The wait that kills

Delays in surgery can be dangerous

By Leda

In April, 2010, I had a mammogram, only eleven months after a previous one that was “normal”.  A biopsy showed that I had a grade 3 tumor (i.e., highly undifferentiated, with a high mitotic ratio) that had already grown to about 2 centimeters.  Surgical removal was the obvious next step, but despite the efforts of my family doctor and friend, it was not possible to schedule the operation in less than a month, if not much longer.  As too often occurs in cases of backlog and delay, the specialist told me that “there is lots of published evidence that it makes no difference whether you are operated right away or in two months from now.”  I was in a daze.

             But I work on breast cancer.  There is plenty of published evidence showing the importance of early detection and treatment.  According to an article published in Lancet (Richards, 1999), a delay of 3 months from detection to surgery increases 5-year mortality (not just relapse…) by 12%!  If this were not so, why would the government pay for screening mammograms?  Not all breast cancers are slow-growing, and even cancers that advance slowly at the outset, pick up speed as they progress and accumulate mutations.  How quickly an invasion will kill is anybody’s guess at the time of the initial biopsy.  But, you are supposed to wait your turn as you wonder how quickly your cancer is spreading.  I was told to “do yoga” or “go biking”  to “deal with the stress of waiting”…

              Luckily, a surgeon friend operated my cancer off a few days later. I am grateful to him forever!  I had no idea how much the cancer had already spread, so I told my son farewell as I left for surgery. “If I do not see you again, I want you to become a good veterinarian.”  My tumor turned out to be among the most aggressive. The whole tissue was cancer, a lobular, pleomorphic, and multicentric variant described in several publications as “particularly lethal,” fast-growing, and fast-invading.  Luckily, my lymph nodes were still negative and PET, bone and CAT scans showed no metastases.  But it would not have stayed put much longer, and once it reached the lymph nodes my life expectancy would have been, according to the literature, about one year.  I have had four more operations and six cycles of very aggressive chemotherapy, but the misery of these was nothing compared to the fear of leaving my children behind as teenagers, 17 and 18.

            I have over 20 friends who have had breast cancer, in Germany, France, England, Poland, South Africa, and Greece.  All, even with DCIS (ductal carcinoma in situ, a precancerous condition), had surgery within one to three days after the biopsy.  All were told that it was critical to have surgery right away.  Why are cancer patients in Canada told that waiting does not matter?  Why take such chances with patients’ lives?  Cancer surgery is not “elective” or cosmetic, but a matter of death or life (death is the default…).

            Greece is not a member of the G8 or G-whatever.  Yet nobody in Greece is told when they are triaged to “be patient, meditate or go biking” as their cancer spreads.  Canada is not a third-world country, but its standards in this matter do not compare with those of most civilized countries.  It is not Canadian doctors, of course, who claim that delays caused by the under-funding of hospitals “make no difference”; many, like my surgeon are my heroes, trying to make do with what there is.  But it is Canadian politicians, Canadian economists, and ultimately Canadian voters, who vaguely imagine that by restricting the numbers of health-care specialists we save some Canadian dollars.  That policy would be unconscionable even if the calculus were valid.  But the calculus is not valid, since allowing the cancer to metastasize and complications to develop is more, not less costly, and in every sense of the word… 

            The latter is puzzling to me.  Why do the powers that be, ie politicians and administrators allow this huge waste of money?  The cancer will not go away by itself, no matter what with delay so the cost is there, unless you die… It will need to be operated off at some point and if it has spread, then a small incision to remove an in situ lump becomes major surgery (~10,000$). Then chemotherapy may be needed (~30,000$?), perhaps Herceptin (~40,000$) or other drugs that are even more expensive.  If it has invaded the lymph nodes, then lymphedema will set in, at a cost of ~3-4,000$/yr for life. I doubt they do not know the cost since they can google it, if they don’t have any knowledgeable advisors, which they do.  The mere existence of the delays creates that nagging feeling, could the reason be the ghost of privatization of health care hanging above us? 

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