Mammogram

MAMMOGRAM

Gary Kinney

Smashwords edition

Copyright 2010 Gary Kinney

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Chapter 1

Health? What is health but the condition of the body when you don’t have to think about it? It is an absence both of disease and thought. To think about health is to worry about mortality; it is to feel vulnerable.

Sweetie, Linda said to me one day as I was about to leave for work, I have to go for a mammogram today. That’s just like her, of course: tell me some important piece of news at a time when I can’t stick around for details. Mammogram? I didn’t think she was old enough to need one. Linda’s 47, I think, but because she is so beautiful with her long auburn hair, cow-brown eyes that see everything, and cheekbones of a Gypsy, I find it hard to believe she’s aged at all in the ten or so years I’ve lived with her. I know those are silly things to hang age on, but I find them so striking that I can’t judge her anymore.

And anyway, she won’t let me judge her -It’s a power-thing Jamie, she says. It implies that you are in possession of more information than you actually have...

No way, Linny, -we have this argument often- It merely says that I have observed something and have formed an opinion about it...

Based on?

In this case, sensory data.

At this point she usually shakes her head. So, I’m beautiful and young because of sensory data? Given the truth of the matter, your data is incomplete and poorly gathered. Not much hope that your conclusions are warranted then, eh?

I forgot to mention pedantic and unnecessarily wordy, I think. Linda’s going for her PhD this fall and so she likes to play with words as if she were reciting her dissertation.

You also forgot to mention how much I love you when you lie like that... Linda’s actually a deer in feminist clothing.

But a mammogram? Is something wrong with your breasts, Linny? I always thought mammograms in women under fifty were for resolution of suspicions. I mean, do you have a lump, or something?

Jamie, you always suspect the worst, don’t you?

You mean because I’m neurotic? Linda thinks I’m an unfunny Woody Allen. I even look like him, I guess: glasses, short, kind of uneven clothes... I have a beard, though, so even though I sort of identify with him in a spiritual sense, I would never be mistaken for him in a movie line up, or anything.

She nodded her head sagely. Yup.

Well, do you?

Do I what?

Don’t play games, Linny. Do you have a lump, or not?

She thought for a moment, choosing her words carefully. No.

Good. Definitive answer. Brooks no contradiction. Then why..?

Sweetie, my family doctor just wants me to get a baseline mammogram, okay? She doesn’t suspect anything. I don’t suspect anything. There isn’t anything.

Then why did you tell me about it? Linda can’t fool me. She goes for all kinds of tests, does all kinds of things without mentioning them until later -days later, often.

Well, I’m never going to tell you again, that’s for sure. She looked away, as if she was mad, but I could tell there was something else.

Sweetheart, I said, putting down my briefcase and giving her a hug. What is it? Are you worried?

She hugged me tightly, as if she wanted to melt into me. No, not really... I looked into her eyes; they were moist. It’s just that... Well, not that there is anything, but... what if? You know, I can’t help but wonder why my GP decided to do a mammogram now, not next year, not when I turn fifty. Now! A tear trickled quietly down her cheek and she wiped it quickly on my shoulder.

She’s just being careful, Linny. She knows you appreciate her thoroughness.

Sweetie, I’ve got a feeling she has an intuition about something. She’s very good, you know, she added defensively. As if her talents need defending. Dr. Garent was the only doctor Linda ever trusted. She followed her even when she moved her office half way across town. They could talk, apparently: discuss things. Mutual respect, I guess.

I’d never seen Linda like this. She was actually worried about a non-event. Linda was nothing if not a pragmatist. Sift the data, categorize it, and then risk a hypothesis. No conclusions without corroborative facts, no Procrustean logic. Linda simply did not consider unsubstantiated anything. I couldn’t get away with generalizations about Americans, or women, or health... That’s silly, she’d say. How can you say the Americans are arrogant? Do you know even one Arrogant American? And before I could reply she’d add, My friend Ginny’s American. You said you liked her... Is she arrogant? How do you argue that?

