The Surgical Mind
Patient presents with a locally advanced cancer in the left breast. ("Locally advanced" = large tumor; as in, breaking through the skin.) Large axillary and supraclavicular nodal masses bilaterally; metastatic lesions to bone (ribs and spine.)
This is metastatic breast cancer; already spread; not curable. Got that?
After a small biopsy to confirm (!) the diagnosis (ok; actually to get information about cell type and receptors for prognostic and treatment planning purposes) she begins chemotherapy -- and responds BEAUTIFULLY! Truly amazingly. All tumor masses shrink markedly. Bony pain from mets goes away. Awesome. Regular CT and PET scanning confirms the response.
Three years (yes, years; no typo) later -- still on chemotherapy -- repeat scans show only a small-ish residual primary tumor mass in the left breast. The not-unreasonable decision is made to send her for a simple mastectomy, as getting rid of what's left of the primary tumor can't hurt. The surgeon who performed the original teeny little biopsy has relocated, so the patient sees another surgeon who performs the mastectomy. It goes fine; the patient does great; everyone's happy.
I got a letter from the surgeon today in follow-up that details just how well the patient has done, but then goes on to say:
I see she hasn't had a mammogram of the right breast in over a year. PET scan is negative, which is reassuring, but she really needs a mammogram; I'll arrange for it.Er, why?
We already know she has breast cancer. Metastatic breast cancer, as in already spread; not curable. She's still on chemotherapy, for crying out loud. STILL. ON. CHEMO.
Think this one through with me: What if they see something on mammogram? (No palpable masses in the right breast, either.) What are they going to do? The PET scan is already negative, arguing against cancer. But even so...even if she has another tumor, WHAT ARE YOU GOING TO DO ABOUT IT? Surgery won't cure her, and she's ALREADY ON CHEMO (in case I forgot to mention that somewhere above.) (And no, it's not going to change the chemo regimen.)
The oncologist agreed with me that this patient is not an appropriate candidate for screening mammography of the remaining breast. But how are you going to argue with a surgeon? We agreed the odds of actually finding something were remote enough to take our chances, so it's only money, time and unnecessary radiation we're wasting. As he put it, "The surgical mind is a wonderful thing." Unless what you need is a doctor.
(Sorry -- sort of -- about the dig. It fit the situation. And remember, some of my best fiends are surgeons.)
(No, it's not a typo.)