Doctor, Am I Going to Die?

Do you remember the Seinfeld episode where Kramer acts like he has gonorrhea for medical students? Well, we really did have actors in medical school. One of the actors I remembered posed as a patient receiving the news of cancer from me, then a medical student. I walked into the room, not even knowing what kind of cancer she had. I sat down and said, “I have the results of your test. It shows cancer.” She started crying and then I had no idea what to say. I asked, “Are you going to be okay?” The feedback I got was not the greatest. I could’ve been more empathetic… I thought, I hope I never have to do this for a living.

Fast forward to last week. I had a young woman in her forties whose breasts became rock hard 1 month ago. Since then, she had developed facial paralysis in half her face andwas having terrible body aches. She went to the emergency room a few days prior to seeing me and they could only reassure her that she had not had a stroke.

So here I am, meeting her for the first time for a biopsy. She looks horribly ill. I begin the same way I always do, explaining the procedure and what she can expect to feel. She doesn’t really seem to care. She is too focused on the discomfort she is feeling in the rest of her body. As I start to give her her numbing medication, she begins bleeding instantly. I stop and hold some pressure. It appears I am going to be here a bit longer than I really want to be. As I start to place the biopsy needle into her breast, she asks me, “Do I have cancer?”

Not really wanting to have this conversation while performing a difficult biopsy, I reply, “Do you really want to know what I think?” Of course she replies, yes. “I think you have lymphoma, which is a type of cancer.” She starts breaking down crying. I have to continue on with the biopsy. After what feels like hours of sobbing, she then asks me, “Am I going to die?”

The truth was maybe. I have seen women with lymphoma of their breasts die. I reply, “I don’t know.” More sobbing. I then say to her, “I know there is nothing I can say that will make you feel better now. All I can say is that I will get you an answer. Once we have that, we can move forward and get you treatment.”

I am not going to lie and say I wasn’t happy to leave the room when I was done. But once I left the room, I just went on with my day and didn’t really think twice about it. That was until yesterday, when my rep who sells me the biopsy needles (who was in the room during the whole procedure) said, “Wow, that was a really emotional case the other day. That was one of the toughest situations I have seen and you handled it really well.” When I took a step back and thought about it, I tried to picture how I might’ve handled it when I first started. I probably would have just done the procedure and tried to get out of the room as soon as possible.

Over the years, I have accepted the fact that I will never know what it feels like to be on the other side. I will never understand the fears that go through my patient’s heads. The only thing I can do in that moment is to offer support. I can’t promise them that they will live, but I can promise them that I will take care of them and always be there for them. That is what working with cancer for 5 years has taught me, not some actress in medical school. That is the art of medicine.

Reducing Cancer Risk – Practicing What I Preach

One of the most common questions I get asked by patients is, “Is there anything I can do to reduce my chances of getting cancer?”  My response is always the same, “Live a healthy lifestyle. Eat healthy and exercise.”  Now, that won’t necessarily mean that you won’t get cancer, but it is one of the few things you can control to reduce your risk of getting cancer.  The majority of my patients are overweight and that is definitely a risk factor for breast cancer as well as a whole host of other diseases that can kill you.  Also, being healthier allows you to recover sooner from necessary surgeries and tolerate treatments better.

But it’s easy for me to tell someone to lose weight, be healthy and exercise.  I myself have never had a weight issue so I don’t know the struggles that come with trying to lose weight.  But after living at my dad’s house for 3 weeks where I had no control over what there was to eat and a road trip where every meal was either fast food or eating out, I ended up in Houston feeling completely disgusted with myself and ready for a fresh healthy start.  After all, shouldn’t I practice what I preach?

Cover via Amazon

I recently read Jackie Warner’s “This Is Why You’re Fat” book after having bought some of her workout videos.  Her book talks about how the foods you eat affect the hormones in your body, including human growth hormone, testosterone, estrogen and insulin.  It made me realize that although I am not fat, I would still benefit in many ways by eating in a manner that would keep others thin.

