When to worry about

Woman's Era - - Short Story -

ou are in the shower, con­duct­ing monthly breast self exam, ( ex­am­in­ing your breasts on your own) sud­denly your hand freezes. You have found a breast lump.

A lump in the breast is ex­pe­ri­enced by the pa­tient with the pho­bia of can­cer, this is due to lack of aware­ness, shy­ness on part of pa­tient as its per­ceived as so­cial stigma, fi­nan­cial con­straints, or some women are re­luc­tant to con­sult male doc­tors.

Breast Lump In­ves­ti­ga­tion:

TRIPLE AS­SESS­MENT test is used as GOLD STAN­DARD in di­ag­nos­ing all pal­pa­ble breast lumps.

It In­cludes com­bi­na­tion of three tests: • Clin­i­cal ex­am­i­na­tion • Ra­di­o­log­i­cal Imag­ing (Mam­mog­ra­phy,

Ul­tra­sonog­ra­phy) • Pathol­ogy (FNAC, Core nee­dle biopsy)

Clin­i­cal Ex­am­i­na­tion • A de­tailed his­tory and ex­am­i­na­tion are

per­formed by a breast sur­geon . • In the his­tory, clin­i­cal de­tails of pre­sent­ing com­plaint, any po­ten­tial risk fac­tors are iden­ti­fied, in­clud­ing fam­ily his­tory and cur­rent med­i­ca­tions. • The full breast ex­am­i­na­tion is done, in­clud­ing breast pal­pa­tion and as­sess­ment of the ax­il­lary nodes.

Ra­di­o­log­i­cal Imag­ing • The main­stay of imag­ing dur­ing the triple as­sess­ment is based around ei­ther mam­mog­ra­phy or ul­tra­sound in­ves­ti­ga­tions: • Mam­mog­ra­phy is an X ray of breast, is a pref­fered screen­ing method for breast can­cer. It shows com­pres­sion views of the breast across two views (oblique and cran­io­cau­dal), al­low­ing for the de­tec­tion of mass le­sions or mi­cro­cal­ci­fi­ca­tions. • Ul­tra­sound scan­ning is more use­ful in women <35 years and in men, due to the den­sity of the breast tis­sue in iden­ti­fy­ing anom­alies. This form of imag­ing is also rou­tinely used dur­ing core biop­sies.

Pathol­ogy • FNAC is now be­ing su­per­seded by

core nee­dle biopsy. • A core biopsy is re­quired of any sus­pi­cious mass or le­sion pre­sent­ing to the clinic. A core biopsy pro­vides full his­tol­ogy ( as op­posed to fine nee­dle as­pi­ra­tion ( FNA) which only pro­vides cy­tol­ogy), al­low­ing dif­fer­en­ti­a­tion be­tween in­va­sive and in-situ car­ci­noma. • This test gives im­por­tant in­for­ma­tion about tu­mour grad­ing and stag­ing, and has a higher sen­si­tiv­ity and speci­ficity than FNA for de­tect­ing breast can­cer. Triple As­sess­ment is very use­ful di­ag­nos­tic tool to eval­u­ate pa­tients with breast lumps and rule out can­cer. The in­di­vid­ual case will then be dis­cussed at a Multi- Dis­ci­plinary Team ( MDT) meet­ing where a treat­ment plan will be de­vel­oped. Triple as­sess­ment donot re­quire hos­pi­tal­i­sa­tion and is per­formed on OPD ba­sis.

A Va­ri­ety of Be­nign Breast Lumps: Most be­nign breast lumps are di­rectly re­lated to your men­strual cy­cle, to fluc­tu­a­tions in your hor­mones and to the fluid buildup that comes with monthly pe­riod.

Other be­nign breast lumps may be re­lated to plugged milk ducts, in­fec­tions, or even breast in­juries.

Most com­mon be­nign con­di­tions are:

Fi­bro­cys­tic Changes: A gen­eral lumpi­ness that can be de­scribed as “ropy” or “gran­u­lar,” these lumps are the most com­monly seen be­nign breast con­di­tion, af­fect­ing at least half of all women. Symp­toms of fi­bro­cys­tic change in­clude ten­der,fi­brous, rub­bery tis­sue; a thick­en­ing of tis­sue; or a round, flu­id­filled cyst. These changes, re­lated to hor­mone fluc­tu­a­tion, may in­crease as you ap­proach mid­dle age and then dis­ap­pear with menopause.

