After Laura Wilcox's lumpectomy at 32, she was sure the future looked bright. But just as hope springs eternal in the human breast, so can cancer.
Mary Ellen Mark
“I think she is very open because she has been through so much,” says Mark of the breast-cancer patient she photographed for “The Barest Hope.” “She is a lovely-looking woman who is in great shape and has a really positive outlook. Her story is an inspiration for any woman who might have to face something like this.” Mark is working on a book of pictures taken in America from the 1960s to the present that will be published by Aperture.
Laura Wilcox wearily regarded the hospital smock. No matter what a woman looked like in her street clothes, her shoulders tended to slump once she put on that faded blueberry-and-cream wrap top with "UCLA Medical Center" stamped in a big circle on the back.
This was the last place she had expected to end up, and her whole demeanor-the vivid makeup, the perfect posture, the neatly arranged clothes- was an attempt to preserve the illusion of health. Laura had gone through life being told she was beautiful. In her 20s, briefly, she had been a model, and although she had not modeled in more than 15 years, she worked hard to protect and refine her appearance.
Laura [at her request, her name has been changed] was a production executive for a television personality who wanted to break into movies. At 38, she was painfully aware that most development executives were younger, late 20s or early 30s. She tended her body diligently -vitamins, regular meditation, no red meat, and 300 sit-ups a day to maintain the flat stomach she was so proud of.
When she'd decided in 1988 to have breast implants, it was not because she wanted big breasts to impress men. She simply considered her tall, curvy frame and decided that her A-cup breasts were out of proportion. So she fixed them. If she could not position herself as a wunderkind, she could be a beautiful woman with brains. That would buy her enough time to become an independent producer, a job in which she would have the autonomy to age gracefully. The only problem was her personal life, or her lack of one. Laura was single despite a couple of promising romances and more obsessed every day with settling down and having a family. If her hands fluttered just a bit and a thin vertical line appeared between her brows, it was because the scenario she'd been imagining for herself hadn't included any more downtime for illness.
Laura was diagnosed with breast cancer for the first time when she was 32, just nine months after her implant surgery. She had a lumpectomy and radiation rather than a mastectomy, but since she had one positive lymph node-the standard measure of whether a cancer is likely to metastasize, to escape into the bloodstream and spread to distant organs- she also had chemotherapy. She felt a second lump in her right breast in October 1993 and decided to see if it disappeared when she got her period. It didn't. She had a surgical biopsy on New Year's Eve. The report showed a malignancy.
Doctors were able to save Laura’s right breast the first time they found cancer. But the second time, there was no way around it: A masectomy, then reconstruction. (A scar on her left breast is the result of implant surgery.)
She came to UCLA because breast surgeon Susan Love -author of Dr. Susan Love Breast Book and an outspoken advocate of more research and better care- had recently started a multidisciplinary program that enabled a patient to see all the specialists she needed in a single afternoon. When Love appeared, Laura rattled off the details of her case as if she were reading the weekend grosses on a new movie. Her voice wavered only slightly as she got to the important questions: Why did she have breast cancer twice? Was this a new cancer, or had the old one come back to kill her?
Love believed that Laura may have had a local recurrence, a slow-growing "leftover" cancer from the 1988 surgery-not an indication that the cancer had spread, but a portion of the tumor that remained after the surgery, "which doesn't mean the surgeon's bad." Love hoped she was right. Residual cancer like this was usually a matter of housecleaning: Laura did not have breast cancer again; she had it still. (Recurrences happen to approximately 10 percent of women who have had breast cancer. Any surgery leaves some breast cells behind, and any of those cells could be malignant.) Laura did not have to be any more frightened than she'd been the day before she found it.
"You'd have to be God, I guess, to get it all," said Laura, relieved. "You know any surgeons like that?"
"I know some who think they are," said Love.
She gestured at the resident who'd been standing in the corner of the room and asked Laura if she would mind letting him feel the lump as well.
"Oh, I'm used to it," said Laura, lying back down.
Love flashed a grin. "They say the most frequent side effect of breast cancer is that you say, 'Hello,' and immediately start unbuttoning your blouse."
After the specialists had seen the afternoon's patients, they met to evaluate each one. It was five o'clock when Love finally returned to Laura's examining room. Things were not as simple as she had hoped. The remnants of Laura's invasive cancer might have been relatively easy to remove, but when the pathologist looked at the slides from Laura's biopsy, he also saw extensive intraductal carcinoma, or DCIS, a precancerous condition of the breast that changed everything.