Let’s face it, us women have a hard time taking care of ourselves.  I often ask my patients, “How come you haven’t come for a mammogram in 4 years?”  Has it been that long?  I’ve been so busy I didn’t even realize!  As I remind my patients the importance of taking care of themselves first so they can continue taking care of others, I am now realizing that I too need to do the same thing for my family.

So let me share some of the things I am doing to take that step towards healthier living:

1. Always eat breakfast and have some sort of protein at breakfast. (This usually means eggs or a protein shake.)  Breakfast is the most important meal.  Studies have shown that by adding breakfast into your eating regimen you can increase your metabolism.

2. Don’t have any junk food in our pantry.  That means no cookies, no chips, etc.  I do still indulge in Healthy Choice fudge bars (100 calories, 5 gm of sugar) and 25 calorie fruit bars made with Splenda.  Those make my kids happy enough not to complain.

3. Eat more protein and less white carbs (potatoes, white rice, pasta).  This is supposed to help balance your insulin levels.  In college I had started the Zone diet which was based on balancing your insulin levels.   Prior to starting the diet, I always fell asleep in my afternoon lectures.  But after the diet, I was able to stay awake no problem!  I totally believe that the post lunch sugar crash was the cause of my inability to stay awake in the afternoons.  As a result, I have been incorporating whole wheat bread, whole wheat tortillas, whole wheat pasta, brown rice and quinoa as my carbohydrate staples.  I can’t give up carbs completely!

4.  Eat fish at least once a week.  This is a source of protein in my diet and provides the healthy Omega 3 fatty acids which are good for your heart.

5.  Take a daily vitamin.  For some reason, I just keep forgetting to pop those pills.  I don’t know if I subconsciously don’t like the idea of having to take a pill.  But I do it for my kids, so why shouldn’t I do it for myself?

6.  Drink lots of water.  I am just really bad at doing this.  If it’s not in front of me, I don’t think to go and get it and I can go a whole day without drinking much.  I literally need a bottle attached to my arm…

7. No more excuses about working out. I am going to try to devote 15-20 min to some form of exercise every day.  Jackie Warner has a great DVD with 15 min workouts you can do at home.  Jillian Michaels 30 Day Shred workouts are 20 min long.  When you think about 15-20 min, it doesn’t seem like much time, does it?

8. Get a good night’s sleep.  I like to stay up late at night.  In fact, several of my posts have been written close to midnight.  It’s the only time I have to myself.  Unfortunately, I am still getting up when my kids get up.  Ultimately, I am depriving my body of its time to recover from the stresses that it goes through on any particular day.  After a while, it will take its toll…

Just so you know, I have been trying to implement these for the past 2-3 weeks.  I am doing well with 1-4 but still working on 5-8.  It’s not easy to make so many changes but I already feel better doing some of the above.  Eventually, I hope to be able to say I do everything above.  It’s okay if it takes time to get there, as long as I get there.  By then, several of those should become second nature.  But until then, I will have to remind myself of those goals and what it will do for my well being and how that will make me a better mother, wife and doctor.   That is the best motivation.

My Epiphany: The only person who can make you happy is yourself

I am sure everyone knows someone that is always happy. No matter how bad things are, they keep on smiling. Do you ever wonder how they do that? Do you envy them? I certainly did.

A few years ago, I was at a point where I had to struggle to find happiness in my life. I was unhappy in my job, my husband wasn’t making me happy, family life seemed more difficult with two kids…

As I was reading the Five Languages of Love, I was trying to figure out how my husband could “love” me more. If he did more chores around the house, would that make me happier? If he told me how beautiful and smart I was, would that make me happier? If we spent more time together, would that make me happier? When I really thought about those things, I realized the answer was “no” because he had tried those things and I was still unhappy.

So, why couldn’t my husband make me happy? I finally realized that it was because I was not letting myself be happy. It sounds too simple, but it was true. And just like that, I decided I was going to be happy. Life hasn’t been easy since I decided to be happy. But the stresses and struggles I faced since then have seemed easier to handle than before. And, I have never gone back to the world of utter unhappiness like I had been before.

You are probably saying to yourself, “It can’t be that easy.” But it really is. It is so easy to get bogged down with the challenges and difficulties we face in everyday life. We don’t realize the toll it can take on us physically and emotionally. The first step is to be aware of how these things affect you. Then you can make the conscious choice not to let those things bring you down.