So what’s the big deal about an X-ray? Typical male reductionism. They do it; you go home and forget about it till the next time.

I obviously punctured a pipe on that one. Just an X-ray?! Do you know what a mammogram is, Jamie? Do you know what they have to do? I tried to nod my head (I am also a medical doctor, but of other areas.) but Linda would have none of it. First you have to expose your breasts in front of a stranger. Then they squash them in a vice. One at a time. Very slowly... Her face was beginning to contort at the idea she had conjured up. Linda is sometimes a bit maudlin when she doesn’t like something.

Well, then, I said in what I hoped was a professionally soothing tone, Why not tell your GP you’d rather wait till you turn fifty..? I mean there are no lumps...

Why do you always have to try to solve things? She interrupted loudly -so much for the soothing, empathetic stuff that works in my office. Can’t you just listen? Can’t you just let me talk? Good point. Problem is, if I’d done that, she’d have accused me of precisely the opposite: of not listening to what she says, of not taking her seriously. The answer, I’ve discovered through trial and error over the years, is a delicate balance of head nods and appropriately timed ‘Mmmmhmmm’s’. Unfortunately, I always get sucked into problem-resolution responses because that’s what I do for a living. I keep saying ‘next time I’ll remember’, but I never do... I’m a failed psychotherapist; most surgeons are.

*

I have an office in town across from the hospital. Nothing much, I suppose, but it is better than most in the area. Everybody seems to like it, at any rate.

To start with, it isn’t one of those take-a-number drop-in clinics where everybody sits in an auditorium with people waiting for other offices. A cold sitting beside a screaming baby sitting beside a paranoid schizophrenic never struck me as conducive to a calm patient. Or doctor.

My waiting room is small –too small, perhaps- but cozy, and decorated in plants and pictures, and it has a play area for whatever kids my patients drag along with them. It’s not that I have taste; before I met Linda, I was eating microwaveable fish dinners and enjoying them. No, Sheila, my nurse has the taste. The only thing I can claim is an ability to profit from another’s refinement.

My actual office –the place where I have my desk and chat with patients- is a bit messy, but every so often I find that all the journals I’ve filed under the window for rapid accessibility are on the bookshelf. Only the tree whose branches rub against the glass and maybe the ocean that I can see out there know who does it, but I doubt it’s the Iranian cleaning lady.

Sheila also has to remind me about a lot of things. She gets my charts ready for the OR, organizes my meetings... The ones I usually forget are the teaching sessions and the lectures. I don’t know, I do so much teaching I suppose that one lecture more or less blends in with another. I’m better at the evening lectures where I am the invited speaker because I usually put them on the calendar. Hormone replacement therapy is the current rage in these talks, and I have to steel myself for the hostility in the crowd. It used to be endometriosis which brought out the support groups with their pamphlets of resource phone numbers and lists of sympathetic physicians. Before that it was contraception, complete with religious advocacy groups, parents’ organizations, and social workers. Nobody falls asleep in my talks...

I sometimes get caught, though. The other day I was headed out the door of the office, having measured ten or fifteen pregnant women, listened to ten or fifteen fetal hearts of various ages, and then counseled the twenty or thirty people it makes when they arrive as a couple. I was looking forward to a leisurely lunch with the ‘guys’ in the cafeteria –social intercourse, Sheila used to call it. Unfortunately as I hurried past her, she grabbed my lab coat long enough to remind me that I had a lecture scheduled with the medical students in one of the small lecture theatres in the hospital basement. Great! No lunch again.

I hate the little rooms they give us, too. In the basement, of all places! Mixed in with the animal labs, the morgue, and the laundry, are three tiny rooms with thirty bolted-down seats in each, inadequate lighting, no workable projectors, and radiators that alternately gurgle like a stomach after pizza, or hiss like a cat in a corner. Cold in the winter, unbearably hot in the summer, they were walled off from the old laundry in the days when nothing much was expected from a lecture.

