Hard case

"I just want you to know," she said, "I hate surgeons. Surgeons have mutilated me. I don't want to be here." This was before I had a chance even to say hello. I'd flipped through her chart (Darlene G., her name was) before entering the exam room, opened the exam-room door, and walked in as usual, hand extended to introduce myself. This took me aback abit. Thought one: turn around leave, let the referring doc know, and move on to the next patient. Thought two: I'm not the usual surgeon. Rapport R Us. I can overcome this and hear what she's really saying. So I stayed.

Darlene G. was a mammogram referral, one of many I saw every day. She'd had a regular followup study for her previous breast cancer, treated elsewhere by lumpectomy and radiation, along with hormone therapy. Her initial cancer had been detected on mammogram, by the finding of small calcium deposits: the way mammography is most useful and life-saving. That's the good news. The bad news is that lots of things can cause small calcifications in a breast, and by far the majority of them are harmless. So deciding which deposits look suspicious is the key thing.

Calcifications show up as tiny white spots on a mammogram. They come in a wide variety of shapes, sizes, and patterns. Some can be quite confidently recogized as harmless: round little dots, for example -- almost certainly insignificant cysts. Others raise major alarms: clusters of variegated shapes and sizes, irregular. The former can, under most circumstances, safely be ignored, but the latter need investigation. And there is a broad range of "indeterminant" patterns: not highly suspicious, but not clearly innocent.

Unfortunately, those represent a big chunk of the types we see. Since most of these things are not associated with a feelable lump (which is why, in part, when malignant they are associated with highly curable stages of cancer), sampling them for microscopic investigation requires the help of a radiologist, in one of two ways. Using xray guidance, a radiologist can place a thin wire with its tip at the area of concern, which the surgeon can then use to lead him to the target, doing an open (surgical) biopsy.

Or the radiologist can do the whole thing herself (I'm switching "him" and "her" here randomly, to be sexually neutral -- making no insulting assumptions of who joins what profession...), using a quite clever stereotactic setup which three-dimensionally lines up the target area and fires into it a broad hollow-cored needle, taking a sample in the process. Choosing one over the other technique is a matter of several factors. Maybe later...

The radiologist who read my patient's current x-ray reported that there was a cluster of indeterminant calcifications in the previously treated breast which, in comparison to a prior x-ray, had increased in number. Biopsy, according to the radiologist, was recommended.

There are about a dozen difficulties here, not counting the verbal assault I'd received. First of all, I hate it when a radiologist recommends therapy. It boxes me in. I want a reading, an interpretation, a diagnosis when possible. Leave the surgical decisions to me. I've had many a go-around with individual and grouped radiologists over this. Suffice it to say, there's disagreement.

As to the rest of the difficulties: a breast that's been injured, whether by surgery, radiation, or other trauma is prone to forming calcifications. It's what happens, quite often, within damaged tissue: part of the injury response leads to calcium deposition. In some areas of the body -- bone, mainly -- that's nice. In the breast, not so much. So seeing calcifications in a post-treatment breast is hardly a rarity, which is exactly the problem. This lady had three reasons to have increasing amounts of calcification: surgery (she'd had to have several, which is the "mutilation" issue); radiation; and, of course, a history of cancer.

After listening to her vilification of her previous surgeon, and trying my best to establish a level of trust, I showed the X-rays to Ms G. Indeed there was a cluster of calcifications, and whereas they were not highly worrisome to my eye, we had the report that they had increased in number. Making matters worse, the old films, to which they'd been compared, had already been returned by our x-ray department to the out-of-town hospital whence they came.

The lady was infuriated by that news, and directed her fury at me -- who'd had nothing to do with it. I told her we could certainly retrieve the films; but meanwhile, the operative (to coin a phrase) issue was the report that there'd been an increase in the number of calcifications. And, I told her, it seemed that that was an objective enough finding that we could rely on it, despite being able to confirm it ourselves. That, it can be said with clarity, did not assuage her.

I went on to tell her that given her history of cancer which had been associated with calcifications, and given an increase in number currently, the option of observation would be a hard choice: one can safely observe in many situations. But what one is observing is stability. When the area is not stable, observation stops making sense.

So, I told her, I felt under the circumstances a biopsy is what I'd recommend. Having the radiologist's recommendation of biopsy further mitigated against a non-surgical approach. Absent that, and given the relatively innocent nature of the spots, I might have considered a repeat exam in three months or so. The lady's anger made things worse: was she going to hate me more for falling into her view of surgeons -- namely a thoughtless cutter -- or if, unlikely as it might be, the area turned out to be cancer after we delayed a diagnosis.

Next question, she asked: could a stereotactic biopsy (the above-mentioned core needle) be done. I doubt it, I said: her breasts were quite small, the operated one distorted, and the area was close to the chest wall, which makes that technique difficult and often impossible. Well, if the wire-guided technique, could it be done under local? I frequently do them that way, I said. I've even done them, when I had reason to be very confident about the ease of wire placement (a poorly placed wire can make for a very difficult operation.

There've been times when I sent the woman back to x-ray for a re-do, rather than risk missing the target, in my office. But, I told her, in her case I'd want to do it with an anesthesiologist available, because placement might be more difficult due to her scar tissue; and scar tissue can sometimes make filling the area with satisfactory levels of local anesthetic. None of this was what she wanted to hear.

I can't do justice to the tension in the room. I'd asked my nurse to be present during the exam (for reasons of efficiency, and certainly against the advice of any attorney or insurance agent, I didn't always do so. Only when alarms went off. Never had reason -- dumb luck probably, infallible judgment maybe -- to regret that modus operandi.)

Now my nurse was long gone. I'd have melted, if Darlene G's eye-beams were generating heat. She stormed out of the room, huffed past my nurse, glared her way through the waiting room, and was gone. Next I heard from her was in the form of a complaint filed with the local medical board. Unnecessary surgery, she claimed, along with an unnecessary anesthetic. The fact that I'd only offered an opinion didn't dissuade her from filing her complaint, nor, of course, did it stop the board from initiating a (short-lived) investigation.

In my practice, it was typical to see ten women a day with breast issues -- couple of thousand a year, for around 20 years. I saw countless lumps, x-ray abnormalities, vague and dire situations. I was comfortable choosing observation over operation in more situations than the average surgeon, by a long shot. Because I was scrupulous with followup, and with data-gathering to justify the approach.

And I made sure patients were totally comfortable with whatever approach we chose, and I emphasized that no plan was carved in stone. If a woman went home comfortable and woke up worried, she should let me know immediately. In all those years, and in all those cases, that was the only failure of communication, the only complaint. It was a number of years ago.

And it still bugs the hell out of me.