Healthpharmablog. About Health & Medicine

How long will I have to wait for an operation to remove a lump from my breast, and will a long wait make a difference to the outcome?

Although most breast cancers are relatively slow growing, and therefore a delay of up to a month or two between the discovery of a lump and its removal should make little, if any, difference to the outcome, efforts are made to avoid a long wait for surgery for the sake of the peace of mind of the woman concerned. The ideal strived for is usually to operate within a couple of weeks of diagnosis of a breast cancer. If you have to wait much longer than this because your consultant has a long waiting list, it may be worth asking your GP if it is possible for your operation to be done by another specialist who can treat you sooner.

I have had a mastectomy and there does not seem to be any sign of spread of my breast cancer to other parts of my body. However, I am constantly anxious about any small ache or pain I have in case it is a sign of cancer in the bones or brain. Can I ask for a total body scan to reassure myself that there is no further cancer in my body?

Unfortunately there is no test available which will confirm the presence or absence of cancer everywhere in the body. If you do develop any symptoms, tell you doctor, as scans can be done of individual parts of the body if necessary. Almost all doctors will be sympathetic and understand your anxiety, and will be quite prepared to put your mind at rest about any particular symptoms.

However, even if it were possible to scan the whole body, microscopic cancer cells would not be visible if they were present, and such a scan would therefore not tell you anything conclusive. The possibility that cancer could have spread to other parts of the body before an operation to remove the breast, or that it could recur in the future, is well understood as a cause of anxiety to women who have had breast cancer, and you should receive all the support you require when trying to come to terms with this.

You will have regular check-ups for many years so that any symptoms or signs can be picked up early, but do talk to your GP, consultant, or breast care nurse if you are worried, and do not be afraid that you are pestering them – they will understand your concerns and should take them seriously. You may want to discuss the possibility of having counseling if your fears continue to cause you distress.

What will the wound look like when I have had a mastectomy? I have a fear of seeing it after the operation, and of being horribly disfigured for the rest of my life.

After your mastectomy there may be a pressure dressing over your wound so that you will not be able to see it. When this is removed – usually about 24 hours after your operation – it will probably be replaced with a clear dressing which will remain until your stitches are removed or for up to 10 days if your wound has been stitched with an absorbable material. Through the clear dressing you will be able to see the cut edges of the wound and either a single ‘running’ stitch or separate stitches across the wound itself. The cut edges may be red and angry looking, and there is likely to be some bruising.

Once your stitches have been removed or the wound has started to heal, it will begin to look much better.

Although many women find the first sight of their wound shocking, most do gradually get used to seeing it as it heals. Within a few months, it will probably have faded to a white or pinkish line, which over the years will fade still further.

As your entire breast will have been removed, you will be left with a flat chest wall on that side, and the wound may be a horizontal or diagonal line. Your nipple will also have been removed during the operation. Sometimes, however, there may still be fat left on the chest which was overlying the breast. If so, you will have some breast contour rather than a dip where your breast used to be. There may be puckering around the wound which may settle after a while.

Following a wide lump excision or lumpectomy, when the nipple is retained, there is usually some nipple distortion, particularly if the operation was to remove a tumour just beneath the nipple. The length of the scar will depend on the size of the lump which was removed. Following a mastectomy, however, there should eventually be only a neat line where the skin was cut.

If I have to have chemotherapy or radiotherapy following my breast operation, what side-effects can I expect to experience?

The drugs used nowadays for chemotherapy are much improved in terms of their side-effects, and you may not experience any at all. It is unlikely that your hair will drop out, and although you may feel tired and nauseated for a while, many women do not even suffer these problems.

Radiotherapy for breast cancer is similarly unlikely to have any seriously debilitating side-effects, although – as with chemotherapy – different women react differently. The skin in the treated area may become sensitive, red and dry, and you will be advised about how to care for it during your treatment.

Do ask your consultant and/or breast care nurse to discuss any possible side-effects of the particular therapy you are to receive.

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A conservative laparotomy for endometriosis is surgery which attempts to remove or destroy as much endometriosis and as many adhesions as possible while still retaining the uterus and at least one ovary and fallopian tube so that conception and pregnancy are possible. It will also try to correct any other problems of the reproductive organs if they are present.

Who is suitable for a conservative laparotomy?

