SISTERS UNDER THE SKIN | Carol Scott-Conner
In the depths of an Iowa winter more than eleven years ago, I learned I had breast cancer. It began with an annual mammogram supplemented by a new diagnostic modality—tomosynthesis, or “tomo” for short. Just an ambiguous shadow on that first screening study, then a truly ominous shadow clearly confirmed on ultrasound.
I was, at that time, Professor of Surgery at the University of Iowa, and I specialized in the treatment of women with breast cancer.
The radiologist who did the ultrasound, a close colleague, turned the screen so that we could both see the irregular, densely-shadowing spiculated mass with associated vascularity, invading rather than displacing adjacent tissue, taller than it was wide—all the features of breast cancer were there. It was the size of the tip of my index finger. The center seemed to sparkle; perhaps embedded calcifications reflected the ultrasound beam back to the transducer. It had a strange kind of beauty. Mesmerized, I found myself thinking maybe yes, maybe no.
I could feel the ultrasound probe slipping over the mass underneath. When she removed the transducer, my fingers similarly slipped over the mass, and I wondered how long it could have been growing there without my awareness. I couldn’t remember the last time I had checked my own breasts.
Had it popped up in the interval since my last mammogram? That was just over a year. Or had it been there for a long time, growing slowly, and I hadn’t noticed, or looked, and only the newer high-tech mammograms revealed it? I just couldn’t be sure.
In my long career as an academic surgeon, I’ve taken care of innumerable women with breast cancer (and some men, too) in this very hospital. Several of the radiologists gathered around me as I walked back to the changing room. News spreads fast in a University Hospital like ours; strangely, rather than feeling violated I felt embraced.
“We can do the core needle biopsy next Monday,” the senior radiologist said. That was a major accommodation; it would mean adding me on to the schedule, probably already full. Sensing my hesitation, she spoiled the mood a bit by adding, “Just suck it up, Carol.”
My mind was racing. Tuesday, I was scheduled to fly to Los Angeles to be visiting professor. Did I want to fly with a sore breast? To get the results when I was alone, in a strange city? I shook my head, “No, thanks. I’ll be away next week. I’ll schedule it for when I get back.” Even as I said the words, I realized that these were excuses. The real reason was simple: an automatic don’t rush me reaction. I added, “Call Mary*.” The radiologists always called Mary, our nurse-coordinator, when they had a woman who would need a biopsy. That call would then trigger an automatic referral to one of us, the breast surgeons, unless a woman already had a surgeon. “Tell her I want Dr. Harris,” I added, as I fled into the changing room, leaving them outside. They would have a plenty to talk about over lunch.
I was already late for my next appointment; where I would chair an editorial board meeting of our medical literary journal. My throat seemed to swell and close down as I scrambled into my clothes and adjusted my white coat, making sure everything was in the pockets. At home, my husband remained comfortably oblivious. He was the only person I wanted to talk to. Not over the phone, I wanted to tell him face to face. I wouldn’t be home for another couple of hours. The next best thing would be to call him.
But I was running late. So, instead of calling him, I rushed to my next meeting and struggled to join the flow of the discussion.
The editorial board meeting was surreal. My life had changed, and the rest of the group was unaware. I could barely focus. The managing editor had taken over when I was late; I let him continue to lead the discussion. I picked at a piece of vegetarian pizza that I normally would have wolfed down. My throat still felt as if it were clamped shut. I forced myself to eat. Like a prisoner eating every scrap of an unpalatable meal, I knew I would need every ounce of my strength if I were to escape the trap I found myself in.
From there it was a trek back to the other side of the medical center to chair my second meeting: Breast Tumor Board. Yet another irony: by sheer longevity, I was now the most senior breast surgeon at our center. Gradually, over the years, I had pruned my practice of complex gastrointestinal surgery, laparoscopic surgery, trauma surgery, burns…and now all I did was breast.