Breast Cysts A cyst is a com­mon dis­crete mass found in pa­tients pre­sent­ing to a breast clinic. They are ten­der to the touch and filled with fluid. They may come and go with men­strual pe­riod, be­com­ing larger and more ten­der at the be­gin­ning of your pe­riod and dis­ap­pear­ing at the end.

This tu­mor is the most com­monly di­ag­nosed be­nign breast lump. Oc­cur­ring in young girls and women in their teens and 20s. About 10% of pa­tients have mul­ti­ple fi­broade­no­mas on pre­sen­ta­tion.

Gi­ant Fi­broade­noma is a breast fi­broade­noma more than 5 cm oc­cur­ring in young women and man­i­fest­ing as breast asym­me­try or de­for­mity. It has a bi­modal age of pre­sen­ta­tion , may also oc­cur in 45- 50 age groups. Di­ag­no­sis is made by core biopsy . Sur­gi­cal ex­ci­sion is done by cos­metic in­ci­sion.


Sus­pi­cious/can­cer­ous Lump: A can­cer­ous breast lump will have an ir­reg­u­lar shape (though at times it can be round) with a peb­bly sur­face, some­what like a golf ball. It is of­ten very hard, like a slice of raw car­rot. It may not be mov­able dur­ing a breast self- exam. Most of­ten breast can­cer is pain­less, though breast can­cer can some­times cause breast pain.

Symp­toms of Breast Can­cer: • Pain­less , hard lump • An un­ex­plained change in the size or

shape of breast. • Skin dim­pling or puck­er­ing (some­times

look­ing like an or­ange peel) • Nip­ple re­trac­tion (turn­ing in­ward) • Red­ness, sca­li­ness, or thick­en­ing of

the nip­ple or breast skin • Nip­ple dis­charge ( other than breast


So if you find a Breast Lump: Your first pri­or­ity is to take care of your­self — which means “go see a Breast Sur­geon.”

All breast lumps should be eval­u­ated by a breast spe­cial­ist, who can help you de­cide how to pro­ceed. Most be­nign breast con­di­tions are treat­able, and some will even go away on their own, but it's best to let your doc­tor be the one to tell you that.

De­spite most cases of breast lumps be­ing non can­cer­ous, breast can­cer still re­mains the most com­mon can­cer and lead­ing cause of death in women and there­fore a di­ag­no­sis should not be ig­nored.

her, like the friends and their phone num­bers for one thing or the fact that she had fre­quently missed at­tend­ing her classes as whis­pered to her by one of the well-wish­ers.

he first night was bliss­ful. Mythili stretched like a cat lazily watched by Surya and she blushed. His eyes said that it was spe­cial for him too. The stolen kisses in the the­atre or in the pub­lic park though very ex­cit­ing never equaled the real thing. He had taken her to a small get­away on the out­skirts of the city as they had just the week­end for them­selves. He promised her ex­otic hol­i­days, later on when he could ac­cu­mu­late some leave. The small room was not a kind she was ac­cus­tomed to on hol­i­days but she ac­cepted that get­ting a bet­ter room on lit­tle no­tice was not easy. He gave her some gifts. She at­trib­uted the gar­ish­ness of the gifts to lack of taste. Her gifts to him ap­peared lav­ish and ex­pen­sive. Her ten­ta­tive query re­gard­ing get­ting in touch with her par­ents were brushed aside and he told her that he wanted her to him­self for just this week­end and she suc­cumbed to his charm­ing as­sertive­ness.

