Breast Cancer: Fear and Facts

Vice President-designate Nelson Rockefeller and his wife Happy waved at reporters in the lobby of Manhattan's Memorial Hospital for Cancer and Allied Diseases, where only eight days before, Happy had undergone surgery for breast cancer. "We're very grateful to Betty Ford for her example to all of us," said Rockefeller. "I would like to say that self-examination and courage on the part of women throughout the world can do for them--in case they need it --what it did for Happy."

The Rockefellers had good reason to be grateful. Two weeks earlier, after reading about First Lady Betty Ford's well-publicized operation for breast cancer, Happy decided to do what doctors urge all women to do regularly: examine her breasts for suspicious growths. To her dismay, she found a small lump in her left breast. Happy wasted no time asking for an appointment with her gynecologist, who found several more lumps. Then she checked into the hospital for a biopsy to determine if the growths were in fact cancerous. When the tests proved positive, doctors immediately performed a mastectomy. They amputated her breast and removed much of the underlying tissue as well as the lymph nodes under her left armpit.

Happy's quick action may well have saved her life. Doctors reported that the cancer had been discovered before it had a chance to infiltrate the lymph nodes and then begin spreading throughout her body. They pronounced her prospects for long-term survival "excellent."

Waiting List. With their admirable courage and frankness, Happy Rockefeller and Betty Ford have effected a profound change in the general attitude toward a dread disease. Women are showing a new willingness to discuss breast cancer openly, to face it directly. Across the nation they are besieging hospitals and doctors' offices, seeking examinations and information. Manhattan's Guttman Clinic, which screens women for breast cancer, until recently received 30 to 40 telephone calls a day. It is now receiving as many as 400 calls, and has placed women seeking examinations on a waiting list that extends to January. The American Cancer Society's division in Atlanta has been overwhelmed by phone calls from women inquiring about breast cancer, and two local hospitals offering free breast checks are now booked through next July. Dr. Robert Olson, a Chicago gynecologist, reports that his patient load has doubled. The publicity surrounding the Ford and Rockefeller operations has also had an impact overseas. In London, for example, the "Well Woman Clinic" at Royal Marsden Hospital has been so swamped with calls that it has appealed to women not to turn up without referral by a doctor.

That her lack of reticence about her illness has helped to produce so massive a reaction has been particularly gratifying to Mrs. Ford. "When other women have this same operation, it doesn't make any headlines," she told TIME Correspondent Bonnie Angelo last week. "But the fact that I was the wife of the President put it in headlines and brought before the public this particular experience I was going through. It made a lot of women realize that it could happen to them. I'm sure I've saved at least one person--maybe more."

Indeed, both Betty Ford and Happy Rockefeller faced their terrifying illnesses with remarkable poise. Their examples should help thousands of others to overcome quite natural fears, and to learn the facts about a serious and little understood disease that once was discussed only in whispers.

Breast cancer is not a new disease. The papyrus records of ancient Egyptian medicine contain references to breast lumps and swellings. But this ailment has drawn increased attention in recent years. It is the leading killer of women in the 40-to-44 age group and the primary cause of cancer deaths among women of all ages, striking one out of every 15. Before 1974 has ended, some 90,000 American women will learn that they have cancer of the breast; another 33,000 will die from it.

Their deaths will result not simply from the growth of the cancer in the breast, but from the invasion of other parts of the body by the malignant cells. Untreated breast tumors can metastasize, or spread, rapidly--invading the lungs, skeleton, liver or brain. The spreading cancer can also kill by interfering with the production of substances the body needs for normal functioning, thus weakening the victim and leaving her unable to resist infectious disease.

Greater Risk. Any woman can develop breast cancer,* but some seem more susceptible to it than others. Statistically, the woman in the greatest danger is someone in her mid- to late 40s, who began menstruating early and continued late, who never had children or did not begin having them until she was past 30, who is obese and whose mother or sister had the disease. This does not mean that someone who fits most or even all of these categories is certain to develop breast cancer. Nor does it mean that the disease is hereditary; no evidence whatever has been found to suggest that genes for breast tumors are passed from generation to generation.

But the disease does have a disturbing tendency to run in families. A woman whose mother or sister has had breast cancer is twice as likely to develop the disease as a woman with no such family history. If both her mother and sister have had breast cancer, her risk may be 47 times greater.

