Calling Dr. Chang

Lisa Leff's last article for the magazine was about the City News Service

As she sits next to Cindy Crawford in a conference room at the Revlon/UCLA breast center, Dr. Helena Chang, lauded surgeon and cancer researcher, looks as if she would rather be any place else on earth. It's the day before the annual Fire & Ice Ball, the glittering Hollywood gawkfest-cum-gala that raises millions for women's cancer research at UCLA. And in a stroke of public relations moxie, Revlon has enticed "Entertainment Tonight" and "Good Morning America" to visit the labs and clinics where the money goes by offering up its spokesmodel as guest interviewer.

As the breast center's new director, Chang is an obvious choice as interviewee. But with a boom mike hovering and a roomful of strangers staring, the strain of the public appearance shows in her tight smile and clenched hands. The 49-year-old doctor, fresh from a morning spent cutting another woman's flesh with an electric scalpel, flinches when Crawford reaches over to brush a strand of hair off her face. Her answers to softball questions sound stiff, despite several rehearsals.

As soon as the crew starts to pack up, Chang slips out and begs off the next stop, a date with CNN.

"They don't need me, do they?" she asks a UCLA spokesman stationed in the hall.

It's optional, he says. "So that was harder than operating, huh?"

"Absolutely."

It's difficult to imagine a similar scene starring Chang's predecessor at UCLA, the outspoken and camera-ready Dr. Susan Love. A passionate and impatient agitator who helped put breast cancer on the federal health-care agenda and the author of two popular books on women's health, Love was, and still is, a widely admired publicity magnet. Her characteristically provocative quip that modern medicine's approach to breast cancer treatment amounted to "slash, burn and poison" made her a talk-show regular and the nation's best-known breast surgeon.

Temperamentally and philosophically, Chang occupies a separate universe. A woman so shy that her husband jokes she married him because he is big enough to hide behind, and so driven that she began her surgical residency 48 hours after giving birth, she abstains from the politics of disease. Until arriving at UCLA from Brown University last October, she had been a quiet crusader, confining her breast cancer fight to the research lab or the operating room. Even now, inhabiting an office with a built-in bully pulpit, she defends the strides that have been made in treating breast cancer rather than flag any deficiencies.

This preference for science over celebrity put Chang on the short list to lead UCLA's clinical war on breast cancer in the post-Love era. During her four years as the breast center's founding director, Love clashed with some doctor colleagues who resented her contrary style--men in particular felt her barbs--and the time she spent away from the Westwood campus playing on a bigger stage. Love resigned and stopped seeing patients in May 1996, citing a desire to devote all her time to national women's-health issues.

Her exit left UCLA with a huge vacuum to fill. The number of breast center patients dropped as much as 40% after her departure and has yet to rebound fully, in part because the 1990 bestseller "Dr. Susan Love's Breast Book" pulled in so much business. Though Love attributes her departure to mid-career angst, her supporters outside UCLA suspect that petty jealousies pushed her out. That perception gained credence last year with the publication of "To Dance With the Devil," an account of the modern breast cancer movement by L.A. journalist Karen Stabiner that chronicles Love's squabbles with her bosses.

Besides lending an air of calm, Chang is expected to help a renowned research institution strengthen its reputation as a premier provider of cancer diagnosis, consultation, treatment--and breakthroughs. Breast cancer, in particular, is big business and good politics. The center Chang runs is not only a place to treat patients but also a giant petri dish for testing medical advances.

"If you are going to have any kind of presence in cancer, based on numbers, breast cancer is going to be one of the areas where you will want to have major expertise," says Dr. Dennis Slamon, chief of hematology-oncology at UCLA's Department of Medicine. Federal research funding for the disease, which will strike about 171,000 women this year, has more than tripled since the turn of the decade. And the demand for clinical services will spiral upward as baby boomers confront a cancer that favors women over 50. Locally, UCLA has keen rivals in the contest for patients at Long Beach Memorial Medical Center and St. John's Health Center in Santa Monica; a recent Self magazine poll of health-care professionals ranked those hospitals, but not UCLA, among the nation's top 10 for patient care.

