The patient is not real, but her cancer is.
Rita is 75 years old. She felt a small, hard lump in her left breast one month ago. Her most recent screening mammogram was done last February and was considered completely normal.
There is no history of breast cancer in her family, though her father did have prostate cancer – which in a recent study increased the risk of breast cancer in their daughters. Here’s the link to the relevant paper, released in 2015: https://bit.ly/2yx8lD
Rita first got her period when she was 9 years old. She began smoking cigarettes when she was 17 – one pack per day until 3 years ago when she had open heart surgery. Now she’s down to 1/2 pack per day. (She could never quit, and never really tried.)
Rita has been married for many years, but she has never been pregnant. She never used birth control pills or hormone replacement therapy. She had a natural menopause when she was 40 years old.
She drinks 2-3 glasses of wine with her family every week.
She worked as a secretary for the pubic school system and retired fifteen years ago on a full salary and with all her health benefits provided at minimum cost. (Her co-pay is still only $10 per visit.)
In addition to her heart problems (blocked coronary arteries and a malfunctioning heart valve), Rita has osteoporosis and spinal stenosis. But she seems to get around just fine, and is a very cheerful person, full of pep and vigor.
The small hard nodule in her left breast was easily felt by her doctor, too. It measured about 8 mm – the size of a navy bean. There were no skin or nipple changes and no palpable axillary or supraclavicular lymph nodes. Her right breast was completely normal.
Even though Rita’s last mammogram in February was completely normal, her doctor ordered a new (diagnostic) mammogram of her left breast and a left breast ultrasound. Both of these were read as “negative for malignancy; i.e., normal.”
Rita returned to her doctor for the results and was glad that “everything looked normal” – except for her breast exam, of course. Her doctor then ordered a breast MRI.
The MRI was abnormal: it showed a suspicious mass in her left breast exactly where everyone could feel the little lump. The radiologist ordered a repeat “targeted” left breast ultrasound. The rationale was this: even though the first ultrasound was “normal”, a more focused look at the area in the breast that “enhanced” on the MRI might actually show the mass … if you looked again and looked more closely.
Indeed, the repeat “targeted left breast ultrasound” showed a small, suspicious mass exactly where the palpable lump was located.
There was no need for surgery at this point. A needle biopsy using ultrasound guidance was done by the radiologist at the imaging center – very standard procedure these days. The specimen was sent to an outside pathology lab, one that served Rita’s insurance carrier (Aetna).
The pathologist called the radiologist, who called the doctor, who called the patient two days later: he found a small invasive ductal carcinoma, the kind that 80% of women with breast cancer in this country get.
Rita did not sound surprised when she heard the news. Again, as ever, she was cheerful.
ASSESSMENT AND PLAN:
Rita has a very small, new breast cancer that was not seen seven months ago when she had her annual screening mammogram. (BTW, she’s been very faithful with her screening mammograms and never misses a year.) Women often ask, “Can a breast cancer come ‘out of nowhere’ in less than a year?” Yes. That is precisely why women are told to have a mammogram once a year – because breast cancers can ‘pop up’ in less than 12 months’ time. So don’t delay if you’re overdue!
We now know that Rita has a common type of breast cancer. It didn’t show up on her mammogram in February, but it shows up now – after a good, hard look – on her breast ultrasound, and it was clearly visible on her breast MRI. At this point, there is no indication that the cancer has spread to other parts of her body such as her lymph nodes, bone, or internal organs. But a PET/CT would provide definitive proof of that, and her doctor will order one for her this week.
A complete excision of the mass will be recommended. This is referred to as a “lumpectomy”. It can be done as an out-patient procedure.
What about her lymph nodes? Good question.
Rita will discuss with her surgeon whether she would like to have her lymph nodes examined. Depending on further studies of her tumor, she may not need to have her lymph nodes analyzed to benefit from standard treatment. You see, she’s 75 years old. It’s likely that she will do just as well with standard post-operative anti-estrogen therapy, whether she has her lymph nodes examined or not. But she’ll cross that bridge with her doctor (and his consultants) once the final pathology report from her lumpectomy becomes available.
NOTE: Cigarette smoking is a risk factor for breast cancer. Women who smoke, particularly if they begin smoking when they are young, have an increased risk for breast cancer, and they have an increased risk of developing lung metastasis, and they have an increased risk of dying of breast cancer.
A FURTHER THOUGHT: The virus that causes breast cancer in mice and that has been found in 40-94% of women with breast cancer (i.e., the mammary tumor virus, MTV) has been found in men with prostate cancer, and in the same average percentage of cases as it has been found in women with breast cancer. Is this, perhaps, the link between the risk of breast cancer in daughters whose fathers have had prostate cancer? What a good question! I think I’ll try and answer that.