Personal Views

The quality of the b(r)east

BMJ 1995; 310 doi: (Published 20 May 1995) Cite this as: BMJ 1995;310:1339
  1. Ann McPherson

    I had been struggling to write the first chapter for a woman's health book commissioned by the BBC for Woman's Hour. “The benefits and burdens of breasts” was a starting point because breast cancer seemed to be the number one worry for most women. A colleague who read the draft of the chapter said, “Interesting but unbalanced. You say that only one in nine breast lumps is malignant and then ramble on about cancer with one moving cancer story after another.”

    As a female general practitioner I had read these accounts with mixed feelings as some of them told the familiar tale of “seeing the doctor, being reassured that there wasn't anything to worry about, and then wham—it was cancer after all.” I see women with lumps, thickening, and tender breasts every day and I still find it difficult to tell the normal from the abnormal. It's the nature of the b(r)east.

    You can guess how I felt two weeks after finishing the chapter, when pulling off a thread from my own breast: “What was that? A tiny lump? Perhaps it's just a prominent rib or normal porridgy breast tissue.”

    I had never been a great breast self examination person and I had become increasingly confused as to the difference between self examination and being breast aware. Yet I was breast awarish and gave them the occasional feel even though there was no breast cancer in my family and I thought of myself as low risk: no contraceptive pill, breast fed children, low fat diet, and lots of vegetables, plus an occasional daily fix of chocolate to get me through a surgery.

    As my gut feeling was that the lump was nothing much, I decided to practise what I preach—wait a couple of weeks and see if it disappeared. I mentioned it in passing to my daughter after another sneaky feel while watching television. “Mum, do something about it now,” was my daughter's cry. I rang my general practitioner, while my epidemiologist husband was at the meeting of the British Breast Group, to say I hoped I was not making a fuss but I thought even though I was not quite 50 it might be a good idea to have a mammogram.

    On a bleak morning I trod the same path up to the local screening clinic as many of my patients, who had been called up by the national screening programme. It was friendly and efficient though the mammogram was more painful than I had expected. At least I could now tell patients what it is really like and that it did hurt. The clinic doctor and I looked at the mammogram together. It was all right and I was filled with relief.

    “Better just have an ultrasound of the lump as a double check,” said the sympathetic woman doctor in charge of the programme. Up on the bed I had a more detailed manual examination and then an ultrasound examination. The left breast was all right; the right breast—”something non-specific but not cystic, but you ought to get an opinion from the breast surgeon.” By this time I was convinced that I had just been neurotic. It must have all been in my mind with all that reading I'd done about breast cancer for Woman's Hour.

    Two days later off I went for the next stage after an endless morning surgery and then a visit to an 87 year old woman. I had to tell her that her shoulder pain was a breast cancer secondary 20 years on. Before the surgery that morning I had also done an interview for a new audiotape on—you've guessed it—breast cancer and the pill in young women.

    At the hospital I realised that I had last met the female surgeon (10 years my junior) at a meeting of the British Breast Group. Since then we had frequent discussions on the telephone about shared patients. “Yes,” she said, it was there, but small and felt a bit fibrous so she wanted to do a fine needle aspiration. “Do you want to wait or you can go home and I'll ring with the results.” I decided to wait.

    It is always difficult breaking bad news and even worse telling colleagues. “The cytology has been double checked and the cells looked nasty. Yes, they are malignant.” All I could think of was how to tell my daughters, already sensitised because their paternal grandmother had died from breast cancer at 38 and because their father was a breast cancer epidemiologist. Next it was memories of close colleagues who had died from breast cancer, not those who had survived. Tears overwhelmed me. The surgeon gave me a hug and offered to drive me home—an offer I refused as I tried to continue in my role of super woman still in control of my destiny. But I distractedly zipped through the red lights at the bottom of the hill behind an unobservant police car.

    At first it was like watching it all happen to someone else. I even had to ring the surgeon the next day to make sure that it had all happened. Care in the community, though not the underfunded kind promoted by Virginia Bottomley, came to my rescue. The family was there, and friends cooked me meals and took me to the cinema in the afternoon.

    Now I wait to have the lump out and face the decision of what to do next—radiotherapy, chemotherapy, tamoxifen. But all the information on outcomes with various forms of treatment are on survival figures—where is the information on the quality of life after treatment? Why have so many thousands of women been randomised to different treatments and yet there is so little research on the long term quality of life after these treatments? By this I do not mean psychiatric problems but tiredness, energy levels, well being, sex, self esteem, and intellectual function.

    Perhaps some good will come out of this episode and I will get people interested in what is as important as survival when making decisions about treatment which will make them feel ill and which might not even be needed. There is no going back—even the BMJ has recently published more depressing survival curves in its ABC of Breast Diseases. The strangest sensation of all has been living with the uncertainty and having the horizon of my life suddenly drop from 75 years to 55 years.—ANN McPHERSON is a general practitioner in Oxford

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