The Second Breast
November 2006 to February 2007, Royal Oak, Michigan
By Ruth Lerman
I’m an internist, specializing in breast disease, and I’m a survivor of three breast cancers.
C.N. was on my schedule as a new patient, needing follow-up for the cancer she had six years ago. I’ve seen a lot in 24 years of practice, but every time I sit at my desk and review the chart of a very young survivor I feel a subtle gasp. Young women with breast cancer face far more than their older counterparts. Employment and insurance issues, dating, sexuality, motherhood, a foreshortened life, all these loom larger and longer for the rare, very young woman with breast cancer. Which of these would be on her mind?
Then there was the future. How to keep her healthy for years to come? I mentally ticked off the tough topics we would need to address: genetic testing, hormonal therapies, MRI screening, insurance coverage, and prophylactic surgeries. The record review completed, I rose from my desk and focused on clearing my mind as I walked down the hall, knocked on the exam room door, greeted her, and washed my hands.
It’s hard to remember what we talked about, but she radiated vitality and courage. So many survivors emanate unhealed wounds.
But the priorities of my checklist plan were swept away when she opened her gown.
As she sat on the table in my flowered exam room, I looked and cringed inside. Now I was afraid for her, with her 25-year-old breast missing and her 31-year-old breast lumpy.
There were ripples and dimples and pebbles clustered just above the nipple on the surface of the left breast.
“I don’t know,” she said when I asked how long it’s been like that. “With the babies you know … pregnancy and nursing … it changes so much it’s hard to tell. It got ultra-sounded a while ago.”
Her daughter was born three years ago, her son, one.
“How long ago did you stop nursing?”
“Five months ago,” she replied.
Heart trembling, I probed for lymph nodes. There were only a few small, soft, mobile nodes, healthy sentinels at the ready. My relief proved brief.
“Lie down. Turn like this. Arm like this.” I checked the reconstructed side first. The remaining, left breast felt as it looked: a thick, irregular band of tissue arced above the nipple like a long fleshy brooch I neither desired nor admired.
My fingers found what my eyes told me. Odd feeling. Curious in someone else, but her? Her of the one in how many with breast cancer at age 25? Her of the sister with breast cancer at age 31? It was not curious; it was cancer until proven otherwise.
Who missed this? Who ignored this? Who delayed this diagnosis?
She had moved forward so boldly. Single at age 25 and now, at 31, married with two children nursed on this remaining breast. Maybe no mistake was made.
I measured, marked, and diagrammed. It was mid-afternoon yet I called radiology, knowing that her story would add her to the already long roster of ladies in waiting.
I was not surprised by the post-ultrasound phone call. The radiologist reported, “Well Ruth, I can see what you’re feeling. It looks like normal breast tissue though it is distinct from the surrounding breast. I know you’re going to want me to biopsy this, but it’s too late today.”
My patient was so grateful. The ultrasound guided core biopsy (usn core) was scheduled for five days later. She didn’t complain.
On Friday the dance began in earnest. I was called by a good radiologist who had shown the ultrasound to another good radiologist. They agreed that it looked like normal breast tissue, so they preferred an MRI or a surgical biopsy. A third good radiologist wanted the usn core. My surgical colleague wanted something expedient.
None of us were happy. We were all afraid for her.
After an hour of intense debate, the usn core was performed. I took C.N. home with me that weekend. She and her story accompanied me into my zendo-writing studio, sat with me on my zafu, and spilled into my notebook.
My colleagues sneaked in, too. At work, we didn’t talk about our fear directly but we turned to one another for advice. You could measure our concern by counting how many of us and our ideas were stewing in C.N.’s diagnostic cauldron. My patient didn’t know how many of us there were, let alone the back story we each brought to our work.
Was I the most emotional because multiple breast cancers, when my children were young, is my story, too? But Dr. Q is a young mother, Dr. T is at increased risk for the disease, and Drs. S’s and T’s wives are survivors. And I know on the deepest level that the diagnosis doesn’t mean the end of life and happiness.
C.N. turned out to have extensive DCIS, a non-invasive breast cancer. She had a mastectomy, is undergoing breast reconstruction, and should live a long life. I read a version of this piece at Breast Tumor Board, the weekly conference where physicians and trainees review medical quandaries. I hope they learned or remembered that looking at the breasts is a crucial part of the exam. Just as importantly, the reading provided a pause to acknowledge the individuals, patient and doctors, in our clinical world.
Epilogue: C.N. read this piece, gave her approval for the publication, and wrote the following:
It’s different to read something about yourself and see it through others’ eyes. I just want to add that at times I have felt blame as well for the one who didn’t follow up with this in the past but all I can add to that is maybe Avery wouldn’t be here if they had, and I am so incredibly thankful to have my children. At 25, when I had the first cancer, I was so scared I would never get to have a family. Now, with this new cancer, I’m not scared for me, I’m scared for my kids. People say I’m strong, but what other choices are there? I’m just so very thankful we found this when we did and that we can do everything possible to keep my kids and me healthy.
Ruth Lerman’s writing has been published in Annals of Internal Medicine, CANCER, Bottomline Health, and on PBS. She is donating the proceeds from publication of this story to support Silver Linings, Breast Cancer Survivor’s Workshop.
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12 Responses to “The Second Breast”
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February 21st, 2007 at 7:15 am
This is the world’s best web site. Wonderfully presented, compasionate and not too long for the non scientist.
Yasah Kochechech!
