Sunday, April 6, 2014

About A Boob

#clownmakeupselfie #selfbreastexam
Forgive me for sounding cynical, but I am SO not getting this whole no-makeup selfie for breast cancer awareness trend on Facebook. In case you're not familiar with it, it's where women post bare-faced (and in some cases looking downright haggard) photos of themselves with the hashtags "cancerawareness" and "nomakeupselfie" as a means of drawing attention to a subject which already receives a sizable amount of public awareness. I mean, seriously, it is a nice gesture, I suppose. But, if the ubiquitous pink ribbons aren't getting women to self-examine their breasts, why on earth would anyone expect a barrage of frightening au naturale mug shots to accomplish what symbolic imagery has failed to do?

People are scared of clowns for a reason. Wearing THAT much makeup is definitely unnatural, concealing what really lies beneath. Unfortunately, these no-makeup selfies come across as clownish and self-congratulatory. Hell, even the breast cancer survivors are pissed! As if masquerading publicly for a minute without makeup could ever pretend to demonstrate real empathy. I mean, if the point of this exercise is raising breast cancer awareness, why not just post a self-breast exam selfie or video instead? Oh, jeez, I forgot, we're not allowed to show our tits in public! LOLZ. (Please note that I am by no means judging the individuals who got sucked into this campaign, only the mass hysteria and collective call to conformity that fueled it).

Mom, breastfeeding me 
My mom was diagnosed with breast cancer twenty years ago at age 60. It was the first time in my life I'd ever seen Mom so sick. For weeks, she was incapacitated. She went through lumpectomy surgery, radiation, and chemo, lost all her hair, and was hospitalized once or twice for a dangerously low white blood cell count which predisposed her to a life-threatening array of normally harmless infections. Several years ago, new tumors were found in both breasts, at which point she decided to undergo bilateral mastectomies instead of more chemo or radiation. Poof! The breasts that nursed me, my sister, and my two little brothers were gone.

Spartacus, his mom, & brother Brian (1964)
Spartacus's mother died from an aggressive, untreatable form of breast cancer when he was only six. Three summers ago, his beloved stepmom died from complications following LVAD (left ventricular assist device...a heart pump) placement for end-stage congestive heart failure she'd incurred as a result of having her mitral valve severely damaged from breast cancer treatment in 2001 with the chemotherapeutic agent, herceptin. And then, there's my cousin who was diagnosed with breast cancer in her twenties. She underwent radiation, bilateral mastectomies, breast reconstruction, and chemo. Both Mom and my cousin are doing great. Clearly, I'm well acquainted with the grim reality of breast cancer.

Strategically placed tomatoes=instant boob lift!
Recently, the value of mammography has come under scrutiny, especially for women younger than 50. For a screening test to be of value, it has to be both sensitive and specific. Sensitivity identifies true positives and specificity identifies true negatives. In the case of mammography, true positives are being diagnosed along with what seems to be an unacceptably high rate of false positives. In other words, breast cancer is being overdiagnosed. Women who really don't have breast cancer risk being treated for it, as do women whose indolent breast cancers wouldn't have harmed them if left untreated. My poor younger sister, who has dense fibrocystic breasts like me, tells me she's had at least 25-30 mammograms since turning 30, along with ultrasounds, a biopsy, and titanium clip placement. Because our breasts are difficult to image, we've both been called back for further imaging after a routine mammographic exam, only to be told it's nothing again and again. Do the benefits really outweigh the risks?

I'm a less-is-more kind of gal. Coming from a 51 year old physician, especially one whose own mother had breast cancer, that may sound odd. It really isn't odd at all. Doctors make pretty lousy patients. The nature of our profession dictates that we're not allowed to be sick...ever. Who'll take care of our patients? When it comes to our own deaths, physicians tend to be minimalists. We know enough about the limitations of modern medicine to know with certainty that we don't want to die the slow, horrible, painful deaths in the ICU so many of our patients unwittingly opt for. I may not know how I'm going to die, but I sure do know how I don't want to live.

The mammography suite: "No Country For Ripe Tomatoes."
But, I digress. Back to the less-is-more thing. Until about a month ago, almost two years had elapsed since my last mammogram. In the meantime, all the media and research hullaballoo surrounding mammography's predictive value gave me pause. It's not a benign procedure and has to be approached with cautious consideration. Because my mom's breast cancer was post-menopausal, my risk for developing it isn't significantly increased. I've never smoked, have always maintained a healthy weight and been physically active, had my children when I was young and breastfed them, blah, blah blah. The idea of being exposed to any amount of radiation isn't very appealing. I'm sure I've already accumulated quite enough after years of working in the operating room with all those X-rays and fluoroscopy. Thank goodness for lead aprons and thyroid shields! And then, there's the simple fact that having my boobs squished between two pieces of hard, cold plastic totally sucks. Theoretically speaking, compressing breast tissue like that could lead to derangements in cellular integrity. So many anxiety-producing what ifs. Too many. And that's not even taking into consideration the stress of having to wait in limbo for a week to ten days to get the results.

Autonomy, self-determination, & mischief
I know my body better than anyone else. I also know what types of intervention I will and won't accept. I'm a believer in the autonomy and self-determination of each individual, as well as in self-advocacy. I don't share the same blind faith in science that many of my colleagues do; in fact, I think the acceptance of scientific facts actually requires more in the way of faith than believing in God does. As Sherlock Holmes astutely observed, "Facts are always convincing; it's the conclusions drawn from facts that are often in error." I guess I'm a bit of a skeptic, especially when it comes to being voluntarily incapacitated or disfigured. Treatment options for cancer are a highly personal thing. I don't view a person who abstains from aggressive treatment as being any less courageous than someone who chooses chemo, radiation, and radical surgery. Everyone has their limits, and I know what mine are. Were I to develop breast cancer, I'd agree to non-disfiguring surgery, but not to chemotherapy or radiation. The thought of having my boobs cut off is just too much. So is the thought of chemo drugs and X-rays indiscriminately rearranging my cellular architecture and DNA. Again, I'm not judging you, so don't judge me.

