problem doing great.
Mhm.
Why?
Hello.
How are you?
What are you doing here?
My sister was operated on for breast cancer yesterday.
Oh I'm sorry.
Is she doing all right honey.
Could I talk to you for just a few years?
What sit down with you
with women,
you know?
Yeah.
I don't know.
Uh huh,
mm hmm.
You know my mother and also an
aunt had cancer of the breast.
I want to know if breast cancer runs in
families and if so,
what are my chances of developing cancer?
Well,
it certainly puts you in a high risk group and in fact it
increases your chances about three times.
But your sister,
your aunt and your mother having breast cancer.
Well,
isn't there something I can do to prevent my developing
it?
No.
Really there's not.
We do suggest that every woman wants a month.
Check her breath,
memorize them.
And she feels any changes go in and see your
family physician.
And I would certainly suggest that you have mammograms
done because exact rates can often show up a
lot often before they're ever felt.
Well,
I appreciate the information.
And also I think I'm going to take your advice.
I'm going to make arrangements today to get that mammogram made.
Hope your sister will be all thank you so much.
Good bye.
Good afternoon.
Mrs watch.
Have you had any problem with either breast?
No,
except for the mass titus.
And I am in the high risk group because of a family
history of breast cancer.
And also because I had my first pregnancy after the
age of 30.
Also there's the master titus.
Yes ma'am.
Well let's get your mammogram is your doctor ordered?
A mammogram is dangerous.
Well there's always a theoretical risk involved in any
kind of radiation in your case you're in a high
percentage group because of family history and other things.
So you already have a 7% possibility of
having breast cancer with the one rad
absorbed dose that you get from mammography.
Your risk increases only by
.07% which is really very low.
Well that really isn't very much you know ma'am.
It isn't in our particular center we have a special added
filtration Which cuts your risk from
.7 even lower 2.28.
Well how do you know the radiation level remains
constant.
Were monitored each week by a special physics center
and um it's a scientific center and we do a
little test for them and they measure the radiation
doses and chips are filming that sort of thing.
I see.
Have you found many cancers of the
breast with mammography?
Yes Ma'am and about 75% of the ones that we
found has not been felt either by the physician or by the
patient And in about 45% of these
cases the cancers were insight to that is they hadn't
had an opportunity to spread to any other part of the body.
So in 85% of the women that we found there has
been no recurrence of cancer in any other part of the body.
And so that leaves us with about an 88%
pure.
We're gonna take your film now.
So if you'll just turn right around.
Mhm.
Mhm.
That's just right now.
Take a deep breath and hold your breath.
Let what I see is a tiny cluster
of calcifications here that frequently
are carcinoma.
It can be just calcifications
obstructing the ducks however,
and could represent a benign lesion.
Did you feel a lump in the latest breast?
No,
she has nothing though.
The lumpiness that one would find normally in a
mastitis.
But there's nothing that I would feel suspicious of.
This is one of those legions.
I guess that uh we find too
often now seems like a non palpable lesions and we'll
just have to take a radio that you get a needle to locate that
lesion in Jackson die so we can find it at surgery.
Well now you should do as you well
know of specimen
radiography here to pick up the
calcifications for the pathologist.
Yes,
we'll do.
That's the only way you can really tell whether you've got the right stereo.
That's fine.
Thank you so much as well.
Yeah.
The mammogram showed some very small
calcifications in them.
Which We don't know that this means
cancer,
but about 30% of the time we find this type of
calcification does mean cancer.
The calcium really comes in when the Ducks are stopped
up.
This can be done by cancer can be done by a
mastitis can be scarring at Nanosys,
many many things,
70% chance it's not cancer,
but 30% it is.
So I think what we've got to do is taken to the
hospital and put a little needle in the
breast and locate this with the X
ray and then inject some dye along
that track so that we can find it
exactly and take that little core out so we can examine if it
is or not like this.
We'll have to just set up as soon as you can do such
well.
I think it as long as it has to be done,
we might as well go ahead and make plans to do to me.
Well,
we'll get the girls now.
There's a lot of things that I'm quite sure that you want to know about
this.
A complete physical examination is essential for medical
reasons,
but it is also essential to give the patient a sense of
satisfaction that her surgeon knows of
any other weakness that might be present.
Following this,
She feels more confident in whatever he says.
And whatever he does,
the situation about her breast must be thoroughly
explained the crisis which envelopes the
female when she discovers that she may have cancer
of the breast is one of extreme emotional distress.
