Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, February 21, 2008

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.)


At Thu Feb 21, 05:54:00 PM, Anonymous Anonymous said...

If you have decided to surgically remove the "small-ish" residual tumor in the left breast, then the same thinking would lead one to consider removing any tumor in the contralateral breast should one be found. Otherwise, why remove the residual lesion on the left if it was asymptomatic and the patient appeared to be continuing to respond to chemotherapy. It all depends upon whether you believe that local tumor control by surgery has any value in the patient who cannot be cured. I would not severely criticize the surgeon. The issue is not cut and dry.

At Fri Feb 22, 07:14:00 AM, Blogger Dr. Smak said...

I agree with you Dino - little useful information to be found. But, if you for some reason REALLY wanted to know, seems like a diagnostic breast MRI is going to yield much more fruit (and less rads) than a screening mammo. But of course, cost a little more.

At Fri Feb 22, 07:31:00 AM, Blogger #1 Dinosaur said...

But SMAK, even if you found something on MRI, the PET SCAN IS ALREADY NEGATIVE! Even so, you don't need more tissue to tell you she already has breast cancer. You don't biopsy every new metastatic lesion once you know it's malignant, do you?

At Fri Feb 22, 09:11:00 AM, Blogger William the Coroner said...

Yeah, that'z just silly. I don't need the extra specimens.

At Fri Feb 22, 09:23:00 AM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

With a negative PET scan, what more does one need?

I'm with you on this one.

At Fri Feb 22, 11:01:00 AM, Anonymous Anonymous said...

What happens if something is found? He'll probably just punt it back to you or the oncologist. Typical.

At Fri Feb 22, 11:31:00 AM, Anonymous Anonymous said...

Very interesting post....., Although as a recovering surgeon (who now does health policy work) I don’t think it’s only surgeons who make curious decisions that might fit a simple guideline recommendation rather than actually be appropriate for the individual patient.

At Sun Feb 24, 09:56:00 PM, Blogger Doctor David said...

Awesome post. And I'm with you all the way. I can't imagine there are data supporting screening mammography in the PET-negative patient. So even if the mammogram finds a suspicious lesion, it's incredibly unlikely to be cancer, so there's nothing to be done. That organ between the ears is called "brain" and it needs to be used more.

At Sun Mar 02, 08:50:00 PM, Blogger JenL said...

I'm a surgeon; recently I biopsied a suspicious node in a patient which turned out to be lymphoma. She was referred to an oncologist. Several weeks later she is back in my office, b/c she complained about "neck lumps" while at her oncologist's office. The PA told her to call me (but apparently did not talk to the oncologist). Now, I couldn't find anything on my exam...but I ask you, what was the point of asking her to go back to a surgeon? She has a confirmed diagnosis of lymphoma! What new information could I possibly provide?

At Sun Mar 02, 09:00:00 PM, Blogger Doctor David said...

None whatsoever.

Unless the patient had subsequently completed chemotherapy and these were new nodes that arose post-treatment. Then you might diagnose a relapse.

I guess it's kind of important for us doctors to communicate with each other.


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