Is Watchful Waiting Right For You?
Recently a patient of mine came in for a check up and asked about watchful waiting. The patient is 41 years old with no family history of breast cancer. She recently had a mammogram, ordered by her primary care doctor. The mammogram was read as negative for malignancy but did show dense breasts. The patient had an ultrasound of both breasts which showed a small cyst in each breast. Both cysts were less than a centimeter. The radiologist recommended biopsies of both cysts to make sure they were not cancer.
The patient asked me about watchful waiting and if she was a candidate for it. Basically watchful waiting means you don’t go straight for biopsies but see what happens to the areas in question after a period of time usually 6 months to a year. Generally you repeat the imaging study that showed the abnormality to see if there is any increase in size and then proceed with a biopsy.
To understand if watchful waiting is right for you, you need to be comfortable with a few principles.
-
Guidelines for when to start routine mammogram screening vary widely between various medical groups and countries. Recommendations may be different for high risk women. The American College of Radiologists recommends starting routine screening at age 40 and having yearly mammograms. The American Cancer Society recommends starting at age 45 and having yearly mammograms until age 55 then every other year. The US Preventative Task Force recommends starting at age 50 and having mammograms every other year until age 74. The Canadian Medical Association recommends starting at 50 and having a mammogram every 2-3 years. The United Kingdom recommends starting at age 50 and having a mammogram every 3 years until age 70. Two years ago, the Swiss government stopped doing mammograms entirely. Interestingly there are no appreciable differences in breast cancer mortality rates in any of these countries.
-
Mammograms and ultrasounds for dense breasts are all aimed at detecting microscopic disease, meaning abnormalities that you or a doctor cannot feel. Stage 1 breast cancer, which is 100% percent treatable, is palpable, about the size of a grape. Many times microscopic abnormalities on mammograms and ultrasounds go away on their own and are simply false positives. Obviously, for some women they progress. They grow. Stage 0 breast cancer is not palpable but microscopic. Going from microscopic disease to palpable stage 1 breast cancer does not happen quickly but generally takes a few years.
-
90% of all breast cancers are NOT genetic but related to lifestyle so if breast cancer runs in the family then it may be because there are shared lifestyle factors.
-
There are three categories of breast cancer. Category 1 is extremely slow growing and usually found in women over 75. Category 2 is moderate and progresses over years. This is the category where stage 1 is 100% treatable. Category 3 is highly aggressive and RARE. Mammograms, ultrasounds, and MRIs are designed to deal with category 1 and 2. Researchers are working on a test for category 3 but at this present time there is none.
-
A plant-based diet seems to decrease one’s risk for breast cancer and other diet-related cancers.
-
A woman may be at a higher risk for breast cancer if she has a mother, sister, or daughter with breast cancer before menopause. A woman with multiple family members on one side of the family with perimenopausal breast cancer or a woman with a male family member with breast cancer has an increased risk of carrying the gene for breast cancer known as BRCA. Again only 10% of breast cancers are caused by this.
Watchful waiting is right for you if you can expect to have reasonable access to healthcare in the future. It is right for you if you will not be overwhelmed with anxiety at having to wait to repeat your tests. It is right for you if you understand that some forms of aggressive breast cancer are not detectable early on any currently available imaging studies.
With any medical advice, patients should ask about all options and the risks and benefits of each option. About ten years ago, my cousin was diagnosed with stage 2B breast cancer at age 42. She is doing fine now. After I learned about her diagnosis, I became a strict vegan and lost 40 pounds. For what it's worth, I continue to pretend that I live in Switzerland but that is because it is the right decision for me.
www.drpadmagarvey.com
Other articles by Padma Garvey