Living with Uncertainty
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It’s October. The leaves are changing color and the pink ribbons of breast cancer awareness are everywhere.  I have been thinking a lot about breast health this past year and also about the limitations of our knowledge and the challenges of living with uncertainty. 

Last winter I developed a symptom in my right breast.  I called my doctor and was quickly scheduled for an evaluation at the Breast Center.  Breast exam was followed quickly by mammography and ultrasound.  No explanation for the right sided symptom was found but abnormalities were noted in the mammogram of the left breast.  This led to a biopsy which revealed a very small focus of hyperplasia and a very interesting
conversation with the breast surgeon.

For my appointment with the surgeon I had two issues to discuss.  First, how do we approach the hyperplasia in the left breast?  Second, do we need to do anything further to assess the symptom in the right breast?   To provide some background regarding the first question, the standard of care for the type of hyperplasia I had/have is open-breast biopsy with the medical literature suggesting a 20% possibility of
cancer being identified at the time of biopsy.  However, as I dug deeper into the literature I realized that the 20% was an average and the likelihood of missing cancer on the initial biopsy, if present, was lower if a large bore needle was used.  The size and number of foci of hyperplasia were also directly correlated with the risk of cancer being present.  Since my biopsy had been done with a large bore needle and I had only one “minute focus” of hyperplasia my risk was lower.  In fact, according to one study my risk of cancer may have been less than 1%.  My surgeon and I explored this data and despite the “standard of care” being open biopsy we decided to wait with close follow-up. 

The second question was also challenging.  I had a symptom which was suggestive of cancer but could also be explained by a number of non-cancerous conditions.  Testing had not definitively ruled in or out any particular diagnosis.  We discussed the likelihood that a cancerous lesion was present in the right breast and while the likelihood was very low, it was not zero.  My next question was, even if we don’t find cancer, what is the likelihood that surgery would answer the question as to what was causing the symptom? (Sometimes my curiosity gets the better of me!)  My surgeon estimated a 50% likelihood that we would know more after the surgery than we did at the time of the appointment.  With such poor odds I elected to forego the risks of surgery. 

This as an excellent example of what is known in the medical field as “shared decision making.”  Doctor and patient working together to best understand risks and benefits and formulate a treatment plan with which both parties are comfortable.  Uncertainty is a constant in my life as a doctor.  Daily, I am faced with questions from patients who wonder how serious a symptom may be, how useful a test may be, or how effective a treatment may be.  Rarely can I know for sure the answer to any of these questions.  The
medical literature and my clinical experience help to inform my answers but even a well-supported answer is only a likelihood.  I can’t know for sure that this intervention will help you feel better but based upon the literature and my clinical experience I feel it has a high likelihood so I recommend you give it a try.

As a patient, dealing with medical uncertainty can be unnerving. We live in a world of information technology which offers a false sense security that the answer is out there if we only look hard enough.   Unfortunately, looking has only given us statistics.  Despite our scientific advances, we have yet to be able to take into account all of the variables which act upon our biochemical individuality to alter our personal risks and responses.  I had the advantage of my medical background and an appreciation of the benefits and limits of the medical literature to do my own research prior to my visit with the surgeon.  But when we began talking it was obvious to me that she had done her homework too.  She initiated the conversation by telling me that she was on the fence about proceeding with surgery, listing for me what she saw as the positives and the negatives of both surgery and close follow-up without surgery.  As a patient, this type of doctoring should be an expectation.  Whenever a test, therapy, or intervention is recommended be willing to ask the hard questions of your doctor but recognize that if you are not given a straightforward or clear-cut answer your doctor is likely doing the best she can in the face of uncertainty. 


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