Despite years of research, doctors still know relatively little about the cause of breast cancer. There is no certainty about the role of viruses, despite the fact that they are known to cause breast cancers in animals; research has yet to establish that they can do the same in humans. Virus-like particles have been found in the breast milk of women with cancer and family histories of the disease. But viruses have also been detected in the milk of women who have not had cancer. Hormones produced by women during the menstrual cycle and pregnancy are also under suspicion, but no one has yet determined how they might cause breast cancer or be controlled to prevent it.

Diet has also been implicated as a factor in breast cancer, which appears to be more common in countries where people consume large quantities of animal fats. In the U.S., the disease appears more frequently among the affluent and well fed than among other groups. Japan, where the traditional diet is low in animal fats, has the lowest breast-cancer rate of 39 countries covered in a recent study. But even there the rate is rising as Japanese forsake their old diet of fish and rice for a Westernized menu of meat and fats. Japanese women who emigrate to the U.S. have higher breast-cancer rates than those who remain in Japan. Their U.S.-born daughters have breast-cancer rates approaching those of American women in general. But how and why high-fat diets might trigger breast cancer remains a mystery.

Doctors can say with certainty only that injuries to the breast do not initiate the disease and that birth control pills do not appear to be responsible for the increasing cancer rate among younger women. A study of 1,770 women, which was released last week by California health authorities, showed no correlation between cancer and the Pill. Researchers are also practically convinced that breast feeding has no influence--for good or bad--on breast-cancer rates.

Fatal Delay. Breast lumps are sometimes discovered by doctors during routine examinations and occasionally by women's husbands or lovers. But most suspicious growths or such other signs of possible cancer as the sudden inversion of a nipple or puckering of breast tissue are initially spotted by the victims themselves --by accident or during self-examinations (see "Cancer: Self-Examination" page 110). Finding them is made more difficult by the fact that tumors, especially small ones, rarely cause pain or feel sensitive to the touch. "I wish breast cancers did hurt," says Dr. Guy Robbins, acting chief of the breast service at Memorial Hospital. "Then women would discover them faster."

When a lump is found, some women try to ignore it, hoping that it will go away. Jean Tyler, 44, a former showgirl and fashion model who now works as a fashion consultant in Hollywood, discovered one in her breast a year ago. "I put it out of my mind then," she recalls. "I knew there was something there, but I didn't want to touch it." Her doctor dissuaded her from further delay. In the past, frightened women often waited as long as a year before reporting a suspicious lump to their doctors; if the tumor was malignant, that delay was usually fatal. Now, says Robbins, as a result of widespread educational campaigns by the American Cancer Society, the average time between discovery and a visit to the doctor is down to 2 1/2 months--still a dangerously long though obviously shrinking interval.

In most cases, the discovery of a lump is not a prelude to disaster. The female breast, which changes daily throughout the menstrual cycle, is particularly susceptible to abnormal but harmless growths. Many younger women develop cysts, or small packets of fluid. Fatty growths are not uncommon. In fact, reports the American Cancer Society, 65% to 80% of all breast lumps are not cancerous.

In examining breast lumps, doctors can quickly rule out growths that are not cancerous. If it hurts, according to gynecology texts, it is unlikely to be malignant. Manipulation can also help screen out the innocent lumps; if they seem unanchored and can be moved about under the skin, they are usually benign cysts. A needle biopsy, in which a needle is inserted into the lump and fluid or cells are withdrawn, can also be used to identify cysts. But some growths are too small or too well concealed behind other tissues for such procedures. In those cases, the only way a doctor can determine if a lump is cancerous is to have a biopsy performed, usually as a surgical procedure. A surgeon removes the lump and it is rushed to the hospital's pathology laboratory. There it is frozen with liquid nitrogen and then, with a device called a microtome, sliced into sections thinner than onion skin for examination under a microscope. If the cells are cancerous, the surgeon will usually know in minutes.

For the cases in which the tissue proves to be cancerous, immediate surgery is the only prudent remedy. How drastic that surgery must be, however, is a matter of considerable debate. For some years now, the standard treatment for breast cancer has been the radical mastectomy, a traumatic and disfiguring operation in which the surgeon removes not only the breast but other tissue that may have been invaded by cancerous cells: the pectoral muscles that support the breast and the lymph nodes under the affected arm. There is growing opposition to such extensive surgery, some of it from women's liberationists, who see it as a deliberate mutilation performed by male doctors who can neither understand nor appreciate its impact on their female patients.

