True Story Number 3           

Diane is a woman’s fitness instructor. In May, she noted a lump in the outer part of her breast. This was around where the end of the underwire of her bra touched her breast, and it felt like it was bruised.

Diane made an appointment with the nurse practitioner in her doctor’s office. The nurse practitioner assured Diane that the lump was likely to be OK, and ordered a mammogram and an ultrasound. The mammogram did not show anything different from her previous mammogram, and an ultrasound exam did not show anything.

Because Diane was insistent — but only because Diane was insistent — the nurse practitioner referred Diane to a general surgeon. The general surgeon recommended watching the area to see if it changed. To assuage Diane’s anxiety, she ordered a fine needle aspiration (FNA) biopsy of the lump. The FNA did not show cancer.

Nothing was done for the next three months, except that Diane worried; but her doctors reassured her that she had nothing to worry about. They told her that the lump was not cancer.

In September, Diane decided that she was tired of watching the lump and she wanted the lump removed. She had to force the surgeon to remove the lump. In fact, Diane’s surgeon described removal of her lump as elective surgery so her health insurance refused to pay for the biopsy.

Diane’s lump, however, was a cancer. Because Diane insisted on a biopsy, her cancer was only 0.7 centimeters in size (just over 1/4 inch) when it was removed. This is what doctors call a T-1 size cancer (“T” is for tumor size), i.e. the smallest size of cancer.

Diane got her cancer removed when it was small because she insisted that the lump be removed. Her comment was, “I know when there is something wrong with my body, and this just wasn’t right.”

It is not possible to tell what a lump is by how it feels. You must have a biopsy of some kind to know what a lump is.

In medical school, students are still taught to look for specific details of how a cancer feels to the touch. The signs of what breast cancer feels like were first described by doctors over 100 years ago, before there were enough pathologists to be able to do a biopsy on every breast lump. In fact, the earliest descriptions of what breast cancer feels like were published before techniques to look at tissue with a microscope were available anywhere. One hundred years ago it might have been OK to guess whether a mass was cancer by how it felt; but that is not good enough in the 21st century.

In the 21st century, a biopsy must be used to determine if a lump is cancer — or if it is not cancer, i.e. benign.

A fine needle aspiration biopsy (FNA or FNAB), as was used for Diane, can help diagnose early cancer (as it did for Carol in her story), but FNA is not perfect. The FNA only works when the needle gets tissue from the exact mass that is being felt. This is also true of a surgical biopsy. No biopsy is reliable if the person getting the specimen does not get tissue from the lump and the pathologist is unable to examine tissue taken from the lump itself.

While it is not wrong for your doctor to suggest that you follow a lump for a short time to see if it resolves, if a lump persists and continues to be in your breast, you should request a biopsy. Needle biopsies are good, but you always have the option to request that the mass be removed. You can make that choice.

Your voice is important. You have the right to speak up, even if the doctor tells you not to worry. Whether or not to worry is a discussion between you and your doctor — not an instruction from your doctor.