A little breast rant

I used to pay for thermography (http://www.thermographyclinic.com/) as my breast screening tool.  It was expensive but non-invasive and relatively available in my city.  When my sister got breast cancer, I let my family doctor know.  She had previously been on board with my choice but was no longer, so I started having mammograms.

We know that mammography is not only an imperfect tool, but carries its own risks, most notably radiation and an increase in additional testing and unnecessary treatment (http://www.nejm.org/doi/full/10.1056/NEJMp1401875).

A few years ago, after my mammogram, the technician at the breast screening clinic asked me to wait for an additional ultrasound after their physician had reviewed the mammogram.  I sat in my open-back “gown” trying not to panic but feeling awfully vulnerable.  Following the ultrasound, a doctor came to repeat the test and pronounced the glitch they had seen on the screen to be “nothing”.  Relief.

This year, they did the mammogram then sent me home, saying they would call if there were any concerns.  A few days later, I got the call.  Not only did they want to do an ultrasound, but said it would be preceded by a second mammogram.  No additional information or explanation was available.  I felt I had no choice but to book the appointment.

Coincidentally, I had just posted the article above on my professional Facebook page, which concluded,

“It is easy to promote mammography screening if the majority of women believe that it prevents or reduces the risk of getting breast cancer and saves many lives through early detection of aggressive tumors.  We would be in favor of mammography screening if these beliefs were valid. Unfortunately, they are not, and we believe that women need to be told so. From an ethical perspective, a public health program that does not clearly produce more benefits than harms is hard to justify. Providing clear, unbiased information, promoting appropriate care, and preventing overdiagnosis and overtreatment would be a better choice”.

I reasoned with myself that I was in the same situation as the last time, with the exception of having to wait a few days before being re-tested.  But reason rarely trumps anxiety.

I hardly slept the night before the appointment and assume the diarrhea was the result of too many kidney beans.  I packed my bag for a yoga class following the appointment, hoping that it would be a celebratory session.  I also printed out the article above to use as a talisman if there was any problem with the coping strategy I had worked out.

At the front desk, I told the clerk I wanted to speak with someone before any testing was done.  She saw this as a reasonable request.  I changed and read the local free paper, absorbed in the politics of the day, surrounded by other gowned women.  When my name was called, the technician had me sit in the examining room while she explained the reason for the re-test.  It was indeed exactly the same glitch as the last time, which gave me hope.

“I would like to do the ultrasound before the mammogram.  Is that all right?”  She said that if the ultrasound was definitive, they would not need to do the mammogram.  I told her about the article in my purse and she quickly agreed that mammography had its faults.

When she finished the test, she said the breast appeared normal, but she needed corroboration from a doctor.  The doctor who came in said that they were checking for a malignancy.

“Oh, you used the “m” word”.

“Well, we like to give our patients complete information.”

That sounded like overkill to me, because one cannot test for malignancy without a biopsy.  However, after performing the ultrasound again, he agreed that what they were looking at was just breast tissue.  He went to consult with a third doctor who agreed.  Free to go.

So here’s the rant:

First, it is unfortunate in the extreme that they could not do the follow-up ultrasound on the same day.  Second, I had to reason with the technician to avoid being exposed to radiation a second time.  I doubt that the majority of women would feel informed or assertive enough to do the same.  Third, the doctor used the “m” word unnecessarily, although I can’t imagine his motivation.

And fourth, Canadians are no longer having annual exams (http://www.ctvnews.ca/lifestyle/is-an-annual-physical-necessary-the-doctor-is-out-on-that-one-1.2017959).  The news report states:

“Three years later, what this panel of experts concluded was that the “routine annual physical exam should be discarded.” Instead of full annual exams, doctors should create “selective plans of health protection packages” appropriate to the health needs of the different stages of life.”

What that means for women is that it could be a few years between one clinical breast exam and another.  The breast screening clinic does not start with a clinical breast exam: they use their machines.  I had to ask my doctor to do a clinical breast exam.  Breast self-exam has long been controversial (http://www.berkeleywellness.com/self-care/preventive-care/article/re-examining-breast-self-exam).

Where does that leave us?

We are very much at the mercy of a technology that is universal but imperfect; and a system that does not ensure the simple preliminary tool of clinical breast exam.  A glitch means subsequent testing –  possibly leading to even more testing – and down the rabbit hole we go.  There must be a better way.

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