Adventures in Ethics and Science

Blogging my mammogram.

At the urging of my colleague Abel, who liveblogged his own vasectomy, I’m documenting my first mammogram. Given that I had pretty much no idea what to expect going into this, I’m hopeful that this post will demystify the experience a little for those who know they probably should get mammograms but have been putting it off.

Let me preface this by saying that there was no special reason that my primary care physician ordered a mammogram for me aside from my being 40. As such, there’s no special cause to be worried for my health as I wait for the results.

Beginning of the month
Had my first regular check-up with my new primary care physician, who ordered the mammogram. The “patient instructions” sheet I was given at the end of this appointment devoted four pages to a discussion of screening mammograms.

None of these pages said anything about what the actual procedure is like for the patient.

What I have heard in passing about other people’s mammograms ranges from “uncomfortable” to “painful”. My previous first-hand experiences with medical imaging include ultra-sound (the twin joys of a full bladder and a goopy belly) and MRI (where, in my own experience, one is offered music to listen to during one’s time in the tube if one has “grown-up” insurance but gets to listen to the banging sound of the imaging if one is on the student insurance).

I bike home forming an unfortunate mental image of a mammography device that is a hybrid of a pillory and an iron maiden.

Yesterday
I finally get around to calling radiology to schedule my mammogram. They have an available slot the next morning. Sure.

For the first time ever, I am asked (albeit over the phone) whether I have breast implants. Nope.

I am instructed not to wear antiperspirant to the appointment. I decide this rules out my biking the five miles to the appointment (since I’m also supposed to make sure my breasts and armpits have been washed before this appointment — a brisk bike ride tends to undo that).

This morning
Drying off after my shower, I have to stop myself from opening the medicine cabinet and putting on the antiperspirant — not once, but three times.

Drive to the appointment.

At the Radiology reception area, I’m given a clipboard with a one page questionnaire about my relevant health history. Previous mammograms? Nope. Surgical history with respect to my breasts? None. (Implants? Not since I made the appointment yesterday afternoon.) Hormonal medications? No. Previous cancers or cancer in my family? No. Pregnant now or breastfeeding within the last three months? Nope.

Of course, there’s the obligatory box to initial to indicate that the mammogram uses ionizing radiation. Sure. My previous experiences with ionizing radiation have not been painful.

Pretty much as soon as I finish the questionnaire, my name is called. The radiology technician takes the form and leads me to the room. About the size of a regular exam room, but the lighting is nicer. No fluorescents blazing down from the ceiling (although it takes me a few moments to figure that out). The room has a chair, a computer station with a largish flat screen (pointed toward the middle of the room, so I don’t see what’s on the screen), and a sleek, squarish, harmless looking piece of equipment … the instrument of my breasts’ inquisition.

The radiology technician is really friendly … and, it turns out, married to someone I know from work. “But don’t worry! We don’t talk about who I saw for a mammogram.”

Technician looks at my questionnaire and asks whether I have breast implants. (The answer is still no.) The form I filled out was redesigned very recently, so that information isn’t in the place where she was expecting it to be. We spend a few moments considering how the design of forms drives all manner of human activities.

Hearing that this is my first time getting a mammogram, she reassures me. “You’ll tell me how you’re doing and we’ll work together to get good pictures.”

I’m asked to strip from the waist up. There is no messing with the usual paper gown, as apparently even that would show up in the imaging and make the results harder to interpret.

Escorted to the sleek squarish device and told we’re taking four pictures today. Right breast resting on the ledge of the imaging device, right hand holding a handle designed to keep the right arm out of the way. Had to be gently reminded to let my left arm dangle at my side rather than wrapping it around the imaging device.

Then the glass plate descends and commences the squashing of my breast.

This is not the familiar, boa constrictor-tight embrace of the blood pressure cuff. This is squashing. Ooof.

“Try not to move.” Why does this request make me twitchy every single time I hear it? Luckily, the actual imaging takes less than a minute. As predicted, I don’t feel the ionizing radiation. The vise-grip of the apparatus keeps my right breast from moving, apparently, as the first image is deemed acceptable.

