Friday, 14 February 2014

Breast cancer

It hopefully will come as no surprise that in addition to being a trauma surgeon, I'm a general surgeon as well.  While it is true that I repair colons that have been lacerated by bullets, fix stomachs slashed by knives, and remove spleens that have been shattered in car accidents, I also remove gall bladders, infected appendixes (appendices?), and many kinds of cancers.  One of the most difficult cancers to treat is breast cancer - not because it is technically difficult, but rather because it is very common as well as a very sensitive subject in a very sensitive part of the female anatomy.  I've been unlucky enough to be the one to tell innumerable people that they have cancer, and it seems that as soon as the word "cancer" escapes my lips, patients begin planning their own funerals.  But when it's breast cancer, the impact is always that much greater.

To give you an idea of the scope of the problem, there are approximately 1,500,000 new breast cancers diagnosed each year worldwide, and over 500,000 people die annually of breast cancer.  That data should be enough to give anyone pause.  Thankfully, because of aggressive screening (with physical examinations and annual mammograms) and equally aggressive treatment, the 5-year survival for breast cancer approaches 90%.

That makes it sound like we're doing a pretty damned good job at tackling a very difficult problem, and further research into both early detection and improved treatments are making our efforts better.  But an article published this month in the British Medical Journal seems to be trying to derail those attempts at improvement.  They studied breast cancer and death rates in 40-59 year old women over a 25 year period who either A) did or B) did not get annual mammograms.  First, they found that the women who got mammograms were found to have 20% more cancers (this makes sense because the mammogram can find a cancer that was not large enough to be felt on physical examination).  But they also found that the proportion of women who died of breast cancer did not differ between the two groups.

Well this is certainly bad news for radiology centers and radiologists, because it seems that we don't need to do mammograms because they don't save lives.  But that's great news for women, right?  We can stop doing mammograms!  Women of the world, rejoice!  No more squashing your breasts every year!

Now ladies, hold it right there before you start burning your mammogram slips along with your bras.  The authors go on to say that the women who were only diagnosed with cancer by mammogram (but were undetectable by physical exam) were "over-diagnosed".

Uh...what?  How do you over-diagnose cancer??  Indeed, the authors claim that because the death rates are the same, that these women didn't need to be diagnosed with breast cancer . . . yet.  Because you see, if they had just waited until the cancer was large enough to feel on physical exam, their risk of death was the same anyway, so we may as well not even do mammograms for women between 40 and 59. 

I don't know if that makes any sense to you, because it certainly does NOT make sense to me.  Leave an otherwise-detectable cancer alone until it grows bigger?  This flies in the face of everything I know about cancer, which is to get it out as early as possible.  I have a feeling Terri (not her real name) would probably agree with me and tear your lips off for suggesting anything different.

I first saw Terri a few years ago when she was 40, though she looked much younger.  She had no family history of breast cancer or other specific risk factors, but she listened to the advice of her primary doctor and dutifully got her first mammogram.  When the mammogram revealed a very small lump in her left breast, her doctor sent her to see me for a consultation.  Because Terri's breasts were so large, when I examined her I couldn't feel the mass.  But when I looked over her mammogram, there was definitely something there.  It was small, round, and smooth, and the radiologist read it as a probable fibroadenoma, a common benign lump.

Terri wasn't satisfied with that.  I wasn't either.  I don't have breasts, so I can't imagine living with a mass in there that someone thinks is probably not cancer.  Put another way, if I found a lump in my testicle and was told, "Eh, it's probably nothing", I would swim through a pool of broken glass to investigate it further.  So whenever I see a woman with a breast mass, I offer to biopsy it or remove it outright.  She opted for removal.  And it's a damned good thing she did.

The mass turned out to be an invasive ductal carcinoma, the most common type of breast cancer.  We did further genetic testing as well, and it confirmed that she was a carrier of the BRCA-1 gene mutation, which confers not only a 65% risk of breast cancer, but also a 50% risk of developing another breast cancer (even in the opposite breast) and a 40% risk of ovarian cancer.