The house of the Kr­ish­nans was like a tomb. There was a hol­low­ness that both Sita and her hus­band Anan­tha Kr­ish­nan could not evade from. There were no more tears left and the worry lines were etched all over their vis­age. The po­lice were of lit­tle help. They very kindly al­luded to the fact that be­ing an adult their only daugh­ter could have eloped with her paramour. They also said that there were hun­dreds of cases like this and begged their for­give­ness for not giv­ing the mat­ter the at­ten­tion the par­ents might feel it de­served. It was more than two days since their beloved daugh­ter Mythili’s dis­ap­pear­ance. Anan­tha sim­ply could not ac­cept that his beloved daugh­ter who was named af­ter his mother could do any wrong. He felt that the po­lice was wrong and his wife could not bring her­self to tell him about the missing cloth­ing, the few pieces of fam­ily heir­loom and the pass­book. She knew she had to but she wept afresh at the agony her daugh­ter had heaped on them. She won­dered for the umpteenth time, ‘Where had they gone wrong? ‘

“Could the po­lice be right?” Anan­tha asked Sita at one in the morn­ing. He knew she was as awake as he. Their going to bed was just to stretch them­selves and give their aching backs some rest and also strength to face the next day. The agony of the daugh­ter’s dis­ap­pear­ance was com­pounded by the fact that she was en­gaged to a young doc­tor who was well re­spected in the small town where he was serv­ing. He had been on ex­tended leave and he also knew that be­ing a Se­nior Vi­cePres­i­dent of a com­pany, he could ill af­ford to do so for a stretch of time. The en­tire of­fice knew that he had per­formed his daugh­ter’s en­gage­ment and the mar­riage was to be six months away. He had dis­trib­uted sweets the day he had come back from the groom’s town. Some of his close friends had also ac­com­pa­nied him for the same and they had been all praise for the newly en­gaged cou­ple. They felt that the match was per­fect.

The en­gage­ment cer­e­mony was done in style with the boy’s par­ents not spar­ing any thought to ex­penses. As they said, “My son de­serves this and much more.” Anan­tha Kr­ish­nan and Sita won­dered with great deal of trep­i­da­tion how they would face them. Both of them squirmed when they thought of the man­ner their daugh­ter let all of them down. Even the dot­ing fa­ther in him had to con­cede that his daugh­ter was ter­ri­bly will­ful and he knew he was to be blamed to a large ex­tent. He stretched out a hand to his suf­fer­ing wife and both wept in each other’s arms for what ap­peared to be hours. They were not sure what was the greater evil; the pos­si­bil­ity of an ac­ci­dent seemed a bet­ter op­tion than an elope­ment. They also knew that she wouldn’t have made a good match if there was a need to elope.

The stark bare­ness of the sin­gle room and the nar­row cot with its lumpy bed did not de­ter the newlywed from hav­ing the most won­der­ful time on their first night home, though she must ad­mit that she was more than a lit­tle flus­tered when she en­tered the room. Surya had al­ways been hon­est. He had told her that he had a hum­ble abode in the top­most floor of the build­ing. He had told her that he used to sit by the win­dow on days he could not meet her, dream­ing about her while look­ing at the blue­ness of the wa­ter. She had imag­ined a onebed­room house over­look­ing a lake to say the least and hardly ex­pected to be led to a dingy build­ing in a nar­row al­ley. If she had been shocked by the ap­proach, the stink­ing stair­way lead­ing to their one- room ten­e­ment was a ma­jor cul­tural shock. Then he had en­veloped her in a bear hug and she had forgotten it all. Now, she moved to the win­dow to see for her­self the wa­ter body of which he had spo­ken of at length, only to see the bare face of an­other equally dingy apart­ment build­ing. She froze.

ythili knew that she must con­front him, but sud­denly she was scared. The mad­ness of the en­tire elope­ment, the se­cret mar­riage, the side of Surya that she had never imag­ined was brought home with a harsh re­al­ity. She also knew that she had let down her par­ents very badly. She felt em­bar­rassed by the fact that she had al­lowed Surya to talk her into en­ter­ing an en­gage­ment with an­other

Mythili knew that she must con­front him, but sud­denly she was scared. The mad­ness of the en­tire elope­ment, the se­cret mar­riage, the side of Surya that she had never imag­ined was brought home with a harsh re­al­ity.

man know­ing very well that she was plan­ning on elop­ing soon af­ter. His rea­son­ing had ap­peared solid then. He had told her that he needed to make ar­range­ment for the mar­riage and as her par­ents had in­sisted on the en­gage­ment there was no harm in pleasing them. She felt guilty and ashamed at the agony she had caused them. She started sob­bing un­con­trol­lably, for she knew that they would have been mad with worry.

