There are many things a doctor must learn -- some of them not so nice, but nearly all of them necessary.
One night, during my first month as a doctor at Columbia University Medical Center in New York City, I was nearing the end of a busy shift in the emergency room. I had seen more than 20 patients, admitting some to the hospital but sending several home with a quick remedy, a reassuring word, and a follow-up appointment. Eyeing the clock, I picked up one last chart from the growing stack and walked into the exam room.
The patient (I'll call her Ms. Smith) was in her late 60s, thin, quiet, and sitting primly on top of the gurney, her hands folded in her lap. We exchanged hellos, and when I asked her what had brought her to the emergency room, she said she'd been very tired. I asked about her diet, her sleep habits, and any other symptoms, but she had no other major complaints.
She answered my questions softly but thoughtfully. Many young doctors might have simply gone through the motions with this patient, but since I had a special interest in aging, her fatigue was as important to me as someone else's chest pain. We went through Ms. Smith's short medical history. She took medication for high blood pressure and, every month or so, saw her regular doctor of 15 years so he could monitor it.
Hoping to find something that might spur a diagnosis, I began the physical exam. I didn't ask Ms. Smith to get completely undressed, however. I had several reasons, and only later did I realize that my reasons were actually excuses: Ms. Smith was wearing only a housedress. The exam "room" was not very private -- just a space defined by a curtain. There was no nurse to help her undress and put on a gown. I was trying to save a little time.
As I had been trained, I started working from the head down. So far, so good-until I placed my stethoscope on her chest to listen to her heart. I felt something very firm, even rocklike. I asked Ms. Smith if she was wearing a special bra or back brace. "No," she said. I asked her if I could take a look
What I saw would have shocked any doctor, no matter how many years of training. Her left breast had been completely consumed by a black, bleeding, softball-size tumor.
"How long has your breast been like this?" I asked.
"Three years," she replied, almost apologetically.
"Did you tell your doctor about it?"
Her answer was simple, direct, and tragic: "He didn't ask."
"Did he examine your breast?"
"No," she answered. "He only treats my blood pressure."
Ms. Smith died three months later from Stage 4 breast cancer that had metastasized throughout her body. Her death was likely preventable, and it teaches women and their doctors many valuable lessons.
More than 211,000 cases of breast cancer are diagnosed each year. Since you are the one most familiar with the contours of your body, it's possible you'll notice a change before your physician will. Examine your breasts on a regular basis, at a time when they're least tender. For women not past menopause, this is generally three to five days after menstruation.
If your doctor does not see you naked at least once a year, she is not doing her job. Because of Ms. Smith, I make this phrase my mantra. The average doctor visit lasts less than 20 minutes, but don't let that fact shortchange your health. If your doctor doesn't ask you to put on a gown, take the initiative and request one.
Overcoming the Obstacles
Despite all of the information about breast cancer and prevention swirling around us, only 27 percent of women get mammograms according to the recommended guidelines for their age group. Also disheartening was a report this year from the National Cancer Institute that showed a decline in the number of women age 40 and over who received mammograms from 2000 to 2005. Although mammograms are not foolproof, they detect lumps one to three years before they are identified by a manual exam.
One of the most common reasons women avoid this appointment is because they find the experience unpleasant. If this has been the case for you, try having the exam two weeks after your period begins. And speak up. Tell the technician that you felt pain during your last exam. That alerts her to take extra care. Ask her if it's possible to control compression yourself. Request a special cushion, which some centers now provide, that sits between the breast and the machine. This doesn't interfere with the quality of the exam and may diminish pain.
A mammogram is only as good as the person taking the X-ray and the person reading it. Look for a center that specializes in breast imaging. If that's not an option, request that a copy of your films be sent to the closest university medical center, where a doctor with the most experience can double-check your mammogram.
Get the Right Follow-Up Test
Although a mammogram is the screening test of choice for breast cancer (and the one most insurance plans cover), several recent reports are directing certain groups of women toward other tests. The breast ultrasound is one of them, and it's used in conjunction with the mammogram, not in place of it. It may be particularly important for women who have dense breast tissue. Dense breast tissue appears white on a mammogram, the same color as an abnormality, making an accurate assessment difficult for the radiologist. And since breast tissue becomes less dense after menopause, it is often younger women who need to be most concerned about obscured tumors. Ask your radiologist or even the technician performing your mammogram about the density of your breast tissue and whether an ultrasound would ensure the most thorough exam. (Your density level may have been noted on prior reports, which is one reason why it's important to keep medical records organized and accessible.)
The New England Journal of Medicine and the American Cancer Society made big news this year when they reported that magnetic resonance imaging (MRI) can find tumors that regular mammograms miss. This may be especially important, once again, for women with dense breast tissue or for those with breast implants. An MRI can also better detect missed tumors in a woman's breast after she is diagnosed with cancer in the other breast. The American Cancer Society recommends that women with a new diagnosis of breast cancer get an MRI of the other breast to help determine the best treatment options. In all of these cases, you'll need to check with your insurer to see if it covers the cost of the test. You should also ask the radiologist if he has had experience reading breast MRI. Because this is a new approach, some radiologists cannot yet read the tests with the most knowing eye.
Talk About It
Although modern mammography has been available since 1969, breast cancer was largely a taboo subject until 1974, when First Lady Betty Ford candidly told the nation about her battle with the disease. But even now, 33 years later, many people still refuse to talk or think about it. Indeed, another of the most common reasons women give for not getting a mammogram is that they "just didn't think about it." It's worth asking the women in your family if they are doing everything they need to do.
October is National Breast Cancer Awareness Month. You will hear many stories that are sad and many that are triumphant, and I hope they will all be inspiring. I also hope you don't forget them. I've never forgotten Ms. Smith.