In some ways, Chang seems unlikely to give UCLA what it wants. She started treating large numbers of breast cancer patients only five years ago. She put in a few years as second-in-command of a small East Coast breast center but is untested as a top administrator. In the lab, most of her research has been on pancreatic cancer, which killed an aunt of Chang's when she was in medical school. She avoids schmoozefests and talks in hushed tones, betraying none of the imperiousness associated with doctors. "If I were any younger, I wouldn't take this position even if it were offered to me," Chang concedes. "And I would probably be very anxious because I would think there are so many expectations. It would drive me crazy."

Yet if her past is any indication, she possesses the determination to become a leader. Though UCLA courted her for more than a year, chipping away at Chang's refusals to uproot her family and sacrifice her hard-earned local reputation, doors did not fly open earlier in her career. Says Dr. Wallace Ritchie, executive director of the American Board of Surgery and a mentor of Chang's since her surgical residency in Philadelphia, "Helena's real story is she pulled herself up by her bootstraps."

When Chang came to the United States from Taiwan as a 21-year-old PhD candidate in 1971, she spoke hardly any English and memorized books to make it through exams. She chose a medical specialty overwhelmingly dominated by men and went on to juggle a surgery practice and research, making her even more of a rarity. Since completing her studies in 1988, her relationship with both patients and breast cancer has become more personal, giving her, if not Love's sense of outrage, then at least a sense of mission. And so, despite the awkward Hollywood debut, those who know Chang believe she will eventually master every facet of her new job.

"It is not in her nature not to be excellent," says her 22-year-old daughter, Joyce.

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Because Love and the breast center had become so entwined, UCLA felt pressure to name a successor quickly. To hear people involved in the 16-month search tell it, finding a replacement for Love was akin to isolating a single human gene on a strand of DNA. The committee--doctors and administrators--wanted a woman because breast cancer patients increasingly prefer them. But the pool of experienced female breast surgeons is small; nationally, women make up just 9% of general surgeons. It also wanted a doctor with an established research record--another tough order. And on top of that rare combination, the job description called for a caring advocate for patients, one who could also represent the university in public forums, oversee a $720,000 budget and motivate a team to work together.

This extensive wish list signals progress in the movement to heighten awareness of breast cancer and its treatment options. For a long time, male surgeons on the verge of retirement gravitated toward breast cancer practices. Performing the then-standard full mastectomy required less technical finesse, and what's more, a breast surgeon could see three to five patients a day and still make it home for dinner.

With the advent of breast-conservation surgery 15 years ago, the specialty has become more demanding, prestigious--and promising. The goal today is to figure out ways to make breast cancer less mutilating and less deadly. Breast cancer centers not only diagnose the disease and test new treatments but also run prevention programs for women whose genetic histories put them at high risk and help patients manage the psycho-social aspects of the disease.

"Twenty years ago, [UCLA] never would have had a search for a surgeon," Love observes. "They would have looked for someone who is not very busy and said, 'You run the breast center.' That they looked so hard and took so long reflects the fact that breast cancer has come of age."

Chang, with a doctorate in immunology and microbiology accompanying her medical degree, certainly had the right credentials. In Providence, R.I., doctors responding to a local magazine poll picked her as the surgeon they would most want to treat them. Equally, if not more, important to UCLA was Chang's credibility as a researcher. Her work developing a vaccine that uses human antibodies to keep pancreatic cancer from spreading to other parts of the body has been funded since 1992 by the National Cancer Institute. She is now studying whether similar technology might be used to prevent breast cancer.

When it hired Love to start up the breast center in 1992, UCLA needed someone to humanize a teaching- and research-oriented hospital known for being cold and bureaucratic. Patients were frustrated by how long it took to get test results and dates on the operating table. To make UCLA more patient-friendly, Love initiated a weekly "multidisciplinary clinic" that gave recently diagnosed patients easy access to the combined expertise of a surgeon, a medical oncologist, a radiologist, a pathologist and a social worker. The idea was to let anxious women get all of their appointments over with in one afternoon, rather than over several days or even weeks. At the end of the day, the team of specialists would review each case and come up with a treatment plan.