No one else can make you happy unless you do it for yourself first.  You have a choice.  Choose to be happy.

The Self Breast Exam – It can save your life

I often ask my patients, “Are you routinely feeling your breasts?”  The answers I commonly get are:

My breasts are always lumpy.

I don’t know what I am supposed to be feeling for.

I am too afraid to do it.

I cannot even begin to tell you how many women find their own breast cancers by feeling a lump in their breast.  40% of breast cancers are found through feeling a lump or changes noticed in the breast by patients.  Some women come in when the cancer is quite large, but many have found them when they have been small.  I am often surprised at how good patients are at finding masses in their breasts.  Many of them are young as well.  For example, one 40 year old woman felt a 7 mm cancer in her breast, one that was hard to see on mammography because of her implants. (Stage 1 tumor size is under 2 cm. I consider anything under 1 cm to be really small!)  Also, small cancers can hide on mammograms in your normal breast tissue and many women are able to feel their breast cancers before they will manifest on mammograms.

If you are younger than 40 years old, it is really the only way to detect breast cancer, as screening mammograms are recommended beginning at age 40.  I saw a 36 year old who noticed a tiny bit of dimpling of the skin on her breast and could feel a 6 mm lump.  When I did her mammogram, half her breast was filled with DCIS and in the middle of it, there was a small invasive cancer, which is what she felt.  If she had waited until 40 for her screening mammogram, she would probably have metastatic breast cancer.  Instead, she saved her own life.

So, how to I respond to my patients?

My breasts are always lumpy.  That is normal.  Most women’s breasts are lumpy.  You need to get to know what your normal lumps and bumps are, so that if something changes or a new lump shows up, you will know that it is different.

I don’t know what I am supposed to be feeling for.  You don’t have to know what cancer feels like.  You just have to know when something is different.  I advise my patients to feel their breasts once a month.  If you are still having regular periods, do it 3-5 days after you first get your period.  You breasts tend to swell right before you get your period, so any lumps or bumps or benign things, such as cysts, will tend to be more pronounced at that time.  These tend to go away or lessen after your period.  If you feel something new, don’t freak out.  Come back to it in a few weeks and if you can go right back to the same area and feel it without any difficulty, then you need to have imaging done.  Don’t feel your breasts too often either, or you will not be able to appreciate change.  You know how your parents notice how big your children have grown because they don’t see them every day?  It’s the same thing with feeling your breasts.

I’m too afraid to do it.  Why?  If you get to know your breasts now, there is nothing to be afraid of.   Not all masses are cancer.  The important thing is you might be able to find a cancer when it is smaller.  Do you want to wait until there is cancer sticking out of your breast (which I have seen many women in denial do)?  You could very well save your own life.

Here are the reasons why I recommend doing self breast examination:

1.  It doesn’t cost you anything to do it.

2.  It rarely leads to unnecessary procedures.

3.  It allows your breasts to be checked at monthly intervals instead of yearly as with mammograms.

4.  It covers the areas that mammograms and ultrasounds might miss.  I had one patient who had a negative mammogram.  She came in a few days after her mammogram complaining of a lump.  I though it might have been related to trauma from the mammogram as her breasts were fatty and really easy to read.  Well, it was a cancer.  Even after I knew where it was, we still had trouble getting that part of the breast onto the mammogram.  She saved her own life.

5.  You will be better at it than your doctor (who feels a lot of women’s breasts but only yours once a year).

In my opinion, there is almost no downside to doing it.  There was one patient who insisted that there was something that felt different in one of her breasts.  She had a mammogram and ultrasound done which were negative.  She was told by several people that there was nothing there and not to worry about it.  She finally convinced a breast surgeon to do a surgical biopsy and guess what?  He found an invasive lobular cancer (which is often difficult to detect with mammogram and ultrasound).  She saved her own life.

You could save your own life too.  In this day and age, none of the tests we have are perfect.  So we should try to use everything we’ve got to help find cancers when they are small and the self breast exam is one of those tools.

