Friday, September 29, 2006

Take Your Lumps


What to do with a patient referred for a finding that you can't interpret on a test you'd never have ordered? It's a tough one, and not as rare as you might think, especially in the area of breast lumps. As a topic for posting, the subject comes up in a roundabout way. A couple of other medical bloggers picked up on my mammorable patient" post, and a comment on Orac's site raised the issue of the morbidity of medical screening. It's a fruitful object of scrutiny: false positives, for example, (a finding that requires further evaluation, possibly invasively, that turns out to be nothing) add up on the other side of the ledger. If a person suffers harm -- or even death -- from investigation arising from some sort of routine screening (for whatever...), when the issue raised turns out to be harmless, well, that's not a good thing. There's lots to say about it. I won't, exactly, now. It's just that it reminded me of something that used to drive me crazy.

I could rant all day and into the night about evaluation of breast lumps and where I think the surgeon's role ought to begin. I had a sometimes friendly, sometimes antagonistic relationship with a number of radiologists over breast evaluation, and I tried over my whole career to educate (based on my own biases, of course) primary care docs in the matter of breast lumps. A dispassionate review would likely show I won the occasional battle, but lost the war.

In a nutshell, it comes down to this: when there's a lump you can feel, diagnostic imaging (Xrays, ultrasound, etc.) is a waste of time and money. OK, that's a bit over the top: you get needed information about the rest of the breast, and the other side, which will come into play at some point. But getting a bunch of studies -- particularly without the input of a surgeon -- as the initial step in working up a lump adds up to lots of unnecessary running around for the patient, distractions in the diagnostic process, and -- not rarely -- detours into side roads that never needed taking. Ain't nothing like a good physical exam by a person highly familiar with breast exams, followed, when indicated, by the quick poke of a needle. Don't get me wrong. I recognize that radiologists do good in this world. In fact, I'll admit that the occasional interventional radiologist has saved my bacon more than once, with a well-aimed drain into an abscess here or there. But as the evaluators of a palpable lump (emphasis: palpable. When you can't feel it, that's a whole different ball of wax), they either muddy or bloody the waters.

Mild to moderate disclaimer: ultrasound quality and interpretation is constantly improving. It probably has a role in the screening of breasts too dense for useful mammographic interpretation; and as specificity improves, it may become more reliable in the interpretation of solid lesions. But, basically, the value of ultrasound in the study of the breast is to determine if a thing is solid (which means a possible tumor in need of a biopsy, usually) or liquid (which means, almost always, a harmless cyst in need of no further investigation.) And when is it useful? When a thing shows on a mammogram, and when the thing can't be felt. Period. If you can feel the thing, poking a needle into it gives the same info and more; cheaper, quicker, and more definitive. If it's a cyst, the needle will produce fluid and can empty the cavity, which in most cases makes it go away permanently. So it's diagnostic and therapeutic. Or if the thing is solid, then with the knowledge of simple technique, a sample can be taken with the needle, smeared on a slide, and reviewed under the microscope; often giving a final answer. It makes me lunatic bonkers when the first stop for a woman with a lump is the radiologist's store.

She finds a lump in her breast: it's round, tender, and she's sure it wasn't there a month ago. Because it's the way things work, she sees her primary doc who -- because it's the way things work -- sends her for an ultrasound. Or, more likely, a mammogram and ultrasound. Or a mammogram, leading to an ultrasound which is hopefully done at the same time, but maybe requires a return visit. As expected, the finding is of a fluid-filled cavity consistent with a cyst. (Once in a while, the report will refer to some "debris" floating in the liquid, or some echoes that suggest some irregularity in the cyst wall, of uncertain significance. Now she's worried. My office gets a call: our patient is scared to death over her report. Can you work her in today? Even if there's not the fear element, she's coming to see me much later and lighter in the wallet than if I'd gotten a call about it in the first instance. So I see her, use my handy little needle, diagnose and disappear the cyst, talk to her about cystic breast problems. Depending on age, time since last one, I might have ordered a mammogram, if I'd seen her first. (There's another reason for holding off on it: why get a picture of a thing that'll be gone?)