Dr Harris, my chosen surgeon, sat on my right with our breast fellow in the seat next to her. At the end of the meeting, I leaned over toward them and said, “You may already have heard this. I have a shadow on my mammogram. It’s suspicious. It could be a breast cancer. I’m having a needle biopsy in a week, and I want you for my surgeon. If it’s cancer...” I outlined my preferences. From the look on their faces, it was obvious that neither of them had heard yet.
I stood up, and they stood up automatically in response. That’s a trick I learned years ago. To terminate a difficult conversation, just stand up. If necessary, move toward the door.
It was clear I would need surgery. The mass just looked too suspicious; it wouldn’t be safe to leave it, even if the needle biopsy was benign. So, we set a date, and I started making calls. I told my administrative assistant exactly what was going on, what was known and what was unknown. What was known was there was a shadow. What was unknown was how much of a disruption this would require. Together we made a short list of people who needed to know. I sent an e-mail to my Department Head, also a breast surgeon.
My assistant asked, “Is it better or is it worse that you know so much?”
I hadn’t considered that aspect of the whole thing. “Better, I think. There’s less uncertainty. Less fear of the unknown.” But there was as yet so much unknown. Was it cancer? If so, how bad? Would I need chemotherapy? Radiation? What beyond surgery? Was this to be the defining moment of the last measure of my days?
We had to cancel several of my clinics and offer the patients appointments with another surgeon. What should we tell the patients? I’m old-school, so all we cited was personal reasons. My assistant took care of all of this. Ironically, on the day my life changed (as I would later come to call it) I had shared the inner waiting room with one of my own patients. No woman looks her best in a voluminous faded mammography smock, yet my patient recognized me. I smiled and told her we were both “sisters under the skin.” I had wished her well with her mammogram, and she had done the same for me. Sisters under the skin. Now, I recalled that encounter, and thought—more than you know, sister.
One of my first e-mails went to the director of a first-year medical student class I taught. I’d need a substitute for at least one session. After rewriting the e-mail several times, I picked up the phone and called him. He was a senior physiologist whom I regarded as a close friend. I explained my situation to him. He reminded me that I’d operated on his wife for breast cancer. I hesitated—not bound by confidentiality like the medical professionals, she might tell her friends.
Iowa City forms a small, tight-knit academic community. Should I ask him to keep this information from her? Our long friendship, my privileged relationship with his wife, dictated otherwise. She had the right to know. So, I simply told him to give her my regards.
I realized at that point I had lost all control of the information.
When I called my husband that afternoon, I found myself softening the news. “I went for my mammogram today.” I stopped a minute to let this sink in; I doubt he even knew I had it on my schedule. “They see a shadow. It could be an early breast cancer, but there are other things it could be. It’s very small. I’ll have to have a needle biopsy when I get back from LA. I’m probably going to need surgery either way.” Silence. I forged ahead,
“It’s going to be okay. It’s very small.” The second part of this statement was certainly true. The first part was largely unknown; taken on faith.
I flew to Los Angeles a few days later. Alone, in my hotel room that first night, I bared my chest and looked at myself in the mirror. I felt the lump. I didn’t like the way it felt. I prepared to say goodbye to my breast.
The next day was very full. I gave a lecture, toured the medical center, and met with residents, students, and junior faculty. At dinner, surrounded by new friends, the conversation ranged away from surgery into the greater world of ideas. Books, movies. I found my concentration wavering. Someone asked me what I thought, and for a moment I almost replied, “I think that I have breast cancer.” I caught myself in time.
That supposition would be proven correct in just a few days, when I returned home and had the biopsy. When my surgeon called to tell me the results of the biopsy.
The residents and faculty and my colleagues and even a lot of my patients quietly joined the circle of those who knew. Every patient encounter seemed fraught. One of the major medical journals had just published a paper about whether or not physicians should share their own experiences of illness with their patients. Correspondence had been lively, both pro and con. I wasn’t sure which side of the debate I would have favored, before my diagnosis.