But students nowadays are technology addicts. They simply will not come to a lecture where there are no colour slides, or audiovisual aids like videos, or live televised sessions from recognized experts in the field. I am merely a local expert; I do not command a large audience. If I fill the place fifty percent of the time, I’m doing well...

This time, the topic was –surprise- Hormone Replacement Therapy, or HRT as it is fashionable to abbreviate it these days. It was a third year medical school class group who were on their gynaecology rotation at the hospital. The room was full, and a few were even sitting on the floor in the aisles – a first. A colleague had obviously forgotten about his or her group until the last moment, and told them to come to my lecture.

I had my PowerPoint, but the graphs and statistics were obviously not holding their attention. Okay, time for the direct-talk approach.

Look, I said, as head after head began to nod. Enough of the stats! Turn on the lights, somebody, please... I flicked the projector off and the room suddenly became silent apart from the incontinence of the radiators. What you really need to know is this: hormones are not just an expensive icing on a faraway cake. They actually serve a purpose –several, in fact... Judith, –I recognized her face from the time she spent as a student in my office- What happens to the hormones at the time of the menopause? An easy question, calling for an easy answer.

Well, they kinda disappear, don’t they?

Kinda? Why?

A hand from the back –they were waking up. The eggs in the ovary stop responding to the gonadotropin signals from the pituitary. I waited for her to go on. And of course the eggs are the source of the estrogen which stimulates the lining of the uterus, and so on...

So what happens to the gonadotropins?

They increase... to try to get an egg to respond, I guess.

Good. So how would you define the menopause?

Another hand. Ovarian failure with elevated gonadotropins?

Is that a question or an answer? I said, smiling.

An answer, I guess, said the shy young man in the back of the room. But the only thing is... well I think they’re elevated before the periods end, so...

"Yes they are. Lack of adequate feedback from the ovary –something called inhibin that the follicle makes to turn the gonadotropins off- is decreased in the perimenopause. We used to think it was just the estrogen, but wouldn’t you know they’d find something more complicated, just when you think you’ve made sense out of it? Anyway, the way to use that in the definition is to specify that the gonadotropins have to be up, and there has to be the absence of a period, although even that is inadequate...

"You have to specify a time frame for amenorrhea because the gonadotropin –FSH- is elevated both before the menopause (which is the last period, by the way) and for three to five years after.

Okay, questions? Silence. I’d lost them. Better get more basic. Estrogen is good and not-so-good. Let me list the ‘goods’ first. There was a shuffle as people searched for long-forgotten pens, and a bit of paper that they wouldn’t lose in their pockets. ‘No handouts today’, I could hear them thinking.

"Goods: relieves hot flushes, sleep disorders, mood changes, and memory disturbances often found in the perimenopause. It decreases calcium loss from bones and therefore prevents and actually treats osteoporosis. It may decrease the risk of -or maybe severity of- Alzheimer’s syndrome –stay tuned on that one, though... And colon cancer -although some recent data puts even that in doubt... How’s that for a quick list?

Bads? Well, it can over-stimulate tissues that have estrogen receptors unless coupled with progesterone. It may have a role to play in breast cancer, although so far that’s been a difficult one to prove one way or the other...

A hand. So why not use progesterone even when the uterus is out? After all, breasts have estrogen receptors?

That’s a good question. I don’t really know why, but the data don’t seem to indicate any added breast protection if progesterone is added. And, interestingly enough, the most active time of breast growth is in the last part of the menstrual cycle when both estrogen and progesterone are being produced in spades.

Everybody was awake now. It was ‘get Dr. Edwards time’.

The same student who had asked about the breasts was not giving it up. You say the evidence is not there to prove estrogen causes breast cancer? What about the Nurses Study?

Somebody had been reading up before the lecture. "True. There are some studies that indicate higher rates in estrogen users, but most studies have suggested the rates are time-limited. That is, estrogen use for more than –oh- five to ten years before there is a measurable risk. Don’t forget that you need large numbers in a study group, with adequate controls and provision for extraneous biases before you can get believable, reproducible results.

