When Doctor Becomes Patient

I (Sheeva) am a breast cancer survivor. And while I have uttered those words numerous times over the past two years, it is still shocking to hear myself say it. I had no risk factors. In fact, I had all the “protective” factors and a “normal” mammogram only six months prior to the diagnosis. Nonetheless, it happened to me. And because I was a seemingly unexpected bystander, I have chosen to share my story with all of you. Truthfully and honestly. So here it goes, the unedited version.

I was 38 years old with two children, and I was “done and done.” And while “done and done” means different things to different people, for me, it meant doing something for myself. This is the part of the story that makes me somewhat uncomfortable sharing, but I decided to undergo elective breast augmentation. Prior to the surgery, I was required to undergo a mammogram. I did as I was told, and a small mass on my left breast was identified. I underwent a needle-guided biopsy, and as suspected, the mass was benign. Off I went to get my implants.

Fast-forward six months; I felt a very discreet pea-sized lump just under the surface of the skin. I didn’t remember it being there before; it immediately caught my attention. I waited it out for a menstrual cycle to see if it would go away (as a GYN I knew that some lumps and bumps come and go with our hormones). But a month later, it was still there—no change. It didn’t budge. But neither did I. I did have my gynecologist (and my colleague, fellow GYN, and best friend Jaime) feel it—we were both confident it was nothing. I mean, it was smooth and rubbery, and it moved: classic textbook description for a benign mass. Ironically, around the same time, I received a follow-up reminder to check on the benign left-sided cyst that was biopsied six months prior. Now I had two reasons to head back to the radiologist—it just seemed to make sense. One trip, two tests.

And what a trip it was. On this solo venture, I was given the most frightening news of my life. In the words of the radiologist who had performed the mammogram, “This is not normal, and it needs to be biopsied.” Despite my shock, I could piece a few words together and replied by saying, “Are you worried?” Stone-faced, she said, “I don’t know; that’s why we need to biopsy it.” Just then, the ultrasound technician joked about the size of the lump and its proximity to the implant: “The biopsy will probably burst the implant.” This was not a good experience, and it didn’t take me being a doctor to know that. I was not going back there.

I went home and did some research, and within 24 hours I had all my images transferred to a different radiologist. A couple of days later, I went in for both repeat imaging and a biopsy. Within 24 hours, my doctor called and gave me the news: “You have poorly differentiated invasive breast cancer.”  

It’s hard to put into words exactly how I felt at that minute, for the next several minutes, and for the next few days. There was so much that was unknown to me, even as a physician, and it was these unknowns that made it so incredibly frightening. How bad was it? How far had it spread? Will I recover? And through all the unknown and unanswerable questions, the pervading thought running through my head was, I have two young children who need me and who I want to see grow up.

That evening, my support team (my family, Jaime, and her husband) came to my apartment, and we mobilized. We got names of breast surgeons, we made appointments, and together, we moved forward. A few days later, I had an MRI that suggested the tumor was localized to the breast. I found out that my receptor status was positive. (Breast cancers that are positive for estrogen and progesterone receptors have a better prognosis and respond to a medication called Tamoxifen, which can be used to lower a recurrence.) I was scheduled to undergo surgery with an excellent physician at Memorial Sloan Kettering.

I was given the option for a lumpectomy, a right-sided mastectomy, or double mastectomy. Although my surgeon eloquently explained that it was a very small tumor and I could undergo a small surgery, I had already made up my mind to go for the bilateral or double mastectomy. I mean, they weren’t real to begin with! At least this way, I didn’t have to go for frequent imaging of any remaining breast tissue. The last decision came down to the nipples, to take them or to leave them. Although for cosmetic reasons, keeping them would be a plus, I decided to part with them as well. After all, I’m a doctor not a breast model…

While I felt confident about the procedure and the surgeon, hurdles still lay in front of me. Would my lymph nodes be negative or positive for the cancer, and would my oncotyping (other gene profiles related to recurrence risk) be unfavorable? If yes, I would need chemotherapy following surgery.

