Dr. Krishna B. Clough – The practice of cancer surgery and reconstruction

Screening

What is the biggest progress in cancer care? The biggest progress is screening, not treatment. The biggest progress in cancer is to detect a tumor at such a small stage that the surgical treatment will be done on an outpatient basis, there will be no chemo, there will be no heavy treatments. So the biggest progress, for me, for patients, is the screening that allows to avoid heavy treatments.

So if we can set up the ideal treatment, it’s a patient who gets detected very early for a small, non-aggressive cancer, who will have a quick surgery, a little radiation and no chemotherapy.

The cancer diagnosis

The period before the diagnosis is something that we don’t see, but we see the after-effects, we see the shock, because in fact the patients come to us with a diagnosis. But they tell us what happens before, and what happens before, we really don’t want to go there, because in fact, you do an X-ray and they tell you: “there might be something”; so in the best cases, they do the biopsy the same day, in other cases they make you come back a week later, in other cases, they tell you: “This period of “wait a bit” can last 2-3 months and therefore there is a whole pre-diagnosis period which is a particularly worrying period, and the patients that we see at the Breast Center are patients who have been diagnosed with cancer, and therefore obviously there is a whole part of these patients who leave reassured.

And so there was a kind of  built-up pressure, and we see patients who arrive with this past 2 months where there is hesitation, we don’t know, so I think the whole pre-diagnosis period, we don’t talk about it much, but it is a particularly unpleasant and particularly anxiety-inducing moment.

So, we see patients who are extremely worried, not only about the diagnosis, but about everything that happened before the diagnosis, and this is certainly something we must continue to work on to reduce these delays.

The consultation

The first visit with the surgeon is a key consultation. It is the consultation that will help defuse some of the anxiety that has built up over the past few weeks. And so we were talking earlier about the surgeon’s work, about teaching surgical activity in the operating room, but in fact for me the work today, at my age, with a few decades of experience, the most important, the heaviest, once the surgical technique is mastered, once the technique is acquired, is the contact, especially during this first visit.

I always tell my students that the patient comes to the consultation, she has death on her shoulders and physically you can feel it, literally, you walk into a consultation room, the patient joins you, in some cases she is scared, she is sweating, and it is a very particular smell of death anxiety, that you recognize… And I tell the teams that work with us: our job, once the technique is mastered, is that she goes in with death on her shoulders but comes out with a smile on her face, and it can take half an hour, it can take an hour, and all my patients complain because I’m always late in my consultations – so it’s a running gag at The Breast Center, I’m late all the time – but as long as I feel the fear, I’m not going to let her go.

The choice of treatment

Surgical treatment of cancer 30 or 40 years ago was still very difficult and left heavy sequalae.

And so my interest during my training was to train in cancer surgery and reconstructive and comestic surgery at the same time, to try to bring, from the moment the cancer is treated, all the tools, all the techniques of reconstructive surgery, so as to reconstruct the breast when it has to be removed, but above all – and this has been our center of excellence and innovation – to allow women who have a borderline indication where their breast could perhaps be kept – and where in fact in many teams, it is removed – to allow these women to save their breast thanks to plastic surgery techniques that we use immediately.

The choice of treatment is often highly calibrated. We are fortunate to have a known pathology with a great deal of publications and research, so in fact the choice is defined and uniform in 90 to 95% of cases; and, fortunately, if you have a certain type of breast cancer, whether you are in Paris, New York or Milan, you will be offered the same treatment. This is the result of 40 years of research that allows us to propose an optimal treatment.

And then there are 5% of cases, maybe a little more, where you hesitate, where you don’t know very well, and at that point it’s the strength of the team that’s come into play. So, there are two solutions: there is the lone cowboy, the surgeon alone who thinks that he has the answer, and then there is the team, what we call a consultation meeting, which meets every week, where for all cases, but especially the difficult ones, we will put all our intelligence together to try to define for this given patient what is the best solution, when we have a choice between 1, 2 or 3 solutions.

And this is also the strength of our specialty: when I don’t know, I ask the other person, and we take time, sometimes a few days, for the patient, which can be anxiety-inducing, but we explain to her, we say: “here you are in a grey zone, it doesn’t mean that it’s serious, it means that there is a choice and that I don’t want to choose alone, because if there is only me who chooses, it will probably be less relevant than if there is my whole team”.

And that’s how in these undetermined cases, we make a team proposal and it’s the strength of the big teams to be able to have several very high-level people who allow to give the patient the best solution.

The therapeutic team

The team is made up of all the practitioners who could take care of the patient at any given time: the therapeutic pillars are the surgeon, the radiotherapist and the chemotherapist, but there are also radiologists, specialists in the analysis of tumors under the microscope, and a psychologist or a psychiatrist in cases where the patient’s psychological state will lead us to one solution rather than another.