Here are some links that describe how to do self breast exams:

• http://www.nationalbreastcancer.org/breast-self-exam
• http://www.youtube.com/watch?v=soEGqOdiU_0
• http://www.everydayhealth.com/cancer/breast-cancer/awareness-month-2007/self-exam.aspx

Being a working mom – Is it good or bad for my kids?

Recently in the news, the Pew Research Center found that in 40% of American households, women were the primary breadwinners.  However, most of these women were single mothers.  After reading the article in the Washington Post, I went on to read the comments section to see what were people’s reactions.  The responses were divided mostly into those praising women for their accomplishments and others expressing their concern over the rise of the number of single mothers and how children should have at least one parent at home.

I struggle with those same conflicting feelings and it was really highlighted when I got the results of Katherine’s gifted and talented test results.  Fortunately, she qualified but when I looked at some of her achievement scores, 4 out of the 6 sections were in the 70th percentile.  I wasn’t too disappointed, just realized there are some areas that might need some work.  But when I told my mother (who happens to be very Chinese when it comes to education), she said, “Well, I don’t want to make you feel bad and it’s not really your fault, but when you guys were young, I spent a lot of time working with you kids at home.”  Which really meant that it was my fault because I was working a full time job and not teaching Katherine at home.

I think my mom saw the conflict as well because she wasn’t telling me to quit my job to be a stay at home mom.  She really didn’t have an answer as to what to do and most of the time she is full of answers.  She was a stay at home mom for 10 years and after getting a divorce she went back to working two part time jobs.  She didn’t make that much money and we never saw her much.  The lesson to be learned was “Never depend on a man.”  So here I am, not depending on a man, even supporting a man through the early stages of a business, and somehow I still haven’t gotten it right.

I don’t know that I could ever be a full time stay at home mom.  I love what I do.  I know I am helping people and it is incredibly satisfying.  I spent a lot of time and money getting here, and right now, I don’t have a choice.  But I love my children more than anything in the world and no one is going to be able to raise them better than me.  So on any given day, you could find me on either side of the opposing views in the comments section of the Washington Post.  It just depends on how much time I’ve spent with my kids the day before.

Will I ever find the right balance?  Does society allow for such a balance?  I guess for now, my internal conflict will just have to continue…

Related articles

• Working moms are now main breadwinners in a record 40 percent of US households with children (Washington Post)

What I have learned from being a single parent for 7 months

My husband moved to Houston in November of last year to open his own practice.  I decided to move down later because it would make finding childcare easier at the end of the school year and it gave me time to prepare the house for selling and moving.  It also allowed my husband to focus his time and energy on building his practice.

Now that I have sold our home, moved out of our house and am ready to drive down to Houston with my two girls to join my husband, I am taking a moment to pause and think about what this experience has made me realize.

1.  Being a single parent sucks.

It is just exhausting.  After working a full time job, having to come home and take care of your kids is tiring (and this is with the help of nanny!).   Also, on the weekends, it becomes a full day job.  I enjoy doing fun things with my kids on the weekends, but it’s trying to get the laundry done, go grocery shopping and cleaning the house on top of watching the kids that becomes challenge.  I have a whole new level of respect for those who are single parents.

2.  I appreciate my husband so much more now.

I used to complain that I always did more than my husband.  Sometimes when we argued, I would say, “You never do anything around here!”  That would get him very angry.  Now that he is actually doing nothing in the house because he is not here, I realized how much he really did help me.

3.  Help a single parent out whenever you can.

I sold our outdoor basketball hoop to a woman who wanted it for her son’s birthday.  I had to take it apart (with the help of my father) for her.  When she came to pick it up, I found out that she was divorced and had a 7 year old son.  I could tell she wasn’t all that handy and asked her if she had anyone that might be able to help her put the hoop back together.  She was from Australia and had no family in the area and mentioned that one of her girl friends might have a few tools.  I felt bad for her because she didn’t have the kind of support that I had.  It made me conscious that there are single mothers out there that don’t have someone to fix things around the house for them, help them with their cars, watch their kids, etc.

