Wednesday, November 18, 2015

Mammogram Callback Follow-up, A Useful Conversation

After getting a mammogram callback about a dense area in my right breast I was urged by my doctor to get more tests ASAP. I decided to wait a few months and retest to see whether anything had changed. I made an appointment with a different radiologist with a different hospital affiliation. When I made the appointment I explained that I wanted one follow-up test – a mammogram or an ultrasound – and not a battery of mammograms like the ones a few years back.

This morning I got a call from the doctor at the breast center where I had made the appointment. On the one hand, any doctor who makes a personal call to a patient (especially a patient she has never met) immediately commands my attention and respect. On the other hand, this doctor had a definite agenda and she was prepared to push it very hard. She was also the fastest talker I have encountered in a long time (including on TV shows) so I had to listen intently to take in what she was saying.

I was impressed with the first point she made: that she and the radiologist hadn’t just read the reports from previous radiologists but had gone back and looked at my films for themselves. She said they saw calcifications associated with an area of density and that the dense area had increased in size from one film to the next. This was new information to me. As far as I had known up to that point, the dense area had just appeared this year. She said that in order to learn more about the dense area they would have to look at the appearance of the calcifications and this would require a “workup,” a series of mammograms. An ultrasound would not provide the necessary information, she said. If the results of the mammograms were worrisome, a biopsy might be necessary as well.

She said that because I was not young and not on hormone therapy a dense area was a cause for concern. I said, “But I am on estrogen-only therapy.” She said hormone therapy can contribute to dense areas in the breasts, especially as women get older. (I later read that estrogen therapy is associated with a higher incidence of false positives in mammograms.) I started to explain that I take estrogen because of research indicating that it can protect against heart disease which is common in my family. I started to say “and certain cancers, including breast cancer” but she interrupted me. I said, “Please let me finish.”

She stopped talking and let me finish. Then she said that reduced heart disease among estrogen users may be because estrogen users probably have better overall health care and that reduces heart disease rather than the estrogen. (This sounded to me like rationalizing speculation by the breast cancer establishment rather than proven scientific fact but I didn’t say so.) She said that a woman’s chances of getting breast cancer increase as she gets older. I said that we’re still talking about less than 5 percent. I also said that one of the reasons why I feel cautious about mammography is that it doesn’t take into account the general health of the person and whether they have diabetes and other health problems although these factors can be correlated with breast cancer. She said that she has to look at the situation from the point of view of breast cancer. I said, “Of course.”

She said she appreciated it when patients were well informed. I said I appreciated her calling me personally. I’m not happy about this new plan but, based on the information I now have, it seems inevitable. I can still veto the biopsy if and when the time comes. I told her I was cautiously optimistic about my situation and she said, “Good.” This conversation cleared up a couple of important misunderstandings and strikes me as a great example of why direct doctor/patient communication (rather than exclusive reliance on tests) is so essential. I'm sure that doctors don't necessarily enjoy talking with opinionated patients like me. On the other hand, they probably understand that patients who get their questions answered up front are less likely to sue if something goes wrong because responsibility for decisions about care was shared.

Two questions remain in my mind. Why do radiologists believe that they can accurately interpret films without knowing anything about the patient’s medical history, including relevant facts like my estrogen use? Is the doctor pushing her agenda so hard because she is pressed for time or because she herself has some doubts about it, or both?