MY PERSONAL BREAST CANCER SCARE

Spoiler alert!!!! This story has a happy ending, but the experience has shaped who I am professionally as a breast radiologist.

Let me first set the stage. This experience took place during my internship. My daughter was 14 months old at the time. For those of you not familiar with medical training, internship is a year of trial by fire training immediately following graduation from medical school. The first two years of medical school focus on making students book smart, the second two years introduce students to patient care under the direct and constant supervision of residents and attending physicians. On July 1stof every year, newly graduated medical students don the title Doctor, but still have a long path of learning to truly earn the knowledge and respect that goes along with the title. Internship year is the beginning of that training during which every intern is fully immersed in patient care, wading through the minutiae of day to day management of complex medical problems so that eventually this knowledge becomes an integral piece of every physician. This was by far the most strenuous and stressful year of my medical training.

Let’s start in December of my internship year. I was diligently performing my self-breast exam when I noticed a lump in my breast. This lump felt different from the normal lumpy breast tissue I have grown accustomed to feeling during my self-breast exam, which scared me. I knew I should have someone evaluate it, but who has time working 80 hours per week with no backup residents if you call in sick? I made the appointment with my OB-GYN during my next scheduled vacation in February. I was worried sick, but didn’t want to rock the behemoth boat of medical education to ask for additional time off– so I was going to wait.

January: internship year. My internship program director was a surgeon who volunteered his services at a women’s health clinic which to this day provides medical care for the uninsured and underserved patients in our community. What was the focus of this clinic? Breast cancer….I spent the morning in clinic performing breast exam after breast exam. With each exam my own anxiety level was increasing exponentially. By the time we were heading back to the hospital, I was a bundle of nerves. Thankfully he sensed my mood and prodded the story out of me. After explaining that I had found a lump in my breast the previous month, but was waiting for my doctor’s appointment the following month, he took immediate action. By the time we were back at the hospital, he had arranged for me to have my baseline mammogram and diagnostic imaging evaluation of the lump. Although the radiologist was kind enough to show me my images (he knew I was headed toward a radiology residency), I really had no idea what I was looking at and had to have blind faith when he said there was nothing abnormal on the mammogram or breast ultrasound (something I realize most of my patients experience when I give them their breast imaging results). After my normal imaging evaluation, my program director had me meet with a surgeon, who decided I needed a biopsy. Since the imaging was normal, a fine needle aspiration was done. This is a biopsy done with a much smaller needle compared with the image-guided biopsies that I now perform. The needle is guided through the lump by palpating (feeling) the lump.

Three days after the biopsy, I returned a page on the house phone off of the main corridor in the hospital. Interns are slaves to the pager as they are the low man/woman on the totem pole in the medical training pecking order. Interns are constantly returning pages from nurses and other physicians. Interns become quite adept at finding the nearest house phone, as returning pages is a big part of the intern’s job. This is how I ended up in the busiest corridor of the hospital when the surgeon who performed my biopsy paged me to discuss my biopsy results. Thinking this was just another patient related page, I grabbed the nearest phone and called the number. When the surgeon began discussing my pathology results, I wished I was anywhere but the busy corridor. He was explaining that the biopsy results were inconclusive– but the pathologist felt the abnormality could be either abnormal cells which are not yet considered pre-cancerous but have the risk of becoming cancer (referred to as atypia) or lobular carcinoma in situ (LCIS). Either way a surgical biopsy was recommended to make a more definitive diagnosis. At the time these pathology terms were Greek to me. Breast pathology is a different world, and until I began my subspecialty training in breast imaging I was not familiar with the spectrum of breast pathology or the subsequent ramifications of each diagnosis. All I heard was this: you might have a non-invasive form of cancer and surgery is needed.

I have to admit– I was not strong when I heard those words. People always wonder how they will react when bad news is delivered, and I was dismayed that I fell apart. This is how I saw it…I was a 30-something new mom with a one year-old daughter and a career that I had been dreaming about since childhood just beginning– and I might have cancer. I sank to my knees right there in the middle of the hospital. I eventually pulled myself together as I started noticing the concerned looks, and went to speak with my program director. He encouraged me to take the rest of the day off to process the information I had been given. I immediately sought solace with my family. No matter how old I am and how much professional knowledge I have (not much at that point I now realize), when something big happens in my life I turn to my parents and husband for support, for which I am eternally grateful.

I was scheduled for the surgery (my first and only surgery to date) during my vacation in February. I had the surgery at the beginning of my vacation, and unfortunately I spent the rest of my vacation in abject fear waiting for the final pathology results. No amount of logic or reason would calm me down. It took longer than expected to get the results, but I finally got word about a week after the surgery that a fibroadenoma had been removed. A fibroadenoma is a benign fibrous tumor that does not have to be surgically removed if there are no abnormal cells identified on pathology following a biopsy. What? That wasn’t even one of the possibilities from the biopsy– what happened? It turns out that fine needle aspirations are notoriously inaccurate, and the results from my biopsy were just wrong. So that was it: no cancer or increased risk for developing cancer. Done– case closed.

This experience has shaped my professional career more than I ever could have grasped at the time.

First, I now have a much better understanding of atypia and LCIS. If this had truly been the final diagnosis my lifetime risk of developing cancer would have increased, but neither atypia nor LCIS is a diagnosis of cancer. Even as a recently graduated physician I had no clue what my biopsy pathology results meant. If I had no clue, I fully understand that the majority of my patients will be equally clueless when I discuss breast imaging findings and pathology results. This knowledge drives me to always try to explain things in a way that every patient can understand — and to try to put it in perspective.

To be fair, the surgeon did explain the pathology results in an understandable fashion; I was just not in an emotional place to truly hear and understand him. This brings me to my second point. I am cognizant that every patient will react to unclear or bad news differently, and that there is no way to predict the reaction in each patient. I heard pre-cancer, and didn’t hear anything else after that statement. If I am being truly honest, I heard pre-cancer and thought how this could easily be changed to a diagnosis of cancer after the surgical biopsy. I did not hear another word he said explaining the possible diagnoses. Because of this, I work very hard to take my time when explaining breast imaging findings to my patients. I try to gauge if the patients are truly digesting the information I am delivering. I want to determine if they are ready for me to provide more details or if they have heard “possible cancer” and have gone into shutdown mode. If I can figure out where their head is, I can hopefully find the most effective way to continue the conversation to ensure that the pertinent information is delivered and heard.

Finally, I strive for compassion and understanding with all patients through the spectrum of reactions. I have seen it all: patients who have the diagnosis of fibroadenoma (benign- no chance of being cancer) who are convinced that this could still be cancer or turn into cancer; patients who are diagnosed with cancer who handle the news calmly; and those who are told the diagnosis is cancer, and suddenly the diagnosis is my fault and they direct their fear toward me with angry and scared words. There is no way to know how you will react until you have been in the situation yourself. Frankly, I feel my reaction was over the top for what I was actually being told. But taking into account where I was in my life at that time, I was scared to death. I have no idea what else is going on in my patients’ lives so all I can do is try to give information in an easy to understand format, to provide any support requested of me, and to not take it personally when on the surface a reaction seems extreme.

Although that was a very stressful two months of my life, I wouldn’t trade the experience for anything. I feel I gained a much larger gift through the process: empathy for my patients.

About the author: Dr. Carroll is a board certified fellowship trained radiologist specializing in breast imaging. She practices in Southern Arizona with Arizona State Radiology. Follow Dr. Carroll on twitter @dcarrollmd. If you are interested in more topics related to radiology, breast imaging, and/or breast health, subscribe to Dr. Carroll’s blog, The Mammo Press.

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