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[Pictured above is the microscopic view of what these cells look like:  Hyperplasia means ‘fast or quickly growing’ and atypical because the cells have begun to lose the clear borders of their cell membranes.  Ductal hyperplasia can be seen in both breast and cervical cancer–the 2 most common female cancers that afflict women.  In the case of cervical cancer, SE Asian women (especially Vietnamese have highest prevalence of this disease.) On the spectrum of ‘healthy/normal’ to full-blown ‘cancer’ cells, atypical ductal hyperplastic cells are somewhere in the middle.  Some conservative doctors consider these potentially slow growing and can be ‘monitored,’ others who treat breast cancer with greater fear/respect, would caution: TAKE THEM OUT!]

The doctor called.  He said “How are you?  I’ve got good news.  You don’t have cancer but you’ve got atypical ductal hyperplasia!”  He didn’t even pause to let me process those big words that once upon a time, I knew so well but in a more academic, impersonal context.  I’m a doctor who’s tended to many breast cancer women–some who survived the deadly disease.  Some who succumbed to it after years of treacherous, painful battles against not just the disease but the war waged against it.  Atypical ductal hyperplasia is NOT good news to hear–I thought?

“Wait a second, Doc..I have what now?”

“Atypical ductal hyperplasia is a condition where the cells of the breast ducts are abnormal and growing faster than ordinary…it’s not exactly precancerous but it’s NOT full-on cancer either.  It’s definitely NOT normal but can sometimes be super slow growing and we cannot know if it will turn into cancer later on in any particular woman.”

“What is my next step: surgical removal or more screening tests?  Breast MRI?” I managed to collect my wits and pose a coherent set of questions.

“Well, some people might watch this with breast imaging.  Breast Ultrasounds would NOT catch this.  Breast MRI imaging would be required.  But if I were you, I’d see the surgeon and get the entire area of abnormal microcalcifications removed.  It’d be harder to monitor your case because you had NO detectable or palpable masses.  Yours was caught on screening digital mammogram,” he replied matter-of-factly.  I don’t blame him, he sees cases like me every week…and he’s a man.  Men are not so fearful of breast CANCER…it’s so uncommon for them and it doesn’t kill them as often.

“Uh…as I recall, there weren’t any such abnormal calcifications on my right breast, right?  When you reviewed with me the digital mammogram last month, the right side looked pretty good, right?  How often should I be screening on the other side, given that there’s increased risk of contralateral breast disease?”  I asked, now having a better idea of what my problems will be.

“Good question.  Yes, we didn’t see anything worrisome on the right side.  But this would make a good case for breast MRI annually instead of simple digital mammography.  You should discuss this with your surgeon after they do the biopsy.”

“Uh…that might be a problem.  MRIs are expensive and I have a very limiting EPO–Exclusive Provider Option–even more restrictive than an HMO plan!  Which breast surgeons in the OC would you recommend?”

“Well, we could word the request in a way that your insurance would have a hard time denying.  This is medically necessary.  As for the surgeon, this too, as you know, all depends on which doctors are in your plan’s network.  But I would highly recommend these 4 women surgeons:  Jane Kakkis (Orange Coast), Michelle Carpenter (Long Beach), Lisa Cuercio (Saddleback), and Jessica Rayahanabad.  Just work with your PCP to see which one your insurance plan covers.”

“And if my EPO doesn’t contract with these doctors…?”

“Well, talk to your PCP and work with her.  She can advise you better.”

I thanked the interventional radiologist who just yesterday took a sliver chunk of tissue out of my left breast with the aid of some very fancy digital breast imaging equipment.  After hanging up on the phone, I brushed this conversation aside and proceeded with my day: Get son off to music class, fix lunch, outdoors playtime after lunch, call the doctor for whom I will start cross-covering tomorrow for extra income this afternoon, etc. etc…the list started to spill out like water.

It wasn’t until I woke up the next morning (today) that I realized, “Holy mierda!”  I could have a precancerous breast disorder that increases my risk later on in life for the mother of all mother F’ing cancers: BREAST CANCER?!

And to think I wasn’t going to get my mammogram for another few years given the latest recommendations by the US Preventative Task Force that found after exhaustive review of the literature that we were over screening women for breast cancer.  There is a trend now to start screening breast cancer in lower risk patients at 50 years old, instead of previously recommended 40 years old.