4. Do everything you can to not be a single parent.

For me, this means making my marriage work.  I’ll admit, it’s been hard work and sometimes the grass may seem greener on the other side.  But ultimately, it is the best thing for my kids and provides them with a healthy balance by having two parents’ time to occupy.  I know this doesn’t always work for everyone else, but I will be right there until the end, fighting to make my marriage work.  Divorce is not an option for me.

Though this is not the first time my husband has been away (two Army deployments), this has been the longest and hardest, with the challenges of selling a house and moving thrown in there.  It has given me a new perspective on parenting and marriage and I hope never to have to do it again.

The Truth About Mammograms – What should you do?

In September 2011, I was interviewed for an article in the hospital magazine about mammograms, in preparation for Breast Cancer Awareness month in October.  The one question I was asked that stuck out in my mind was, “What is you want readers to know about mammograms?”  My immediate answer was, “They are not perfect.”  Somehow that was not really explored in more detail and the point never really made it into the article.  I guess it might have discouraged women from getting mammograms.

Do mammograms save every woman with breast cancer’s life?  Unfortunately not.  As Peggy Orenstein in her recent article suggests, many women are under the misconception that if you have mammograms every year, it will save your life.  It can, but it does not necessarily mean that it will.  But just because it is not a perfect test, does it mean that it should not be utilized at all?  The media isn’t questioning the value of pelvic exams, prostate exams and colonoscopies and they are not perfect.  Patients are subject to false positives, false negatives and risks of procedures that result from those tests.  And, people are still dying from ovarian, prostate and colon cancer.

Do I believe that mammograms save women’s lives?  Absolutely.  I can for sure say that there are young women’s lives who have been saved by mammography.  The problem is that people have been made so aware of how mammograms have helped save lives, that not much has been discussed about the limitations of mammogram until recently.  As a result, people have lost faith in mammography.  However, if you understand the limitations in addition to the benefits of mammography, you can then choose how to best utilize it in screening yourself for breast cancer.

So what should you know about mammography other than it can save your life?

1.  Mammography is limited in dense breasts.  This point has been brought up in the media for a while now.  To understand in simple terms how the density affects mammography interpretation, see my blog “Breast Density and What Does It Mean?”

2. Mammography is not always able to image the entire breast.  The vast majority of breast cancers occur in the upper outer portions of the breast and so the views taken favor imaging those portions of the breasts.  However, the lower inner portions of the breast tend to be more difficult to image and as a result, some cancers that develop in the very inner and lower portions of the breast may not show up on mammography.  In general, the parts of your breasts that are the closest to your chest and farthest from your nipple can be difficult to image as it is difficult to pull every inch of your breast tissue into the machine.

3. The radiation dose of mammography is fairly low.  The dose of one mammogram is equivalent to seven weeks of radiation you get from natural sources in the environment.  The dose of a CT of your chest is equivalent to 10-25 mammograms.  The lifetime attributable risk of fatal radiation-induced cancer from mammograms is 1.3 to 1.7 cases per 100,000 women.  You have a greater chance of dying from a car accident (1 in 84 as quoted by the NY Times) but most people don’t even think twice when getting into their cars.

4. Not every mammogram reading is equivalent.  The number of false positives and negatives can vary depending on who is reading your mammogram.  The readings can also vary depending on how many comparison mammograms the radiologist has.

5. Some breast cancers are just plain difficult to see on mammography, even on easy to read mammograms.  The growth pattern can make some cancers easy to see and others not.  If the cancer grows along the breast tissues, as true of lobular type breast cancers, it can blend in with the normal breast tissue and be difficult to detect on mammograms.  These types of cancers tend to be larger by the time they are detectable by mammography.  However, if the cancer starts to distort the tissues around it, those changes tend to be more easily seen on mammograms, even dense ones.

6. Some breast cancers grow too fast to be detected at a small or early stage.  I have seen a perfectly clear mammogram one year and the next showing a large cancer that has spread to other parts of the body.  I really hate those cases.  I always ask, “What could’ve been done differently?”  Unfortunately, we can’t assume that because your mammogram is good today, you will be fine until you get your next mammogram.  Cancer can happen anytime.

So, what does this mean for you?