And then there is the patient, to whom at some point, we will say: “Here, there is a choice”. When the choice leads to an unequivocal solution, we will say: “this is what we propose to you”. And in a certain number of cases, we will say: “we hesitate, and, here is what we propose to you”. We have to do this as little as possible because in fact today we are witnessing, I think, a kind of transfer of the responsibility of the decision from the medical team to the patient, which is terrible… “Do you want to have the breast removed or do you want to keep the breast?” Me, I see patients who come to us in second opinion saying, “Me, I’m lost, I was told you can keep the breast, you can remove the breast…” It should be done as little as possible, so it’s very rare, but in a certain number of cases, the choice persists and there are advantages and disadvantages to both solutions, and we say: “Here we are and what do you think? And what can we do to incorporate you into that choice.”

So, when I say that, it seems like we hesitate all day long when in fact, once again, in 95% of the cases, we have a solution in consultation, face to face with the patient, if not to say in 98% of the cases.

Healing

Healing is my word. I hate “remission”. I know it gets used all the time, I know it gets published, I know patients say it themselves, but again breast cancer equals 80% cure. So that means that if you tell everyone you’re in remission, you’re going to tell 80% of women who are going to get well that they’re in remission.

And I prefer to tell 20% of women who may not be cured that they are cured, while monitoring them so that there is no loss of chance in this word cure. The day you remove my lung because I have lung cancer and you tell me, Mr. Clough, “you are in remission”, I will look at you and tell you that I did not come for that, I came to be cured and I use the term cure every time that cure is very likely; if I have a patient who arrives with two tumors in the liver and one in the lung, I will no longer use the term cure. But as long as the disease has not spread, my obsession is that the patient be convinced that she will be cured, because I think that this contributes, if not to her cure, at least to her well-being and to the well-being of everyone around her.

You can be the best specialist in the world, but if you are not able to give, to transmit the strength to live, the strength to go through everything that is imposed on them, because it is heavy, it is very heavy in cases of aggressive tumor, well, you have missed a part of your job.

So, some people talk about psychology, it must exist, others talk about accompaniment, in fact we will give you so that you pull through and that you know that we are there with you in this ordeal.

The end of the treatment

The downside of this support is when the treatments stop. Because there is a very particular moment in the therapeutic relationship when we say to the patient, so here you are, you’ve had your surgery, you’ve had your chemotherapy, you’ve had your radiotherapy, so we’ve been seeing each other all the time for 9 months, 10 months, and then: “goodbye, everything’s fine”. And then if we haven’t prepared the patient, and unfortunately, we are so involved in the fight that we don’t always do it, we don’t prepare. The patient says: “But you’re saying goodbye to me? I’ve been with you and your teams for 9 months and I’m not going to see you anymore”… “Yes, you will see me in 6 months or 8 months”. And then, pchhht, there is a moment when the patient goes home, then there is the relatives that say: “it’s great, you don’t see your doctors anymore, it’s great, it’s great, we’ll be able to go away for the weekend, Ah, and then you’ll be able to work again”. And then there is a great emptiness that is: “but I was carried by these people who helped me, who accompanied me, and then all of a sudden they are no longer there every day” and it is a moment of astonishing, paradoxical distress for some patients, because they feel abandoned, and this has been called therapeutic abandonment.

And it is mandatory, because we are not going to go to their house every day, because we have other things to do, then because we have to take care of others and this passage of baton between “you are in the fight of cancer” and “you resume a normal life”, there is something that we did not know how to do, that we did not know how to set up and on which there are certainly improvements to be made…

What’s next?

You have fought your battle, and again it can last 9 months, it can last longer and you go back to a life that is the life of before and where around you, we want it to be like before, but I have many patients who tell me: “But I can’t, I can’t do like before”.

When I see patients during the first visit who tell me that it is terrible, who are in distress from the announcement and that we manage, little by little, with the time it takes, to bring them down to the reality that the vast majority of breast cancers are cured, sometimes we can initiate this little sentence by saying: “Listen, I’m going to tell you something, I would never have dared to tell you this 10 years ago, but I’m going to tell you what I’m told in this place, in this office, in this chair, 1 or 2 years later. Some patients who have had the same thing as you say to me: “Mr. Clough, this cancer did me a favour” and the idea of telling a patient at the moment of distress that finally others, who have had the same thing as them, have enough hindsight 1 or 2 years later to say: something happened, and cancer is a life accident.

I tell all my patients: cancer is a life accident; you could have had a car accident, you could have had a fractured pelvis, you could have lost a child, monstrous things… Cancer is nothing but a life accident and there is an aftermath; and our job is to be the firefighters during the accident, as little aggressive as possible, and to prepare for the aftermath.

I don’t know if it makes all of us who have had an accident in life stronger, I don’t think it makes you feel stronger, but I think it helps you see your life in a more holistic way than you imagined before. You’re less mono-purpose, you know that accidents happen, you know that your life is going to be changed, you know that there’s a before, there’s an after. I’m not sure you’re stronger afterwards, you’re just different.