On to the same view of the left breast. This time the squashing is not unexpected. Also, our conversation about the gardening sunburn on my back distracts me from the discomfort on the front side. (Talking about the sunburn also makes me notice that it still hurts, something I hadn’t been actively noticing, but the pain on my back is my own damn fault.) Still an oof, but not quite the full-on Ooof of the first shot.

Image 2 looks acceptable. On to the next shot.

For the third picture, we’re back to my right breast. The machine is rotated so that the “ledge” is now perpendicular to the floor. After my right arm is positioned out of the way, the plate closes to squash my breast vertically and give a “side view”. I had occasion to notice, as the plates were being tightened, a convenient digital display of the number of centimeters to which my breast tissue was being squashed (around 5) and the number of Newtons (or pounds) of force being applied in the squashing — that number was around 25, but I don’t know to which units the display had been set, so it’s not a terribly meaningful number to me.

Image 3 looks OK, so on to the side view of the left breast.

As my left breast is being squashed vertically, the digital display is not in my line of sight. I think maybe I find the up-and-down squashing more uncomfortable than the side-to-side squashing. However, it may just be that the technician has diverted my attention from the Ooof with our discussion of the presidential transition at my campus.

The fourth image looks OK.

The radiology technician says I’ll hear from my primary care physician with the results in about a week. She wishes me luck with my sabbatical.

Total time in the exam room: 11 minutes.
Number of times in the past 24 hours I’ve been asked whether I have breast implants: 3.
Breasts: a little sore.
Armpits: sweaty.

Comments

  1. #1 PhysioProf
    July 22, 2008

    I had occasion to notice, as the plates were being tightened, a convenient digital display of the number of centimeters to which my breast tissue was being squashed (around 5) and the number of Newtons (or pounds) of force being applied in the squashing — that number was around 25, but I don’t know to which units the display had been set, so it’s not a terribly meaningful number to me.

    If you know the initial thickness, you can compute the spring constant of your boobs!

  2. #2 Zuska
    July 22, 2008

    I cannot believe you got an appointment the next day! Here in Philly I have to call MONTHS in advance to schedule my annual mammo. Though for my mother, who had hers done in Morgantown, WV, the lead time needed was only about a month.

    Also, I had a baseline mammo done when I was 35, then had my second one at age 40, then yearly after. Have they changed the guidelines recently to do baseline mammos at a later age?

  3. #3 ...tom...
    July 22, 2008


    I am sorry, someone has to ask:

    So, have you had any breast implants lately..??

    OK . . .I will go away now.

    Thanks for sharing your experiences, very enlightening…

    …tom…
    .

  4. #4 MikeG
    July 22, 2008

    I remember my Mom’s mammograms (now that’s a strange opening sentence). She and her best friend made a yearly event of it. The paraphrased quote was something along the lines of “if they gotta squish my boobs because I’m a woman, I’m gonna feel like a woman!” The yearly mammo thus coincided with her yearly pedicure, manicure and a great massage.

    Plus a full day catching up with her friend (she was “aunt Jean” to us kids). She actually looked forward to her mammogram!

  5. #5 Dave Syzdek
    July 22, 2008

    Often at medical appointments I will ask what the units are on the equipment and it is pretty rare for the technician to know what they are. As a scientist, that bothers me. You have to know the units.

  6. #6 absinthe
    July 22, 2008

    Your mammography place sounds much more enlightened than the one we have here in my town, where the waiting room and dressing room have all kinds of posters along the lines of “so you’ve been diagnosed with breast cancer…”, or the even more cheery “a breast cancer diagnosis is not a death sentence”. But maybe they were in your waiting room, and you didn’t see them because you didn’t wait in there long enough to notice.

    I think the people who put up the posters mean well, but they don’t realize that scaring the bejeezus out of women getting routine mammograms doesn’t necessarily encourage yearly return visits to repeat the experience.

  7. #7 opal
    July 22, 2008

    I am actually having my first mammogram tomorrow, so I appreciate you writing this up.