Her mind at this time is spinning under the
influence of les literature to which she has been
exposed instead of headlines which read
breast cancer can be cured.
She has seen the multitude of article stating
the disease women fear most must you be
mutilated the diet that cured Susan's cancer,
unnecessary operations are performed.
You have a choice.
These headlines and others in the lay press have caused
the impetus of scientific treatment of cancer of the
breast to be submerged in favor of an emotional appeal
to the patient's vanity.
Thus,
in order to help her psychologically,
the physician must begin helping her at the time.
Surgery is advised even before she enters the
hospital.
She has many fears,
Fear of operation,
fear of losing her breast,
fear of losing her lover's attention,
fear of death,
fear of fear itself.
The physicians,
awareness of the patient's problems is necessary if he
is to sensibly guide this physiological and
psychological rehabilitation of the patient.
The surgeon must be understanding of her feelings and be
cognizant of the many opinions about breast cancer of which
she has read.
He must logically and without emotion,
explain the reasons for the treatment designed to
cure and yet leave her with his little deformity as
possible.
He must explain in simple,
common and understanding language,
the manner and growth of breast cancer,
how many cells in the breast undergo varying degrees
of hyperplasia and a tip which causes the
chances of multi eccentricity.
Be so great.
He must explain how the insight to lesions
become invasive when and where it
metastasizes and therefore why
taking just a small portion of the breast is not sufficient to
ensure a cure.
Well,
he must explain that a significant percentage of the
lesions less than one centimeter in diameter
that can be expected.
Axillary metastases that noted a section of the
axle must always therefore be included.
He must be honest,
understanding and patient in answering her
questions.
The admission to a hospital is an emotionally stressing
and at times overwhelming act even to the most stable
patient.
The cold impersonal routine of admission found
in most hospital is a harrowing experience for
even the most stable patient.
The kind attention of our nurses is of the utmost
importance how she acts,
how she listens,
how she answers,
how she does.
Even the most menial task is magnified in
the already disturbed patients mind all
illnesses have both physical and emotional facets,
yet most are more easily overcome than those
caused by cancer of the breast for the fear of
mastectomy.
In the minds of many women can be intimately related to
the symbol of feminine pride and vanity about her body.
There are some relationships between the breast and uh
some intrinsic sexual significance that have been
lost in our earliest culture and civilization.
You have the anxiety about the loss of or even the
mutilation of the breast may give the woman an illusion of
irretrievable,
distant chant,
mint.
The breast also bears the badge of motherhood as an
organ that serves for nursing the young,
the woman is short of this uniquely feminine symbol.
She may imagine herself bereft of all physical
appeal as well as her visions of motherhood
which she has cherished.
The radiologist is now seen measuring the location of the
cluster of calcifications so that he can place the needle
as close as possible to that area.
The measurement has to be in three dimensions.
The patient's breast is now being marked according to the measurements
which the radiologist desk took.
A wheel of novocaine is placed in the skin and a small
spinal needle is inserted as indicated by the measurements on
the mammograms.
A new X ray is to be made to determine the location of the
point of the needle.
If it isn't exactly right,
the radiologist will reposition the needle and repeat the X ray
and will appoint.
The needle lies in juxtaposition to the small
group of calcifications
you will notice on the mammogram.
The needle is exactly in the side of the area.
The radiologist now injects one millim of methylene blue
into the area.
Then,
as he withdraws the needle,
he continues to inject a very small amount of dye.
This leaves a blue tract which can guide the surgeon to the
area at the operating table.
The biopsy must be done within the next couple of hours.
Otherwise they die may dissipate
the blue dot can be plainly seen and the incision is made
down on it,
all of the blue stain tissue is carefully removed and sent
to the pathologist.
The excised area of the breast is now being X rayed
to determine that the area of calcification has been
removed.
Now I'm making a comparison
of the area uh micro calcifications
seen on the tissue,
X ray examination with that same
area seen on the original zero graphic
examination of the breast.
To be sure that this precise area has been
removed since it is
quite small and is not palpable.
We elect at this time not to do a frozen section,
but we'll submit the entire specimen for permanent microscopic
examination.
The biopsy room is closed.
We must wait for the permanent section on the following day because this
lesion is so small they may lose it in frozen
if there has been a lesion of ample size.
