Doctor, Am I Going to Die?

20131002-230931.jpgDo 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.

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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:

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.

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.

Questions?  Contact Me!

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.

DCIS, To Treat or Not to Treat? – 2nd part of response to Peggy Orenstein

What is DCIS, or ductal carcinoma in situ?

DCIS means that there are cancer cells in your breast but they have not gone anywhere.  They have not invaded beyond the normal breast structures (ducts and lobules) into the surrounding tissues.  Once the cells break through ducts and lobules, it is called “invasive”.  Once it is invasive, it can spread to your lymph nodes and the rest of your body.

Peggy Orenstein is correct in that DCIS alone will not kill you.  Breast cancer solely in your breast will not kill you.  Even breast cancer in your bones will not kill you.  However, when the cancer cells take over vital organs, such as the liver, lungs, and brain, that is when people eventually die from cancer.

Although some DCIS will never become invasive cancer, DCIS has the potential to become invasive.  Although there are some cancers that may never spread to other parts of your body, all invasive cancers have to potential to go to other parts of your body.   The problem is it can be hard to predict what the cancer cells in your body are going to do.  The blanket statement that DCIS in a 40 year old “quite likely would never become life threatening” (I have seen cases that have proven otherwise) is just not true.  It is not that simple and not everyone can be fit into a one size fits all category.  So, what is the likelihood that DCIS will become invasive cancer?   There are a few things to consider:

1.  How aggressive is the DCIS?   DCIS is broken down into low, intermediate and high grades, which are determined by characteristics indicative of cell growth.  High grade or comedo type DCIS means that the cells are rapidly growing and it is very likely that if you leave it in the breast, you will at some point develop invasive cancer.

2.  How much of it is there?    If you have a large area of DCIS, there are more cancer cells there, and thus a greater chance for one of those cells to start invading.

3.  How much life to you expect to have left?    The more time you let DCIS stay in your breast, the higher the risk for developing invasive disease, as you are giving it time to grow.

4.  Is it hormone sensitive and are you premenopausal?  If it is sensitive to estrogen and progesterone and you are still having menstrual cycles, then you are stimulating the cancer cells to grow.

So, if you are 40 year old woman with high grade comedo type DCIS, regardless of the size, I would say that it is in your best interests to remove whatever DCIS is there, as there is high risk that you will develop invasive breast cancer, probably sooner than later.  If you are 70 year old woman a small area of calcifications that showed low grade DCIS and you have diabetes and heart disease, the DCIS is probably not going to do you in before your diabetes and heart disease will.

And if you are somewhere in between?  It may not be so clear cut.  You will have to ask your doctors what they think the likelihood that your DCIS will be come invasive is.  Then you will have to decide, “Do I want to wait to see if this will become invasive cancer, or, do I want to remove these cells now and not give them a chance to become invasive.”  Most people would probably opt for the latter.  Perhaps the point Peggy is making is that we should be giving people the option, which is not something I am against.  It is okay not to treat DCIS as long as you understand the risks.

However, treating DCIS is reducing your risk for developing invasive breast cancer in the future.  Should it be grouped together with invasive cancers in the statistics? Maybe not.  Should it even be considered a cancer?  Maybe not.  (It should be called pre-cancerous in the least.)  To say that we are “over treating” DCIS is a matter of opinion.  Perhaps it should be looked at as a preventative measure rather than treatment.  It may be one of the few things you can do to reduce your risk of dying from breast cancer.  If someone chooses to do that, I ask, “What is so wrong with that?”

Cancer a second time

Stacy was woman in her early fifties who in for a routine mammogram.  She was diagnosed with DCIS 2 years prior and treated with lumpectomy and radiation and was currently on Tamoxifen.  Because she was only 2 years out from her diagnosis, I read her mammogram while she was there.

I opened up her study.  Oh no, those calcifications don’t look good.  I immediately knew that her DCIS had come back, but this time in two spots.  I went in to talk to her and her husband.  I could immediately tell that she was a nervous wreck.

“There are two new areas of calcifications in your right breast that look worrisome.  We need to do a biopsy to find out what is causing the calcifications.”

She breaks down hysterically and starts crying.  She screams, “I can’t go through this again!”  As her husband tried to help calm her down, I stood there awkwardly, not knowing what else I could say.  I couldn’t say anything that was going to make things better at that moment.  So, I quickly passed her on to my patient navigator to schedule an appointment.

I saw Stacy again a few days later for her biopsy.  She is much more composed and her husband is with her again.  We finish the biopsy and at the end, I thought, I’d better prepare her for what is to come.

“If the biopsy comes back benign, I am not going to be satisfied with those results.”

What do you mean?

“I am really worried that those calcifications are due to DCIS.  If the results come back benign, I would want to be extra sure that they were benign by having a surgeon take out a larger sample and make sure that I didn’t miss something.”  It started to sink in.

If it’s cancer again, I am going to need a mastectomy.

She starts crying again.  After a moment, I asked her what was going through her head.

I don’t want my husband to find me unattractive.  Men leave women for those things.

Ok, I didn’t see that one coming.  With her husband being with her every step of the way, I didn’t think that would be a concern to her.  I reassured her that breast reconstruction had come a long way and that her husband obviously cared enough about her to come to all her appointments.

She asked me to tell her husband what I had told her.  When I did, she started crying again, asking her husband how they were going tell the kids. I said, “I am sorry.  Is there anything else I can do for you right now?”

“No.  Just find a cure!” her husband barked at me.

I will never forget the look on his face when he said that to me.  I felt so small and powerless.  As a doctor, I was supposed to help people and yet it didn’t seem like I could help either one of them at all.  Again, I quickly left the room.

Stacy did ended up having DCIS, the kind that probably would’ve eventually become invasive cancer had it been left alone.  She had a breast MRI and it turned out she had DCIS in the other breast too.  She decided to have bilateral mastectomies.

Though I often see the fear and anger that patients go through, I got to experience firsthand the anger that family members have when their loved one gets cancer.  It reminded me that it wasn’t just the patients who go through emotional roller coasters with cancer, and the roller coaster can be even bigger the second time around.

Just find a cure… I wish I could…