But it gets more complicated: she gets her ultrasound, and it shows a simple harmless cyst, as expected. But of course the whole breast has been scanned, and wouldn't you know they saw a five millimeter (less than a quarter of an inch) something somewhere else, too small to characterize fully, can't rule out every bad thing on the planet. See, that's what I was talking about. What to do with something you can't interpret on a test you wouldn't have ordered, found in an area not even part of the original concern? Just to make it realistic -- and worse -- the radiologist who read the study has recommended ultrasound-guided biopsy of this tiny spot.

What I'd do is candidly tell the woman my feelings on the matter: that I think ultrasound is the least reliable and reproducible of the studies we do on a breast; that I'd not have ordered that test in this situation, and that whatever this incidental finding is, at that size it's most likely perfectly safe to leave it alone for now and repeat the test in a couple of months. And that based on my experience, if repeated in that time-frame, it's quite likely it will no longer be there. And, of course, I'd also explain that there's no way to be sure at this point and that if it'd drive her crazy to wait, we should arrange for a biopsy. (In several of such cases, the scheduled procedure was unsuccessful in finding the original lesion.)

In the case of large lumps in the breast, I've seen women sent for mammogram and then, per recommendation of the radiologist, undergo stereotactic biopsy. That procedure is intended for things seen on mammogram and not feelable: whether the recommendation was based on an unskilled exam or without an exam at all, it's an expensive and cumbersome way to handle tissue sampling when a simple office aspiration would have gotten the same info. I've seen infections from such biopsies which the radiologist feels uncomfortable in handling; so I see the patient ex post facto, having received an unnecessary procedure and now, salt in the wound, I'm to care for the complication.

What's the point here? Not, despite appearances, to say that radiologists are the enemy. Rather, it's to say that with breast problems more than any "surgical" problem I can think of, coordination of care makes for better care; more economical, more efficient, less stressful. At worst, it can be fragmented into disconnected pieces, where doctors see the problem through a narrow lens, applying tools at their disposal no matter the alternatives. At best, it can come together in a true breast care center, dedicated to comprehensive and complete care. In the best of all possible worlds, surgeons, radiologists, pathologists, and oncologists are under the same roof and consult freely before diagnostic and therapeutic decisions are made. Such centers exist. They're not widespread; and, sad to say, there are some bogus outfits out there. I know of so-called "women's breast care centers" that imply broad-based care but which in reality are drop-in centers that encourage women to show up without referral, to have a cursory exam, mammogram, and quite often an unnecessary ultrasound. The results, rather than explained and followed up upon, are handed to the woman with instructions to see her doctor. It's a rip-off, not run by legitimate radiologists with honorable intentions, but by guys out to make a buck; some aren't even fully certified radiologists.

In most communities, women with breast problems have to start with their primary doc, and then follow a circuitous path to diagnosis and treatment. The end result is going to be good care, but it's hardly the most efficient journey. It's a microcosm of American healthcare: limited by the absence of agreed-upon protocols, complicated by varying levels of expertise, sullied sometimes by docs guided by self-interest (or at least a limited view), marked by wide variations in efficiencies and cooperation. And it showcases a central unclarity: is the best care delivered via good ol' Doc Jones, who knows and cares for the whole patient, or by taking certain body parts containing certain problems to a specialty center right off the bat? I guess if every doc in every area of practice were perfect, and had skills and knowledge equal to every other doc in their field, the question would be moot.

14 comments:

#1 Dinosaur said...

Whoa! Down, boy. I share your disdain for the radio-illogical merry-go-round, but back off a bit on those jabs at us Primaries. That said, I agree with pretty much everything substantive in your post.

The thing I often have to figure out, though, is whether something a woman points out to me is in fact a lump, or just lumpy breast tissue. I'll often re-examine the area in two weeks (different part of the menstrual cycle) and I've been known to jab a needle into those persistent lumps myself and drain those cysts. Poor patient never even gets to meet Dr. Sid.