The pathologist will give the frozen section opinion at this
time and an indicated surgery could have
proceeded.
Sometimes the patient and her family her to find out the
pathologist report before proceeding.
In that case we always wait.
The permanent section now shows this to be an introductory
carcinoma without any invasion of very early
lesion.
All patients with cancer of the breast should have liver and bones
cans.
While we feel that this is a very early cancer and
probably confined to the breast.
We should gather all the information possible to determine its
exact stage.
We already know that the X ray the chest shows no
metastases ease other common sites for
mitosis of this type of malignancy.
Our liver and bones.
The liver scan,
as you see here has no abnormality and the bone
scan shows no evidence of metastatic disease.
The visitors have gone.
This is a lonely time for the patient.
Her family is gone and she's waiting for her
operation in the morning.
She needs understanding and consolation,
and here is a real opportunity for the nurse to give her
needed support.
The nurse makes her comfortable,
answers our questions with reassuring consoling
and truthful answers in remarks.
Lastly,
of course,
she gives the sleeping pill.
The other breast is being bob.
The opposite breast is biopsy because 12.3% of
our patients with carcinoma of one breast have been found
to have cancer in the opposite breast.
The mirror image area of the cancer in the opposite breast is
excised as well as the upper and outer quadrant of
that breast.
This is all sent to the pathologist for permanent sectioning.
If malignancy is found,
the definitive operation will be done later.
The usual incision from mastectomy has made since
this is an introductory carcinoma,
because these ducks extend to the nipple we always
remove the nipple along with the breast,
although rarely have the pathologist found the process
extending into the nipple,
but it does occur.
The breast is entirely removed,
for we have occasionally found a second and even a third
separate carcinoma in the breast when the whole organ is
submitted to sectioning The nodes lateral to the
lateral border of the pectoral is minor muscle are also
removed.
3% of the introductory carcinomas.
That is the insight to carcinomas have had
metastatic disease in these notes.
If these are two or less in diameter,
we do not find it necessary to go further.
However,
if the metastases is larger,
we do a radical dissection.
All leaders are cauterized.
A suction catheter is placed under the flap to remove blood
or serum.
The Katherine sutured in place.
The suction applied through the caster helps
keep the flaps firmly against the muscles and obviates the need
for pressure dressing the wound is irrigated with one
quarter of 1% Neil.
Myson solution through the suction catheter.
This irrigation,
removes any small clots or collection of blood and
leaves a very light coating a very weakened the
amazing solution on the tissues
infection is rare in mastectomy wounds,
but when it does occur the consequences are quite serious
because it causes scarring,
which will result in severe lymphedema.
At a later date,
post operatively everyone develops a varying degree
of depression.
The surgeon must be professionally solicit us.
He must listen to the patient's fears and encourage her to
express her feelings so that the catharsis of this
experience as well as his replies to her
expressions may bring her more quickly and with less
trauma to her equilibrium.
The problems of the patient had been so well expressed by Terese
Lasser in which she has written.
I recall on awakening after the operation
that my very first thought was I am alive,
but when told that my breasts had been removed,
I wanted to shrivel up and die.
How can I face life as a scarred woman?
How can I go on forever?
Unfit to work or play?
How can I look in the mirror again without sensing the
revulsion of others and having to endure the pity
behind their curious stares and most
tormenting.
What of my husband?
I have been confidence of his love.
But after this there is
indeed a valley of despair,
desolate,
solitary and swept by anguish and darkened by
confusion.
It is our duty as physicians to guide our patients through
this emotional crisis please.
Good morning.
Mrs Walsh.
Good morning.
Hi I'm Diane Carp.
I'm the nurse coordinator who works in this hospital with anyone who's had
any breast surgery.
How are you feeling this morning?
I don't feel too good.
Okay well I'll be available to help make you more comfortable in the
postoperative period and to answer any questions for you
right now I'm going to do a few nursing functions that I think will make
you more comfortable right now.
We'll try elevating the head of your bed a little bit and
this will help you breathe more easily
And I think you find but when I put your arm up on
this pillow that your arm will be kept in a more
functional position and it will be more comfortable for you.
Mhm.
Okay.
Okay.
I'm going to put a small sign up above your bed
which will mind all the staff not to give you
any injections or to take any blood pressures in your left
arm.
So all that should be done in your right arm and you can remind the
staff of that.
Okay.
Well the patient
is shown with a portable suction and its purposes are
explained.