My anxiety-inducing mammogram report
Back to my most recent mammogram, I'm not sure why I scheduled it in the first place. Based on my self-breast exams, I didn't think it was indicated. My doctor certainly didn't pressure me into it. Whatever. It happened. After the boob squishing, the radiology tech assured me my results I'd received my results in three days. A week passed, and still no results. I assumed no news was good news. If something was abnormal, they would have called me, right? Ten days later, I went to have my new IUD placed. My gyn doc hadn't received the results, either, so she called over to the mammography suite to inquire about them. Here's what the report said: "There is an 8 mm mass with an indistinct margin in the left breast at 5 o'clock middle depth. Impression: Incomplete. Needs additional imaging evaluation." Well, la dee fucking da, let the goddamn needless anxiety sweatfest begin!

Me and Spartacus, deeply engaged in needless worry.
Over the ten days I had to wait to have this additional imaging, I gained about 5 pounds from a stress-eating binge that consisted of Dekalb Farmers Market candy (coconut curry cashews, dark chocolate covered almonds, and macha tea and salted chocolate caramels. Mmm-mm, good!) washed down with plenty of red wine. I felt so fat, disgusting, and horrible that I resorted to wearing scrub pants EVERYWHERE. I decided not to discuss this with anyone but Spartacus, my younger sister, and my closest friends. Until it's an issue, it's a non-issue, right? Not so much. Poor Spartacus. He barely got to know his mom before she died from breast cancer, and now, his crazy wife's personified her left breast into a creature that requests--no demands--headrubs, backscratches, and another $6.99 bottle of Protocolo tempranillo from the Candler Park Market.

Shaman chameleons we are.
I debated about whether or not to tell my children. I didn't want to worry them unnecessarily. Because my son, Nick, is studying ayurveda and happens to be a manager at a natural foods store, I decided to talk to him about what was going on. We talked about adjusting my diet. I already drink a boatload of alkaline organic green juice, laden with wheat grass, celery, dandelion, cilantro, fennel, turmeric, ginger, and lime. But, I drink way too much coffee, which is known to aggravate conditions in the fibrocystic breast. Cutting back on alcohol is easy, but caffeine...whoa! I purchased some tulsi (holy basil) tea and started my caffeine detox. I've been pleasantly surprised at how easy it's been to reduce my caffeine intake to one cup of coffee per day. The tea tastes good and it's also relaxing. My confidence was restored...or so I thought.

Hurry, let's get outta here!!!
Two days ago, I had my long-awaited additional imaging. I went to work as usual, came home early, let the dogs out, grabbed some lunch, and headed over to Piedmont Hospital. The anxiety I felt was almost unbearable. So much ado about a boob. Having been told in advance that this ordeal would take anywhere from 1-3 hours, I wanted to be prepared. I stopped at Arden's Garden and got myself a blueberry-sesame Love Bar and a bottle of pH Solution in case I got hungry or thirsty. This next part's a little embarrassing. As any woman who undergoes mammography knows, you're not supposed to wear deodorant or antiperspirant on the day of your test because it can affect the results, i.e. the aluminum in those products mimics calcifications in breast tissue. Needless to say, by the time I hiked my left arm up to position my naked, defenseless boob onto the X-ray plate, I had a raging case of B.O. At first, I thought it was the technician's breath, but no, it was me! Ugh. As soon as I was released from the spot compression imaging, I went and scrubbed my armpits. The tech informed me that, depending on those results, the radiologist might order an ultrasound. Fifteen minutes later, I was called back for an ultrasound. Being familiar with ultrasonography, I watched as the tech located and measured a radiolucent oval. I recognized it immediately as a fluid-filled cyst. Sure enough, that's all it was. Spartacus had driven through horrible traffic to get to the waiting room, and was visibly relieved when I flashed him the thumbs up. We couldn't get out of there fast enough. His feelings might change when we're billed for the $2000.00 deductible, though. Not only is reassurance anxiety-provoking, it's expensive, too.

One of my father's busty bronzes.
It'll be a looooooong time before I consider having another mammogram. For a minimalist like me, I'm not sure screening tests make a lot of sense. The information they yield isn't the problem, it's what I'd do (or not do) with it. I pretty much live life right here in the moment, and I don't go looking for problems or worries. If it ain't broke, don't fix it. Live and let live. In this day and age of prophylactic double mastectomies that are based solely on genetic testing and probability, despite the fact that with early detection the 5 year survival rate for Stage 0-I breast cancers is 100% while stage II is 93%, it seems that perhaps we've entered into a realm of breast cancer hyperawareness. I don't view my tits as unnecessary or expendable. In fact, I'm quite attached to them. Spartacus enjoys them, too. Bottom line is, I'm not sure I'd want to live without them. Once again, making such decisions is highly personal, whether it's undergoing genetic testing and prophylactic mastectomy because of a strong family history of breast or ovarian cancer, deciding whether or not to have chemo, radiation, or surgery if cancer is found, or submitting to routine mammographic screening in the first place. It's a matter of quality versus quantity of life, and quality is something that defies analysis or explanation. It's strictly a perceptual experience. And being held captive by screening tests and all their what ifs doesn't feel like quality to me. I think I'll just stick with my own intuitive version of health and breast awareness. It hasn't failed me yet.