A breast surgeon's guide to early detection


The book addresses the many controversies in breast health and explains what women must do to obtain the best care possible. It is the same advice I would give to my wife or daughter.


Why This Book Was Written

Of the many stories from my forty-plus years of practice, one in particular stands out in memory: that of a young woman named Michelle Watson, who at twenty-one noticed a lump in her right breast. Alerted by the nodule, Michelle saw the doctor in her student health clinic, who told her not to worry. He pointed out that she was the picture of health . . . and besides, she had no family history of breast cancer.

The lump continued to grow. Over the next two years she was seen by several other doctors, all of whom said her fears were unfounded, that she was too young for breast cancer.

At age twenty-three she experienced pain in her chest and back. The pain progressed, and finally a bone scan revealed what nobody had anticipated—Michelle had extensive metastatic disease. A subsequent biopsy of her breast lump, now grown to a considerable size, proved all those earlier medical assumptions wrong. Right from the beginning she'd harbored an invasive breast cancer.

She underwent aggressive chemotherapy, but her cancer recurred, and at age twenty-six she died of metastatic disease.

Michelle's death might very well have been preventable. Had she insisted on an ultrasound during her first office visit, her cancer could have been diagnosed while it was still potentially curable.

Michelle's story is an extreme case, but it sends an important message, one that is central to this book. When it comes to achieving optimal care, women must be prepared to take charge of their health— which includes knowing more about their breasts than some physicians. In the past decade, remarkable progress has been made in improving the effectiveness of breast care. Ironically, this progress has led to a myriad of confusing and conflicting—and even misleading—recommendations about what women should do to ensure they are receiving optimal care. Such confusion often provokes diagnostic delays, resulting in the need for more aggressive treatments and lower odds of survival.

Although I've spent most of my career caring for women with breast issues, I started private practice with a focus on vascular and emergency surgery. In my first year, an event occurred that radically changed my life.

After an auto accident, an eight-year-old boy was brought to the emergency room of a local hospital. He was stable on admission, but in less than an hour he went into shock. He was rushed to the operating room but died before the surgeon could control the bleeding from his ruptured kidney.

I'd done my surgical training in San Francisco, where all serious trauma victims were transported to a single trauma center that had an in-house team of experts. Had this young boy been taken to a trauma center, he would most likely be alive today.

This needless loss of a young life prompted me to do a study comparing trauma deaths in Orange County, California, where trauma victims were transported to the nearest emergency room, to trauma deaths in San Francisco, where all serious trauma victims were taken to a trauma center. The study found that one-third of the total deaths in Orange County were judged to be preventable, but no preventable deaths were found in patients triaged to the trauma center.

This study inspired a worldwide focus on the importance of organizing civilian trauma care like the military MASH (mobile army surgical hospital) units during the Vietnam era. Orange County subsequently established a system of trauma care that became a model for the nation.

A follow-up study proved the new system had solved the problem of preventable deaths in Orange County.

After ten years of promoting the concept of trauma centers, I experienced burnout: too many late-night surgeries and too little sleep. I was in urgent need of a change in lifestyle.

At the same time, a revolution was taking place in the diagnosis and treatment of breast cancer. Studies had proved radical mastectomies were rarely indicated, as similar rates of survival could be achieved with less aggressive surgery. Mammography was finding breast cancers years before lumps could be detected. Plastic surgeons were making major strides in breast reconstruction. Oncologists had new drugs that were more effective and less toxic.

Yet despite these advances, care was fragmented. Breast radiologists, breast surgeons, and breast oncologists were all in different offices and rarely had time to talk to each other. This was the opportunity I was looking for: Like trauma care, breast care needed organization.

I became obsessed with the concept of establishing a center that would address all aspects of care at one location. The basic team would include radiologists who specialized in imaging, together with surgeons and oncologists whose only focus was breast care. The concept included a same-day model in which patients with new problems could be seen within a day of their call to our center.

We opened our first breast center in 1988, originally called Breast Care Center of Orange, and since then we have diagnosed and treated thousands of women with cancer and tens of thousands of patients with other breast issues.

t soon became obvious that the breast center concept was saving lives. Women who followed early detection guidelines were typically diagnosed with small, curable cancers—though the situation was much different for women who did not follow the guidelines.

The majority of advanced malignancies that we cared for occurred in women who had never had a mammogram or had neglected to have one for years. The conclusion was obvious: Aggressive screening worked. The challenge was to figure out how to get more women to participate in our early detection efforts.

My initial approach was to help establish a nonprofit organization (Be Aware Foundation) in 2004 with the goal of inspiring women to follow early detection guidelines. We presented classes on breast self-examination and created a video to help women learn how to do self-exam with confidence. We also created a website where women could sign up for monthly reminders to do self-exam and a yearly reminder to get a mammogram and clinical exam. I wrote frequent articles, sent out with the monthly email reminders, dealing with the evolving controversies in breast care.

Despite my best efforts, the campaign to get more women to follow early detection guidelines was being thwarted by forces beyond my control. Our own government was promoting watered-down screening guidelines. Well-respected nonprofit organizations, who in the past were proponents of early detection, were issuing their own weakened recommendations.

The media was having a great time reporting all this conflicting advice. As a result, public confusion mounted. The net result was that fewer women were following early detection guidelines and diagnostic delays were on the upswing.

I became increasingly frustrated that women were receiving so many mixed messages. It was that ongoing frustration, plus the desire to set the record straight, that prompted me to write this book. To me it was obvious that something must be done to fight back against the "experts" who were the source of so much confusion. I wanted to inspire women to follow early detection guidelines and demand optimal breast care. That said, I did not want to write something encyclopedic . . . and I had no interest in being "fair and balanced."

I wanted to compose a work that easily explains issues in the same manner I use in answering questions from my own patients. As I was wrestling with my approach, I had an appointment with a woman recently diagnosed with breast cancer. After I completed my lengthy explanation of treatment options, I was greeted by a long pause in which I could tell she was having problems processing our discussion.

She then looked me straight in the eye, and with a newfound confidence she asked, "Just tell me what you would do if I were your wife." The advice I gave her that day was the same I would offer members of my own family—mother, wife, or daughter.

And then I thought further: While it's relatively easy to advise my own patients, what about the millions of women who are desperate for information but don't know where to find it?

I hope that this book—written from the point of view of not just a breast care surgeon, but also a husband, father, and son—will be a helpful resource for those women and their families.

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