Monday, September 04, 2006
Breast Cancer: scary tales
Here is a truism by which I've always stood in my breast practice: an excellent way to investigate a palpable (feelable) breast lump is "fine needle aspiration." In fact, I'm a bit of a fanatic about it: I think gazillions of dollars are wasted by unnecessary breast ultrasounds for lumps, and by more extensive biopsies than -- in many cases -- are needed. I'm happy to say I was a bit of a burr under the saddle to many a radiologist, and some primary care docs as well, as I tried to spread the word. (In one particularly enthusiastic moment, during a joint conference between surgeons and radiologists to address such issues, I dis-ingratiated myself by saying, "When all you have is a hammer, everything starts to look like a nail.") I tried -- ultimately unsuccessfully, I'll sadly admit -- to convince primary docs that when they could feel a lump, the first stop ought to be at the surgeon's, not the radiologist's store.
A breast lump is either solid or liquid. For the most part, that's all an ultrasound can tell you for sure. At considerably less than half the price, a surgical consult with needle aspirate will give you that, and much much more. Poke a fine needle (size of one used to draw blood) into a lump: if it's liquid it's nearly always a harmless cyst, in which case the needle withdraws yellow clear fluid, proving the diagnosis and making the cyst go away, usually permanently. Same info as the ultrasound, along with therapy. If the lump is solid, the needle can remove a tiny sample, which, properly spread on a slide and given to a pathologist skilled in such things, can be very accurately assessed. When a lump is cancer, the needle sample either shows cancer, or some cells that are highly suspicious. And when the sample shows entirely innocent cells, and when the lump in question is clinically innocent (as judged by a competent examiner), the chance of missing cancer is extremely low, in which case followup without further biopsy is often a satisfactory option. Few things -- medically speaking -- bug me more than seeing a woman who's had an ultrasound that shows a cyst, referred for treatment. Had it been the other way around, the ultrasound would have never been needed. Even worse is a woman who had a palpable lump, sent first to radiology and getting a mammogram followed by an xray guided (stereotactic) biopsy. Huge waste of time and money. (I may post about diagnostic issues again and get back to this. For now, suffice it to say that stereotactic biopsy is an excellent tool for a NON-palpable lump. And, along similar lines, I'd say this: a mammogram is to find things we can't feel. When a lump is feelable, it makes more sense to me to see the surgeon first: for example, if it's a cyst, and I drain it, what's the good of having taken a picture? It'll be gone on the next one!..... It could take several posts -- or a hellaciously long one, to cover this well.)
So here's the drill: if I saw a lump, I'd generally poke a needle in it. Takes literally about five seconds, hardly hurts. If I'd get clear yellow fluid, and if the lump went away completely, I'd tell the woman with total confidence that it was a simple cyst, explain exactly what that means, arrange followup, and flush the fluid. (It used to be routine to send the fluid to the lab. But several studies confirmed what I'd come to believe: if clear yellow, and associated with a disappeared lump, the tests never showed a thing. So tossing it away became the marching order.) If the lump was solid, I'd sample it with the needle, make a slide, and send or carry it to the pathologist. And when I was sure it was cancer, the sample virtually always showed it. I'm efficient as hell, with a woman's time, and money. But I got two surprises in one week, and they were close to disastrous.
When I saw the referral came from a family doc who always used someone else, I thought this was gonna be something strange, and indeed it was. She'd done a needle aspirate (good for her!) on a young woman with a lump, had gotten clear yellow fluid, observed the disappearance of the lump, but sent the fluid to the lab. And had gotten back the diagnosis: cancer. I was stunned, and deeply disturbed. It was against everything I believed: I'd tossed tens of hundreds of fluid sample into the trash. How could this be? I called the lab, I talked to the lab doc. Was there any chance of an error, a mixup of labels, anything to explain it? There was not. I asked them to double check. They did; there was not. When I examined the woman, the site of the needle poke wasn't visible, and there were no lumps. The doc couldn't say with precision where the lump had been. The mammogram was normal as could be (she was young enough -- early thirties -- that mammograms aren't all that useful, anyway.) Just to make it all more interesting, she was an attorney in the DA's office. To say it was disquieting is to understate by a factor of a pants-full. The woman evidently had cancer, despite the diagnosis being counter to a fundamental principle of my practice. In fact, I already had reason to question my whole approach: I'd just done a needle aspirate on a little old lady who I was absolutely convinced had cancer, and it had come back totally innocent. I must have missed the lump by a mile: me, who made a crusade about the method. Not even my fellow surgeons used it as much as I did. I'd had to do a more expensive, more invasive open biopsy on the lady to confirm the diagnosis of cancer...
Getting goose-bumps yet? It all became clear, about a day or two after I operated on the young attorney. I'd removed the entire quadrant of the breast in which the "cyst" had been, and had done a small lymph-node sampling under her arm. The good news is that because the breast (properly managed, if I may say so) can end up with very satisfactory contour after a pretty large lumpectomy, she got a nice cosmetic result, other than a fine scar. The pathology report, which showed absolutely nothing out of the ordinary, came about the same time I got a phone call: they'd pursued it further and discovered a lab mixup: the slide made from the cyst fluid, and the slide I'd made from the little old lady had been confused by the lab. They even acknowledged that mine had -- as always -- arrived from my office properly labeled and marked and that the error was entirely theirs. Without being asked, the lab doc sent a letter to my patient explaining exactly what had happened, and that I'd twice asked them to double-check. She was surprisingly gracious. And my little old lady, who indeed had cancer, did well despite having undergone an unnecessary open biopsy before her definitive treatment.
And here's the thing: these aren't even the worst stories. I once did a biopsy on a lymph node under the arm of a woman in her seventies. Metastatic breast cancer, was the report. No ifs, ands, or buts. The mammogram, the physical exam were normal. It's uncommon but not entirely rare, and the concensus is that the treatment is mastectomy on the affected side, with around a 60% incidence of finding the cancer in the removed tissues. I was in the recovery room writing post-op orders, having done just that, when I got a call from the pathologist. "Hey Sid, this is Dave. Just got the report from the university. Remember that lymph node? They said it was melanoma. Guess it's lucky we waited, huh?" "WAITED!!!! WHAT THE F--- ARE YOU TALKING ABOUT???? I just took her breast off!!" "Jesus," Dave said. What happened is, they have a weekly cancer pathology conference, at which -- after the final and unequivocal report had been sent out -- another pathologist (he's the one to whom I always carried my breast aspirates -- the best I've ever seen. He was out of town during the week of the first two cases...) had said he thought it might be melanoma. They'd decided to send the slides for consultation, but hadn't bothered to let me know... I said "Dave, you are coming with me when I talk to the lady." Dave said..... well, I don't remember what he said. But he came.
What's the lesson here? Damned if I know. I was inspired to write this after reading the latest post at Urostream. If good news isn't always good news, and bad news isn't always bad, I guess you have to hope to hell you have a team that talks to each other.