DCIS is a surgeon's nightmare. It does not form a palpable lump; sometimes it causes telltale clusters of microcalcifications; sometimes doctors simply trip over it on a pathology slide when they are looking at something else. DCIS only turns into invasive cancer 30 percent of the time, but there is no way to predict if it will. It had to come out -a tricky proposition since it is diffuse and invisible.
"It's not more aggressive, not likelier to kill you," Love explained, "but it doesn't make lumps, it's hard for the surgeon to find it or radiation to kill it. With hindsight, you're not a good case for a lumpectomy." She paused. "Chemotherapy won't get these cells either." Laura listened attentively to Love's biology lesson, but as the surgeon started eliminating treatments Laura's smile began to fade.
"The bad news is the best way to deal with this is a mastectomy." No breast. There it was, after six years of thinking she had gotten off with a small scar. Until this moment she had allowed herself to imagine a side exit, maybe another lumpectomy, but no longer. She was going to lose her breast.
Not an acceptable option for a woman who carried such a clear picture of the ideal form in her head, who had asked the implant surgeon to operate a second time to reduce the size just a bit, to bring her closer to that perfect mental image.
In a fog, Laura heard Love encouraging her to have immediate reconstruction. William Shaw, chief of UCLA's division of plastic surgery, was a pioneer in the "free flap" procedure, in which he removed a section of the patient's own skin and tissue, from her abdomen or buttock, and used it to fashion a new breast. Laura forced herself to focus. She could get rid of the precancerous DCIS and still look like herself. Shaw would work on her at the same time that Love performed the mastectomy, so she would wake up from the anesthetic with something that resembled a breast. She would never have to confront a flat scar. That was pretty good news.
But life refused to be easy. Laura was back to see Love a week later to tell her she was pregnant. Laura had a friend, a man in his 20s, and though they weren't lovers, she had let him spend the night, just once, about a week after her diagnosis, because she couldn't think of any reason not to. It was easier being with him than with someone new and certainly better than being alone.
The father had no idea what had happened, and Laura was not inclined to tell him. What she wanted Love to tell her was whether she could protect her health and keep the baby.
Laura sat on one of the chairs in workday black, cigarette pants and a long, slim sweater, and listened as Love recited her options. She could not have the mastectomy in her first trimester because general anesthetic increased the chance of birth defects, and she could not have it in the third trimester because of the possibility of premature birth. Love felt that the most reasonable compromise was to perform another lumpectomy right away under a local anesthetic to get rid of the remaining invasive cancer and wait until after the child was born to have the mastectomy for the DCIS and reconstruction.
Laura wondered if she ought to have an abortion. She wasn't sure she wanted a relationship with the father nor that she could handle the pressure of being a single mom. But emotion overrode logic. This was the only bit of good news she had had in months. She had conceived a child.
Love teased Laura about the benefits of having the mastectomy and reconstruction after childbirth. "At that point," she said, with a sly smile, "you might welcome a tummy tuck."
Laura studied her worrying fingers. She blamed chemotherapy for screwing up her periods. The drugs often kicked a woman into menopause, but Laura's situation was trickier. She ovulated. She just couldn't predict when. Of course, she had to admit, she could have used a diaphragm and hadn't.
"I have been trying, in my own way, to get pregnant the last couple of years," she said, sighing. So they decided on the lumpectomy in three weeks, once Love returned from vacation. The implant in the right breast would come out then.
Just ten days after the surgery, Laura arrived at Love's office bearing more news: On Valentine's Day, she'd been fired, given two weeks' notice. She would be out of work at the end of the month; her insurance would run out at the end of September. She wondered if she ought to have the mastectomy for the precancer right away.
Love tried to calm her. There'd been no dirty margins from the recent surgery-the invasive cancer was gone-so she could wait until the end of the pregnancy for the mastectomy. She told Laura to go home, take it easy, and try to get used to being lopsided for seven more months. There would be plenty of time to be beautiful after the baby was born.
Once home, Laura reflected on her situation. She could look to doctors for advice on how to fight her disease, but no one could tell her how to go on living. The model from the previous generation was too limited to be useful: She was hardly ready for passive acceptance, for a life of childlessness and cautious necklines.
“At first I said,’I have breast cancer. I can’t worry about aesthetics.’ Well, yes, I can.”
