The Personal Health Navigator is available to all Canadian patients. Questions about your doctor, hospital or how to navigate the health care system can be sent to AskPaul@Sunnybrook.ca
Question: I’m a 34-year-old woman. My family doctor has been keeping an eye on a small lump in my breast. (The doctor called it a fibroadenoma.) I recently went for a nerve-wracking mammogram after I discovered the lump grew slightly. I received a call from my family doctor a day later saying everything looks good and we will just re-do the mammogram in six months. Two days later, they called again – Everything looks A-OK. No need to come back in six months. I was so relieved. Until a day later when they called again, and booked me for an ultrasound the following week! Why the mixed messages? It’s been a rollercoaster of emotions and it kept me awake at night – not only because I had to go back in, but also because I was worried they didn’t know what they are doing! When I finally had the ultrasound, everything turned out to be fine.
Answer: This is a very unusual. Patients don’t normally receive a string of conflicting messages about a test result.
It’s possible your doctor’s office received a preliminary report that indicated no change in the lump. But the final report could have concluded there were sufficient grounds for a follow-up with an ultrasound test.
If your mammogram was done at a teaching hospital, the images could have been read first by a resident – a radiologist-in-training – and later reviewed by the staff radiologist.
“The trainee may have made a recommendation and the staff then reversed it,” speculates Dr. Sharon Domb, the division director of family practice at Sunnybrook Health Sciences Centre.
Sunnybrook is a teaching hospital, but Dr. Domb notes, “in our institution, the report does not get released [to the patient’s doctor] until the staff has signed off on it … so I wouldn’t get a trainee opinion from our breast-imaging group.”
Whatever the reason for the mixed messages from your doctor’s office, your situation illustrates a common challenge – it is not always easy to interpret the mammograms of younger women. And maybe that’s the underlying source of the initial confusion about your results.
Dr. Domb points out that young females tend to have denser, less fatty, breasts than older women – and these differences can affect the way breasts look on a mammogram.
Don’t be confused by the term “breast density ”. It is not determined by how the breasts feel on a physical examination. Instead, density is a measure of glandular and supportive tissue, which appears as white on a mammogram. By contrast, fatty tissue appears as black or various shades of gray on the images.
This means the mammograms of young women with dense tissue may have a predominantly whitish overall appearance – or more light than dark. The problem is that a cancer, or abnormal growth, is also white. So it’s a challenge trying to spot a white tumour on white background. “Technically, their mammograms can be much more difficult to interpret,” says Dr. Domb.
“As you grow older, the breasts typically become less dense and more fatty so they look more blackish with various shades of gray [on the mammogram] and a white mark [of a tumour] shows up more easily,” adds Dr. Domb.
In fact, the difficulty of reading mammograms of young women is one of the reasons why there is little value in population-wide screening programs to detect breast cancer in this age group. (The other reason is that young females, on average, have a lower risk of developing breast cancer than older women.)
There is also a higher likelihood that mammograms performed on 30 and 40 year-olds will find breast changes, or abnormalities, that don’t really pose a health threat. So screening this group may result in a lot of false alarms, misdiagnoses, unnecessary follow-up tests, or even pointless surgeries.
In Canada, leading cancer groups currently recommend that breast screening programs shouldn’t begin until the age of 50 for healthy women who are deemed to be at average risk of developing the disease.
(A major study published in mid-February raised doubts about the ability of mammography screening to save lives in this population, as well. So the question of who might benefit from screening continues to be hotly debated.)
However, if a woman has a family history of breast cancer, or has other factors that elevate her risk, experts generally agree monitoring should begin at an earlier age.
Yet even in these high-risk individuals, mammography alone might not always be the best diagnostic tool.
Dr. Domb notes that young women are much more likely to develop cysts – benign fluid-filled sacs – rather than cancerous tumours. And if a cyst is present in the breast, an ultrasound exam is often used along with a mammogram for getting an accurate diagnosis. “An ultrasound can differentiate between solids and liquids,” she explains.
Furthermore, an ultrasound is good for measuring the outer border of a mass, so this test can help determine if the lump is growing, says Lisa Day, the charge technologist in the breast imaging division of Sunnybrook.
If the combination of mammograms and ultrasounds confirms a change in the size or appearance of the lump, the physician may order a biopsy – a test in which some cells are extracted from the lump and then examined under a microscope.
In your question, you make reference to the fact that the lump in your breast had been previously identified as a fibroadenoma – which is, essentially a benign, or non-cancerous, solid mass with clearly defined edges.
Your doctors likely came to that conclusion based on the how the mass appeared in an earlier mammogram. It does make sense to re-check the mass a number of months after the initial discovery to make sure it has remained stable and confirm the original diagnosis was correct.
If you think the lump is getting bigger you certainly want it properly investigated.
Various factors can give you a false impression of the lump’s size. During certain parts of your menstrual cycle, for instance, a lump may feel bigger even though it’s actually unchanged.
But it’s important to relay any changes you observe to your physician who will be able to refer you to a facility that will perform the appropriate exams.
Unfortunately, these tests can be extremely stressful – even when they end up providing you with a clean bill of health.
Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. His blog Personal Health Navigator is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Email your questions to AskPaul@sunnybrook.ca and follow Paul on Twitter @epaultaylor
The comments section is closed.