I thought I just had a slight increased familial risk for breast cancer, otherwise, I would have insisted to start at 50.  I mean, I am healthy, check my own boobs regularly, eat a low fat, plant-based diet, never smoked, exercise 3-5 days/week–I do all the things I tell my patients to do.  My 2 risks: late age at first pregnancy and my paternal aunt had a mastectomy in her 30s in Vietnam.

Back in the 1980s in the old homeland, we can never know for sure for what condition Cô Giầu had in her breast.  Because in poor, developing countries like Vietnam, there just isn’t enough of anything: not enough technology, science nor support systems to make clear-cut diagnoses.  They just didn’t have the chemical reagents or skills to make accurate histologic diagnoses and the treatment options were also very minimal.  I bet, ‘when in doubt, the surgeons took whatever lesions out.’

My beloved favorite paternal auntie ended up dying at 48 years old of a bad asthmatic attack–only a few days after I left her side, to return to the US after spending 2 weeks at Chợ Rẩy Hospital in Saigon.  (Chợ Rảy Hospital is one of the largest community public hospitals in Saigon.  My 3 months at Vellore’s Christian Medical College in Tamil Nadu, India and my 4 years training at LAC-USC Medical School prepared me very well for the challenges I faced to attend to my 2 paternal aunties, Cô Giầu and Cô Sang).

I returned to my war-torn birth homeland in the summer of 2000 to help in whatever way I could as a recently graduated medical doctor to take care of my father’s 2 beloved spinster sisters who were left behind after the Communist victory in 1975.  Both Cô Giầu and I were tending to her older sister, Co Sang, who had just recently been found to have metastatic uterine cancer (another female cancer)!  But, when I spoke to my then new friend, Dr. Trần Xuân Dại, the director of the Chợ Rảy ICU after Cô Giầu died so suddenly,  he told me that her emergency room Chest XRay showed a ‘lung shadow’ that they feared could have represented a breast cancer metastasis or recurrence.  Who knows?  It could have been a multitude of other things.  We just will never know.  She was promptly cremated and no autopsy was ever done…I don’t think autopsies are offered frequently in ‘Nam?  They are seldomly offered here in the US, only in cases where there is vital need to know a cause of death in mysterious cases or cases of suspected homicide or foul play.

Then I remembered, just recently, my relative here in the Northeastern US had a persistent, painful breast lump that was imaged but I don’t think she ever got it biopsied.  This was several years ago.  Being self-employed too, she had issues and difficulty with good healthcare access.  Shoot! I must call her soon and catch up with her boob stories.  OMGoodness!  This is a real bummer!  I need to get organized and be proactive now.  I need to use my medical education and engage my years of healthcare advocacy–except this time, I need to fight for ME and MY family.  I need to map out my breast cancer prevention roadmap!

Things to add to the already way-too-long To-Do list:

1) Call PCP to schedule surgical consult for MRI-guided resection of microscopic atypical ductal hyperplasia that was not even palpable but detected on digital mammogram!

2) Check with limiting EPO (Exclusive Provider Organization) plan to see which surgeons are contracted and pray that one of the 4 surgeons that Dr. Radiologist mentioned are on the list.

3) Pray…oops!  I need to move #3 to #1 now.

4) Put down the To-Do list and go PRAY/MEDITATE right NOW for the strength to get over this hurdle, on top of all the other hurdles in front of me.

5) Take a few DEEP yoga breaths:

Breathing in… I feel scared and anxious about what I just found out yesterday.

Breathing out… I am letting go of these fears and putting trust to the universe that all will be fine.

Breathing in…I summon my gratitude that the diagnosis was the lesser of two potentially worse possibilities.

Breathing out…I feel grateful for having some health insurance (albeit limited) that will get me through to a healthier place.  I know everything will be all right!  I’ve got too many people who count on me but I also have so many people to count on–to walk this journey with me.

Nam Mô A Di Dà Phật

Nam Mô A Di Dà Phật

Nam Mô A Di Dà Phật

Addendum follow-up on 4/12/11:  My awesome PCP was on top of this one.  She called yesterday and lobbied hard for me to see #1 choice Dr. Kakkis.  The EPO denied it fervently.  She referred me to the contracted surgical group.  I was unable to reach them several times, calling in-between patients to make an appointment.  I will try again today.  Hope and pray this won’t be too hard of a fight…for the journey has just begun and I have to stay strong, keep the faith and keep on trucking.