But I got lucky. My news was good. There had been no spread to the lymph nodes. The invasive lesion was only 7mm, exactly the pimple-sized mass that I was feeling. However, in addition to the invasive lesion I had DCIS (ductal carcinoma in situ; a.k.a. pre-cancer cells) throughout my entire right breast, including the nipple. When discussing these findings with my surgeon, she said, “Your intuition about taking the entire breast and the nipple out was right; if you would’ve opted to keep them, you would have needed another surgery.” The last piece of good news came about two weeks later, when my oncotyping returned as low risk; chemo was not needed.

Over the next three months, I went every one to two weeks to have my “tissue expanders” (the equivalent of an inflatable implant) inflated. Slowly, over time the skin stretches to accommodate the future implant. While it wasn’t necessarily painful, it was an odd sensation. I underwent the exchange surgery, in which the tissue expanders are removed and the permanent implant is placed, and I was left as I am today. The final step in this process is the third surgery to create a nipple, which I for now I will forego.

Medicine wise, I am on Tamoxifen, an anti-estrogen pill that impairs the ability of estrogen to bind to its receptors; it lowers my risk of a recurrence. My relationship with Tamoxifen won’t be short: I am scheduled to be on it for the next 10 years. And while it makes you a bit sweaty (think mild hot flashes), in my mind it is a small price to pay for lowering my cancer return risk.

It’s funny that, while I was embarrassed to undergo elective augmentation and admit it to anyone but my close friends, I truly do believe that those implants helped save my life. The implants are placed beneath the breast tissue. They pushed what little breast tissue I had (and my surgeon attested I was in the group with “lowest volume breast tissue but had cancer”) to the surface of my skin. A foreign object made me more aware of my native tissue. Ironic, huh?

According to the current guidelines and recommendations, I would not have had a mammogram for several years. I was not yet 40, I had no family history, and I was not a BRCA carrier. The American College of Obstetrics and Gynecology recommends that yearly mammogram start at age 40; a breast exam is performed by a health care provider every one to three years (from age 20–39) and yearly after 40. Furthermore, while there have also been advances in mammography (digital mammography vs. traditional film mammography), MRIs for high-risk cases and ultrasounds for women with dense breasts are not routinely used on the “regular” no-risk patient. I was that totally “random” patient who would have been missed. Except for those implants…

In reviewing my case, as both a doctor and as a patient, I have tried to understand what went wrong. How was the lesion on my right breast missed on that first mammogram? First, mammograms are not foolproof. They are pretty good, but tumors can be missed, no matter who is reading them. In retrospect, it appears that my cancer was lateral (far out wide), and perhaps the first time, they did not get adequate views. Basically, they did not go far enough out. But while we can rehash the views and the images, it won’t change my outcome. What we should stress is the benefit of breast self-awareness and self-breast exams. Without them, I am not sure when I would have found the lesion, how big it would have been, or where I would be now.

I am not alone. One in eight women will get breast cancer, and most of us are going to be the “randoms.” We won’t be BRCA carriers, we may not have a family history, and there is a chance we will have no identifiable, real risk factors. All you can do to protect yourself is to be proactive and to follow preventative screening measures. The earlier a breast cancer is identified and treated, the better the patient will do. And unfortunately, many cases are still missed, despite diligent exams and other screening.

I share my story in hopes that maybe one woman or more will be prompted to do her own breast exam, go in for her long-overdue GYN appointment, or get her first mammogram. I’m not writing this for sympathy or pity. I am not a drama queen, and honestly, I’m not too fond of attention. However, by baring it all, I hope to shed light on why it is important to know your body, particularly your breasts. It could make the difference between life and death.

I often say I was dealt the “good cancer card.” Breast cancer is one of the few cancers we can detect early, with excellent survival rates. This is why every October is deemed #BreastCancerAwarenessMonth. While medicine is evolving and our cancer colleagues are making major strides, most cancers simply do not have the same prognosis as breast. This is why I am lucky. I am grateful every day that this was the card I was dealt and by a stroke of fateful events I felt this pea-sized lump. To my sisters out there battling more extensive disease—I send you my love and support. Together, we fight and raise awareness. No cancer diagnosis is in vain. We love, live, and learn more with each life affected.