A Country Doctor Writes:

Emily Green knew there was a lump in her right breast. She was a new patient I saw a few weeks ago. Her previous doctor had sent her for a mammogram last year, but she had not come in for a clinical breast exam. She was a busy professional, who admitted she sometimes cut a few corners with her own health care.

I remember signing the order for her annual mammogram even before I met her. At that point in time, she had not made an appointment to see me, but I signed the order anyway.

In years past I used to stick to my guns and not order a mammogram for patients who had no intention to come and see me for a breast exam.

We all know that a mammogram is best done after a clinical breast exam, so that women with abnormalities on their exam can have a more comprehensive, or diagnostic, mammography study with an ultrasound examination to distinguish between solid and cystic masses.

Purist that I was, I insisted on doing the job right, and on my terms – exam first, then mammogram. I don’t know how many patients ended up having nothing at all done because of my stubbornness. After a lot of thought I decided to authorize mammograms for any woman who wanted one, whether she came in for a breast exam or not, since doing something seems better than possibly doing nothing to screen for cancer.

When I finally met Emily Green for her first appointment, she told me she was concerned about a small lump in the lower portion of her right breast. I agreed with her – the lump was a little larger than a pea, nontender and freely movable against the overlying and underlying tissue. Another, larger, irregular cluster of lumps toward her breast­bone in the 3 o’clock position seemed like typical fibrocystic disease.

At the end of her appointment we agreed on getting a diagnostic mammogram followed immediately by an ultrasound. Whether these tests showed anything or not, we also agreed to have her see a breast surgeon in consultation because of the suspicious nature of the lump at 6 o’clock. We also decided to get some updated blood tests and change her blood pressure medication.

I signed off on her normal radiology reports and added “cc: Dr. Fowler” at the bottom of each page.

When I saw Emily Friday to follow up on her blood tests and new medication, she had already seen the breast surgeon the day before. She was quite animated when she said:

“I can’t believe the tests didn’t show anything. I mean, I felt the lump, you felt it, and Dr. Fowler found it instantly. She’s set me up for a biopsy in less than two weeks! I never realized doctors might disagree with an x-ray.”

“A test is only a test” I mused. “Mammograms are probably best at finding little microcalcifications we can’t feel with our hands.”

“I guess so, but I still feel like I had a near miss”, she said. “What if I had just trusted the mammogram and not bothered to come and see you until the lump had grown some more?”

I reminded her that the biopsy may still come out negative, but agreed that it was very good she had taken the time to come in with her concern.

I still wonder, which is the better thing to do, authorizing screening mammograms to any and all or start insisting again on seeing patients for a clinical breast exam first.