By Tedler D. Depaynos, MD
Over unending cups of black coffee an older colleague was recalling the recent patient he just encountered. The patient was 43 years old, single and has been in the United States for quite some time but apparently she never sought consultations or treatment. Her concerned mother when she learned that her daughter was sick insisted that she should come home immediately and even sent her dollars for her transportation for home.
When interviewed, the patient mentioned that she initially felt the “mass” in her left breast more than 3 years ago but because she felt no pain and because of her work she never went to a doctor. It was only when she experienced coughing and difficulty of breathing which gradually worsened especially when working hard and when climbing stairs that she realized she had to finally see a doctor. Meanwhile her “mass” grew bigger and “hard” which started “ulcerating.”
A routine chest x-ray revealed massive bilateral metastasis so that a contemplated simple palliative surgery to mainly remove the “ulceration” which is expected to be “foul smelling” after sometime was deferred. Although the expected anemia was corrected with blood transfusion, the anesthesiologist and internist were afraid that giving general anesthesia to the patient would be very risky. My colleague was thinking of referring the patient to a younger more aggressive highly trained colleague but I just smiled because he was saying it as a joke.
With obvious sadness, my older colleague related that he just made a simple “incision biopsy” under local anesthesia and referred the patient to a lady “cancer specialist” who has a lot of experience in treating these 4th stage cancer patients . He was hoping that with “chemotheraphy” and probably with “radiation” the metastasis maybe reduced so that the fear of the anesthesiologist may be lessened and the contemplated “palliative surgery” may be pushed thru just to make the patient comfortable.
Actually the patient was just one of those my older colleague encountered where diagnosis was delayed leading to the spread of the disease making the patient manifest the classical signs and symptoms of advanced breast Ca.
In his vast experience he also recalled other patients with similar conditions who consulted him a few years ago. One patient was an OFW in Hong Kong who suddenly felt a “mass” in her right breast. Her lady “master” brought her to a hospital and was advised surgery but she preferred to be operated at home on her coming vacation. Because her expected vacation was repeatedly delayed and even postponed, her surgery was also likewise delayed. Although her lungs were still negative for any metastasis, her Ca was graded Staged IV unfortunately after undergoing a major surgery.
Another patient of his was an executive of an exclusive financial institution who felt a “bulging” in her left axilla. Initially she thought it was just part and parcel of her enlarging muscles because she does regular work out in a local gym. When her husband noticed a tiny “mass” in her left breast, she decided to seek consultation from her favorite surgeon. Although the surgeon who did a simple excision on her more than a decade ago had already a not so good notion especially after the ultrasound was done, it was only after she underwent a modified radical surgery that he revealed the diagnosis of advanced Ca.
Just like any Ca, late stage manifestations could be prevented with early diagnosis. Females are advised to do self-examination from time to time preferably 8-10 days after menstruation because the swelling that usually accompanies menstruation is expected to have subsided. It is done with the arms at the sides while in front of the mirror to see any asymmetry, dimpling or any mass. The arms are then raised above the head and later at the hips pressing them together to contract the muscles (pectoralis) beneath the breasts making them protrude outwards hence emphasizing any abnormality. Each breast is then palpated by the opposite hand while lying down with the other hand placed over the head. Preferably a pillow is placed beneath the breasts while doing the examination. The axillas should also be palpated together with the areas above and below the clavicles where metastatic lymph nodes could be felt.
Some masses maybe vague and the palpation unsure. Ultrasound is then recommended. Although the incidence of breast cancer is higher at middle age and above, doctors however now advice routine bilateral ultrasound whenever a “vague mass” is palpated because of increasing incidence of breast Ca in patients from 20 to 40 years old. Because of this, an electrical company required their 35 years old and above female employees to undergo a routine bilateral breasts ultrasound as part and parcel of their yearly medical examination.
With a breast mass, a biopsy is recommended. Some just have their “masses” removed and because their surgeon commented that they were “benign looking” they did not have to send them to the laboratory for histopath examination. This is observed most especially if the surgery is done outside hospital settings. All masses must be sent for definitive laboratory diagnosis and this must be routinely done!
With early diagnosis, early definitive treatment may be done. This is more possible with breast malignancy because of the external location of the organ.**
