Day 2

This morning I had a patient who came in with 5 pages of questions about cancer excision and axillary dissection, and a breast cancer mentor she had found through the ACS website who told her to be sure to ask about combining the dissection and surgery into one operation. Thing is, she had atypical ductal hyperplasia, which is not even cancer. A lumpectomy is advised because there's a 15-20% chance that DCIS or invasive carcinoma will be found in the tissue around ADH. But, that means there's a 80% chance nothing will be found at all. We had a patient next who was so terrified about getting localization wires placed because of an uncomfortable biopsy experience that when we tried to reassure her, she raised her voice and screamed, "No, the American Cancer Society says that plenty of patients experience pain during a biopsy!"

Throughout the day, we had 6 new cases of breast cancer, a good number of return patients and some benign findings too. In general, I think increased breast cancer awareness has been a good thing. Promoting monthly breast self exams, regular screening mammography, increased research funding, providing support for cancer patients are all good things. Cancer is always scary, but this hyperawareness of the possibility of breast cancer has created an almost counterproductive amount of fear and anxiety.

Out of the patients I saw today, at least four were opting for bilateral mastectomies, with one side being entirely prophylactic. They were BRCA negative and didn't have any outright risk factors for aggressive disease. It's just for piece of mind, which IS very important. But after all the work that's been done in support of breast conservation and the studies and research that show that lumpectomy + radiation has the same survival as mastectomy, and the same risk of distant metastases, it just seems wrong that the number of women electing bilateral mastectomies has increased by 150% in the last few years. It breaks my heart. I spend the day with patients who are so scared, shaking, holding back tears, sitting in stunned silence, dazed, to the point that I don't think they can even process the options that are out there. Some can't believe that the mass is benign glandular tissue even after an inital exam, imaging, and a stable 6 mo followup.

There are a lot of scary cancers out there...brain tumors, pancreatic, angiosarc, ovarian but somehow, breast cancer is the one we women fear the most. I think a lot of this is due to Susan Komen, ACS, the breast SBE info card that hang in the showers of college dorms etc. Public awareness is important, but there's so much bad information out there, and this all encompassing fear can be incapaciting for everyone involved. It's said that breast surgery is 1/3 surgical onc, 1/3 plastics, 1/3 psychiatry.

I've been really fortunate to spend so much time on surgical onc services these last few months. I've worked with patients who've had the entire bottom half of their jaw removed, neck irradiation, the entire mobile tongue removed, laryngectomies, fungating tongue masses, metastatic thyroid disease, massive kidney cancers, invasive bladder and prostate cancer, but when I started the breast service yesterday, there was something very different. There is no patient like a breast cancer patient.