The reasons for having a conservative laparotomy vary widely and they may include any of the following:

• moderate or severe disease

• endometriomas or cysts greater than two centimeters in diameter

• adhesions, especially if they are causing pain or distortion of the reproductive organs

• involvement of other organs such as the bowel or bladder

• moderate or severe symptoms that have not responded to other treatments

• inability or unwillingness to take hormonal treatment

• desire to conceive immediately

• desire to avoid hysterectomy

• woman’s preference

• gynaecologist’s preference.

A conservative laparotomy is often the most appropriate form of treatment for more severe forms of endometriosis, particularly if large cysts or adhesions are present. Some gynaecologists believe that a conservative laparotomy is of little benefit for those with minimal or mild endometriosis and that in those cases it should only be used as a last resort if hormonal treatment or laparoscopic surgery is unsuccessful.

Hormonal treatment has little or no effect on adhesions or large cysts and endometriomas greater than two centimeters in diameter as they are made up largely of scar tissue. Surgery is the only way to remove or destroy any adhesions or large cysts and endometriomas.

If your endometriosis involves nearby organs such as the bowel or bladder, surgery may be necessary to ensure the normal functioning of those organs.

Things to discuss before conservative laparotomy

Before your operation it is important that you discuss with your gynaecologist what is intended to be done during the operation. Also ask any other questions or voice any concerns that you may have. In particular, you should make sure that you both agree on the purpose of the surgery and you should discuss what procedures are proposed and you should make it clear if there are any procedures that you particularly do or do not want carried out. You also need to remember that, because each case of endometriosis is unique, until your gynaecologist actually starts the surgery it is difficult to be certain what procedures will be needed.

If your symptoms are manageable and if you are contemplating becoming pregnant soon it may also be worthwhile discussing the timing of your surgery with your gynaecologist. Most infertile women with endometriosis who conceive following a conservative laparotomy do so in the first 12 months after their surgery and you are more likely to conceive after the first bout of surgery than subsequent surgeries. Some gynaecologists believe that, if possible, a conservative laparotomy should be timed for when the woman wishes to become pregnant.

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Although each patient is different, there are certain typical errors of thinking that they usually fall prey to. Let me describe some of these errors.

Black-and-white thinking: By this I mean the “all or nothing” attitude. For the anorexic, fat is hell, the ultimate nightmare, the horror of horrors. Thinness, however, is heaven, bliss, a goal worth dying for. There is no middle ground. Did she gain a pound this week? Then obesity is just around the corner. “If I can’t be one hundred percent perfect,” she tells herself, “then I am a total failure.”

A bulimic sees certain foods as “good” and others as “bad.” Bad foods must be absolutely, totally banished from her diet. Her characteristic thought is, “If I eat a little of this food then I’ll lose control. I won’t be able to stop until I become extremely fat.” But if she gives in to temptation and takes even a single bite of the forbidden food, then all is lost. She goes ahead and stuffs herself until she can hold no more. For her, there is no such thing as eating in moderation. All or nothing. Black or white.

She thinks the same way about other areas of life. She considers a grade of “B” on a school assignment to be a failure, since it is not perfect. Becoming sexually involved with someone means she is a loose woman. One patient saw herself as an “angry monster- if I’m not totally in control, then I’m totally out of control.”

One clue to black-and-white thinking is the fact that many of the patient’s statements contain such phrases as “I must” or “I should.” A patient might remark, “I must eat the same foods every day or I’ll swell up like a blimp.” Another might say, “I should exercise at least three hours a day.” The psychoanalyst Karen Horney coined the phrase “the tyranny of the ‘Shoulds” to describe this state of mind.

When patients divide everything into such extreme categories, they reveal their need for certainty in their lives. Because they mistrust their own feelings, their own ability to judge, they look outside themselves for guidance. The drive to be perfect shows their inability to determine when they are good enough. In cognitive therapy we spot the “should” and “must” thought-tyrants and challenge their right to rule the patient’s life.

Some time ago, researchers devised an ingenious experiment that revealed black-and-white thinking in action. They asked a group of dieters to drink milk shakes and then eat some ice cream. What the dieters didn’t know was that the “milk shake” was actually a ringer-it had a relatively low calorie content. Surprisingly, the dieters who were told that the shakes were high-calorie went ahead and ate more ice cream than those who were told the truth. Why? Well, the researchers called the dieters’ action “counterregulation.” The dieters felt that drinking a high-calorie shake had caused them to “blow” their diet. They had already failed, so why bother holding back while eating ice cream?

Magnification: This word describes the patient’s tendency to blow things, especially negative things, all out of proportion. Most prominent in their minds, of course, is body size. Many of my patients say they know perfectly well they are thin-they can see it in the mirror, their friends all tell them-but they feel fat. That feeling overrides and distorts any logical arguments to the contrary.

