Yesterday’s news was a-twitter about the fact that Amy Robach, who underwent her first mammogram on Good Morning America on October 1 this year was diagnosed with breast cancer. While the top of the Yahoo feed states that she will be undergoing bilateral mastectomies on Thursday, without further information, it is premature for anyone to offer any specific commentary about her diagnosis or her decision.
Did the mammogram save her life, as one doctor was quoted as saying? The answer, of course, is we don’t know. While mammography is capable of finding about 26% of cancers at a point where it makes a life-saving difference in the outcome, it also finds many lesions which would never have gone on to be life-threatening and others which will still be life-threatening in spite of early detection and rigorous screening.
The problem is not the mammogram as a detection tool, but the natural history of the disease, which brings us to the crucial point…not all breast cancers are the same. Before a treatment is prescribed or chosen, it is critical that a woman or man knows what kind of breast cancer they have of the roughly 5-7 kinds we can now recognize. There are probably many more kinds that we just don’t know about or know how to recognize yet. The behavior of the cancer is dictated not as much by when it is found as by what kind it is and how that kind usually behaves. This information informs the decisions about treatment.
If a cancer is the kind that spreads before we can find it, the risk of dying of cancer elsewhere in the body trumps the risk of it coming back in the same or the other breast. In this case, bilateral mastectomies will not have much benefit, but chemotherapy, hormonal therapy and/or herceptin will. On the other hand, a woman who carries the mutated gene for breast cancer has a high risk of getting a cancer in the other breast and might well decide on prophylactic surgery. These questions are complex, and armed with the knowledge about the type of cancer and its typical behavior, the choice of treatment is a very personal one.
My message is that a diagnosis of breast cancer is NOT an emergency. There is time to collect all the information and make a decision that both matches the disease and the patient’s preferences in that situation. I always suggest that women who are newly diagnosed take a deep breath and get a second opinion. Give yourself time to let the shock wear off so that you can start to think clearly. And bring a recording device to every appointment, not instead of a friend or partner, but in addition. You can’t remember everything the doctor says nor can your significant other, not to mention the fact that you can’t even spell most of the words. Record the conversations so you can listen to them later and start to absorb what is being said. And if the doctor doesn’t want you to record the visit, get another doctor!
At the end of the day, the purpose of the mammogram is to take a photograph that may or may not reveal signs of breast cancer, which then still requires further tests to be characterized before treatment protocols are recommended. More often than not, we can make real differences not by rushing into treatment but by taking the time to do the right treatment for the right kind of cancer.
We all need to help tone down the hype that mammograms are the be-all/end-all life-saving tool and stop fueling mass fear that a questionable mammogram is a potential death sentence.
The real question that we should be debating is why we are still doing so many mastectomies and why, after thirty years of breast cancer awareness-building and the availability of early detection methods, major surgery is still a frequently utilized treatment by women because the medical profession still doesn’t have better answers!