Dream of a senologist

A testimonial from Dr M. Granger, Senologist, July 21, 2021

Mrs PS, 50 years old, from Paris, consulted in August 2010 for advice.

On June 23, 2010, she had a 3rd mammogram in a Parisian SENOLOGY CENTER, classified as ACR4 for a "poorly systematized zone of architectural distortion in the upper right quadrant." She had microbiopsies the same day, which resulted in the "diagnosis": "Proliferative fibrocystic mastopathy with atypia, ductal type (Atypical ductal hyperplasia)." She has an MRI appointment in a few days and is very concerned about the speed and bad turn of events: what is she supposed to do?

My findings:

After carefully inspecting the mammograms that were brought to me, I notice, with some initial concern, that this "zone of poorly systematized architectural distortion" escapes my sagacity.

The magnifying glass brings nothing: I see, in comparison with the left breast, which underwent a total adipose involution, only a banal aspect of a glandular remnant.

The appearance was identical on a mammogram done precisely seven years earlier.

Moreover, my clinical and ultrasound examination was strictly normal.

Surprised by the Parisian radiological diagnosis but reassured by the constant imaging, I advised this lady to wait for the MRI results and send them to me. These results arrived three days later, on the same evening as the examination.

"The zone of right superior-external architectural distortion is confirmed, with no suspicious morphological character on MRI." However, we are aware of the underestimation of MRI for intra-canal lesions. A surgical excision of the atypical area should be planned”.

The patient, caught in the "concordant" vise of 3 reports - mammogram, biopsy, and MRI - consulted a breast surgeon at the Gustave Roussy Institute (IGR).

A few days later, she sent me the following report: "I have received the result of your breast MRI, which confirms the elements described on the mammogram, i.e., a poorly systematized area of the upper right quadrant. However, given the histological findings of the biopsy, which revealed fibrocystic mastopathy with ductal atypia,  an excision surgery of this area is necessary".

I am sending this email back to Mrs. PS

Dear Mrs,

In response to your email, here are my conclusions:

- Your MRI is normal; the exact text is: "area of right superior-external architectural distortion that does not show, on MRI, any suspicious morphological character." As usual, the rest of the report ("however...") is just an umbrella formula.

- The letter from the IGR retains the negative part of this report ("poorly systematized zone" [which means what, by the way?]), opening the umbrella in turn: "an excision surgery is necessary...". A surgeon operates.

I warned you about this logic. I encounter it every day. It's not mine, given the mammograms you brought me, which haven't changed in seven years. This stability, in my opinion, is worth all of the umbrellas in all of the institutions on the planet, especially when the MRI is normal.

I remain in favor of simple surveillance, the specifics of which have to be determined for your moral comfort and safety: I would recommend a first X-ray and ultrasound control of the right breast within a year or less (contact my secretary), and then we will see.

You are thus confronted with choosing between following your new provincial senologist and the big Parisian machinery! Make this decision in your soul and conscience, discarding all Hierarchies and listening only to your deep feelings: the good answer will be found there.

Sincerely yours. M Granger

Mrs. PS finally chose to follow her provincial senologist.

She "comes from far away" but "knows why." I saw her until 2017, without noticing anything new, with clinical and X-rays and ultrasound examinations remaining unchanged for over 15 years. One who has been saved...

What can we learn from all this for the teaching of Senology?

Several observations, among many others, appear to be beneficial to me:

- The radiologist's initial description ("poorly systematized architectural distortion") was the starting point for a path that the patient had to climb alone... until the anxiety became too much for her and she decided to seek advice.

-This initial description was at no time questioned, and the radiologist's opinion was final.

However, it should be noted that the ACR classification can be easily "twisted" to achieve the desired result: if the radiologist accepts simple surveillance, he will grade the images as ACR2; if he wants close surveillance, he will grade them as ACR3; and if he wants a biopsy, especially if he can do it immediately, he will grade them as ACR4, as in this case.

A detached viewpoint will see things differently: simply comparing all of the mammograms taken, sometimes a dozen(!), will lead to a different conclusion, in this case normal (or ACR 2, if you are a fan of the Americas). That would have put an end to this lengthy diagnostic rambling.

-As previously mentioned, the initial description/classification was not discussed: because each professional works independently, without controversy, and is thus not directly accountable to the patient. In fact, this chain can be described as a vertical commercial agreement from which all parties have benefited. In the wild animal world, this is known as "horde hunting," and we know that if all of the subjects in the cohort are potentially targeted, only the strongest will escape .

Mrs. PS, a graduated lady working in the high public service, was able to get out of it by making the Cornelian decision to resist the IGR Institute... many others are not.

The remedy to this chain of medical control without counter-power is NOT to be found in the RCP (multi-disciplinary consultation meeting, editor's note): I have never seen a pathologist, a surgeon, or a radiotherapist oppose and break the chain biased from the start towards biopsies - micro, macro or surgical.

As a result, there is a de facto agreement not to question the initial diagnosis, and individual psychoanalysis of the "validated decisions" in RCP would be fascinating. The breast is a highly invested organ that everyone loves to argue about and share.

You may have realized that I am living the dream that our father (Charles-Marie Gros, from the Hospices Civils de Strasbourg) had in the 1960s: that the SENOLOGIST is recognized as that breast specialist, a little/lots/passionately a specialist in all the disciplines involved-from the various forms of imaging to anatomopathologist, to the relative interest of surgery and the oncologists' panoply... a specialist who coordinates and tempers everyone's enthusiasms and anxieties, a specialist ultimately accountable to the patient.

A communicator who is willing to take his time and sometimes loses it. But, as you're probably aware, the dream is still a dream, and SENOLOGY is a beautiful utopia. Mrs. PS and her struggle sisters occasionally awaken it.


A few comments from Cancer Rose

It is absolutely clear that screening has increased the number of unnecessary mastectomies.
We presented our study on mastectomies in France at the French Society of Senology's annual meeting in Lille.
It is undeniable that non-cancerous lesions are "over-operated," and this is yet another example of an over-detection drift, namely over-treatment.
Yet, this obviously explains why, as described in our study, there are increasingly more mastectomies in comparison to the incidence of invasive cancers.

The observation also confirms the ACR classification drifts: ACR3 hardly exists any longer, there is a tendency to classify very quickly in ACR4, and we voluntarily "upgrade" our examination classifications to have immediate access to a tissue sample, to avoid omitting anything, rather than taking time, settling down, and possibly rechecking at a later date.
The ACR4 becomes a catch-all for anything that appears "abnormal." More information can be found at https://cancer-rose.fr/en/2020/12/30/arc-classification/.

Finally, while there is a double reading during screening for cases classified as "negative" (see here: https://cancer-rose.fr/en/2021/03/30/what-is-a-screening-mammogram/), there is none for cases classified as "positive." This is not entirely logical.
But, even if there was, who would have the courage to "negate" an image previously classified as positive by another colleague...


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