urya gave her per­mis­sion to con­tact her par­ents that day. He wasn’t wor­ried about the po­lice as he very well knew that she was above the le­gal age. “We will go to your place this evening. Call them so that they can pre­pare for the grand ar­rival of their daugh­ter and son-in-law.” The tone in his voice caught her at­ten­tion. She looked at him sus­pi­ciously as he whis­tled non­cha­lantly as he dressed him­self. He picked up his over­alls stained with oil and sud­denly she was afraid to ask him what he did for his liv­ing.

“Sita…our daugh­ter is on the phone,” Anan­tha’s voice cracked with emo­tions. Switch­ing on the speaker phone for both of them to hear, he con­tin­ued, “Kanna, where are you? Are you all right? What did you do…we were so wor­ried. Are you hurt?” Sita sobbed, “We won’t scold you…..please tell us where you are , We will come and pick you up.”

“Amma, Appa….i am mar­ried.” Mythilis voice cracked. She had prac­tised this line so many times and each time it had come out joy­ous, but now it sounded so bland bereft of emo­tions and sud­denly she re­al­ized the mag­na­nim­ity of her ac­tions. She had burnt her bridges and she knew that Surya would not take kindly to her change of mind even if she wanted to. She wanted to run to her par­ents and al­low them to take charge like all the times be­fore, but she knew that she had grown up in a hurry. She forced some hap­pi­ness in her voice, “Surya and I will be com­ing this evening to meet you, appa.. Amma, are you there? Please speak up….. please……you will like Surya, he is won­der­ful” Sud­denly she re­alised that this was what was wrong with her love, the rea­son for elope­ment, for she knew that her par­ents would be aghast with her choice and they would never ac­cept him even in hun­dred years and Surya was once again wrong. It had noth­ing to do with the caste, but… “Amma,” her voice was hes­i­tant, “Appa,….” She sobbed and their heart melted de­spite all the agony she had caused by her ac­tions.

“Come home…. with him.” Anan­tha whis­pered and cut the call. Both he and his wife were bro­ken­hearted. They cried for their lost child, they cried for the agony, they cried for the sleep­less nights wor­ry­ing about her fate and now they cried for the mis­take they knew that she had com­mit­ted. They knew her voice, there was no joy, there was hes­i­tancy and fear and they cried for the ir­rev­o­ca­ble dam­age she had ob­vi­ously done to her life.

“Amma,” Mythili hugged her mother sud­denly look­ing at the aged, frail per­son. Her fa­ther too looked older and sud­denly Mythili re­alised with a pang what she had done to them. She had been in­or­di­nately proud of her dis­tin­guished fa­ther and here she was see­ing a bro­ken man. He asked her then, “Why did you get en­gaged to an­other man? Are we that much of your en­emy that you need to not only hurt us but also break our re­spect in the so­ci­ety?” His voice rose steadily and his fa­mous anger at any kind of wrong­do­ing was mak­ing it­self vis­i­ble. Mythili was rarely at the re­ceiv­ing end of his fa­mous ire, but to­day she knew that there would be no stop­ping him and Sita tried in­ef­fec­tively to calm him down. She knew that the neigh­bours would be all ears to know what was hap­pen­ing. “Is this the rea­son we ed­u­cated you? If you had been cer­tain of your love, why did you not have the courage to come out with it?”

Both he and his wife were bro­ken­hearted. They cried for their lost child, they cried for the agony, they cried for the sleep­less nights wor­ry­ing about her fate and now they cried for the mis­take they knew that she had com­mit­ted. “Amma,” Mythili hugged her mother sud­denly look­ing at the aged, frail per­son. Her fa­ther too looked older and sud­denly Mythili re­alised with a pang what she had done to them. She had been in­or­di­nately proud of her dis­tin­guished fa­ther and here she was see­ing a bro­ken man.

Dr Ra­jin­der Kaur Saggu MBBS, MS, Fel­low­ship Breast: Tata Memo­rial Hospi­tal, Mumbai

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