A breast surgeon weighs in on breastfeeding and breast cancer survivors
When I was a surgical resident, I donated 150 ounces of breastmilk to a woman I’d never met, a woman who had undergone a bilateral mastectomy for cancer. It was an easy decision – I had more than I could use, she had none that she could provide. This experience became a major one in my decision to specialize in breast surgery. The dichotomy of breasts fascinated me. Breasts are highly sexualized, yet the source of comfort and food to babies. Breasts can make life-sustaining milk, and they can develop a cancer in up to 1 in 8 women that can be life-threatening. It is no wonder that society’s relationship with breasts and breastfeeding is complicated.
I have had many patients (too many) in my practice who were young and pre-childbearing, or even pregnant or breastfeeding at the time of diagnosis. Most experience the same terror that Ms. Wax-Thibodeux felt. Many choose bilateral mastectomies, prioritizing their health and a minimization of future risk. I also care for young women with benign breast disease, that still require surgical biopsies. I do discuss the potential impact of any surgery on breastfeeding. For a lot of women, this is a side effect they hadn’t even considered. It often does not ultimately change their mind about their own most appropriate surgical choice, but there can be a pause. A moment where they consider what that means, when they reconcile themselves to that consequence, when they have the moment to grieve. Unfortunately, I suspect that not all of my colleagues do this. I wasn’t ever trained to discuss it. We spent more time, significantly more time, discussing the cosmetic changes of the breasts than any functional changes (including, unfortunately, changes in sensation that may affect sexual enjoyment.) So, for women whose world has been rocked by a cancer diagnosis at a young age, who are terrified about their survival, there is probably not the opportunity to mourn the loss of breastfeeding, until that moment comes when they hold their babies in their arms.
And then, guilt sets in. A useless, impotent guilt. A guilt that in this situation can be exacerbated by ultimately well-meaning people. A guilt that in Ms. Wax-Thibodeux’s situation was worsened by lactation consultants that obviously did not look at her medical record as they should have, by acquaintances that misinterpret critical commentary as breastfeeding support rather than determining what, if anything, they could offer to help. And while, as Eleanor Roosevelt famously said, “no one can make you feel inferior without your consent,” the demands and uncertainties of new motherhood do wear you down. You do feel guilty, over a necessary sacrifice, over a choice that you make that is ultimately the best for your family (a mother that is alive and free of cancer? Yes!)
In that situation, it is so difficult to say simply “I am doing the best I personally can, though it is not perfect.” We all want to be perfect for our children. So, we become defensive. We look for more reasons, every reason, why the rejected option was not only less right, but completely wrong. We find the study that supports our own bias, ignoring the overwhelming majority of studies that contradict it. We label a sibling study as “groundbreaking” when it is really just a casual and flawed form of case-control study (below metaanalysis, various forms of randomized controlled studies and cohort studies in a hierarchy of study designs), one that ignores the essential and very important difference between those siblings: whatever changed in the family that led one child to be breastfed and another formula fed. We deflect the judgment we perceive on to others, resorting to name-calling like “breastfeeding Nazis.” We close ourselves off to novel alternatives like milk donation, because it hurts to stray from the belief that it doesn’t matter which we have convinced ourselves is the truth.
I get it. At only 5+ years from her treatment, the surgical wounds have healed but the psychic wounds of cancer are still there. I have only experienced it as a witness, but I see my patients coming back for checkups years later, with clear imaging and exams, and still with racing hearts and sweaty palms. And I get it as a mother, who has made other decisions, other sacrifices, because they are right for my family, and who knows the pang of reading an article discussing the possible consequences of those decisions. Things can matter, without being the only things that matter. Breastfeeding matters, and it still matters even for women who cannot do it.
Shannon Tierney, MD, MS is a member of ABM and a breast surgeon at Swedish Cancer Institute in Seattle, Washington. She is a featured speaker at the ABM 19th International Meeting, November 13-16, 2014.
Blog posts reflect the opinions of individual authors, not ABM as a whole.