During my post-diagnosis, pre-surgery period I realized that the question of whether or not someone knew would become more and more difficult to answer. One patient, who was a friend before she became my patient, happened to give me a book of poems during her office visit. She had bookmarked a poem about breast cancer. I hesitated. Finally I drew a deep breath and said, “I don’t know if you’re aware, but I was just diagnosed with breast cancer.” She hadn’t known. Was I right to tell her? Would I have been right to withhold?
Several weeks later, when I had returned to work, I ran into a colleague from another department. I didn’t remember ever telling him that I’d had breast cancer, but from the way he spoke to me I was sure he knew. I told him I had squeaked by without chemotherapy and was on an aromatase inhibitor.
“Do you say, to yourself ‘I have cancer’ or do you say, ‘I had cancer?’” he asked. I recalled, in that moment, that his wife was a Hematologist-Oncologist with special expertise in bone marrow transplant. She must have seen my name on a list somewhere.
I had not yet thought in those terms, but my answer was clear. “I have cancer. I take a pill every day to help prevent it from coming back,” I said. This was a position that increasingly solidified in my mind. I was not a survivor, not yet. Maybe not ever. I was just another pilgrim like my patients, slowly walking through life one day at a time.
Today, more than eleven years have now passed and the winter constellation, Orion, is visible in the night sky. I remain cancer-free. Checkups are now annual. I retired eight years ago from the practice of surgery, but retained an Emeritus (teaching) appointment.
I was recently approached by a woman who used to work in Hospital Administration. By the nature of our jobs, we had had a casual acquaintance before we both retired. “You have breast cancer, don’t you?” she asked. Not – “You used to be a breast surgeon,” or, “You do breast surgery,” but “You have breast cancer.” I simply answered yes and then the familiar discussion began. She had a relative who was just diagnosed… I tried to say noncommittal things (not knowing the details of the case) and offer comfort.
Comfort—this is something I can offer from my altered perspective. I understand uncertainty far better now; I sense the inherent ambiguity of the question I was asked years ago—is it, “I have breast cancer” or “I had breast cancer?” Increasingly, of course, it is tempting to say that “I had breast cancer” and most likely that is true. But breast cancer is tricky stuff, sometimes returning after lying low for 15 or 20 years. When I feel compassion for a woman with breast cancer, it truly comes from my heart, as one who is walking that path herself. Could I have done this when I was still active as a Breast Surgeon, or did that role mandate that I maintain the façade of invincibility?
When a woman sat in my exam room and we talked about her breast cancer, she was the focus of the entire encounter. We talked about her breast cancer, her treatment plan, her fears, her hopes. My diagnosis occurred several years before I retired; during those last few years in which I was both breast cancer survivor and breast cancer surgeon, I did not spontaneously insert my own experience or feelings into that space. And virtually no-one asked.
But I’m retired now. When I encounter a woman who wants to talk about breast cancer, my own experience may be relevant and worth sharing. So, my identity has shifted. Occasionally I see a former patient, who happily approaches me to share news of how well she is doing and remind me how many years she has gone. I still struggle with the question of whether or not to share the commonality of our situation. Mostly I do, casually saying, “You might know I was diagnosed with breast cancer more than ten years ago—I’m doing fine.”
It’s a small town; generally, the woman nods her head and says, “I thought so.” And when that happens, I feel like I’ve passed some kind of test—I’ve acknowledged, as I could not when I was the omniscient surgeon, that we truly are “sisters under the skin.”
Carol Scott-Conner is professor and chair emeritus in the Department of Surgery at the University of Iowa Carver College of Medicine. She serves as fiction editor for The Examined Life Journal, and is the author of numerous textbooks and two books of short stories. She recently attained her MFA in creative writing, specializing in Narrative Medicine, from Lenoir-Rhyne University. Her prose and poetry explore the relationships between surgeons and patients, and the experience of being a female surgeon.