I agree that the purpose of ultrasound is to characterize a palpable mass, but I never skip the mammogram (after about age 35.) You'd be amazed at how often Gd puts a benign cyst in one breast to get a woman to the doctor so the non-palpable cancer in the other breast can be discovered and treated early.

By the way, the latest most useless radiographical ploy is breast MR; the ultimate waste of time and money.

Greg P said...

Nonetheless, I think the gist of the commentary is right.
I'm not a surgeon, I'm a neurologist, and I see so many patients that have had X-rays, CTs, MRs, EEGs, EMGs, blood tests, none of which individually or in concert are able to come to some conclusion, then FINALLY a neurologic consultation is obtained.
We have a legal protective attitude these days, and especially when you are asking someone to take a stand based on some lab numbers, some pixels on a PC monitor, without ever having seen or talked to the patient you get defensiveness:
"Cannot exclude..."
"An MRI may be more informative..."

Every year I see several patients who come as a "possible MS" (multiple sclerosis), strictly based on a radiologist's comment about "white matter lesions." All without any connections to symptoms, physical findings or really any knowledge whatsoever of the person who had the test. I've had patients' scans in which I struggle to even FIND the "white matter lesions" that are referred to in the report.
This isn't a situation where it's just a little wasted money, and I can be a savior by saying, "Well, don't worry, you don't have MS," I'm dealing with someone who's been frightened out of their wits.
The other thing I know is that some screwball in his legally defensive radiology report has just screwed this person's chances of getting reasonably priced health insurance, life insurance, maybe a job, because that report is out there and can't be modified, corrected, or destroyed and can be found by someone as soon as the consent for information is signed.

Sid Schwab said...

#1 dino: Fact is, I've tried to get primary care docs to do their own aspirations. Good for you! Also, I entirely agree that a simple recheck (after the next period in a premenopausal woman, or in a couple of weeks) is a great first step in a lesion that may not be a lesion. And I assume you meant to say that ultrasound is for a NON palpable mass! Nor would I omit mammogram; it's a question of when. And I totally agree about MR. Finally; I didn't mean to be attacking primary care docs, if that's how it came off. I do wish there were more consistency in approaches to certain surgical problems, especially breast lumps. The way to get there is by cooperation and feedback. In the best of all worlds....

Greg: I'm with you 100%. I got into trouble at a conference between radiologists and surgeons, called because of rising unhappiness over readings that direct care, make various suggestions. I said "When all you have is a hammer, everything starts to look like a nail." Not politic, in retrospect. But the point is serious: everyone (including the patient, as you point out) gets put in a hole by radiology reports that go overboard. I realize the radiologist has to cover his/her rear as well. Again, in an ideal world, we'd talk amongst ourselves more. And we'd have time to do it!!

Anonymous said...

I would caution the Dr.s that say after 35yrs. of age, they wouldn't skip it.( I commend them, however, for not waiting until 40 and poo pooing them until then.) Check out
www.youngsurvival.org. We are younger and younger with very aggressive cancers in the breast. I think the guidelines of "after 40" are crazy. We are in our 20's and 30's being diagnosed at stages 2b and 3. I was lucky and called a surgeon right away. My Gyn said he "didn't feel anything." My surgeon, Gd love him, couldn't find it on palpation. I put a pen marked x on it. He went right in, right then and biopsied. Yep, cancer, but in two areas. Needed the mammogram to tell us that, but was no where near 40.

Anonymous said...

at 33, my lump's ultrasound suggested nothing to worry about so I didnt worry but had a surgeon take the lump out anyway just over two months later (I had already had a benign lump removed a couple of years before) - thats when it was found it was cancer after all - 6 yrs and lots of treatment later Im now terminal.

I can't be sure if I had had a needle biopsy things would have been much different but I hate to think about if I hadnt had the surgery...

Sid Schwab said...

anonymous: that's part of my point. Ultrasound isn't very good beyond telling if it's a cyst or not. If yours was cancer, it wasn't a cyst, and therefore, no matter what the report said, badness couldn't have been ruled out. Since your lump was feelable, my approach is that it never would have had an ultrasound.

nuclearvision said...