  8. #8 KSmith
    July 22, 2008

    You’ve reminded me that I need to call to schedule my appt. I had a baseline a few years ago, but I was supposed to have another mammogram this year since I’m forty. Time for my other yearly appt as well. Oh joy.
    I wasn’t sore at all after mine, but my mom always is. She just had to have another one, more in-depth, and have a needle biopsy while they did it so they could see an abnormality more clearly. She said it was like having her whole breast stuffed into a tin can. Fortunately the results were good. I guess knowing she’s okay was worth the hassle for her!

  9. #9 NM
    July 23, 2008

    Janet

    How about a discussion of the ethics of this particular screening method since it’s fairly equivocal whether it’s actually worth the hassle and all the false postives in women aged 40?

  10. #10 Theo Bromine
    July 23, 2008

    Must be mammogram season – I have one (my 4th annual) scheduled for tomorrow. Around these parts (Ottawa, Canada), lead time seems to be about 3 months for the appointment. I was pleasantly surprised to find that the procedure was much less uncomfortable than I had been led to believe. The worst part of the experience was the 10-15 minute wait to get a *parking spot*!

    Interesting to note the difference in age recommendations for baseline. My doc starts at ~45 (or did a few years ago anyway) . As I understand it, conventional wisdom had been that much before that, the breast tissue was too dense to get a useful baseline; I wonder if that number may be going down as imaging technology improves.

    Regarding units: From the perspective of scientific curiosity, knowing the units is satisfying. But speaking as an engineer, I would say that it is less important for the technician to be able to know and understand the exact SI unit represented by the numbers on the display, and much more important that they know, for example, that you need at least 5 for a good reading, 15 will make the subject scream and 20 would cause permanent injury.

  11. #11 AnnR
    July 23, 2008

    Was it a digital machine?

  12. #12 bioephemera
    July 23, 2008

    Glad it didn’t turn out to be so bad, after all! Although I am also glad I have a few years left before I’m expected to let someone make a glass sandwich of my breasts.

    I love this observation:

    “We spend a few moments considering how the design of forms drives all manner of human activities.”

    That is so. totally. true.

  13. #13 the real cmf
    July 23, 2008

    Nice observation on implants;-)
    Next time, try the “armpit-sweat-free” mammogram:
    http://www.internetmammogram.net/

  14. #14 wheatdogg
    July 23, 2008

    I watched while my wife had her first in a long while done a few weeks ago. The process did not look comfortable, but she was clear, so it was worth the squashing, I reckon.

  15. #15 gretchen
    July 23, 2008

    great blog. check out http://www.beautyandthebreast.org

  16. #16 Me
    July 24, 2008

    Have you seen these “exercises”? :-)

    “EXERCISE 1:
    Open your refrigerator door, and insert one breast between the door and the inside of the refrigerator. Have one of your strongest friends slam the door shut as hard as possible and lean on the door with lots of pressure for good measure. Hold that position for five seconds. Repeat in case the first time wasn’t effective. Insert the other breast and repeat the instructions.

    EXERCISE 2:
    Visit your garage at 3:00 a.m. when the temperature of the cement floor is just perfect. Take off all your clothes and lie comfortably on the floor sideways with one breast wedged comfortably under the rear tire of the car. Ask your husband, boyfriend, or whoever is up at 3:00 in the morning to slowly back the car up until your breast is sufficiently flattened and chilled. Switch sides, and repeat for the other breast.

    EXERCISE 3:
    Freeze two metal bookends overnight. Strip to the waist. Invite a stranger into the room. Have the stranger press the bookends against either side of one of your breasts and smash the bookends together as hard as she can. Repeat for the other breast. Set an appoinment with the stranger to meet next year to do it again.

    You are now properly prepared for a mammogram.”

  17. #17 Lab Lemming
    July 24, 2008

    Did you get an explanation on the armpit thing?

    My best guess is that those antiperspirants which contain zirconium salts might create false positives due to the high z number (40) of Zr relative to the common constituents of the human body.

