Standing on the Shoulders of Giants

When my girlfriend Teri saw this picture of me with my breast surgeons, radiation oncologist and pancreatic doctor( L-R Dr. Maria Stapfer, Dr. Brian Kim, Dr. Mel Silverstein, me, Dr. Nirav Savalia) she immediately said “They look like giants next to you” comparing my 5’2 status with this group of tall doctors (even though I was wearing heels). I replied ” I’m actually “standing on the shoulders of giants” to borrow a quote that Isaac Newton popularized in the 17th century after  he borrowed it from Bernard of Chartes who is said to have used it first in the 12th century. Newton wrote “If I have seen further, it is by standing on the shoulders of giants.”   The state of the art care I received during my breast cancer treatment was made possible not only by my brilliant team, but because of the knowledge passed on to them by those that came before them. But most importantly, they took that knowledge and expanded upon it.

During my search for where I would be treated I had both my friend Trena and my surgeon friend, Dr. Gerry Lau, refer me to Dr. Mel Silverstein at Hoag Memorial Hospital Presbyterian in California. I figured I had better pay attention and do some research about this doctor as the universe was certainly sending me some very strong messages from more than one direction.

I quickly  learned that  was he a man that had not only dedicated his life to helping women with breast cancer, but had the vision of developing a revolutionary surgical procedure that will some day make mastectomy of thing of the past for women with early stage breast cancer.I really had no idea just how big those shoulders I was standing upon were until I had completed my oncoplastic surgery from stage 2 breast cancer.  In his newly published article (Nov 2015) “Radical Mastectomy to Radical Conservation (Extreme Oncoplasty): A Revolutionary Change” he states that “the combination of mastectomy, reconstruction, and radiation therapy is the least desirable option for local treatment”. Although this may not be an option for all women with breast cancer, it should certainly not be over looked as an option, especially for women with early stage cancer with tumors <5cm.

Dr. Silverstein did not arrive to this revolutionary place without a deep history in the treatment of breast cancer that has spanned 40 years. The difference is that he saw the physical and emotional brutality of the traditional radical mastectomy popularized by William Halsted, MD as a surgery he no longer viewed as one that offered complete healing to a woman. He realized the physical scars, potential physical upper body limitations along with the emotional devastation of the loss of a breast could not be viewed as holistically healing. He eagerly investigated  the teachings about segmental resection for breast cancer (lumpectomy) from Dr. George (Barney) Crile Jr and later was inspired by Dr.Bernard Fisher’s article on ” The surgical dilemma in the primary therapy of invasive breast cancer:a critical appraisal” published in 1970. This changed his entire perspective of the radical mastectomy and gave him the foundation to pursue  the breast preserving surgical technique of oncoplasty that he would later explore and pioneer  in the mid 1980’s at his Van Nuys Breast Center; the first free standing breast center in the US and a role model for breast centers worldwide.

From observing a plastic surgeon performing a breast reduction with specialized incisions, he realized that perhaps those techniques could be utilized during breast cancer tumor removal surgery while providing the woman an improved look in just one surgery. While he was developing oncoplastic surgery in the US, three physicians in Paris, Dusseldorf and Milan were also utilizing oncoplastic surgical techniques. In spite of this worldwide development and his surgical fellowship that began in 2000 where he has trained a total of 39 breast fellows (23 of them at Hoag Memorial Hospital), the option of oncoplastic surgery is not offered to most women seeking treatment for early stage breast cancer.

Studies have now shown that oncoplastic surgery with radiation has the same survivorship as mastectomy, with less local reoccurrance, a lower breast cancer mortality rate, a better quality of life,  and better cosmesis (the preservation, restoration, or bestowing of bodily beauty). So, why is it that so many women are still opting for mastectomy or even worse a bi-lateral mastectomy? I can only think that there are not enough doctors trained in oncoplastic surgery and women do not know to ask for it. Rather than referring a woman who would qualify for this procedure to another doctor, most physician’s don’t discuss it and they keep their patient, (whom is a paying customer) and perform a mutilating surgery even though oncoplastic surgery could be available at another breast center. This needs to change. As the push for  lumpectomy ( with radiation)  rather than mastectomy was driven by the insistence of women, oncoplastic surgery will become the preeminent (early stage) breast cancer surgery if we demand it.

I was very blessed that my friend and general surgeon, Dr. Gerry Lau, put himself aside and referred me to the brilliant team of Dr. Silverstein and Dr. Savalia so that I could reap the benefits of oncoplastic surgery. My health would certainly not be where it is today with out the teachings of the many physicians that came before them, but most importantly, that they took this wisdom and expanded upon it. Thanks to Dr. Mel Silverstein and his surgical partner and plastic surgeon, Dr. Nirav Savalia, I was not subjected to a surgery of the past. May many more women benefit from oncoplasty by standing on the shoulders of those who dare to explore, develop, learn and teach new breast preserving options in treating early stage breast cancer.


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