Malignant Clusters. While most doctors believe that surgery is essential, there are those who insist that complete amputation is not necessary. Dr. Vera Peters of Toronto's Princess Margaret Hospital advocates a simple procedure called "lumpectomy," in which only the cancerous lump is removed. She says her research shows that in cancers that have not spread to the lymph nodes, lumpectomy is just as effective as the more radical operations and far less damaging psychologically. (The problem is how to determine that the lymph nodes are uninvolved; most doctors feel that the only sure way to tell is to remove the nodes and study them under a microscope.)

Dr. George Crile of the Cleveland Clinic considers the radical mastectomy a holdover from the 19th century. For many cases he advocates an operation called partial mastectomy, which, while more serious than a lumpectomy, still spares most of the breast. Crile's wife Helga, daughter of Poet Carl Sandburg, had the operation eight months ago, and Crile feels that its widespread use could make women more willing to face a diagnosis of breast cancer.

Other doctors now concede that in some cases, radical mastectomy can be replaced by slightly less drastic operations. Happy Rockefeller's doctors performed a modified radical, removing her breast and lymph nodes but leaving some of the chest muscles. A report released a month ago by the National Cancer Institute suggests that "total mastectomy," or removal of the breast but no other tissues, may be as effective as radical surgery in treating cancers that doctors feel confident have not yet spread to the lymph nodes.

But there is little professional acceptance of the simpler procedures advocated by Crile and Peters, which most surgeons believe do not remove all the malignant cells and leave a woman vulnerable to a recurrence of cancer. Memorial's Robbins points out that most cancers have been growing for anywhere from six to eight years before they are discovered. By that time they may have spread to other parts of the breast as microscopic clusters of malignant cells that cannot be detected clinically. Studies of breast tissue removed during surgery have revealed that even when there was only one small identifiable lump in the breast, there were, in a majority of cases, micrometastases elsewhere in the breast, the lymph nodes of the armpit and the nodes beneath the pectoralis major, or major chest muscle.

This helps to explain the notable differences in survival rates achieved by the various surgical procedures. Of 53 women to undergo partial mastectomy at the Cleveland Clinic during a nine-year period, for example, only 18, or 34%, survived ten years. Of the 304 women who had radicals at New York's Memorial in 1960, 185, or 61%, were alive ten years later.*

The chances of a breast-cancer victim are markedly improved if the tumor is detected and a mastectomy performed before malignant cells spread to the lymph nodes. A study conducted by the American Cancer Society dramatically shows how earlier detection can be achieved. During the past year, doctors at 25 centers screened 75,000 women over the age of 35 for breast cancer. They used three techniques: physical examination, thermography (a method of measuring the heat given off by a tumor) and mammography. Of those women who underwent biopsies to determine if suspicious growths were in fact malignant, 289 were found to have cancer. But in 77% of these victims, the cancers had not yet spread to lymph nodes under the arms. However, self-examination remains the technique by which about 95% of all breast cancers are now found. In more than half such cases, the cancerous cells have already reached lymph nodes. Thus the early detection provided by professional screening can make a vital difference: a woman whose cancer has not reached the lymph nodes has at least an 85% chance of being alive five years after her operation; if the nodes are involved, her chances decrease by half.

Russian Roulette. When a woman enters the hospital for a biopsy, her surgeon usually asks her permission to perform a mastectomy if the biopsy should be positive. Thus most women go under anaesthesia without knowing whether they will wake up breastless or not. Surgeons defend this practice on the ground that it reduces both the risk and the expense of two operations. Even so, some women would rather know beforehand what they face, and some surgeons agree that there is no harm in waiting a few days between a biopsy and a mastectomy. "A cancer isn't going to grow that much in a day or two," says Robbins. "But if a woman decides to go surgeon shopping and delays a couple of weeks, she's taking her life in her hands. You can't play Russian roulette with breast cancer."

Most women agree, and in all but a handful of cases, they courageously go along with their doctor's recommendation. "Do whatever has to be done to help me live," said Mrs. Ruby Flynn, 41, of Atlanta, when she entered Piedmont Hospital for a biopsy and--ultimately--a mastectomy two weeks ago. But no woman can really anticipate the shocking reality of awakening to discover that one of her breasts is gone. Her husband's tears told Gina Thompson, 36, of Malibu, Calif., the result of her operation. "Because everyone was so upset, at first I was more aware that I had lost my breast," she said. "It was only a week or so later that it fully dawned on me that I had had cancer."