Similarly, patients distort their impressions of food itself. A case in point: A twenty-one-year-old, eighty-six-pound woman named Ondine swore up and down that at home she always ate three good-sized, nutritionally balanced meals, plus snacks, a day. I admitted her to the hospital. Yet when the first tray was brought to her, Ondine panicked. “I can’t eat all this!” she cried. “This is more than I eat in a week!” Obviously, her perception of a “good-sized” meal was somewhat skewed.

Magnification occurs in other areas as well. A certain homework assignment temporarily becomes the be-all and end-all of the girl’s life. An interest in sports turns into the compulsion to jog ten miles a day and play tennis to the point of exhaustion. A broken date becomes a billboard announcing the patient’s un-desirability to the world.

Personalization: A fifteen-year-old bulimic told me she had been too afraid to go to the beach during the previous summer. “I knew they’d all be staring at me and thinking that a whale had washed up on the beach.” This patient was personalizing-assuming that everyone’s undivided attention was focused on her and her alone.

Patients sometimes personalize an otherwise innocent remark. “You’re looking good,” an office colleague might say. The patient twists this to mean, “You looked so bad before.” The idea that people might observe and comment on a patient’s appearance can occupy her mind the rest of the day, and trigger a binge when she gets home that night.

Magical thinking: Examples include such statements as, “Bread is poison,” or, “With my metabolism, everything I eat after lunch turns into fat.” One patient told me, “If I eat one Oreo cookie at ten o’clock at night I’ll be all right, but if I give in and eat it earlier I know I’ll binge.” Magical thinking about eating, exercise, or interpersonal relationships is very common, especially among anorexics.

Sensory distortions: A lot of patients report that their senses become keener during their illness. One patient fought constantly with her brother because he kept his stereo turned up too high. Maybe he did, but there was no doubt that her hearing had become much sharper during starvation. Some patients wear sunglasses, even indoors, because average light has become too bright. Many report that colors are more vivid, smells more potent. Often, these cognitive distortions are direct, physical consequences of starvation itself.

Errors of attribution: These are mistakes in figuring out the relationship between cause and effect. For example, a patient may gain a pound and believe it is because she ate a chocolate-chip cookie the week before. When we look at the facts, however, we may find that her weight gain is actually the result of premenstrual water retention.

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A little black dress hung from Dinah Burnette’s closet door, reminding her of the past and showing her what the future might hold. But at 245 pounds, she couldn’t even pull the dress over her hips.

Being overweight was a new experience for Dinah. When she was a teenager, she stayed trim despite hearty meat-and-potato meals and midnight pizza sessions. And as a young woman, her figure always snapped back after the birth of each of her four children.

But when Dinah was in her late twenties, she added 100 pounds to her frame in just 2 years. During that time, she had started taking a prescription medication that sometimes causes weight gain. But she also suspected that her metabolism had just slowed down.

Even though the clothes in her closet grew bigger and bigger, Dinah didn’t acknowledge just how much weight she’d accumulated until she saw photographs of her 1996 nursing-school graduation. “I was in this fantasy world that there were several girls in my class bigger than me,” she says. “When that class picture came, I was the biggest. I just remember being so embarrassed.”

So the Winston-Salem, North Carolina, woman began a self-styled regimen of healthy meals, a gallon of water a day, and lots of exercise. “When I started walking, I couldn’t even do a half-mile,” she says. “But in 6 months, I worked my way up to 3 miles every day.” For motivation, Dinah hung her expensive black dress, the only piece of small-size clothing she’d kept, on her closet door. The last time she had worn it was to a wedding in early 1989.

“I would try it on every 4 weeks and see how close the buttons were getting. Gradually, I could get it on, but the buttons were 4 feet apart,” she laughs. One year later and 100 pounds lighter, she could once again fit into the size-12 dress—this time with room to spare.

Now, her closet contains only one larger-size garment, which she keeps around so she’ll stay inspired to maintain her present weight of 145 pounds.

It’s the size-24 white dress that she wore in that graduation photo.

WINNING ACTION

Measure your progress with your wardrobe. Keep one article of clothing handy that will fit when you reach your ideal weight. Try it on from time to time to measure your progress. Use your try-on as motivation—and don’t let yourself get depressed if it doesn’t fit for weeks or months. Remember Dinah: The buttons on her black dress didn’t close at first, but she persevered. Now, she has room to spare.

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