1.  Decide first if you want to be screened for breast cancer and at what stage you want to find your breast cancer.  Often DCIS (see my blog about DCIS) and sometimes very small invasive cancers are only seen on mammography.  Ultrasound tends to find breast cancers after they have formed a mass (i.e, become invasive).  If you want a chance at finding your breast cancer early, then have a mammogram done.  Remember that the cancers in women who are not in menopause (50’s and younger) tend to grow faster and be more aggressive than the ones that show up in those who are in menopause.

2.  If you decide on having a mammogram done, find out if that is enough when it comes to imaging studies.  If you have dense breasts, an ultrasound may indicated as an additional means of screening.  If you have a high risk or strong family history, MRI may be indicated for screening.  Talk to a radiologist whenever you can to find out what imaging tests are best for you.

3. Always feel your breasts, particularly in the areas farthest from your nipple.  THIS IS VERY IMPORTANT, for several reasons.  First, feeling your breasts allows the areas that can be missed on mammography and even ultrasound to be checked.  Second, it allows your breasts to be checked between the yearly mammograms should something grow in that interval period.  Third, no one is going to know your body better than you.  You are going to be better at finding that breast cancer than your doctor if you regularly check your breasts.  (Blog to follow about self breast exams…)

4. To reduce the false positives and negatives, be consistent.  Screening works the best when you have a timeline.  Get a mammogram done every year to reduce the chances that something might get missed.  Always have your prior films for comparison as it reduces the likelihood that you will get called back for additional imaging and helps the radiologist appreciate any change that might be significant.

5.  Have a breast radiologist read your mammograms.  The more mammograms someone reads, the better they will be at knowing what is normal and what is abnormal.  Also, radiologists who perform biopsies get feedback after getting the results, thus learning what varying forms cancer can present as.

The problem with breast cancer screening is that everyone’s breasts look different and not every breast cancer acts or presents the same way.  It’s hard to have a “one size fits all” approach.  Mammography is not perfect but the things listed above can help overcome its shortcomings and improve detection of breast cancer at an early stage.   If you don’t do mammography, what are you left with?  You are left with waiting until you develop a mass, or invasive breast cancer.  The larger the cancer, the higher the risk of it spreading to other parts of your body.  That’s the risk of not doing mammography.

As you will find on my blog, my philosophy is that the patient always has a choice.  Just be properly informed of the risks and benefits of the choices you have.  Don’t be afraid to ask what your options are.   It is your body and ultimately you are the one who has to live with the decision you make, not anyone else.

Stay tuned for upcoming posts about self breast examination, breast MRI and ultrasound.

Related articles

• Mammography’s alleged harms: Separating fact from fiction

Should I have a mastectomy? – Supporting Angelina Jolie’s decision

As I read the article on the New York Times about Angelina Jolie’s preventative double mastectomy, I was reminded of the many patients I have seen that have considered mastectomy either for treatment of their breast cancer or for prevention.  Most people see me while in the early stages of their decision making and from my conversations with them, it is clearly not an easy process and many of them ask me for advice on what to do.  Here are some conversations I have had with some patients (skip to the end if you want to read my advice):

The youngest patient I diagnosed with breast cancer was 26 years old.  She had a lump in her breast which I thought was probably going to be benign but being that we could never really be too sure of these things, I went ahead and biopsied it.  It came back cancer and I was floored.  All I could think about was how young she was, how she had so much life left to live and how she had a two year old daughter to take care of.  We did a breast MRI and additional small areas showed up on the MRI near her cancer that may have represented additional disease.  When she came back to see me about her MRI findings, I questioned her about what she was considering for treatment.  At that time, she was thinking of only having the lump removed.  I then told her that I was worried that there was additional disease and that I wasn’t so sure that just taking out the lump would guarantee that all of her disease would be removed.  I told her that she had so much life left to live and she has a two year old daughter to take care of.  Why take those chances?  She ended up opting for mastectomy.