February 22nd, 2007 at 12:12 am
I think its a fitting title for an excellent article… in addition, I feel the note by C.N. offers a nice balance. Thank you for sharing it.
namaste
February 22nd, 2007 at 4:53 am
It is very interesting to hear both sides of the story. I am on round two of biopsies and treatment for cancers located elsewhere. We don’t often know that our doctors and their families have been through the exact same thing and feel so much with us. It’s a very moving story. Thank you Ruth.
February 22nd, 2007 at 7:30 am
Such power of examples presented here. Self-examination of my breasts is the scariest thing I do once a month, but I have found two lumps that went undetected by mammogram, ultrasound and MRI. They were both benign but my breast specialist assures me that the careful knowledge I’ve gained of my breasts is a priceless gift that I give to myself. The courage and wisdom described in this article spur me on to continue to face this fear of my breasts.
February 22nd, 2007 at 9:54 am
Ruth so clearly writes about the in-the-moment diagnostic thinking, clinical judgments, doubts, hopes, and fears that we as physicians experience all the time. The best of us worry about what has or hasn’t happened, and about what is to come. It is impossible not to take these stories home with us. And C.N.’s perspective is so valuable in rounding out the story. Thanks to both!
February 22nd, 2007 at 10:29 am
I can really feel myself there - in the room with Ruth and her patient, in the office, and, above all, feeling afraid to learn the outcome. This example of narrative medicine is excellent, and I commend Ruth her courage in both writing and her task in the healing world.
February 22nd, 2007 at 5:52 pm
What a fine story of careful diagnosis and a crew of caring doctors. We are all so human, and so fragile, something other than a purely scientific diagnosis is needed–as in this case. The breast has become a scary part of the anatomy: friend and enemy. The other side of diagnosis–the human side, has to be addressed more often–that terrible fear before determination to live settles in. I’m so glad this young woman found Ruth Lerman. I wish them both well.
February 22nd, 2007 at 8:01 pm
This IS a very cool website. As a lover of stories, real stories, Common Ties narratives and comments feed me well. I’ve laughed at an image of myself seated in the hallway of the breast care center with a sign, “Will work for stories.” It is a sacred honor to witness all that I see, feel, and hear. Thanks to everyone for your thoughtful reading of my piece and comments out of your experiences. I know it takes time and courage to post.
I’ve received a number of personal emails about The Second Breast, or as I had titled it, We Are All Afraid. Here is one from my dear friend and scuba divemaster, Alison of Cozumel.
“Hola Ruth,
That is a beautiful story. I like your title: We are all afraid. You can imagine how much \”other people\’s\” fear I deal with in my line of work. Just last week I had a lady panic at 70 feet, spit out her regulator at 30 feet on the way up and I had a physical battle with her at 30 feet to make her take the regulator back for the rest of the trip up. A 10 second battle felt like forever. Life or death. Then she finally took it, cleared it and at the surface she cried and kept saying that she was so sorry. I was almost as scared as she was after that. I told her to stop apologizing, that people do that all of the time. Actually, they do. I held her hand on every other dive for the rest of the week. Every time she felt anxious I went and took her hand and started up with her. By the time we got half way to the surface she had calmed down and wanted to finish the dive. So yes Ruth, we are all afraid.”
The theme I find in the story of CN, her doctors, and so many comments here, is going forward in the face of deep fear. Thanks to Elizabeth and James for this egalitarian website.
March 1st, 2007 at 4:02 pm
Ruth,
Your story is so personal and delicately tender. It is warm and passionate. Thank you for reminding me that God has a purpose for allowing us to experience life\’s adversities. Your ability to touch the lives of women with breast cancer is a gift, wrapped beautifully in the memories of your own story. Hope someday, I can do the same.
Gayle
March 14th, 2007 at 9:58 am
Ruth,
As a young doctor in training it is invaluable to read your piece. I am still at the stage where mastering the physical exam and being mindful of what I am looking for is paramount. I practice my skills on friends, actors, and inpatients who are already being treated. In all of these cases I have no real responsibility for the patient’s well being. I am not yet charged with the awesome duty of diagnosing, comforting, reassuring, explaining, and supporting the patient in their journey towards healing. I will remember this piece when the day comes that I discover something troubling during a history or physical exam and the responsibility to act will be on my shoulders. I will know that it is okay to feel afraid, to have a quickened heart beat and even to be unsure of myself. Thank you for that gift.
Ben
April 12th, 2007 at 4:28 am
I just read this article for the first time. I am sitting here crying at home, its 7:20am. I am waiting for Stef to get back. She is at her 7:00 radiation apointment (she is so strong) and I wait and tend to our little ones (Cam and Avery) until she gets home and then I start my day at work. Ruth thank you for the wonderful story. You gracefully show the harsh reality of what life can throw at you. This story could be any of us at any given time, and its great to know that there are people like you out there to help. Thank you so much for everything!
Chad
June 29th, 2007 at 7:51 am
Dear Chad,
answering your post has been on my mind since April 12. I’ve been dealing with a few “harsh realities” of my own, mostly related to a loved one’s illness. My reply finally percolated up through the thick ooze of life.
You and Stef (C.N.) are a remarkable team. I have seen other young couples stymied by fear of the real and potential outcomes of breast cancer. I felt that I met you through Stef on that first day I saw her. I knew there was a man strong enough and loving enough to meet, marry and have children in the shadow of risk. What an affirmation of life!
Thanks for sharing your tears. I think of them when my own “harsh realities” seem too much. It is such an amazing mystery that sharing our suffering helps us heal.
May you and your family continue to go forth with strength
Ruth