    If you like, you can test this hypothesis by painting your boobs with a similar mean atomic number substance- like molybdenum grease- before your next appointment.

  18. #18 Bardiac
    July 25, 2008

    This is a great explanation! Well done.

    For what it’s worth, I was told a long time ago that taking a couple otc painkillers was okay, and it helps.

    But I’d really like to understand the statistics behind starting screening at 40 something vs other ages in various countries.

  19. #19 thomas robey
    July 25, 2008

    We spend a few moments considering how the design of forms drives all manner of human activities.

    I’ve been hung up on this comment since I read it yesterday. Of course, it’s probably the excellent blog entry surrounding the comment that got my mind thinking in the first place.

    Having referred several patients to mammography, I’ve wondered about this experience. It might be the only procedure I’ve recommended but never seen. I’ll look forward to the discussion on health maintenance guidelines!

  20. #20 Jude
    July 27, 2008

    To me, having avoided any medical tests for at least 6 years (and as one who is never planning to have a mammogram), the ethics of medical testing are intriguing. Why expend so much energy keeping people alive? If I’ve fulfilled my biological existence of bringing children into the world and they are substantially grown, then ethically who cares about extending my life at this point? In other words, why have a test to diagnose something I wouldn’t bother treating (except for the pain)?

  21. #21 Donna
    July 30, 2008

    Re: An earlier age for a screening mammogram.

    I had my first screening mammogram before age 40 because of a family history of breast cancer at an early age. My mother was only a little over 40 when she was diagnosed.

    Otherwise, I would think most women could wait a few more years before they start getting regular screenings.

  22. #22 Jyotsana
    July 30, 2008

    An old family friend always referred to her mammograms as “the ol’ flop-n-squish” :)

  23. #23 fusilier
    July 30, 2008

    Lab Lemming, it’s aluminum chlorhydrate in the antiperspirant. One of the key indicators in a screening mammo is so-called “microcalcifications,” a.k.a. white specks on the order of 10-50 micrometers clustered in small areas.

    Aluminum has a similar radiodensity to these calcifications.

    What is odd is that large calcifications – millimeter or larger – are not an indicator of CA.

    fusilier
    James 2:24

  24. #24 anonRD
    July 30, 2008

    Great summary of the process! I have to chime in about the wait time for an appointment. I’m in the greater-Boston area and I have to call at least 18 months in advance for an appointment! So I’m calling for next years’ when I haven’t had this year’s appt yet. It’s absurd.

    As an aside, I had my first mammogram at 31, right after my sister was diagnosed at 35. When I made the appointment, the receptionist asked my date of birth and proceeded to ask me why I was making the appointment because I was “too young.” When I told her about my sister she said (be sure to read with a very heavy Massachusetts accent), “Oh, that’s a bummah.” Um, yeah, definitely a bummer…

  25. #25 anon
    July 30, 2008

    Question

    What if one has really little breasts? How does THAT work? I am terrified simply because there is nothing there to look at.

    Anyone????

  26. #26 Tony Jeremiah
    July 31, 2008

    Anon:

    Males are also at risk for developing breast cancer. So based on the assumption that the typical male chest is smaller than the typical female, and, that you’re not exaggerating your chest size, you may want to check out the similarities and differences between male and female breast cancer.

    Check out Male Breast Cancer that offers some comparison between the two. I’m not a medical professional (although this topic has come up in my developmental psych class), so I’d suggest asking your doctor, nurse, or some such person for more reliable information.

  27. #27 Ann
    November 13, 2008

    I would consider a couple of factors before going for your routine, annual mammogram. Consider the amount of radiation; if the Mammogram is effective in detecting cancer; Other methods of detecting cancer, including thermography. Please see the following articles: http://articles.mercola.com/sites/articles/archive/2000/10/01/mammograms-part-one.aspx
    http://v.mercola.com/blogs/public_blog/some-mammograms-fail-to-detect-breast-cancer-9576.aspx
    http://articles.mercola.com/sites/articles/archive/2000/10/29/thermography.aspx