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Post-Polio Health (ISSN 1066-5331)

Vol. 11, No. 4, Fall 1995
Presented at Sixth International Post-Polio and Independent Living Conference, Fall 1994

Facing Surgery When Breathing Is a Problem: Dealing with Breast Cancer Surgery

Ellen Fay Peak, Birmingham, Alabama 

When I was diagnosed with cancer in my right breast on March 2, 1995, my first thought was not "Am I going to die?" but "Am I going to be able to type and feed myself?" On April 3rd the surgeon, whom I ultimately chose, first examined me and said that it would have to come out. I responded, "No, it does not have to come out." He listened closely as I explained the history of my arm and shoulder limitations and watched carefully as I, naked from the waist up, demonstrated my very narrow range of arm and hand use, a range so narrow that I must have full-time physical assistance. There I was in a doctor's office trying to prove that my body had enough to do in dealing with the late effects of polio. Cancer did not scare me. It was the treatment of cancer that tore me up.

What was I doing between March 2nd and April 3rd? On the same day that I learned that I had breast cancer from a routine mammogram, I had a sonar exam of the mass in my right breast, consultations with two surgeons and a needle-core biopsy. Although the surgeons concurred with the idea of immediate surgery followed by radiation, I decided to do nothing until I had more information. I obtained some of the most useful from a friend who had undergone a modified radical mastectomy. Upon hearing my diagnosis, she came immediately to show me the results of her surgery, pointing out where muscles had been removed from her chestwall and down her underarm. She examined my breast and shoulder, drawing her fingers down my skin where the path of a surgery like hers would be. From that discussion, we determined that a simple mastectomy was as much as I could have and still use my arm. Anytime I needed her to, she would come and strip down and let me ponder my decision. She served as both my model and my patient advocate, putting forth ideas and intervening as needed.

On March 13, to try to determine if the cancer had spread beyond my breast, I had a bone scan, additional x-rays of my hips and a chest x-ray, all of which appeared to be normal. Having pretty much decided that I would have no surgery that required general anesthesia, I then investigated radiation therapy. Because of shoulder tightness, my arm could not be positioned for radiation.

I sought advice by phone and letter from doctors who knew me well. I discussed each development with my long-time internist who encouraged me to explore every avenue of information before making any decision. I had several informative conversations with the Medical Director of Post-Polio Services at Roosevelt Warm Springs (Georgia) Institute for Rehabilitation. His having my early polio records and those from his own evaluations of me through the years proved invaluable as we talked about the possible effects of general anesthesia and the types of breast surgery.

I pulled out "Anaesthesia: Considerations for Polio Survivors," an article I had saved from the Fall 1991 issue of Polio Network News, and copies of both Dr. Susan Love's Breast Book, and Post-Polio Syndrome by Halstead and Grimby. Because I was in the middle of planning the program for a state-wide forum sponsored by the Birmingham Post-Polio Support Group, I took the opportunity to discuss my situation with three of the major speakers. Each responded to my questions, providing me with an unexpected source of polio expertise.

Finally, I was in my surgeon's office arguing the fine points of tissue removal so as to preserve the little use I had of my right shoulder and arm: which lymph nodes I was willing for him to remove and what type of mastectomy I was willing for him to perform. I left there with a tentative surgery date, April 18th, to remove both breasts (the left breast looked threatening) and appointments with three more specialists to consult: the anesthesiologist, the pulmonary doctor, and the physical therapist.

On April 12th, I wrote the following letter to my surgeon, sending a copy to everyone else involved:

"When I recently spoke with the Director of International Polio Network about my impending, surgery and my agitation about my functioning, afterwards, she pointed out that she knew of no situation like mine. Thus, I feel compelled to continue to provide my physicians with as much information as I can about my polio state.

"As an upside-down polio quadriplegic since 1936, with post-polio syndrome since the late '70s, I am functioning at the outer edge of possibility. Once my assistant, Kay, dresses me in the morning, I wash my face, brush my teeth, and feed myself, all with my right arm helping my left. For exercise throughout the day, Kay helps me to my feet and I walk around inside my house with either her help or a walker. The walker is merely a balancing tool. I cannot put any weight on it. I spend most of my day at my computer, my right arm supported in a sling attached to my office chair, typing with the eraser end of a pencil between my fingers (my left hand controls the mouse). Otherwise, I read and converse on the phone, activities that require the use of both my right and left arms.

"I further say that, aside from its pain, cancer holds no more threat to me than polio. I am not in awe of it. I view it simply as one more possible obstacle to my functioning. Although in the past I have overcome many such obstacles, I now have so little margin of function left that I am doing everything within my power to protect it. First, I have chosen my surgeon carefully, indeed, with more care than I chose my internist, in those carefree days of the mid-'70s. Although that choice was kind of dumb luck, it has turned out to be one of my very best. I have discussed my situation with the individual I hope to have as my anesthesiologist. I have been evaluated by the physical therapist who will work with me after surgery. I have had the benefit of my internist's expertise, interest and counsel at every step along the way.

"As to the actual surgery: I understand that no paralyzing or other such compromising drugs will be used during the anesthesiological process. I also understand that you will remove both of my breasts and the first level only of the lymph nodes under my right arm. I would be very pleased if you decided to remove no lymph nodes!

"Beyond the surgery: I plan to have no additional therapy beyond the drug Tamoxifen, or its like; plan to partake of inhalation therapy; and interact with the physical therapist to regain the function I now have, not expecting to be rehabilitated out of my wheelchair.

"Finally but perhaps most important, here are some facts to know about me that are a result of my particular bout with polio. Others have their own strangenesses.

"Because of my lack of muscle mass, I am unable to generate body heat if I am chilled. Warrn to you may be chilling to me. When I am chilled, I feel great fatigue; my veins contract. Things that have chilled me in the past are: air conditioning not adjusted for me; cold tables; refrigerated saline to humidify oxygen; refrigerated IV fluids; iced drinks, including water, etc.

"The left side of my throat is weaker than the right; thus I am susceptible to choking on liquids.

"Like the extremely elderly, I am very reactive to the effects of medicine; thus, I have always worked under the plan of starting with the lowest possible dose of any new medicine, and sometimes I wind up taking less than that.

"These are my thoughts for the moment; now I can only hope for the success of all." 

After-surgery note: I wish I had added to the list above two items. Because of my lack of muscle mass, my limbs offer no resistance to such things as bloodpressure cuffs, blood-work tourniquets and manual positionings. My worst pain and a soreness that is still with me arose from the unnatural (to me) manipulation of my right shoulder on the operating table while I was under anesthesia.

Because of my enervated shoulder muscles, even the closure of incisions near my underarms became a major problem. The slightest roughness/lumpishness in that spot created a kind of a speed bump to my alreadylimited arm motion. I have recently had plastic surgery (under a local) to smooth out my right underarm.

I came through all of the surgery with little, if any, loss of function. Perhaps my arms and shoulders tire more quickly, but I am pleased that they serve me as well as they do. As for the cancer, the pathology report indicates that it was Stage One with negative lymph nodes, which means that it was caught early enough not to require follow-up radiation or chemotherapy. And because it contained no estrogen receptors, I am not even taking Tamoxifen.

References

Anesthetic Implications of Poliomyelitis by Joseph D. Tobias, MD. The American Journal of Anesthesiology, March/April 1995, pp. 102-104.

New Neuromuscular Blocking Drugs by Jennifer M. Hunter, MB. The New England Journal of Medicine, Vol. 332, No. 25, pp. 1691-1699.