Terri opted for a bilateral mastectomy, and during that consultation I also spoke to her 3 daughters about getting tested for the BRCA-1 mutation, because they each have a 50/50 chance of inheriting the gene mutation from their mother.Having a bilateral mastectomy increases life expectancy by 3-5 years, which may explain why both Angelina Jolie and Christina Applegate chose to undergo the procedure.
At her postoperative follow-up appointment, I was explaining how I was going to send her to see an oncologist as well as a gynaecologist to discuss removing her ovaries.  While I was talking Terri kept interrupting me to say "Thank you".  I was about to say "You're welcome" when, for the first time since I met her, Terri started crying.  I handed her a box of tissues and told her it was normal to be overcome with emotion at this point.

"No, you don't understand," she said.  "You were the third surgeon I saw for this.  The first two told me the lump was nothing and that I didn't even need a biopsy.  But you actually listened to me.  You saved my life, and probably my daughters' lives too.  Thank you.  Thank you."

You're welcome, Terri.  You're welcome.


  • Miller AB,
  • Wall C,
  • Baines CJ,
  • Sun P,
  • To T, 
  • Narod SA. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. 
  • BMJ 2014; 348.


    1. I wonder how many lives could be saved if doctors took the extra step that you did.

    2. No one told me that it was nothing. My primary care doctor insisted that I couldn't wait the 2 weeks that the radiology center wanted for my appointment with them and pushed them to take me the same day. I never sat in a waiting room. After being ushered directly into the mammography room and having that done the ultrasound technician met me at the door and took me back for the ultrasound. The radiologist was waiting for me in the consultation room to tell me that I had six large masses and that there was already infiltration into my lymphatic system. Yes, I cried. He sent me to the surgeon across the street with his films in hand immediately. I didn't wait in her waiting room but spent the afternoon getting biopsies. The next day I had the pathology report and the day after that I met again with the surgeon to construct a treatment plan. Even now the thought of that awful day still fills me with tears.

      What the study doesn't say is that even though the study doesn't equate to decreased mortality it does lead to longer survivalship and in those women who are diagnosed early and a better quality of life. If breast cancer can be found in stage 1 it is likely that the woman won't need to lose her breast and can avoid chemotherapy.

      On April 14 I will celebrate 10 years of survivorship. Because I did have to do chemo and modified radical mastectomy and radiation treatments that ruined any hope of over all health. These 10 precious years have allowed me to finish raising my children. A woman who is diagnosed with an earlier stage cancer may not have to go through what I did and that is what makes early detection priceless.

    3. As an outside observer, I find it easy to always say that when dealing with anything potentially serious, always seek a second opinion. But I think I trust doctors too much... if a doctor told me I had a tumor but it's benign, I'd just listen to him and be on my merry way. If ANOTHER doctor told me the same thing, I would DEFINITELY believe him.

      Maybe I should be less trustful.

    4. Certainly Terri's experience shows that women shouldn't stop getting mammograms, but you also hear stories like this one (, where a woman was diagnosed with ductal carcinoma and ended up getting radiation and taking Tamoxifen when there was no real guarantee that she needed much more than a lumpectomy. It doesn't specify whether she was tested for the BRCA-1 gene mutation, which could have been a larger factor. I think testing for the gene mutation should actually be the first step, rather than mammography, since the odds are astronomically higher if you have it. Large-breasted women should also be informed that they are in more need for mammograms, since you might not be able to find it during a physical examination (like Terri). However, if I ever had a lump in my breast, it would have to be about the size of a pencil eraser or smaller to be undetectable during a physical exam. Just food for thought.

      1. I feel compelled to point out that while it may be the 15th wherever the blog is, it's the 14th over here, and I was greeted with a CAPTCHA that read "romance," surrounded by pink hot air balloons.

      2. Mine was a teddy bear next to the work "roses".

      3. Food for thought Kitri, I has 6 lumps, 3 over 5 cm (2 inches diameter). They can hide better than you think they can. And overtreatment is the exception more than the rule. It is more common to be told that "it's nothing".

      4. Lisa--I read your earlier post and I'm interested in exactly the circumstances of your diagnosis. It doesn't seem like you were told it was nothing--it seems everybody was pretty convinced that you had a problem that needed attention.

    5. What they mean by overtreatment is removing things that weren't actually dangerous. I have a very hard time believing that there is as much mortality from that as from missed cancers, though. Maybe what we are seeing is how poorly their system deals with cancer.

