Taking charge of what is in our control is all we can expect from our patients and all we can expect from ourselves.
“Ta eph’hemin, ta ouk eph’hemin – What is up to us, what is not up to us?” Epictetus
She was sitting in front of me with her husband, the couple was very close, having just celebrated their 50th wedding anniversary a few days ago. She had not said a word yet, she was visibly nervous, touching her face, eyes darting right and left. I sensed that she was looking for something, almost immediately, perhaps instant reassurance.
We settled down to have a long conversation, and I listened to her story. Sophie was a 70-year-old lady who had been regularly attending Breastscreen NSW, our imaging program for early detection of breast cancer for more than a decade. She felt that she was protected because of the clear mammogram and ultrasound many months ago, so when she noticed the left breast lump, she thought ‘my screening appointment is coming up anyway, why bother.’ Sure enough, she let it be, and just two weeks ago she fronted up for her regular screening and the lump had grown to 20mm. Further tests, including a core biopsy, were done and it was confirmed to be breast cancer.
She said to me, “I thought it would go away. I didn’t think it was anything, I did have my scheduled Breastscreen appointment.”
I could not stop thinking about her for the next few days and wondered about all these patients who are only screened once in two years. What happens in between the screening?
Do they know about Interval breast cancer?1
Do they know that they can perform self-breast examinations?
Do they know how to do this — the technique and the frequency?
Do they have a little ritual that they can use to remind themselves?
I tell my all patients to perform a breast self-examination on the first of every month in the shower or when lying in bed. This historical practice2 now comes under the umbrella of breast awareness. The initial first few examinations are just to get a ‘lay of the land. They then forget about it until the next month comes along.
Studies have shown that when this is done too often it can lead to extra stress and anxiety. If they find something different from the month before, that is when they see their doctor for further examination and may require additional tests.
The triple test – clinical examination, imaging and biopsy — is 99% accurate for breast cancer diagnosis. Screening is a tool for detection of cancer before symptoms, like the faecal occult blood test for colorectal cancer and the HPV swab for cervical cancer screening. These tests essentially detect asymptomatic patients; patients who have no inkling that they are harbouring a possible malignancy. Breast self-examination is a simple, easy-to-perform check, in between screening appointments. It is a really good way to circumvent timing issues and detect interval breast cancer early.
I did not go into all of this for Sophie and her husband as they faced me. I examined her first, then reassured her, saying that it is still possibly stage 1 breast cancer just around 2cm in size. And how she had many options for management and now that she is here, we can start on a management plan.
I performed a wide excision of this lesion along with sentinel node biopsy and I was pleased to report those results and to her and her husband. Pathology confirmed clear margins and fortunately, she had a negative sentinel node biopsy.
I had, as standard practice, discussed her at my multidisciplinary meeting, and she was booked in to have discussions regarding chemo and/or targeted therapy for systemic treatment and radiotherapy for local treatment.
After all of this, she will have a yearly surveillance mammogram and ultrasound. I have reiterated to her, the important thing to do between breast imaging appointments and clinical specialist appointments is to perform her own routine monthly check, breast self-examination.
Sophie made a beautiful recovery and went on to have all her appointments and treatments. She promised me that at the end of the treatment journey, she will take charge of what is in her control. And that, I believe, is all we can expect from our patients and all we can expect from ourselves.
Dr Sandra Krishnan is a surgical oncologist at Northern Surgical Oncology, Sydney Adventist Hospital.
References
- Houssami N, Hunter K The epidemiology, radiology and biological characteristics of interval breast cancers in population mammography screening NPJ Breast Cancer 2017; 3(12): 1-13
- The missing member of the breast-cancer team: “Breast self-examination”… CA: A Cancer Journal for Clinicians 1950; 1(1): 30-31