"Losing a breast, part of her femininity, is a pretty devastating thing to a woman," says Ruth Roseland, a Quincy, Mass., psychologist who counsels mastectomy patients. "Women feel that they have done something wrong, that mastectomy is a form of punishment." Some become bitter and angry. Others become withdrawn and depressed, particularly as they begin to undergo the frequently debilitating X-ray or drug treatments usually necessary to control any residual cancers.

Fear of Rejection. How a woman copes with her ordeal and moves ahead depends in great part on her own self-image. Betty Ford has an open and natural attitude: "I told Jerry the other day, 'You've got a better figure than I have.' He's trying to lose weight, but all I need is a little padding." Alice Roosevelt Longworth, 90, the daughter of Theodore Roosevelt, jokes about her two mastectomies and refers to herself as Washington's only "topless nonagenarian." Julia Child, television's "French Chef has a no-nonsense attitude about her operation, which she revealed publicly for the first time last week. Says she: "I would certainly not pussyfoot around about having a radical because it's not worth it." Both Shirley Temple Black and Marvella Bayh, wife of Indiana Senator Birch Bayh, have made it equally clear that a mastectomy is less tragic than some believe.

A common feeling among mastectomy patients is that they will be rejected by their husbands or lovers, and some in fact are. Though few marriages have broken up solely as a result of the operation, many troubled marriages have been pushed past the point of no return by a husband's inability to accept his wife's operation. "My husband is an alcoholic, and this was just one more thing he couldn't handle," says Mrs. Judy Keating, 37, of Atlanta. "He told me my scar was downright ugly."

Stable marriages not only survive the surgery but often seem strengthened by it. Says Happy Rockefeller: "My experience is that this is the sort of thing that brings families even closer together." Some husbands are so grateful that their wives are alive that they quickly overcome any adjustment problems. Mrs. Martha Knighton, 44, of Atlanta, attempted to apologize to her husband Don after her operation. "You signed up for a matched pair and I've broken up the set," she said. But Don dispelled her fears. "Every day my hair falls out," he said, "I'm not the same either."

Social Test. Married women generally resume normal sexual activities as soon as they recover from their operations. But single women tend to find the adjustment more difficult. One of Fashion Consultant Jean Tyler's male friends was obviously uneasy over the fact that she had lost a breast. "He was terribly nice and understanding, but I noticed that he kept me at arm's length all evening," she recalls. There are some single women who even feel that a mastectomy has some social value; it provides a good test of any relationship.

Sex is not the only trial for single women who have had mastectomies. Employers are sometimes unwilling to promote them for fear that they may not last long on the job. They also have problems in obtaining medical insurance that married women can get more easily through working husbands. Then there are those patronizing or oversolicitous friends. "You always have to look 'on,' at the office," says Jane Bingham, 36, a Manhattan journalist who had a mastectomy in 1971. "I couldn't have a hangover or a cold or just feel rotten without people starting to buzz."

Reordered Priorities. The woman who undergoes surgery for breast cancer has little trouble finding someone willing to help her overcome its aftermath. Reach to Recovery, an organization composed of mastectomees (TIME, Oct. 14), sends volunteers around to hospitals to visit postoperative patients. They suggest exercises that will help women regain their strength and offer advice on where to obtain breast prostheses and clothing tailored to their particular needs. Memorial Hospital runs its own encounter-style rehabilitation program to assist the physical and psychological recovery of patients.

What helps women most is their own determination to get well. Once they recover from the shock of mastectomy, most of them become acutely aware that their alternative was death and quickly opt for life. "I decided my life was more important than my vanity about my shape," explains Marie Powers, 32, a Boston social worker who had a mastectomy in 1973. "It makes you reorder your priorities." Like others in her situation, she has returned with gusto to the business of living and is now dating again. Joan Dering, 38, a teacher from the Milwaukee area, has resumed playing golf and has taken up sailing and skiing since her 1971 mastectomy.

Their attitude is typical of thousands of other courageous women who have awakened after surgery to find bandages where a breast used to be. Losing a breast to cancer is a traumatic experience that scars the mind as well as the body of a woman. But that grievous loss buys time and makes her more aware than those around her that life is dear.

*So can men, although breast cancer appears 100 times less frequently in males than in females.

*Doctors use five-and ten-year survival rates as statistical mileposts, not goals. When cancers recur they generally do so within five years. Thus while a woman who has survived five years after a mastectomy without a recurrence of cancer may still suffer one, she has a good statistical chance of surviving ten and even 20 years or more.

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