Surgeon Hester Oldenburg on the breach
One in seven women will experience breast cancer in her lifetime. Breast cancer surgeon Hester Oldenburg can talk about it: she was affected by the disease twice. “I now understand even better what my patients are going through.”
She had already operated on thousands of women, when surgeon Hester Oldenburg herself was told in 2007 that she had breast cancer. Exactly in the year that The Breast Cancer Book was published, the ‘bible’ about the disease that Oldenburg wrote together with fellow surgeon Marie-Jeanne Vrancken Peeters. Recently a completely revised version of the book was published, with the new title: All about breast cancer.
The previous version was from 2013. What has changed since then?
“Eight years ago we had a standard approach, with surgery, chemotherapy, radiation and/or hormone therapy. We only deviate from this in exceptional cases. Since then, not only has the number of treatment options increased, but we also choose the right mix more emphatically in consultation with the patient. We can do that because we know better and better how different forms of breast cancer work. And therefore also whether certain treatments are useful or not. Sometimes the conclusion is that more is needed than stated in the guideline. Often it is precisely that we can leave things behind.”
And as for operations?
“We are operating smaller and more precisely. If a larger procedure is nevertheless required, we will do a direct reconstruction of the breast in order to preserve the skin and nipple if possible. Another thing is that until a few years ago, we used to remove all affected axillary glands. Patients could suffer from unpleasant complaints, such as numbness, nerve pain, a stiff shoulder and lymphedema. We rarely do this procedure anymore. Radiation appears in many cases to be a good alternative or otherwise an armpit-sparing operation. In any case, we operate less and less for breast cancer. This also has to do with the tailor-made treatment: if you combat cancer cells in a targeted manner with medication and radiation, you can perform more sparing or smaller operations. In some cases, we can omit surgery altogether in early stages of breast cancer.”
You say that the best choice is made in consultation with the patient. Wasn’t that the case before?
“Obviously we discussed the options. But the advice was usually: let’s follow this path, because the guideline says so and we, as doctors, think it’s the best. Nowadays, the consultation is much more equal. We ask patients what is essential to them, what makes their lives worth living. Suppose someone’s greatest passion is painting. But there is a good chance that he will develop nerve pain as a result of certain chemotherapy and that he will not be able to use his hands as well. Then we discuss together how much that weighs and whether there are perhaps other options.”
Do you still find the population screening useful?
“Yes. But I do think it could be more effective. The best thing is if we can make a personal risk profile of women in the future. With information about, for example, density of the glandular tissue in the breast, heredity and lifestyle. On the basis of this you can then determine whether and, if so, how often it makes sense to examine a woman for breast cancer.”
Due to corona, far fewer women were screened last year.
“Correct. And fewer people were referred to an oncologist by their GP. In addition, in December, the cabinet decided – in connection with capacity problems, partly due to corona – to temporarily call on women over 50 once every three years instead of once every two years. All this worries me a lot. There is a risk that people with cancer will only come into the picture later, so that they have to undergo more severe treatments or are even no longer curable. My advice is therefore: don’t wait if you feel something suspicious in your chest and go to the doctor.”
As a result of the screening, many precancerous cancers are also discovered that may otherwise never have been found and treated.
“That is a difficult point. Every year, more than two thousand patients are diagnosed with DCIS: ductal carcinoma in situ, a pre-cancerous stage of breast cancer. The chance that these abnormal cells will actually develop into invasive breast cancer is very small, about 1 to 2 percent per year. But because we cannot yet predict which DCIS abnormalities are harmless and which later lead to breast cancer, we usually treat them with surgery and possibly radiation. The same applies to this: once we know more about how DCIS is developing, we will be able to offer tailor-made solutions. The number of unnecessary treatments is expected to decrease drastically.”
What can we expect from new developments in the coming years?
“One of the most important is immunotherapy: a form of medication that activates a patient’s own immune system to attack and clear cancer cells in a targeted manner. There are now also forms of immunotherapy for breast cancer, but for the time being they are only used in research. Another development is the increasing focus on lifestyle. We now know that postmenopausal overweight women have a 30 to 40 percent higher risk of breast cancer than women of a healthy weight. Overweight women who develop breast cancer also have a poorer prognosis. Smoking and regular alcohol consumption also increase the risk. In my opinion, we need to focus much more on that before, during and after treatment.”
You yourself had breast cancer twice, in 2007 and in 2013. Did that make you look at your patients differently?
“Absolute. I understand even better what women go through. How weak you can feel, how afraid you can be, how difficult it is to absorb information in such a situation. Even if, like me, you know an awful lot about the disease. We doctors find it quick if we can give someone a result within five days. But for a patient, that’s an eternity, I now know. After breast-conserving surgery in 2007, I received radiotherapy. Like many women, I thought: I’ll give it a go. Once under the radiation device, however, panic set in. I’m being damaged, I don’t want this, flashed through my head. The rational doctor in me was completely gone. The surgeon and radiotherapist then talked to me, put me back on my feet. In the end, I finished the radiation.”
At work, you speak to women with breast cancer every day. Wasn’t that confronting after your own treatments?
“More than I thought. In 2007 I went back to work two weeks after my last radiation treatment. Then came the real blow. Suddenly I realized what had happened, what could have happened. I had totally underestimated that feeling, that tightness. All patient stories seemed to be about myself. Then I stopped for three months. And I sought psychological help. In order to become a doctor again, I had to stop being a patient.”
Hester Oldenburg (57) studied medicine at the Free University in Amsterdam. She has worked for 21 years as a breast cancer surgeon at the specialized cancer hospital Antoni van Leeuwenhoek in Amsterdam. There she operates about two hundred patients a year. Together with fellow breast cancer surgeon Marie-Jeanne Vrancken Peeters she wrote All about breast cancer. In 2007 and 2013, Oldenburg himself had to deal with the disease.
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