Physicians’ Tumor Boards Weigh Agonizing Choices in Treating Breast Cancers
The doctor’s voice was somber as he faced his colleagues and debated the best treatment for a 39-year-old teacher recently diagnosed as having breast cancer.
“In this particular case, mastectomy is the obvious choice.”
He paused.
“But, when I sit in a room with this woman and look in her eyes, I have terrible anguish. This lady would clearly like to save her breast. I don’t want to do a mastectomy on her.”
The speaker was Dr. Melvin J. Silverstein, a surgical oncologist and medical director of the Breast Center in Van Nuys, a relatively new type of comprehensive center devoted to the care of women’s breast maladies.
He was addressing other members of the center who had gathered, as they do 50 times a year, for a meeting of the Breast Tumor Board at Valley Medical Center, next door to the Breast Center’s Van Nuys offices on Sherman Way.
Medical Histories Reviewed
During the weekly hourlong dialogue, sponsored by the center and Valley Hospital Medical Center, and open to any community physician, the doctors view slides of one or two patients recently diagnosed as having breast cancer, review the victims’ medical histories and try to formulate a treatment plan.
Tumor boards are not new to the medical community. But confining such meetings to discussion of breast cancer patients is less common.
Breast tumor board meetings are increasing in the San Fernando Valley and elsewhere, said a spokeswoman at the San Fernando Valley Unit of the American Cancer Society. Their growth, experts say, reflects women’s growing awareness of treatment options and physicians’ need to choose carefully between new approaches.
In the Valley, two such centers exist: The Breast Center (which sees about 3,000 new patients a year, 200 of whom have breast cancer), and the Breast Diagnostic Center at Humana Hospital West Hills in Canoga Park (which screens about 2,600 women annually, only a fraction of whom have breast cancer).
The Breast Center’s Breast Tumor Board meetings began when the center opened in 1979. About six months ago, similar meetings began on a monthly basis at Humana Hospital West Hills, which opened its breast center two years ago.
The goal of such board meetings is to improve the survival rate of women with breast cancer, a disease that the American Cancer Society estimates will affect one of every 11 women in the United States and will kill 40,200 in 1986.
Listening in on a Breast Tumor Board meeting reveals a side of doctors unfamiliar to many patients. Rather than sounding infallible or omnipotent, physicians participating in board meetings can sound indecisive about the best treatment, full of anguish over how to save a patient’s life and scared that their best efforts won’t be good enough.
During a recent meeting at Valley Hospital, physicians agonized over whether to recommend a mastectomy or radiation therapy for the 39-year-old teacher.
“Medically and legally,” noted Silverstein, “the decision is easy--a mastectomy. But psychologically, I’d much rather save her breast.”
Dr. Robert Hoffman, a psychiatrist at the Breast Center, didn’t think the woman was psychologically ready to make a treatment decision.
“She’s a terrible candidate for any treatment right now,” he said. “She’s very insecure about her appearance, especially her breasts. She’s under tremendous stress and she’s fragile.”
Not all the benefits of the board meetings are limited to patients, however. Physicians and others who attend regularly contend that the meetings help them deal with the often depressing specialty of oncology, in which patient deaths are common.
“Sometimes employees will come to me and say: ‘I can’t go on any more,’ “said Silverstein. Despite some successes, oncology experts all realize, sooner or later, that, as Silverstein puts it, “You can’t be in the cancer business and save everyone.”
“Oncology is a very difficult field to be in,” acknowledged Dr. Bernard Lewinsky, a radiation therapist. “And it’s very difficult to say: ‘This isn’t going to affect me.’ I often wake up at night with solutions to office problems.”
Hoffman agreed, noting that much of his work centers on “helping patients look at stuff I’m scared to look at--death and deformity--and working with someone who’s going to die.”
When the feelings of depression get too intense, oncology physicians said, they try to take some time off. Or, they talk about their feelings. At a recent meeting they spent the entire hour talking, not about patients, but about their own feelings of burnout.
“We need a place where we can reach out and touch each other,” said Silverstein.
At last week’s meeting, participants debated which treatment should be given after a modified mastectomy: breast reconstruction (via a new procedure called a tummy tuck, in which skin from the abdomen is rotated and fashioned into a new breast) or chemotherapy (drug treatment).
The tummy tuck is too new, as one doctor explained, to have a large data base of patients from which to analyze results.
Some participants believe the tummy tuck ought to be done first, pointing to several studies that show the psychological value of immediate reconstructive procedures after a mastectomy.
But other doctors wondered if chemotherapy shouldn’t precede the reconstruction, since the vomiting often associated with chemotherapy might affect the abdominal area involved in the tummy tuck operation.
As conversations at the tumor board meeting show, decisions about breast cancer treatment have become increasingly complex in the past several years, primarily because of an increase in treatment options.
Today, breast cancer management includes two approaches: a mastectomy followed by breast reconstruction, if desired, or breast-saving surgery, in which only the tumor is removed and the breast is exposed to radiation. Chemotherapy may be suggested as a supplementary treatment. As a result, modern breast cancer treatment is the realm not only of surgeons, but also of chemotherapists, radiation therapists, pathologists, diagnostic imaging experts, psychiatrists and patient educators.
“There’s sometimes no way to get all these people to agree,” said Dr. Robert Rosser, a pathologist at the Breast Center. “We sit in tumor board meetings and debate.”
Even so, the board meetings, say those who attend, help to make sense of the dilemmas of breast cancer treatment.
“Breast conferences, or tumor boards, allow a group of doctors from different medical specialties to all sit together at one time, in one place . . . and come up with the optimal decision relative to the management of the patient,” said Dr. Samuel Kremen, a pathologist who participates in breast conferences at Humana Hospital West Hills. “It’s the old story of two heads are better than one.”
“The tumor board is an intellectual arena,” said Dr. James Waisman, a medical oncologist at the Birth Center. “You take a position and that position will be confronted. Sometimes, it humbles you. You hear another point of view that makes sense.”
Occasionally, a physician will change his mind about the best treatment after discussion at the board meeting, Waisman said.
He changed his mind after the December meeting devoted to the discussion of the teacher.
“I recommended a mastectomy,” he remembered. But nearly everyone else favored lumpectomy and radiation.” Lumpectomy is removal of the tumor and a small segment of surrounding tissue.
“Too many observers said the lady would not be a functional person without her breast,” he said. “It wasn’t a black-and-white issue, and the scale tipped just enough in y mind.” Waisman eventually recommended breast-saving treatment.
