Today I had to tell a patient that she has breast cancer. As a nurse practitioner in primary care, I don't very often have be the bearer of such bad news. Other patients who I suspect have serious problems like lung cancer or colon cancer are referred to specialists who then have to deliver the bad news. I don't expect it's any easier for them than it was for me today.
Linda, my patient, is 49 years old. She doesn't drink, she doesn't smoke, she's not overweight, she nursed four babies including twins for an average of nine months each. She is pre-diabetic and watches her diet. Her last A1C was 6.4%. On Lipitor, her LDL is 56. Her HDL is 52. She's had yearly mammograms starting at age 40.
Her most recent mammogram was in October of 2005 and was normal. Yes, I know that mammogram sensitivity is about 10 % overall, but this mass was 1.9cm x 1.2 cm, not exactly tiny!
So how did Linda find out she had breast cancer? She found it herself. Along with all her other good health habits, Linda has been doing breast self examination (BSE) every month since she was in her twenties. She found a lump, she had a clinical breast exam, she had a mammogram, she had an ultrasound, she had a needle core biopsy resulting in a diagnosis of invasive breast cancer. She'll be seeing an oncologist next week.
I'm really glad nobody told her that BSE is now optional because studies show it doesn't significantly reduce mortality. See studies here and here
According to the American Cancer Society 2005 Cancer Screening Guidelines, BSE is no longer reccommended, and we (medical providers) are to inform women of the potential limitations, risks, and benefits of BSE, if women choose to continue it.
The U.S. Preventive Services Task Force (USPSTF) recommends screening mammography, with or without clinical breast examination, every 1-2 years for women aged 40 and older.
The USPSTF concludes that the evidence is insufficient to recommend for or against routine clinical breast examination (CBE) alone to screen for breast cancer.
The USPSTF concludes that the evidence is insufficient to recommend for or against teaching or performing routine breast self-examination (BSE).
I wonder, if Linda hadn't found her cancer in June, how much bigger would it have been in October when she had her annual mammogram?
Personally, I'll keep doing BSE.
Find a good general resource on BSE and the new recommendations here.
5 comments:
Teresa,
As long as these boobs are on MY body, they get a BSE and I don't care what the statistics say or who decided what.
Honestly, why would we now change a method women have been using for decades to augment other means of discerning a mass?
We've all heard the stories of the woman who felt the mass two months after her "normal" mammogram.
Ladies, get to know your own bodies. Remember, they used to tell us HRT was sooooo wonderful and then changed their mind?
To quote Will Smith in "Independence Day":
"Oooops!"
Holy cow...my jaw is on the floor. I never did BSEs before but I think i'm going to start. Thanks for the motivation.
One year to the day after her last mammo, six months before her next one, my mother found a ~2cm lump during her BSE. We had absolutely zero family history of any cancers, at all.
That was seven years ago this month. Ma's still here.
Yeah, I'm going with the BSEs, thanks.
My close friend L. found a lump at age 38. Went for a mammo, which didn't show the lump. She insisted on a songram, and bam. There it was. Tiny, but there. Biopsy confirmed what she dreaded.
5 years later she's gone. It was an aggressive bloodborne cancer. I have to wonder how lessened her time with us would have been a) had she not done BSEs and b) had she not pressed for a sonogram.
I think they're crazy for suggesting such a stance of no longer encouraging women to check their breasts monthly.
As a surgeon whose practice was about half occupied with breast disease, I can say I always encouraged breast self-exam, and saw innumerable women over the years who found their lumps themselves. While it's true that ideally all cancer would be found before it's palpable, the reality is that not everyone gets regular mammograms; nor are mammograms perfect. The problem with studies of large populations is they include both care-givers and patients who have a broad range of skill. A good self exam, followed by exam by a professional who knows what she/he is doing can only do good.
As an aside, regarding one comment: when the lump is feelable, you can get a lot more info a lot faster than sonogram by doing a needle aspiration. I've tried to get primary care providers to understand that for years....
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