Unprepared, Part 2

The Anatomy of Hope: How People Prevail in the Face of Illness
by Jerome Groopman, M.D.

(Page 2 of 2)

Since beginning the surgery course on the first of the month, I had assisted in several operations and seen how the operative field was treated, as if it were a domain distinct from a larger living human being. The surgeon initially identified the relevant anatomical landmarks, like a surveyor delineating his planes. This promoted psychic detachment, lowering the emotional temperature and facilitating the intense concentration the cutting required. A stylized sequence reinforced this mind-set. Each set of incisions was followed by a formal appraisal of the newly exposed anatomy and a resetting of landmarks. The aim was to fully encompass the diseased region with minimum destruction to surrounding healthy tissues and maximum preservation of normal structures. But today's operation was different. In the event of a radical mastectomy, total destruction of the normal anatomy was planned. The mammary tissues of the breast would be removed, along with the muscles overlaying the chest wall, including the pectoralis and all the lymph nodes of the armpit. What would remain were scar and ribs. This draconian approach was rooted in Halsted's contention that cancer cells migrated stepwise from the primary tumor into the surrounding tissues and then, much later, through the bloodstream to distant sites like liver and bone. Only by extirpating a complete block of flesh on the chest could the surgeon remove the cancer cells hiding beneath the breast. Dr. Foster had lectured at length on how Halsted's insight had advanced the treatment of breast cancer from a plethora of haphazard operations to a uniform and highly scientific surgery.

Dr. Foster delineated the margins of the breast mass above Esther's left nipple and then instructed the resident to biopsy it. He made an incision and retrieved a wedge of gritty, glistening tissue. A pathologist was called to perform a "frozen section." He would flash-freeze part of the mass and immediately examine it under the microscope to determine whether malignant cells were present. If he saw them, the mastectomy would proceed.

Our wait in the OR was a short and silent one. Dr. Foster seemed deeply absorbed in his thoughts, and neither the resident nor I dared disturb him. The pathologist reentered the OR. His face was grave. There was no doubt about what he had seen on the frozen section.

Dr. Foster began making bold strokes around the circumference of the breast. I held a cautery, and as Dr. Foster cut, he directed me to burn the ends of small bleeding vessels. Wisps of acrid smoke with the distinctive odor of charred flesh wafted from the cauterized vessels. My stomach tightened.

After over three hours, the dissection was complete. When the breast en bloc was lifted from the chest wall, globules of fat and lymph seeped from its base, the underlying muscles raw and bleeding. More than a dozen lymph nodes had been removed from the axilla.

My mind drifted. I looked up from the operative site to the tube in Esther's mouth that delivered the anesthetic. She would awake to a drastic change in her form. It was impossible to predict how she would react. But I imagined that being Orthodox and married, with an established faith and family, would help her cope.

The recovery room was a large open space brightly illuminated by overhead panels of fluorescent lights. At the entryway was a board on which each patient's name was written next to the number of the bed the patient occupied. A nurse and I wheeled Mrs. Weinberg on a gurney into the recovery room, which was filled with other patients. We stopped to write her name on the board. "Foster's radical?" the clerk at the board asked. I nodded. "Bed six," he directed.

Using the undersheet for leverage, we lifted Esther onto her assigned bed. A harsh chorus of voices resonated in the room--"Run more saline in that line"; "His pressures are low, ramp up the dopamine"; "Check her oxygen, she looks a little blue around the lips." Dr. Foster marched through the din like a reigning royal. He dispatched the resident to scrub for the next case. Ordinarily, I would have returned to the wards to assist in chores. But Esther had been promised that I would be at her side when she awoke.

I looked down at her. Beads of perspiration glistened on her forehead. Her hair, matted by the sweat, was cropped close to be easily covered by a tichel.

Dr. Foster squeezed her right hand and said her name several times until her eyes opened and stayed open. She struggled to focus, the effect of the anesthetics still in her system.

"Mrs. Weinberg, the surgery is completed." Dr. Foster paused. "I'm sorry, we had to remove the breast."

Esther was silent for a while, then nodded slowly and turned toward me. "Groopman, you'll understand," she whispered. I held her gaze for a long moment, but her glazed eyes seemed opaque. She soon drifted back to sleep.

Just outside the recovery room, Dr. Foster stopped abruptly. "What did she mean by that?"

I had no idea.

Three days later, I received some clue to Esther's enigmatic comment.

On morning rounds Dr. Foster told Esther that because of thelarge size of the tumor and its spread to more than a dozen lymph nodes, the cancer was likely to recur soon. Chemotherapy would now be given to destroy the lurking cells in her body; it would begin once the mastectomy healed. "Chemotherapy is unpleasant," Dr. Foster allowed, "but potentially lifesaving." Foster himself would oversee the drug treatment, a common practice among cancer surgeons of his generation.

I visited Esther alone later that day. I had decided to take the initiative and ask her to explain her statement in the recovery room. But it didn't prove necessary.

"You should call me Esther. May I call you Jerry?"

"Of course," I said.

"Jerry, I was unsure at first if I could trust you. Can I trust you?"

Out of reflex, I extended my hand and grasped hers. Esther did not withdraw. She smiled, but it was a smile forced to fight back tears.

"My cancer is a punishment from God," Esther said flatly.

I began to reply, but Esther stopped me. "Wait."

She explained that Markus Weinberg, her husband, was from the same German-Jewish community in Washington Heights and had been chosen for her by her parents. He was twenty-one at the time, and she was nineteen. They had met twice before the wedding, and she knew on each occasion that she could not love him. She described him as meek and complacent, with little interest in the larger world. He worked as a grocer in a family business not far from their home. Esther exchanged few words with him, mostly about who would do what chore, or whether one of the children was progressing well in her schoolwork.

"I felt I could breathe only out of the house. Inside, I couldn't."

She knew that even with the formless skirts extending to her ankles, the billowing blouses with sleeves reaching her wrists, and her hair covered by the tichel, men turned when they passed her on the street. And she saw that her boss, middle-aged with a family in New Jersey, paid special attention to her. He told jokes that seemed designed to make her laugh, complimented her work and small changes in her appearance, like when she wore amber earrings that he said offset her eyes.

Copyright © 2003 by Jerome Groopman, M.D.. Excerpted by permission of Random House Trade Paperbacks, a division of Random House, Inc. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

About the Author

Jerome Groopman, M.D., holds the Dina and Raphael Recanati Chair of Medicine at the Harvard Medical School and is the chief of experimental medicine at the Beth Israel Deaconess Medical Center in Boston. His research has focused on the basic mechanisms of blood disease, cancer, and AIDS. He is a staff writer in medicine and biology for The New Yorker and is the author of two popular books, The Measure of Our Days and Second Opinions, which were the inspiration for the television series Gideon's Crossing. In 2000 he was elected to the Institute of Medicine of the National Academy of Sciences. He lives with his wife and three children in Brookline, Massachusetts.