I recently drained a benign cyst in a 40 year old woman.  I called her with the results and she told me she was considering having a double mastectomy.  I was caught off guard as most of these conversations end with, “Great!  Thanks!  See you in a year!”  I asked her what her reasons for this were.  Her mother died from breast cancer at the age 33.  Every year she comes in for a mammogram, it gives her incredible anxiety and she was already on anti-anxiety medications.  I told her that her mammogram was fairly easy to read and that if she develops a breast cancer, we would have a good chance of finding it when it was small.  That was no reassurance for her.  She didn’t want to take the chances.

Another woman in her late 40’s had very difficult breasts to image on both mammography and ultrasound.  She had numerous cysts in both breasts and was coming in every 6 months because her breasts looked different every time we imaged them.  She had been through several cyst aspirations and a couple of benign biopsies.  When she came in to see me for her results, she told me she wanted a double mastectomy.  She asked if I thought she should have her breasts removed.  She was practically begging me to say yes so she could jump on board with the decision.

A woman in her early fifties was diagnosed with a triple negative (very aggressive) breast cancer a few years earlier.  While the mass was small, she opted for mastectomy.  She came to see me for a mammogram of her other breast which remained.  It was dense and so I discussed having a breast MRI done to screen that breast.  During that conversation, I mentioned that her breast cancer was an aggressive type, which she did not know.  I told her that I thought it was probably a good idea that she had a mastectomy as the recurrence rate with those types of breast cancers were high and that I probably would’ve done the same thing.  She almost started crying.  “You don’t how good it feels to hear someone say that.  I have had a lot of people make me question whether or not I did the right thing.”

A lot of patients ask me, “If you were me, what would you do?”  My response is, “I am not you and so I can’t answer that.  I haven’t had the same life experiences you have had that might influence my decision.”  In many instances I say, “I don’t what it’s like to watch my mother/sister/friend die from breast cancer.”

If you are considering a mastectomy, here is my advice:

1) If you are in your 30’s or 40’s and are diagnosed with breast cancer or have a family history of breast cancer (particularly in family members in their 50’s or younger), get tested for the gene.  If it is positive, then the decision might become a whole lot easier as your risk of developing breast cancer is significantly higher.

2) Seek opinions from a few breast surgeons to see what their recommendations are.  If you have breast cancer and several surgeons recommend mastectomy, it is most likely because they feel that your risk of recurrent disease would be higher with a lumpectomy.  If you don’t have breast cancer and are not gene positive, they can still assess your risk of developing breast cancer.

3)  See a few plastic surgeons.  Most people don’t know what reconstruction entails.  A lot of people are under the misconception that they will walk out of there with better breasts than what they have.  There are many different methods, some which are better for certain body types and there are complications that can be associated with each.

After doing so, you should consider:

a) What is the risk of developing breast cancer (or recurrent breast cancer) with and without mastectomy

b) What are the risks of mastectomy and reconstruction

c) What are the possible outcomes of reconstruction and how much does that matter to you

d) How much does lifestyle matter to you (whether or not you want to have continual tests to monitor for recurrence)

Ultimately, you are the one who has to live with whatever decision you choose to make, not anyone else.  As long as you are informed and have considered all of the options and their possible outcomes, whatever decision you make is the one we should support.

Related articles

• http://www.nytimes.com/2013/05/14/opinion/my-medical-choice.html

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Teaching Kids the Value of Money – A Failed Experiment

One day, my daughter Katherine told me she wanted a Barbie doll.  (By the way, she already has seven, more than I had in my entire childhood…)

Well, you need money to buy that.

“How do I get money?”

You need a job.

“What’s a job?”

A job is something you do for someone and then someone gives you money for doing it.

“Can I have a job?”

I paused for moment.  I had flutters in my stomach thinking about how I could use this opportunity to teach Katherine the value of money and claim it is as one of my great achievements in parenting.  I had to quickly think of something she could do.  What could a five year old do to earn money?

If you put your pajamas away in the morning, I will give you a quarter.

She gave me a look.  “A quarter?  How about a dollar?”

I was taken aback.  Apparently, this child knew more about money than I had thought.  I started to do the math… a dollar a day, 30 dollars a month, 360 dollars a year?!?  Do you know how many hours of babysitting I had to do as a teenager to make that kind of money?

Why don’t we start with a quarter.

“Okay,”  she said with a bit of disappointment.