    6. This is not specific to breast cancer alone. There has been a lot controversy over screening for people who are at risk for lung cancer too. (Relatively) New low dose CT scans make it possible but the bean counters have said the same thing there. That it won't decrease mortality. Common sense tells anyone, even people with no medical education that it is always better to diagnose cancer at its earliest possible stage. Unfortunately, most cancers are detected only once symptoms are present which is usually when they're advanced. That's why the mortality rates for lung cancer haven't changed since Nixon announced the "War on Cancer"...a dismal 15% survivability.

      Think about it. What are the most survivable cancers? Breast, prostate and colon, right? The one thing all those cancers have in common is a way to screen for them. Prevention is a better bet but not always possible. Screening saves lives. I just hope the ACA won't change the availability of screening.

    7. I'll say it too..thank you, Doc.

    8. I read this sentence over and over and it still repulses me—“(breast cancer) Over-diagnosis refers to the possibility that a screen detected cancer might not otherwise become clinically apparent during the lifetime of the woman.”

      I am going to voice two opinions that are not going to be popular.

      1. Substitute “testicular cancer” for “breast cancer” in the repulsive statement above. You at least acknowledged that in your essay, DB. Is it less acceptable for men to walk about with (potential) cancer? Are women just attention-seeking babies who over-react to itty-bitty lumps? Do doctors/surgeons just think we are all crazy and suffering from Munchausen’s Syndrome?

      I know that when I had a suspicious mammogram and was awaiting a diagnostic ultrasound, all I could think was “get that thing out of me.” It was just an itty-bitty cyst, so tiny I could not feel it. Yet it took a couple of weeks to get me back in for that ultrasound. By that time, I’d already planned to ask for a BRCA-1 test (even though no females on either side of my family had ever had any kind of breast cancer) while waiting to schedule a possible double mastectomy, and was trying to figure out if I could get out of having radiation therapy. Nurses do make the worst patients!

      I even got to the point of wondering if I’d been a man with a lump in my testes, would I have immediately been whisked away for more testing and a definitive answer within hours or days, versus weeks?

      2. Canada is a single-payer system. Doesn’t it behoove the single payer (government) to keep costs down? So isn’t it “better” for that system to not excise or treat a cancer until it’s large enough to be felt or cause signs/symptoms? If the single payer is lucky, perhaps the woman with an itty-bitty not-yet-feelable breast cancer dies of something else, hopefully something cheaper or impossible to treat. When is it ever good to walk about with cancer, even if it is “just” carcinoma-in-situ?

      When I was in nursing school (79-82), one in ten women could expect to have breast cancer at some point in her life. At that time most breast cancers were in post-menopausal women, but I recall taking care of two very young women (late 20s-early 30s) with very aggressive invasive ductal carcinoma (one had the type that did not react to estrogen or progesterone) while I was a student doing my oncology rotation. Neither was expected to survive a year, let alone 5 years.

      Hasn’t the incidence of breast cancer now increased to one in eight in the 30-plus years since I was in nursing school?

      DB, thank you for listening to Terri, a smart lady with a hunch who wasn’t going to gamble with her health. Thank you to Lisa’s doctors for acting on their suspicions, thereby giving her the gift of life, and time to raise her children, and hopefully be around for grandchildren.

    9. Here's some trivia: Does anyone know how many people die from breast cancer each year? The correct answer is zero. People die from metastasis, not from breast cancer.

    10. I hope if I ever find myself in a situation like this, I have a doctor like Doc Bastard.


    12. This comment has been removed by a blog administrator.

      1. This was a disgusting advert for a breast enhancement clinic. I am deleting the content (though leaving the place holder) just so everyone can see how unscrupulous people can be. I sent a very nasty letter to the head physician and clinic administrator letting them know exactly how I feel about such things. I think they got the message.

    13. I've tried looking for other medical blogs as awesome as DocB's. Recently, I came across one whose opening line referenced this very study, saying "Preventive care doesn’t save money and now it turns out mammograms don’t even save lives." Unlike Doc's, this post didn't have a twist nor was it sarcastic.
      I think I'll end my search now ><'


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