The pioneering approach was--and still is--a hit with patients, yet it has never translated into the volume or kind of business UCLA expected. Love's widely circulated name brought women in the door. Some 320 patients were evaluated at the center each month, and about half the women who participated in the multidisciplinary clinic elected to undergo their surgeries and chemotherapy elsewhere. "One of the problems, if you will, of bringing in a person of that much notoriety is the center and the person start to blend too much," says Dr. Robert Bennion, a surgeon who was the center's interim director until Chang arrived. Women who had read Love's book "flew across the country to be blessed by Susan," only to be disappointed if they could not see her personally. And because the doctors volunteered their clinic time in hopes of garnering patients, Love's heavy travel schedule bred resentment.

While Love blames the old systemic problems for diminishing patient satisfaction--"it took two weeks to get biopsy results"--some former colleagues say her shoot-from-the-hip leadership style damaged her drawing power. The antipathy grew, eventually prompting some UCLA faculty members to refer cases to St. John's, says Dr. David McFadden, a UCLA surgeon who headed the search committee that hired Chang. "You suddenly have this live-wire person coming in with different ideas and who speaks her mind, which isn't bad, but she didn't put a muzzle on it. She came in with both guns blazing."

The shift from a champion rabble-rouser to a hard-boiled scientist makes sense, search team members say, now that the center is up and running. "I get the sense that people are ready to move on," says Dr. Judith Gasson, director of the UCLA Jonsson Comprehensive Cancer Center, of which the breast center is a component.

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One of breast cancer's particular cruelties is that it most often strikes out of nowhere, when a woman feels perfectly healthy. With other forms of cancer, unexplained weight loss or fatigue usually suggest something is wrong. "But breast cancer--most times no one is prepared," Chang says.

It is surprising then that she has taken on such a capricious adversary. Guided by an implacable belief that one can never be too ready or too careful, Chang has pushed herself, sometimes mercilessly, toward her goals. As a child, driven to be first in her class, she would plunge her feet into buckets of ice water to stay awake while studying. "I felt that somehow I was not good enough," Chang recalls, "although I didn't know good enough for what."

Joyce Chang, a recent Princeton graduate, tells a story about her mother's concept of self-discipline. When Joyce was 6, she wanted to take piano lessons. Fine, her mother said, but only if you'll make a 10-year commitment. Joyce's interest predictably flagged after a few years, but the elder Chang refused to let her quit, because "you can't start something and not achieve some level of competency or why start in the first place?"

Even now, the only leisure activity Helena Chang indulges in is watching televised ice-skating competitions at her Bel-Air home, and only then with journals or reports on her lap. "My mom is not one to relax," Joyce says. "She sleeps with a knitted brow."

As a teenager in Taiwan, Chang had found a role model in Marie Curie. "I was so touched by her devotion, achievement," Chang says. Eager after college to pursue an interest in cancer, she applied to graduate schools in the United States, a decision that perplexed her family. "They weren't so sure I could make it, because I was so shy, so sheltered," she says.

At the now-defunct Hahnemann Medical College in Philadelphia and later at Temple University, where she pursued her doctorate, the predictable world of academia suited Chang's personality. But while studying the haywire life cycle of cancer cells, she started to have doubts about a life devoted solely to scientific inquiry. "I started to ask, 'How am I going to help people?' " And so, at age 28, and with a year-old daughter, she entered Temple's medical school. Once again, her parents, both educators, were flummoxed. Chang's husband, Bill, explains: "There are only two things that are important to her--her work and her family. Everything else is totally peripheral. She just doesn't care."

Two days after her younger daughter, Leda, now 17, arrived, Chang began her surgical residency at a small Philadelphia hospital. She had hidden the pregnancy during her final year of medical school beneath baggy surgical scrubs. "I did a lot of things I would not recommend to anyone," she recalls. "But as a foreign woman in a physician-training program, I did not want to be a thorn, to tell anyone I was pregnant or having a baby. I said, 'I decided to do it, I will take all the consequences.' "

The sacrifices of family time continued during a post-residency fellowship at New York's prestigious Memorial Sloan-Kettering Cancer Center. For two years, Chang lived in New York while her mother helped Bill, a computer consultant, care for the girls back in Philadelphia. She saw them only on weekends. Chang refused to dwell on what she was missing. "To some degree it's my loss," Chang says, "especially seeing the girls go to Daddy, 'Daddy, remember when we did this?' Sometimes I felt left out, but that was the condition we agreed upon."

