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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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 of "This Is Why You're Fat (And How...

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.

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?”

Is Breast Cancer Awareness Overhyped? – First part of the response to Peggy Orenstein’s article

Probably.

In the past month or two, I saw three young girls for a lump in their breast.  One was 19 years old, the others 15 and 12.   The mother of the first girl was recently diagnosed with breast cancer and was finishing up chemotherapy.  I put the ultrasound probe down and saw a benign appearing mass, most likely a fibroadenoma.  I told them that just that.  I looked into both their eyes and there was no sense of relief.

Ok, maybe they need more than that.

Not entirely sure what it is they needed to hear, I continued on:

“The options for management include watching it in 6 months or biopsy.  I am not sure if you would want to consider biopsy, given your own personal experiences and that way you will have a definitive answer.”  The mother breaks down crying.

Oh shoot.  I said the wrong thing.

I gave the mother a moment.  She apologized.  It was okay.  By now I have gotten used to cancer patients having moments where they just need to break down and cry.  Finally, when she was able to gather herself, I tried again:

“I am 99% sure that this is not cancer.  It would be incredibly unlikely in someone of this age to have a mass that looks like this end up being cancer.  If she were my daughter, I would opt for watching it, just to make sure it does not rapidly grow.”  Finally, I see some relief in my patient and her mother’s eyes.

I don’t know know why I even mentioned biopsy as an option.  I almost never suggest biopsy in someone of this age because it is so unlikely to be something abnormal.  If it were my own daughter, I wouldn’t have even worried for a second.   Now, in this situation, the patient’s mother had breast cancer, and that probably contributed largely to their fear, and probably to some degree mine.  But the mother of the second girl I saw did not have cancer.   The mother of the third, 12 year old girl, repeatedly asked me if the several benign cysts were normal.  I couldn’t help but to wonder if this is just a normal parental response, or is there so much hype around breast cancer that we are now making our teenage daughters check their breasts for lumps.

I see the look of fear almost every day in my patients’ eyes.  For many patients, if I offer six month follow up, I get this look of “are you sure?”  I have actually done biopsies when I didn’t think someone needed them because the patient wanted it.  Many women can’t stand the thought of waiting, as though there was a ticking time bomb in their breast.

Awareness is a good thing.  It helps people take initiatives to get preventative services that might actually save their life.  But all of this awareness has instilled a great deal of fear, in not just patients, but their doctors as well.  We have to live up to the notion that early detection will save our patient’s life.  Don’t miss that breast cancer when it’s early!  If you don’t biopsy and something turns out to be a cancer, be ready to explain that to your patient (and possibly their lawyer)…  And it’s not just radiologists who fear it too.  When my partner and I felt that we could safely follow certain things in a year, we received some nasty responses from referring physicians who basically told us that that was not the protocol and we were putting them at risk for lawsuit.  They would no longer send us patients unless we forced people to come in at 6 months for followup.

I agree with Peggy Orenstein about how the “awareness” aspect of breast cancer is borderlining on hysteria.  We, as a community, need to have a rational outlook on breast cancer so we can better focus our energies on prevention, detection and treatment, and make sure that what we are doing is really helping women.

Why I am here

This past weekend there was an article published in the New York Times Magazine by Peggy Orenstein titled “The Feel-Good War on Breast Cancer.”  I was warned by a colleague to be prepared to address the article with patients.  So, on Sunday night after my girls went to bed, I looked it up on the internet and read it.

I immediately had mixed feelings about it.  There are some things I agree with and some things I disagree with.  But my concern was mostly about how women might react to such a piece.  As with most articles I read on the internet, I continued on to the comments section.  As expected, many breast cancer patients described their experiences, some with good results, many with bad results.  There were also some people who described facing the possibility of having breast cancer, ultimately ending up with benign results, and how that experience negatively affected them.

Although I did see a rare post from a radiologist defending mammograms and the need for biopsies and surgery, there is very little out there about what it is really like to be in our shoes.  Every day, we sit here examining numerous mammograms, trying to determine whether or not we should call someone back for additional views.  Could that be a cancer?  Or when we see something we are not sure of, do we biopsy or watch it?  Our patients’ lives rest in our hands and our decision at this moment could mean the difference between someone having cancer and doing well versus someone having cancer and ultimately dying from it.

Part of my job includes performing biopsies and giving the results.  I have told many women that they have breast cancer.  Fortunately, I have been able to tell many women that there are reasons to stay positive.  But like the article describes, there are still many women I cannot tell that to, and some I know have not done well.  There are many times I have wanted to cry with the patients but because of professionalism, I hold back the tears.  But I am right there with them feeling the sadness, the disappointment that I couldn’t find this earlier, and the fear of what their future holds.

I have had so many experiences with patients that have changed my outlook on life in so many ways.  After reading several blogs of breast cancer patients, I thought to myself, “It might be nice to share some of my experiences with other people.”  Perhaps, it might be reassuring to some patients to know that we (as breast radiologists) are on their side.

That is why I am here.