The next day I reminded her of her “job”.  She put her pajamas away and I gave her a quarter.  She seemed excited.  This continued for a few days and then Katherine lost interest and didn’t seem to care about the quarters she earned from her “job”.  Instead, she found it easier and more satisfying to take the quarters off my dresser than having to do some work.

Now, as Katherine shakes her piggy bank filled with quarters from around the house and proudly proclaims, “Look how much money I have!”,  I think about when the next opportunity might present itself and how I might be successful next time at accomplishing what I want.  Will she ever understand how hard her mommy and daddy have worked to allow those quarters to so easily slip into her hands?  I guess only time will tell…

Breast Density and What Does It Mean?

I requested a patient return for a screening ultrasound of her breasts.  When she returned, she wanted to know what it meant to have dense breasts and if she needed to have ultrasound ever year.  We hear about breast density quite often and how mammography is limited in people with dense breasts.  But what does that really mean?  How does it affect mammography?

To make it simple for people to understand, I compare reading mammograms with hunting for deer (no, I do not actually hunt):

I am the hunter looking for deer (breast cancer).   If I am looking for a deer in a field with no trees, the deer is easily seen.  In fact, I will be able to see a small deer easily in a field.  If I am looking in a densely wooded forest, I may have more difficulty seeing deer, particularly smaller deer.

If you have fatty (not dense) breasts, you have the “field”.  If you have dense breasts you have the “forest”.  The density of your breasts depends on whether you have mostly fields or forests in your breast.

We grade density on what percentage of your breast is filled with “trees”.  If 0-25% is filled with trees, then you are predominantly fatty;  25-50% is graded as scattered densities, 50-75% heterogeneously dense, and 75-100% is extremely dense.

In reality, it is not that simple.  The distribution of “trees” in the breast can vary significantly and makes classification difficult.  Suppose one acre has 100 trees but they are spread out over the entire acre (100%).   There is enough space between the trees that you would probably be able to see a small deer between the trees.  But what if the 100 trees were packed into 1/10th of an acre (10%)?  If the deer happens to show up in that 1/10th of an acre, you might have difficulty seeing it.  The first scenario would be classified as dense (>50%) and the second would be classified as not dense (<50%).  And what does it mean if we are around 50% (borderline scattered versus heterogeneously dense)?  Our current system of grading breast density doesn’t necessarily correlate with our ability to find breast cancers.

Unfortunately, determining the density of your breasts and the likelihood of finding a breast cancer is not a perfect science.  It is left at the discretion of the radiologist.  Not every radiologist may necessarily agree on whether or not you need additional testing, such as MRI or ultrasound.  So what should you do?

1.  Have a mammogram done.  You cannot tell density by how firm your breasts feel.  There is no correlation.  If your breasts are fatty, then it mammograms may be a really good screening test for you and you may not need anything else.

2.  Have your mammogram read by a breast imaging expert.  The radiologists who read more mammograms are going to be better at it.  An easy way to tell who is an expert is to see if they have received additional training (“fellowship”) in breast imaging.

3.  Have a discussion with the radiologist when you can.  If you get called back for additional imaging, ask to speak with the radiologist.  That is the best person to tell you about your breast density and whether or not you may benefit from additional testing.

4.  If you have family history, consider seeing a breast surgeon.  If you are at increased risk of developing breast cancer, you may benefit from having breast MRIs for screening.  The breast surgeon can determine your risk and also provide you with genetic testing.  If your risk is high enough, you may benefit from additional imaging, even if your breasts are not dense.

I spent about 10 minutes with the patient I described above explaining what her breast density was and what it meant for her.  She was borderline dense and although I felt that I would probably be able to find a small cancer in her breast, her ultrasound was negative and posed no risks (such as short interval followups or benign biopsies).  I told her I was not sure she needed the ultrasound every year, but that if she wanted it, there would likely be no downsides to having it done.  So at the end, we decided together that she should have a mammogram and ultrasound together every year.

As she was walking out the door, my patient turned around and said to me, “Thank you for what you do.  I know you are trying to save lives.”  I was incredibly touched by what she said.  It makes every minute I spend talking to a patient worthwhile.