It was April Fools' Day 1992, during a scholarly trip to California, when Walters Art Gallery curator Joaneath Spicer learned her breast cancer had recurred. She hung up the phone in a daze. "I remember going in the bathroon. And it's very satisfying to see that there is no sign -- to see that you are yourself."
Over the next month as she prepared for a mastectomy, the promise of breast reconstruction helped Dr. Spicer preserve her belief that life would one day return to normal.
Unlike many women facing the same choice, the curator was not deterred by ambivalence about whether breast reconstruction is a matter of sanity or vanity -- a debate that threatens to influence insurance coverage. Instead, she approached her decision as an art historian would.
"It came to me as revelation that I was simply treating myself as a damaged work of art," Dr. Spicer says. "As a curator, I was used to making decisions about what's an appropriate treatment for a painting. And I had looked at myself -- a middle-aged woman -- as a middle-aged work of art and asked, 'What's appropriate?' "
She recalls some female acquaintances speculating that her desire for a new breast was a visceral reaction to a breast-obsessed society. "They suggested: 'How can you really consider yourself a feminist and go through with this, alter your body?'
"Authenticity can mean many things: It can mean scraped down to the bare bones of a painting. It can also mean the authenticity of the idea, that maybe you owe it to the artist to maintain his vision. To my mind, there is a direct corollary with one's sense of self."
She says women with breast cancer often struggle against deep-seated attitudes about any part of the body that relates to female sexuality.
"People can impose a kind of morality which is completely in-appropriate about breast reconstruction. Sometimes people use the word 'cosmetic' for reconstructive surgery, and that makes a woman -- or the public -- think that it's frivolous to do this."
In recent years, fewer women have chosen breast reconstruction because of the increased popularity of the breast-conserving lumpectomy with radiation.
A question of insurance
Physicians and women's health advocates worry, however, that many health insurance policies that once covered breast reconstructions now reflect a bottom-line view that such surgery is unnecessary. They also worry that women may delay cancer treatment because they fear losing a breast and do not understand their options for breast reconstruction.
Since the controversy about the alleged hazards of silicon gel breast implants, women often wonder if any reconstructive surgery is safe.
"There are people who believe that if they tamper with what's been done, they're going to bring the disease back," says Paul Manson, chief of the division of plastic surgery at Johns Hopkins Hospital, who is Dr. Spicer's surgeon. "They are afraid the surgery will undo some sort of temporizing measure that is keeping the disease in control."
Reconstruction has no known effect on recurrence of disease in the breast, nor does it generally interfere with any subsequent chemotherapy or radiation, according to the American Society of Plastic and Reconstructive Surgeons. Yet less than half of the women receiving mastectomies choose reconstruction.
"The most common reason is that the general surgeon never talks to the woman about it," says plastic surgeon Christine Horner-Taylor, a spokeswoman for the American Cancer Society. "The surgeon's concern is the cancer and curing the cancer. Some surgeons offer it to their young patients but not to their older patients.
"I did reconstructive surgeries following bilateral mastectomies on a woman who was 65 who told me that this surgeon who usually offers breast reconstruction never offered it to her. And when I talked to him -- he was a young man -- he said he thought that it just wasn't that important to older women.
"The thing about breast reconstruction is that it's not a question of age or beauty. It has more to do with a woman's sense of wholeness."
Lillian Ingram, 67, an oncology nurse at Harbor Hospital, chose reconstruction six months after her mastectomy last year. She remembers encountering skepticism before linking up with surgeon Bernard McGibbon, head of the division of plastic surgery at Greater Baltimore Medical Center.
Dr. McGibbon is a local pioneer of the TRAM-flap procedure -- in which a breast is reconstructed by moving tissue and muscle from the abdomen to the chest. The TRAM-flap and saltwater implants now are the most frequently chosen options.
Mrs. Ingram chose TRAM-flap surgery, which her insurance covered, but she had to pay out of pocket for surgery to make her healthy breast symmetrical with the reconstructed one. She says she is thrilled with the results.
A new attitude
Dr. Horner-Taylor lost her 75-year-old mother to breast cancer in August, and says she was struck by the way breast reconstruction improved her mother's life. The plastic surgeon, who practices in the greater Cincinnati area, is leading a national campaign urging states to pass legislation that would guarantee that all insurance providers covering mastectomy would also cover breast reconstruction. (An exception would be self-insured corporations.)
So far, only 10 states require breast reconstruction coverage: California, Arizona, Nevada, Washington, Florida, Illinois, Michigan, New Jersey, Maine and Connecticut. California and Maine have also passed legislation guaranteeing a 'symmetry operation' that accompanies many reconstruction procedures.
"I think there is a general, and probably very good, reason for always having a bias against so-called unnecessary surgeries," Dr. Spicer says. "But to my mind, this falls in a different category. We're talking about mental health.
"If doctors just give the patient the facts -- 'This is what you have to have [the mastectomy], this other surgery is unnecessary but you can have it, etc.' -- that is going to have an impact on the patient.
"Especially if there is some implication, which there sometimes is, that you ought to be happy that your life is being saved. Well, yes. But if you can have more, why not have more? Why not have yourself back?"
Dr. Manson invited Dr. Spicer to deliver her views at "grand rounds" at Johns Hopkins Hospital -- a weekly tradition in which a physician discusses a case with his or her peers. She has lectured to art conservators at the National Archives and to breast cancer survivors. A paper based on these lectures has appeared in the Annals of Plastic Surgery.
Dr. Manson says some patients have found it helpful to apply Dr. Spicer's analogies to their situations.
"Do you owe any less to yourself than you owe to a work of art?" she says. "Surely that's a question that shouldn't need to be asked. But unless you ask it in those terms, frequently people don't see it that way."
Roughly 6,000 people are expected to participate in the Susan G. Komen Breast Cancer Foundation's Race for the Cure beginning at 8 a.m. Saturday in the Inner Harbor. The annual event raises money for breast cancer research and funds local efforts to provide breast health care and educate the public about the disease.
Events include a 5K (3.1-mile) run-walk course for women only, a 5K run-walk for all and a 1-mile fun walk.
Nancy Brinker, founder of the Komen foundation, will sign copies of her book "The Race Is Won One Step at a Time: Every Woman's Guide to Taking Charge of Breast Cancer" from 3:30 p.m. to 5 p.m. Friday at Owings Mills Mall and from noon to 2 p.m. Saturday at Dalton's Bookstore in Harborplace. All proceeds from the book will benefit the foundation.
Registration is $20. For information on registering, call (410) 433-RACE.