As a Radiologist, all I can say is we try our best. In the aboce mentioned "white matter disease" post, I frequently will describe it as of doubtful significance in my impression..you see it in most MRI's in people over 40....it just isn't a good descriminator in pathology.

What I can tell you is I continue to be amazed at the over utilization of imaging. 15 CT pulmonary angio studies in 6 months, all normal, on young 30 year old people..25 CT's of the abdomen in a year on a 40 year old with chronic abdominal pain..all normal.

I love when an old crusty surgeon comes in and says.."They's got an appy, they already got the CT, do you agree?". The young guys come in and say "I haven't seen the patient, labs, or looked at the chart, can you tell me what's wrong?"

Imaging is good....but like everything, it comes with significant downsides.

Sid Schwab said...

Nuke: I much preferred to diagnose an appy by exam. Hardly ordered CTs. But, as you say, that's pretty much out the window, for various reasons. Nor am I unmindful of the "cover your ass" aspect of lots of testing, pulmonary angios being one.

Anonymous said...

anonymous at 33, That's why I posted my account, to caution Dr.s about us young ones getting this horrible disease. We need them to know how young we are getting this. Please join us at www.youngsurvival.org and find some comfort and support. Many are going through what you are too.
If I can save just one life by saying please investigate this, even if they are 16, because we've had them. In the young, they are usually extremely aggressive cancers.

NoAcuteDistress said...

Dr. Schwab, THank you for this civilized discussion on the differences in apporach to a clinical problem that we have with our colleagues-in this case radiologists. It's a shame that we live in a society in which these folk have to adopt such a CYA atttitude, that it complicates the life of the patients and treating physicians and surgeons.

As Nuke points out, it's a two-way street, with excessive request for imaging studies by clinicians, and most dramatically the situation in which a patient is diagnosed and triaged on the basis of imaging studies alone, before a physical examination has been performed.

You will find a tremendous amount of bluster and defensiveness on other medblogs with respect to this issue of "tests vs. physical examination." It's sad that a number of our colleagues no longer believe in the value, accuracy or efficacy of good clinical skills. I see this dichotomy primarily between surgical types and medical types. It also seems to be a generational thing, so to some extend it probably reflects the teaching curriculum in medical schols and residencies.

drcharles said...

great commentary. i especially agree with the pandora's box of unnecessary imaging. thanks for the good case illustration re: the breast lump. i refer them all to the local breast surgeon for consultation and bx.

Anonymous said...

I am a radiologist. I have seen a number of cases where a breast lump had been aspirated and it did not resolve. I am then asked to ultrasound the mass. By ultrasound the lump is a bloody mess. Is it a bloody mess because that is what it is, or because it has been aspirated? I have seen such lesions resolve in several months time, and also seen them persist and turn out to be malignant. The patients were of course dismayed by the delay in diagnosis. If I get first crack, I can diagnose a simple cyst with certainty. If I don't get first crack, then I am forced to recommend biopsy on what may have initially been a simple cyst.

Sid Schwab said...

See, the problem is there's absolutely NO reason to ultrasound a lump after it's been aspirated. It gives no useful information, as you have pointed out. If a lump fails to resolve after aspiration, first of all the aspirate should be evaluated pathologically, and then it needs either to be followed very carefully or undergo surgical biopsy. Again, it depends on who's doing the aspiration: someone who knows what he/she's doing, or not. There remains no reason to ultrasound a palpable lump, unless the woman absolutely refuses needle aspiration, or unless the person holding the needle doesn't have the operating manual.

Anonymous said...

Very interesting observations. Does it ever work the opposite way? Because he elicited a nipple discharge during my breats exam, my OB-GYN referred me for diagnostic mammogram and ultrasound and also referred me to a general surgeon. He could feel no lump or papilloma and neither the mammogram nor the ultrasound showed anything suspicious at all. Does it make sense to follow up with a surgeon if there is nothing to feel or see? Been calling my OB-GYN for two weeks to ask this question and keep getting the message that he's still waiting for the report. What is a surgeon's role in this type of situation?