Having grown up in Southern California, she believed initiative mattered more than tradition. She wanted to keep the baby. But she couldn't make a perfect husband appear or the cancer disappear. She told herself she would take a chance if she could just find a job, but the world refused to cooperate. She did not see how she could possibly handle everything at once. With barely four weeks left before the end of her first trimester, she scheduled an abortion-and arrived at the hospital for the appointment on the morning of March 10 a jittery wreck, begging for a Valium to help her calm down.
For a week afterward she refused to answer the phone. Finally she called the man who had spent the night and told him what had happened. He told Laura he loved her. She got off the phone and muttered, "Who cares?"
Right now the idea of intimacy seemed ludicrous. Every time she got in the shower she looked at her uneven breasts and wondered how she'd ever be able to be naked with a man again. Even if a man were to say that he loved her, even if he said he did not care what her breasts looked like, Laura cared. There was no way she could enjoy sex now.
The real trick was to stop caring. She thought that if she could just let go of her vanity she would love herself and be loved, but she could not quite give it up. Three hundred sit-ups a day were as important to I her as her daily meditation.
There was no longer any reason to postpone the mastectomy and reconstruction, which she scheduled for May 24. But a few days after the abortion her gynecologist phoned to see if she could drive right over. The pathologist had found something abnormal in a tissue sample. It was a possibly precancerous condition called a hydatidiform mole, a mass that fed on a pregnancy and could develop into a serious, sometimes fatal uterine cancer if left untreated. It was a fluke coincidence, unrelated to her breast cancer, but for the moment the mole trumped the breast-cancer diagnosis. This was the kind of problem that required an immediate response.
The doctor explained that Laura would have to have weekly blood tests to see if the levels of Beta-HCG, the same hormone produced in a normal pregnancy, were still high. After an abortion, Beta-HCG levels were supposed to drop-unless the premalignant mass fooled the body into thinking there was still a pregnancy to nourish. If the hormone levels stayed high-or dropped, then spiked again-it would mean Laura was still in danger. She would have to have a course of chemotherapy immediately. The mastectomy and reconstruction would have to wait.
The only cold consolation was the news that she inevitably would have miscarried; the abortion had in fact saved her from grief further down the road.
Laura took refuge in planning: She would not cancel any of her preop appointments for the mastectomy and reconstruction until the blood tests said she had to. On April 18 she paced around the plastic-surgery examining room waiting for the flap consultation, too wound up to hold still. The second week's blood test showed that her levels of Beta-HCG had dropped. One more week like that and she'd be officially safe.
When William Shaw arrived, he studied Laura as though she were a piece of sculpture. He asked her please to stand up and remove her slacks, then he sat on a low stool in front of her, reached up, and squeezed her healthy left breast, the one that still had the implant in it. With the same mute detachment, he reached down to feel how much fat she had in her abdomen. Not much. He reached over to squeeze her hip and her buttock, looking for enough tissue to approximate her healthy breast.
"OK, now," he muttered, without looking up. "You'd like the size to be about the same as what you are now?" He gestured toward the left side.
"No, we can go much smaller than that," she said, flustered. "I don't mind a small breast on me. I've been around the block with my breasts. As long as they look OK, I don't care." Shaw could remove the left implant. The only issue now was what to use for her new right breast-abdomen or buttock or hip.
She sighed. "I've got scars here," she said, pointing to her breast. "I'm single. I'd like to think of myself dating again someday, and the idea of all these things here," she gestured at the front of her body, "I don't think I can handle it. Can I handle something back here?"
"I think so, yeah," said Shaw. "You're going to have a scar somewhere, and my personal experience is that for younger women, scars in the hip and buttock tend to go a little bit better."
"OK," said Laura, suddenly confident again. 'Then I feel very good about choosing this area. At first I said, 'I have breast cancer, I can't worry about aesthetics.' Well, yes, I can. It's important to worry about aesthetics."
"Cancer or no cancer," said Shaw, "it's the same."
"Thank you for saying that."
"Unless you can put it back together in a reasonable shape," he said, "the patient is going to have a hard time."
When, in the third week after the abortion, her third blood test did indeed spike, Laura grimly canceled her mastectomy and submitted to one session of chemotherapy-but luck finally broke in her direction, and the subsequent tests were normal. She quickly rescheduled the surgery for June 28 and began another assault on the job market. Once her severance ran out, all that stood between her and being broke were a few souvenirs of easier times -a treasured diamond bracelet, a heavy gold necklace- that she would sell if she had to.
She heard about one job opportunity that sounded perfect. The president of what she considered a very cool production company was looking for a vice president. All she had to do was write him a letter explaining why he should hire her.