The patient moves her arm early by flexing it up to about
90°. The nurse should be a good listener and
should listen to the patient's problems and encourage her to talk.
She should tell her also of the reach to recovery visit of the
volunteer from the American Cancer Society.
Hello mary.
Hi.
I'm Martha Knighton from reach to recovery the american cancer
society.
Yes.
They told me you were coming.
They said you could help me.
How How can you possibly understand what
I've been through and what I may have to face in the future
because I had the same surgery 14 years ago.
Yeah you did.
But you look so I'm going to help you solve some of your
problems.
The way I solved some months.
I brought you up little kit here to show you what to
do can exercise is to take
and a little temporary prosthesis
for you to have to get you home
a little booklet that tells you all about what's
happened,
places to get a bathing suit
things to do about clothes and in the back of this
book there's a place for my name,
my telephone number.
So if you have any questions after we've gone through this
and you think of them again,
call me on the phone and we can talk about it.
And also when you get ready to be fitted for your permanent
prosthesis I'll be glad to go with the shopping.
We can make a day of lunch.
Now here is a rope.
I'll show you what to do with this.
Here's a little ball with rubber band.
I'll show you what to do with that.
Then we'll get right along and then you can hurry
up and get out of this bed and come help me
okay?
Good morning.
Mrs Welsh,
good morning.
I'm mary walker.
I'm I'm a physical therapist and I'm here to help you with your
exercises.
We're gonna start out with some simple breathing exercises
which are really important for you to do right after surgery
frequently.
Someone who has had surgery on her chest will have
um not breathe as deeply nor as fully as she
should because it causes pain down in the
incision but it is very important for you to
breathe deeply and to fill all the areas of your chest.
Okay then we're gonna start with some simple
exercises for your arms.
We won't be going past your shoulder at first and
later we'll be doing exercises to increase the
motion.
The patient should start breathing exercises the first few
days after surgery exercise is elevating
the arm above the shoulder.
Should wait until the flaps are well adhered to the chest wall.
The physiotherapist starts the patient with the lower
than the upper costal breathing,
followed by abdominal breathing exercises
as the wound heals.
She will demonstrate other prescribed exercises.
If the physiotherapist is not available,
the patient starts with the simple exercises which reached the
recovery have shown her.
If a physiotherapist is available,
specific exercise have begun to improve any weakness or
limitation of motion which occurs.
Each patient needs specific exercises for her specific
deficiency.
It isn't enough to merely tell the patient to
exercise her arm.
Her deficiencies need to be evaluated
and she needs to be carefully instructed and
supervised to be certain that the exercises are
properly performed so that she can be fully
rehabilitated.
The patient is going home.
The nurses helping her get ready to return to her surroundings.
She reminds her of questions to ask her position.
When can she take a bath?
When can she drive a car?
When can she get her prosthesis?
She reminds her of her arm.
Care to wear gloves when she does her housework
where a thimble when she sold.
Use good landline cream on her hands and arms and never
cuts a cuticle when gardening shears to use heavy
gloves and long sleeves.
She has to avoid constricting clothing and use a hand mit when
baking to avoid any burns to her arm.
She should avoid sunburn.
And if she smokes to hold a cigarette in the un operated
side she gives a patient a handout on the
care of her arm.
Well you look good this morning.
I hope everything's going well with you.
We want you to come back and see us every three months.
In the meantime we want you to continue breast self
examination on the opposite breast.
We will we will get a mammogram on your on that
breast once every year and the next wave your
chest every six months now than doing breast self
examination,
memorize how that breast feels.
And if you feel any abnormality at all,
let me know about it.
Your prosthesis looks good.
The overall goal of medicine is to bring the patient back to
normal as soon as possible in breast surgery.
This means that we should bring her back not only
physically but psychologically to do this
make her so that she can do everything that she did
before and feel as good as she did before.
Have a normal life.
This is the quality of survival
too often in the past week positions.
Have operated,
cared for the patient post operatively removed the
futures and then sent the patient on her way without any
thought of the problems which cancer of the breast has caused in the
patient's life.
If we are to heal our patients,
we must not heal a portion of the body,
but we must heal the whole person.
In ST Matthews has found,
what does it profit a man if he gains the
whole world and loses his soul,
may we paraphrase this to say,
what does it profit of the woman to save her life
from cancer of the breast and she loses her ability
to live because she's a physical and an
emotional cripple.