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She was performing surgery when she felt a stabbing pain in her chest. Later, in her office, she reached inside her shirt. There was a lump in her right breast. And it wasn't small, either--two centimeters across. Chang told herself to be calm. She had performed monthly self-examinations religiously, as she counseled patients to do, and the lump hadn't been there during the last one. Still, a cold fear drove her to her lab. She stuck a needle into the mass, hoping to draw fluid, which would indicate a cyst. None--a bad sign.

Tapping every ounce of her professional detachment, she prepared a slide of her breast cells and put it under a microscope. They didn't look like cancer, but then again, she was not a pathologist. She drove home, her mind racing "from it's nothing, to this must be really bad." The next morning, after rounds, she told her department chairman. Within a few hours, she was having a biopsy. Benign.

"It's such an ordinary ordeal for what I do everyday," Chang says, "but when it hits me, I realize it is not an ordinary ordeal."

That scare two years ago gave her an insider's view of the disease, helping her to empathize with patients, an area in which she has not always excelled. She got off to a bad start in her first post-residency job at the University of San Diego Medical Center, where she fielded the senior faculty's castoffs--routine appendectomies, gall bladder removals--leaving no time to develop a cancer practice.

In the switch to Brown, something inside her clicked on. Chang purposefully sought referrals from gynecologists and primary-care physicians, figuring she could avoid grunt work if she brought in cases. As she evolved into a breast surgeon, she gained the recognition that validated her years of hard work. And with self-confidence came a new view of her mission. "Before, it's 'I need to see patients, I need to do cases, I need to do publication, I need to do this and that.' There is not really much of a feeling kind of thing," she says. "Somehow, in the last six years I started to have a vision, to see we can have a connection with my patient."

As she describes this transformation, Chang sounds like someone who has undergone a spiritual awakening. Like many of her patients, she has found, at midlife, a hard-won faith in her capabilities, one that led her here "to do something that will make a significant difference."

At the same time, Chang remains more of a scientist than a missionary. Her career trajectory from researcher to surgeon is apparent when she talks about the current state of breast cancer treatment. Where activists lament the many years the disease went without dedicated research dollars, Chang believes studies on other forms of cancer may be the route to a cure. Where the activists have railed against what they perceive as a shameful lack of progress, Chang credits her colleagues with developing less-invasive treatments. Anger only obscures the facts, she says. "I think if anything is too personal, it is not healthy for the improvement."

Chang sees the next decade's research as pivotal in solving the mysteries surrounding breast cancer. If she gets her way, UCLA will be leading the investigation, but quietly. "I do not go out and rah-rah with people just to make loud noise. That is not me. I'm not good for it, so nobody will listen to me," she says. "I have to be honest with myself. What is my strength? What is my love? Give the best I have. You can't make everybody Sue Love. There is only one Sue Love."

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A few weeks before last Fall's Fire & Ice Ball, Chang sits at the same conference table where she faced the TV cameras. Only this time, she is in her element. Joined by a radiologist, a pathologist, a medical oncologist and two social workers, she will hammer out treatment plans for eight women waiting in the examining rooms.

Patient No. 7, age 50, has already been told by a doctor at another hospital that she will need a mastectomy because her breast is too small to salvage after lump removal. She has come to UCLA for a second opinion. In a voice neither smug nor critical, Chang deems the patient's breast size "quite reasonable" and says she can perform a successful lumpectomy.

Chang hopes to create more satisfied customers and to turn the breast center into "a big-scale clinical entity," one that serves the community while applying medical advances that reverberate around the world. In one of her first moves as director, she increased the number of days the center is open and scheduled herself to work the least desirable hours.

Chang plans to help UCLA compete with smaller hospitals by improving the breast center's efficiency, reducing, for example, the wait for test results and dates on the operating table. Already she has persuaded her colleagues who prepare pathology reports to turn around the information faster. She has started writing applications to get the center involved in more natonal clinical trials, evaluating everything from new chemotherapy drugs to the quality of patients' lives during and after treatment. And last month she opened a lab where she devotes one day a week to her own research.

"I know this is something that takes all my attention," Chang says, "and is something I never lose interest in or get tired of. For my patients, for my study, I can always push the envelope. There is almost no bottom to that, and it always amazes me and sometimes scares me to see how far I can go."

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