She spent a day staring at her computer, trying to remember what she liked about herself. "Come on," she scolded. "Sound like you're a happening broad."
Draft after draft, and nothing that sounded convincing. How was she supposed to make plans when her body kept playing tricks on her?
Finally she got up and went into her bedroom to meditate. When she finished, she marched back to her desk, finished the letter, and called a messenger. Then Laura fell to her knees and offered up a prayer for some good luck.
A few weeks later she heard that the job had gone to a younger woman.
The night before the operation, Laura's sister and her two best friends -her surgery support team- stayed with her to keep her from being nervous and did so well that all four slept right through the four-thirty alarm. Luckily a friend called at quarter to five to make sure they were ready to leave at five. They managed to get in and out of the bathroom in record time, find a predawn cappuccino on their way to the hospital, and land in room 213 by six. Insistently lovely-nails polished, hair burnished to a sheen-the three clustered around Laura's bed as though they could, by their very presence, will her back to health.
Just before seven, Susan Love appeared to accompany Laura to the operating room. When the elevator opened, the orderly rolled her bed in and Laura's friends quickly crowded around. There was no room left for Love, who shrugged and headed for the stairs.
An hour later, with 19 people in the OR, Love stepped over to Laura's side and took her hand. "I think there's hope for you," was the last thing Laura heard before she went under.
"How'd she find it the second time?" the anesthesiologist asked.
"Mammography," said Love.
The anesthesiologist shook her head. "And she's a nice lady, isn't she?"
"A nice lady," said Susan. "Not a very good-luck lady."
Love and her resident performed the mastectomy while the plastic-surgery team prepared to remove the tissue that would be used for her new breast. One of the plastic surgeons complained that Laura was too fit. They needed fat, not lean muscle.
"Buns of steel," he muttered.
"That's it," said Love. "She's been doing 'Buns of Steel.' Only in Southern California would you find buns of steel."
"Right," said one of the attendants. "In most places..."
"...it would be buns of Jell-O," cracked another.
The procedure went on for more than five hours, until Shaw, using a microscope, attached the vein and artery from the flap to the vein and artery pulled down from under the arm, which would now supply the tissue with blood. When he was done, Laura was rolled onto her back, placed on an air mattress, and taken upstairs. By six in the evening, she began to regain consciousness. Fifteen minutes later, Love walked in.
"So," she said, "you feel like a truck ran over you?"
"OK. It did. Ran right over you. But it's done." Love peeked at the new breast. "It looks great."
"Ooh, I did get hit," mumbled Laura, from the far side of her medication. "Gonna throw up."
Love grabbed a tray and handed it to her. "OK. Turn your head."
Laura slumped back onto the pillow. "Maybe not. Ooh."
"OK, where's your bell?" Love rang for a nurse. "See you tomorrow."
It was over. Within two months, Laura was tasting the euphoria specific to Hollywood deal makers, whose future can turn on a phone call. She'd met a novelist who was finishing a promising property and got him to let her option it. Her producing partner offered Laura her house in Sun Valley, Idaho, a favorite getaway spot for the industry. As Laura packed, she happily imagined herself walking down the main street and bumping into deals.
She had survived several varieties of hell and was back to some semblance of normal life. One morning, running errands in Beverly Hills, she decided to take a stroll down Rodeo Drive. When she got to the Giorgio Armani boutique she could not help but stop. She stood frozen in front of the window, staring longingly at a deep brown tweed suit, imagining how wonderful she might look in it, her broad shoulders in that double-breasted jacket, her long legs swathed in effortless wool.
For the first time in almost a year Laura felt like doing a little shopping -which is to say, she was prepared to get undressed under the watchful eye of a salesperson. Being naked in front of Shaw was easy. Being naked in front of someone else was still far harder than she liked to admit.
In fact, she had not yet been naked with anyone. She had no compunction about showing off Shaw's handiwork to anyone who expressed interest, but that was bravado. Intimacy was more difficult. Some days she couldn't even be naked alone; she got out of the shower in the morning and began to weep. Her life was too often a maze of statistics and incision lines and the fear that even the most basic of pleasures-a man's affectionate touch, a week without worry-were beyond her reach. But Love said that a woman's initial grief passed with time; life did go on.
Laura was just now starting to have glimpses of that cleaner future. It was a great relief to stand in front of a store window like a regular person, thinking about how great she would look in that suit-for once not thinking about the details of how she got there.
Excerpted from To Dance With the Devil: The New War on Breast Cancer, by Karen Stabiner to be published by Delacorte Press in May 1997.