The cat knew it

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Testimony of Dr Granger, Châteauroux, July 2021

Story of Mrs AH, 75 years old

My secretary stops me at the beginning of the afternoon:

"I have added a patient to your list at the end of consultation... "
- Well…

Nothing more to say, that's the rule: if a woman "felt something" and wants to see me, it’s right away...That's how it is with the breast. She hesitated... dared to call... she wants to talk, now. As much as possible don't stop that momentum.

- What brings you here today ?...
- You have seen a friend, she told me that I could... I had surgery for a very small breast cancer in 1991 [she was 45 years old at the time, no one in the family had been concerned]... I have been medically followed for a long time. And then I stopped the surveillance: I was told before the intervention that the cancer was not visible on the mammogram. So why continue to do it ? I have the impression that I feel something there (she holds her right breast, under the collarbone), it's not at all in the same place…My friend says he doesn't feel anything, but I think he wants to reassure me. He has glaucoma problems... I told him I was going to the cinema. 
-You're going to the cinema?
-... Yes

At first glance, the right upper-inner quadrant is as if filled, while the symmetrical area on the left side is empty. The hand perceives a large indurated plate, as if frozen. The diagnosis is obvious. The initial lumpectomy scar, at the union of the lower quadrants, is very small, thin and flexible. It is definitely not the same place at all. Upon contact with the ultrasonic probe, another evidence.

- Do you see something?... 
- Yes
- How big is it?...
- It's about 2 cm... (...) How long has it been since you had a mammogram?
- I stopped... It hurts. I saw my's been maybe 3 years...she told me she didn't feel anything, she asked me for a mammogram, I didn't get it. I'm tired of being sick. I'm a former nurse, I won't go to the hospital anymore. I won't go for any more tests unless I'm sick.

When the examination is over, she gets dressed. We'll say more.
- I think it's a repeat of the original problem...
- I knew it. 

Her look is direct, clear. 

-That's why I said I was going to the cinema. I didn't want to tell him unless I was sure.
A nurse once told me: "Cats can sense when their owner is sick, they stick to him". For some time now my cat has been sticking to me, so I understood. Now what to do?...
- You had a conservative treatment, and a radiotherapy, right?... 
- Yes
- The radiotherapy can only be done once...
- Yes, I know
- We have only one thing left to do : surgery. You need to have the breast removed.
- Yes. The sooner the better. I don't want a biopsy, I heard that cells can leave

I did not insist on the interest of this biopsy for the surgeon, on the "procedure", I had neither the heart nor the certainty. On the doorstep her final words:

- Thank you. At least you didn't tell me it was my fault... 
- ?... 
- How could anyone say that?
- Oh you know I've heard so many things!

That was my last consultation. Nothing afterwards to remove these words, these impressions. What does this mean for the teaching of Senology?

  • A woman "knows" when she has breast cancer. All women fear it, all women fear to feel it. Only those who have it really "know". Cats also know, their sense of smell guides them. You should always listen to your cat, its cuddle is a sure guide.
  • In the surveillance loop, there is always someone other than the woman herself, someone else who motivates her or makes her reluctant. We must enter this loop if we want to be useful. First of all, by not saying anything that could be misinterpreted, so we have to be several steps ahead of her.
    For example, don't say that "nothing was visible on the mammogram" because 20 years later this will be a demobilizing argument. Then by telling it like it is: this "tiny little cancer" minimized will become another demobilizing argument one day.
    The initial mammogram, which she had brought to me, although in silver technique in 1991, showed perfectly the cancer, its spicules and the retraction of the sub mammary fold.
  • It is important to remain calm and factual in the announcement. The genius of cancer is infinite, so there is no such thing as a " small " or " good " cancer (don't mistake the enemy for a friend), nor a cancer " that often becomes bilateral " (don't mistake a friend for an enemy). What unjustified prophecies that mask our ignorance! There is no "emergency" either, cancer is always a long story. Things will be named, defined and explained as the consultation progresses. These consultations take time, they do not happen in a waiting room or on a table corner. Radiologists who no longer see their patients and refer them to their imaging site have paradoxically made a wise decision: it prevents them from saying what they don't know!...
  • It is necessary to offer an alternative to mammography for screening or surveillance. This examination is often painful, invasive, and not very informative, since it is usually completed by an ultrasound. Ultrasound which should explain what cannot be seen or understood with X-rays... Ultrasound is indeed an alternative, in trained hands: it could even be sufficient in most cases, for screening and monitoring, but this is another debate. The ultrasound alternative, which is widely implemented, would prevent clinicians and imagers from making women feel guilty by telling them that "it's your fault" or "you had it coming," "why didn't you get the mammogram you were asked for? ".
  • Remember the last words on the doorstep, they are the most important ones, the ones that could not be uttered earlier, and which are truly liberating: this woman, despite the shock of the announcement, was grateful: I had not accused her.

Cancer Rose Comments

This testimony has caused a lot of reactions, and we receive many questions and comments from our readers. Hence this short deciphering:

The patient's strongest message is that of being tired of surveillance, because to continue surveillance is to continue to be sick. 
The examinations are necessary when you are sick, that's what the patient expressed. 
This is an interesting point in the context of screening women with no symptoms, forgetting that screening is intended for healthy people, who have no complaints.
Here the situation is different in that the patient has been ill and has developed cancer, a situation for which annual monitoring is actually recommended, but this is her opinion, and the opinions, choices and preferences of patients must be heard.

The doctor's strongest message: refusal to accuse, refusal to make patients feel guilty. The patient liked that the doctor did not blame her ("you had it coming, you should have done your follow-up"; this is what women hear, although it cannot be said that this would have changed the situation much).
Gratitude of the patient for a too rare attitude of the medical profession: not to reproach a patient for a defect of a monitoring which she judged too long, tiresome, uncomfortable and distressing. 
This removal of guilt is extremely important, because we also see this feeling of guilt in healthy women who do not undergo screening, even though they are not suffering from anything.

On the substance, the doctor is right to point out that "the genius of cancer is infinite, so there is no "small" or "good" cancer". In fact, it is impossible to know if this is a recurrence of the disease, so long after, or if it is a new disease (another location in the breast than the first), if the mammo would have changed much (discovery of the mass immediately voluminous). It is also impossible to eliminate an induced disease (multiplication of mammograms, second radiation-induced cancer since it occurred in the same treated breast, long afterwards).

One will never know, hence the importance of respecting the choice of the patient, to leave the pattern "cancer, sooner taken better is", because, as the colleague writes it, the evolution of cancer does not work according to this automatismpre-...designed by an intellectually comfortable theory (read:
Looking for alternatives to the sacrosanct mammogram in which so many hopes are based and yet which "misses" genuine cancers is also a line of reflection.

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