It was Oct. 20, 2007, a crisp Saturday morning. Helen woke up ready to enjoy a day of raking leaves and bak-ing apple pie with her two daughters after a long week at work. She turned on the shower and tossed her robe on the bed, catching a glimpse of the instructional handout on her dresser. It had been sitting there for two weeks now, but she had not even touched the taboo pink pamphlet, titled “ABCs of Breast Health.” She had received it during a mandatory assembly her employer had called. As part of a proactive health initiative by her company, a volunteer from the American Cancer Society had been invited to talk about breast cancer awareness and the critical importance of monthly self-exams in the early detection of breast cancer. Every employee, male and female, was required to attend the seminar.
Certainly this was not the first time Helen had heard this advice. In fact, seven years earlier she had attended a breast self-exam clinic at the insistence of a co-worker who had recently lost her sister to breast cancer. Helen had followed the prescribed monthly routine for breast self-exam (BSE) for several months, but then she fell out of the habit. And, like many other women who are under 40 and not yet receiving yearly mammograms, she relied on her OB-Gyn to do a yearly exam. Although her maternal grandmother had died of breast cancer, Helen was more comfortable not thinking about it. A part of her believed she could prevent herself from getting breast cancer if she just put it out of her mind.
Ignoring her superstitious tendency, she grabbed the pink pamphlet. A wave of dread washed over her as she looked at the contents. Inside she found two cards: one was “Three Steps to Finding Breast Cancer Early” and the other was a handy plastic card to hang on her shower head, complete with a diagram of how to per-form a BSE. She felt a sense of guilt as she acknowledged how long it had been since she had done a BSE. “Well,” she thought, “I did see my OB-Gyn in April—only six months since I was last examined.” She got in the shower and boldly hung the card on the shower head.
She seemed to enjoy the shower even more that day. The new moisturizing body wash was so silky and refreshing. As she lathered up, she saw the card hanging above her head, raised her left arm and began to examine her left breast. Following the instructions on the card, she completed the BSE on her left breast, find-ing nothing. With great relief and a sense of empowerment, Helen raised her right arm and, following the dia-gram, began to examine her right breast. Incredibly, there at just about two o’clock and three concentric circles out from her nipple, she detected a lump. Stunned, she ran her hand over and over the pea-sized mass. Terri-fied, she rinsed quickly, dried off, put her robe on and plopped down on her bed. She sat there paralyzed, completely forgetting about the plans for the day as a cold panic consumed her.
Moments later, her daughters rushed in. “Come on, Mommy. Daddy made pancakes!”
“Sounds delicious! I’ll be down in a minute.” Gathering all her will and denying the last half-hour of her life, Helen got up and got dressed. She pushed herself through the day, determined not to let the “what-ifs” get the better of her.
On Sunday, she woke up after a fitful night’s sleep, realizing the uncertainty and dread were too much to cope with, and decided to call her doctor on Monday to make an appointment to see about the lump in her breast.
She went to see her OB-Gyn on Thursday. He, too, felt the lump and said that it should be checked out by a specialist. Helen tensed up: She hated hospitals. She hadn’t been to one since she last visited her grandmother.
“I’m just making a big deal about nothing,” she thought to herself. “And besides, I’m too young to have breast cancer. My grandmother was 86 when she died.” But the image of her daughters rushing into her room on Saturday morning, with their rosy cheeks and glowing smiles, flashed through her mind. She realized that no number of counterarguments could keep her from the real truth: She had to go and find out if this lump was something she had to take care of, so that she would always be there for her girls.
My fictionalized account of Helen is based on a real patient, and on my experience shadowing Dr. Souzan El-Eid, a breast surgeon and the director of Benedictine Hospital’s Fern Feldman Anolick Breast Center in Kingston, New York. I found her manner, compassion for patients, and enthusiasm in mentoring me to be all at once generous, unique, inspiring and genuine.
Helen’s story, however, demonstrates the need for that compassion: Despite outreach efforts like this month’s dedication to the disease, the decision to seek help is one patients make in the absence of medical influence.
Every year, 101.1 in 100,000 women in the United States are diagnosed with breast cancer, and 19 die. The rate of survival is highly influenced by the stage in which the cancer is first detected.
Helen was wise to have her lump looked at, even though she was afraid of what she might find out. There are many women who find lumps or abnormalities during a BSE, but avoid going to the doctor or telling any-one, thinking they are too young, or relying on a recent clear mammogram. This mindset, attributed to “the triad of error” (a young woman, a self-detected breast mass and a normal mammogram) aptly describes the patient most likely to delay diagnosis. Some women may go to the doctor, but may decline further testing to determine the diagnosis of the lump. Allowing fear to stand in the way of an enlightening diagnosis can have life-threatening consequences. In a study by Dr. Ivo Olivotto and colleagues, it was shown that “a delay in the diagnosis of asymptomatic breast carcinoma of six to 12 months is associated with disease progression as measured by an increased risk of lymph node metastases and larger tumor size.” Breast cancers are typically divided into five stages, ranging from stage 0, the earliest form of cancer, to stage IV, which is advanced, metastatic breast cancer. If the cancer is detected when it is in stage 0, the five-year survival rate is 100 percent. However, if the cancer is not detected until stage IV, the five-year survival rate decreases drastically, down to 20 percent. So if a woman waits a year before going to see a doctor after detecting a lump, and this lump is in fact cancerous, her rate of survival can decrease drastically.
In the study, published in the American Cancer Society’s journal, Cancer, “a delay of 20-52 weeks [in diag-nosing a breast cancer] was associated with a 1.2-fold increase in the risk of developing metastases, and this risk increased to 2.2-fold for 52-104 weeks and to more than threefold for 104-156 weeks.” It is important to note that “early detection” and “early treatment” are not just catch phrases thrown around with no substantiation.
Adherence to these recommendations has been statistically shown to increase the rate of survival in wom-en who develop breast cancer.
As Helen parked her car in the hospital parking lot on Monday, a shudder ran up her spine. She remembered the sickening smell of illness mixed with overpowering disinfectant that lingered on her clothing after her visits to her grandmother’s bedside. She got in the elevator and pressed the button for floor two, and tapped her foot impatiently as she waited for the door to close. When she arrived at the doctor’s office, however, she was taken aback at how far it was from her expectations. The walls were painted a nice shade of bright pink, and the chairs were covered in pink flowery upholstery. Pamphlets about BSE and the importance of early de-tection were scattered around the office, and posters hung on the walls advertising Breast Cancer Awareness Month and support sessions that met monthly for women to discuss their different stages of cancer with other affected women.
There was nothing cold or clinical about the office at all. It exuded warmth, friendliness and feelings of confidence and reassurance. This was an office in which women were healed, in which women survived.
Juliana Guarente is a senior and premed at Brown University. She hopes to specialize in women’s health and obstetrics.