Responding to cancer as the surgeon or the survivor

“The plastic surgeons tell me that women who like to swim do much better with reconstruction than with prostheses,” says a young breast surgeon at our weekly breast cancer tumor board, the working conference where we discuss every new breast cancer patient before starting treatment.

There’s a slight note of surprise in her voice; to her, it’s simply another consideration when advising women before mastectomy.

For decades, the only option after a mastectomy was a prosthesis, or breast form — something shaped and weighted to fill the empty cup of the brassiere and lie, more or less comfortably, against the chest wall. I sometimes tell my patients that using a prosthesis is a bit like going back to the days when we were little girls, stuffing our bras with tissues or old socks to fill them out.

But now, women have choices. The plastic surgeons can reconstruct the shape of the lost breast. A woman can look at herself in the mirror and feel whole. From the outside, in clothes, no one can tell the difference. And there’s no need for a breast form. But it’s a lot more surgery.

So, in fact, most women do best with reconstruction. There are plenty of studies that show that. And swimmers, in particular, don’t do so well with prostheses.

All eyes swivel to me.

At sixty-seven, I’m the senior breast surgeon and the leader of tumor board at my Midwestern medical school. When I was diagnosed with early-stage breast cancer, a year ago, I had my surgery at my home institution, gladly sacrificing anonymity to stay with the familiar hands, brains and hearts of the best team in the region. I’ve never regretted that decision. But there are moments, like right now, when I’m unsure whether to respond as the surgeon or as the survivor.

The surgeon in me answers.

“It’s absolutely true. The survivor literature is replete with accounts of breast prostheses floating away, heading in the other direction from the swimmer. It’s a simple mechanical problem, and I don’t understand why they haven’t solved it yet.”

For sure, swimming is a mechanical stress test for a breast prosthesis, between the repetitive arm motion involving the pectoral muscles (on which the prosthesis sits) and the lubricating effect of water. A prosthesis that works well for ordinary wear may not swim well.

If you wear a prosthesis in the swimming pool, you run the risk that it will slip out and either (a) sink to the bottom of the pool, to lie there like a dead sea-slug until retrieved, or (b) float away, possibly to surprise the next swimmer in line. Neither option is appealing. And it’s unlikely that your insurance company would pay another couple of hundred dollars for a replacement.

So swimmers have devised various strategies in response. Many women simply use a plastic shower sponge. Cheap, compressible, lightweight and fast-drying. At least one woman in California has had garlands of flowers tattooed across her chest where her breasts used to be and surfs topless. But things are a bit more conservative here in the Midwest.

All of this runs through my head, and more.

When I was diagnosed, I decided on a mastectomy without reconstruction. (Like most women surgeons, I knew what I’d choose long before I was ever diagnosed.) I’m small-breasted, so mastectomy without reconstruction was a relatively easy choice: I wanted to minimize the amount of surgery and maximize my chances of returning to a normal life fast. I sometimes joke that now I’m flat on one side, and flatter on the other.

“But it’s not the prosthesis, it’s the scar,” I say.

Expectant silence. Some members of the group know that I elected a mastectomy without reconstruction; others have probably heard parts of my history and are curious about the rest. But only my own surgeon knows that I love to swim — and that I don’t use a prosthesis, even in a swimsuit.

The silence deepens. Instead of elaborating further, I take a deep breath and call for the next case.

But my mind lingers on the question no one has asked: “How is it for you?”

In the pool, it’s really very simple. I hide the asymmetry with a towel slung over one shoulder, stride to the pool’s edge, drop the towel, and hit the water with a distracting splash. Keep moving, hold your head high and just act natural.

The real problem for me isn’t the prosthesis but rather the cavernous open space of the women’s locker room. Amid the mix of body types in that room, I have never seen another woman with just one breast.

Even the jolly, overweight ladies of the arthritis swim class, who towel off with gay abandon, chattering like a flock of sparrows, unabashedly display rolls of flesh, varicose veins, cellulite, wrinkles and gray hair. But they all have two breasts, and, as best I can tell, both are the breasts they were born with.

Alone among them, I turn my back, restrain myself in mid-stretch and furtively slather moisturizer over my scar.

Alone, in my own bathroom, I look at my chest. I’m not revolted, simply surprised. It’s so easy to forget that I had breast cancer … that I have breast cancer? I’m not sure where I am on the patient-survivor continuum just yet.

The physician in me thought that I had accepted my new body image. Now I find myself wondering: Why do I hide my scar?

The swimming pool has wheelchair ramps and chairlifts for the physically disabled. It’s the law. Are the scarred and maimed a last bastion of prejudice? I ask myself. What impels me to hide? Is it the same instinct that held me silent during Tumor Board?

I guess I’m just not ready to talk about it — to answer the inevitable questions: “Did you have cancer? Are you a survivor? How many years? Oh, my sister (aunt, mother, best friend) had breast cancer, and she’s done well for ten years now (or she died after just five years) …”

Like many surgeons, I’m superstitious. If I call myself a survivor, that might tempt the cancer to recur: Call yourself a survivor, do you? Well, I’ll show you! On the other hand, calling myself a breast-cancer patient implies that the cancer is still there. “Name the devil and he will come,” my grandmother used to say.

If pressed, I would call myself a survivor.

Once, at the pool, I saw a young amputee shed her below-knee prosthesis at the far end and hop deftly to the water’s edge with agility and confidence. In the water, she reminded me of Nemo, the little cartoon fish with a stunted fin on one side. And then I lost sight of her, surrounded as she was by the other swimmers.

Maybe, some day, I can be brave and step confidently out of the shadows like her.

Carol Scott-Conner is a surgeon and author of  A Few Small MomentsThis piece was originally published in Pulse — voices from the heart of medicine, and is reprinted with permission.

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  • Lisa

    Thank you very much for your article. With the emphasis on breast reconstruction, I am very happy to see the alternatives to reconstruction discussed.

    I had a bilateral mastectomy after being being diagnosed with multicentric breast cancer. I chose the bilateral mastectomy because I wanted to be symetrical and the idea of recostruction was repulsive to me. The idea of putting an implant under my pecs made me feel ill and I didn’t want to cut into a perfectly good part of my body to have non-feeling, breast shapped lumps.

    I rarely wear prothesis. I am convinced that very few people notice that I am flat. I get very few puzzled looks from people trying to figure out what is different about my appearance even though I don’t try to disguse my lack of breasts. I dress and undress in the locker room at my gym. No one reacts to the scars on my chest; but then no one reacts to the scars from my hip replacements. But I don’t feel like I am being brave; I just don’t want to have to go into a stall to change.

  • Markus

    About twenty years ago there was a book with seminude portraits of women who had mastectomies. They were wonderful images showing humanity, courage, and true deep beauty. I can’t remember the name, and I can’t thing of a google query that won’t give a lot of results that I don’t want to see.
    I am a man. A part of the beauty of women is biologic. Most of it is achieved. Reading your post has convinced me that you are a beautiful woman. The book I mentioned might be useful. One breast surgeon I know had it in her waiting room.