I lost my breast but is anyone to blame?

British Medical Journal, Jan 31, 1998 by Jacky Reed, Jim Elliott

I often wonder why people cannot accept the risks in life. Please don't get me wrong; I do believe that medical negligence should be exposed and punished. Its just that I also feel that, all too often, patients and their relatives look to blame someone (a doctor) or something (a drug) unjustifiably.

Let me use my own recent medical history to illustrate my points: I started treatment with the contraceptive pill at 15 and remained on it until I was 30. 1 became pregnant a year later but unfortunately miscarried at 12 weeks. Four months later I discovered that I was pregnant again and at almost the same time found a small lump in my breast. I told my general practitioner of both conditions, was booked in for routine antenatal care for the former, and was told that the latter was almost certainly a benign fibroadenoma.

With the breast changes associated with pregnancy and breastfeeding I was unaware of the continued existence of the lump until my daughter was 7 months old. At that time I discovered that it had grown in size quite significantly and again visited my doctor, He still thought that it was a benign fibroadenoma but referred me to a consultant surgeon who I saw a few weeks later. I was told a benign condition was the most likely diagnosis but that the lump should be removed. A fine needle biopsy was done and I was booked in for surgery. Before the lumpectomy I was told that the biopsy had been somewhat equivocal but that they hoped this was due to calcification of the centre of the lump as it had been there for some time. A week later I was told that I had breast cancer and that the tissue was malignant to the edges of what they had removed. A week later I underwent a mastectomy and removal of the some of the lymph nodes under the arm. The cancer had not spread, and I was lucky not to require chemotherapy or radiotherapy at that time.

Once recovered from the emotional shock and the surgery, I began to ask two questions. Firstly, what caused my breast cancer? There is no history in my family so it is probably not genetic. Breast cancer is often under hormonal control, and the lump first developed when I became pregnant for the second time in a few months, so perhaps that triggered it off. It is also known to occur at a higher rate in women whose periods start early--I was II--and in those who remain childless or whose first pregnancy occurs over the age of 30. There is also a small increased risk in women, like me, who have taken the contraceptive pill for prolonged periods, starting under the age of 20.

So there are various possible causes of my cancer, among which is the contraceptive pill. When people develop a symptom or illness that might have been due to a drug they often say that they would never have taken the drug if they had known the risks. In the majority of cases I believe that to be untrue. I firmly believe that patients have the Tight to receive as much or as little information as they are able to assimilate, and feel they need, to make an informed choice about treatment Significant risks should always be explained, along with the reason for the treatment and the expected benefits.

It is easy, however, to be wise after the event For example, if a doctor said to a young woman requesting the contraceptive pill, "If you take this for the next 15 years you will get breast cancer in your 30s," no woman with any sense would ever take it. The reality is that even if doctors tried to fully warn about all possibilities, the best they could say would be, "If you take this for the next 15 years you will be three times more likely to get breast cancer at a young age than if you don't."

In my own case, if we assume that my cancer was caused by the pill and someone had told me 18 years ago that I would definitely get cancer if I took it, then I wouldn't have done so. Had I been told about the possible risk then I know I would still have taken it I have no regrets as I had many years of the undoubted benefits.

The second question was, did I receive appropriate treatment? I have no doubts about the speed and appropriateness of my treatment once I was referred to the surgeon. I do sometimes wonder whether I would still have lost my breast if the cancer had been diagnosed earlier, but then I also know that any treatment would have been complicated by the fact that I was pregnant. However, I do not believe that my general practitioner was negligent in not referring me when I first showed him the lump.

When I first presented with a small breast lump, what knowledge and information did my doctor use to make his decision on whether or not to refer me? I don't know the answer but I can guess. Firstly, what is the chance of a 32 year old woman, with no family history of breast cancer, having a malignant rather than a benign lump? I had just been pregnant, was pregnant again, and benign breast conditions are often hormonally controlled. The lump was small, quite well defined, there was no pain and no other signs suggestive of a malignant condition requiring immediate action. There is emotional trauma associated with undergoing investigations for possible serious conditions even when the outcome is negative, and doctors also consider this when deciding whether to refer a patient I did not go back to my general practitioner for 17 months. As soon as I did I was referred to a specialist. Had I not been pregnant and breastfeeding I would almost certainly have noticed the lump growing and returned sooner. The delay is unfortunate but was due to my personal circumstances and not to any fault in the treatment I received within the system.