, and planning. A year after completing treatment, I want to hear you say, "I'm happy with the treatment choices I made."