She walks through the emergency-room doors sometime in the early morning. In a plastic bag, she carries an object wrapped in a moist towel.
The “chief complaint” on her chart at Grady Memorial Hospital, in Downtown Atlanta, might have set off a wave of nausea in a hospital at a white suburb or almost any place in the civilized world. It reads, “My breast has fallen off. Can you reattach it?”
The patient, Edna Riggs, is fifty-three. She works for the phone company and lives on the southeast side of Atlanta.
Sitting on an exam table, she looks placid. When she extends her hand, it feels limp. She makes fleeting eye contact. This is depression, maybe. Shame does the same thing, as does a sense of doom. "Fatalism" is the word doctors have repurposed to describe this last form of alienation.
In medicine, we speak a language of our own, and Edna’s physical problem has a name in doctorese: automastectomy. It’s a fancy way of saying that the patient’s breast has fallen off by itself.
An automastectomy can occur when a tumor grows so big and so deep that it cuts off the blood supply from the chest to the breast. Denied oxygen, breast tissue dies and the breast starts to detach from the chest wall. At places such as Grady, automastectomies are seen a couple of times a year, often enough to be taken in stride.
This case is different from others I have seen only because Edna Riggs has wrapped her detached breast in a moist, light-blue towel and brought it with her for reattachment. I can’t help wondering why the towel is moist. Some deliberateness has gone into the breast’s care. I cringe at the thought that Edna has kept that package next to her on the gurney in the ER for hours.
In the exam gown, Edna’s chest looks surprisingly normal. I ask how long has she had a “breast problem.”
She first felt something in her breast when her son was in second grade, she replies. It has grown over the years. She speaks correct English, not the language of the streets. She sounds like someone who has had schooling, a person who reads. Her hair is clean and combed, she is dressed neatly.
What grade is her son in now?
I don’t react, not visibly. She has known she had a problem for nine years—why did she do nothing?
Edna’s breast cancer has been growing for at least nine years. It’s unheard of that cancer such as this would be anything but metastatic. The disease has to have disseminated to her bones, lungs, brain, liver. I feel a wave of frustration and anger.
Early on, Edna had some insurance, which didn’t do her any good. Her employer wouldn’t let her take just two or three hours of sick leave to go to the doctor. If she needed to take sick leave, she had to take it in increments of one day. This guaranteed that an employee would exhaust all the leave quickly. If Edna had been fired for taking time off after exhausting her sick leave, her three kids, too, would have lost support and insurance.
Acknowledging the physical problem and facing the consequences became increasingly difficult. Edna tells me that she feared the disease, but she also feared the system. Would the doctors scold her? Would they experiment on her? Would they give her drugs that caused nausea, vomiting, hair loss? Would the hospital kill her?
Edna’s decision to stay out of the medical system was about fear: fear of breast cancer, fear of the medical profession, fear of losing the roof over her kids’ heads. Fear intensified after her employer started to require copayments from workers who wanted to be insured. This extra $3,000 a year made health insurance too expensive to keep.
Payment for medical services and sick-leave policies determine the quality of service we receive. Several years ago, my research team at the American Cancer Society published data showing that people diagnosed with cancer who had no insurance or were insured through Medicaid were 1.6 times more likely to die in five years as those with private insurance.
In breast cancer, patients with private insurance were more likely to be diagnosed with Stage I breast cancer than those who had no insurance or were receiving Medicaid.
I have seen poor breast cancer patients choose mastectomy (surgical removal of the entire breast) over a lumpectomy (removal of the tumor) because of employer sick-leave policies.
A woman who chooses a lumpectomy must also receive radiation, which has to be given daily, Monday through Friday, for six to eight weeks. The treatment requires fifteen minutes in the clinic, but it’s done only during business hours. Unfortunately, this less disfiguring treatment is hardly an option for a woman who knows that longer postoperative treatment will cause her to lose her job.
Much of the problem is that poor people don’t get care that would be likely to help them. The reasons for this are complex. Perhaps they can’t get care, or don’t know where care is available, or haven’t been offered insurance or steady access to care by their job or social services.
Here is the problem: Poor Americans consume too little healthcare, especially preventive healthcare. Other Americans—often rich Americans—consume too much healthcare, often unwisely, and sometimes to their detriment. The American healthcare system combines famine with gluttony.
(Let me add that almost everything about America is 'famine & gluttony')
Edna has stage IV breast cancer. Disease has spread all over her body. Had she come to see me early in the course of her disease, it would have cost about $30,000 to cure her. She could have remained a taxpayer. Her kids could have had a mother. Now, the cure is not an option.
..sometimes cancer drugs give us “long-term survival,” in the dispassionate language of those of us who study outcomes. But for every Sandra, we get fifty patients with metastatic disease who “don’t do well.” They live a median eighteen months, which means that half are living and half are dead a year and a half after diagnosis.
We try three treatments and manage to contain Edna’s disease for a while. She dies at age fifty-five
, about twenty months after walking into the ER.