What is a breast?
Now don't look at me as if I'm mad. It's a valid question, and one that I thought I knew the answer to.
I've trained as a consultant breast surgeon for three years. I then studied towards an MSc in Oncoplastic Breast Surgery. (Oncoplastic is a fancy word for plastic surgical techniques used to hide scars, reshape / recreate a breast mound, reduce, re-size and reconstruct breasts and nipples).
During those two years, I literally read over a thousand scientific papers. I studied the anatomy, physiology, embryology, microbiology and endocrinology of the breast. I reviewed hundreds of clinical trials covering every aspect of breast cancer treatment. I thought I knew all there was to know about the breast. I was wrong.
A breast is an unusual part of the body. Simply, it's just mound of fat covered by skin, with a nipple attached. But it's so much more. It can produce milk to feed a baby. It's an erogenous zone. It can cause severe pain. Every breast is different, and they can change dramatically over a woman's lifetime. Some are perky, some saggy, they can weigh anything from 100g to 1.5kg, and nobody has an identical pair. I tell my patients that their breasts are sisters, not twins, so when I operate, I'm not promising symmetry and perfection, I'm trying to recreate what they already have.
And then there is the social / cultural aspect. Do you show your breasts in public or keep them covered? You may go topless abroad but not at home. You might flaunt your cleavage in a nightclub but hide it in church. Breasts have a sexual identity of their own. Topless celebrity photos sell magazines.
I've never given my own breasts much thought. Until now.
Suddenly I'm facing the prospect of losing a breast. What an odd choice of word. It sounds like I'm careless, and just misplaced it. But what word do you use instead of a mastectomy? The surgical term is a harsh one, and most of us will automatically conjure up an image of an ugly scar across a flat chest. That is so far from reality, as every woman in the UK who needs a mastectomy is now (or should be) offered a reconstruction, and we can do amazing things. Nipple-sparing mastectomies are becoming more common in smaller cup-sized women, and with a scar hidden in the bra-line, it can be hard to tell you've had surgery.
But I digress. My breast is going to go. And I've had to start thinking about reconstruction. I need to work out how my breast relates to me - my identity, my sexuality, my image, and how I'll feel when it's gone. Will I still feel like a woman? Can one breast compensate for two? Do I actually need or want a reconstruction? What about my cycling and triathlons - will that be affected? Will I ever accept what I see in the mirror? Will my husband? Do I want to keep my nipple? Again - how attached am I to it? How does my nipple define my breast? If I keep it, it won't 'work' as the nerves will have been detached, so it will be numb. Do I need to see a nipple in the mirror to help me accept my reconstruction?
I've had the agony and luxury of five months' of chemotherapy to think about all of this. But it's made me think about how I practice breast surgery.
As a breast unit, we get financially penalised if we bring women back to clinic too many times, so I routinely see a woman once after her biopsy. In this allotted 10 minute consultation (which for cancer normally takes 15-60 minutes, so we always run late), I often have to do the following:-
- tell her she has cancer
- tell her she needs a mastectomy
- tell her the risks of needing chemotherapy or radiotherapy afterwards
- as if she would like a reconstruction
- talk through all the reconstruction options and the pros / cons
- tell her whether she is able to keep her nipple or not
As you can imagine, this is a hell of a lot to take on board, but I have to cover it in that one appointment. And the woman takes in a fraction of what I say because she's still dealing with the fact that she has cancer. For those women who want a reconstruction, we'll plan to see them in a week's time once they've made their decision. But that gives them only a week to come to terms with how they feel about their breasts. I've been struggling and I've had months to mull it over.
No-one can imagine how they will feel about their breasts until they're told one needs to be removed, and any decision a patient makes is as a cancer patient, not as a healthy woman. Your priorities and motives are naturally skewed. Often my patients make a compromise, putting lifestyle factors or cancer treatment above cosmesis. Some come back to have revisional surgery and get the reconstruction they initially wanted, but many don't. I never know if they regret their decision. You can only make the decision that is right for you at the time, but it's clear to me now that a breast is not just a mound of fat.