"And you have to follow these women for a long time because the incubation period –if that’s the right word- is probably several years in most cases of breast cancer.

Also there may be different sub-populations skewing the results one way or another. If you happened to have a group of newly-immigrated Japanese or Korean women in one group by chance, their group would look pretty good in terms of lack of breast cancers.

So why is that, Dr. Edwards? Why are theirs so low and ours so high?

There are many theories about that: diet, genetics, environmental toxins...

I read about that, another student said. Don’t the rates of breast cancer increase once they move here from Japan, or wherever?

Yes, that seems to be true...

Then doesn’t that argue against genetics?

Good point.

I heard it’s related to soy in their diets. The student looked at me, defying me to say she was wrong.

Quite possible. In fact there may very well be something to that. Soy is an interesting food, actually. There was a workshop sponsored by the National Cancer Institute in 1990 that identified a number of anti-cancer agents in soy: protease inhibitors, phytate, phytosterols, saponins –whatever they are- and isoflavones...

So should we all start eating soy burgers, or what?

Everyone laughed of course. I suppose, but I must say we really don’t know enough about soy yet. It may be that in fact there is a genetic component to the response to soy. For example it may be that some components like the isoflavones are dangerous to most people in large quantities –they are weak estrogens, after all- but that generations of exposure to soy in Asia has led to populations that can handle and maybe utilize isoflavones. After all, the ones that couldn’t would have died off, according to Darwin.

The medical student shook her head politely. I don’t know, sir. I think perhaps Western medicine doesn’t want to have a place for phytoestrogens like Isoflavones or lignans. I think the fact that plant remedies, and natural substances do occasionally work, worries doctors. After all, could the vegetarians be on to something? Are there some things in heaven and earth that are not anticipated in their philosophies?

Hamlet, right?

She blushed. I just think there’s something to the phytoestrogen thing, Dr. Edwards. Maybe we ought to have a harder look at what we’re currently using for hormone replacement.

Amen. I couldn’t agree more. But medicine is evidenced based –or trying desperately to be so- and hard data are not yet available. A thought suddenly occurred to me: What did you do before you went into medicine? I hope you don’t mind my asking.

Her whole face lit up. Not at all, sir. I was trained as a pharmacologist, but my mother was a naturopathic physician, so I must admit I straddled the line a bit.

It’s dangerous to assume you know more than your students these days.

*

The house is in shambles. We both work, we get home late, and the cleaning company dutifully moves dust from one room to another without seeing the big picture. We have now-adult family members who move back to the nest for months at a time -Just for the summer, honest! -promptly regress to a time when clothes got washed for and not by them, then proceed to complain that meals are never served on time, if at all. My answer, of course, is move out and get a job, but Linda still has the instincts of a cat with kittens, so whatever I suggest meets with deaf ears and guilt-engendering body language. I have the right message, but wrong century, I think.

And we are renovating the house. Have I used the correct word? ‘Restructuring’, maybe, or possibly ‘radically altering’... Our house was never new, never unexperienced I am convinced, so to euphemize our structural changes by suggesting we are renewing them is misleading in the extreme. Let me explain: we live on a farm... That is we have made what we live in, a farm; before we came it was just trees, weeds, and a flat-roofed house that resembled nothing if not two tacky house trailers glued together side to side. It came with the property. You had to take it if you wanted the property because it was also glued or otherwise fastened to the ground right where there would otherwise have been a decent-looking house.

The outside was beyond redemption: old painted wooden window-boxes hung precariously like swords of Damocles from the front-facing windows, swallows nested comfortably under the rotting eves and discouraged all flying insect invasions except for carpenter ants. The siding was cedar -painted cedar (the worst kind). There was a porch, of sorts, kind of tacked on to the end of the house, and then covered by a green corrugated plastic roof as an after thought. It certainly was an after thought because it suited the end of the house about as much as a baseball cap on a slug.

The inside of the house is what makes it worthwhile. I am reminded of those grotty old doors in dirty, broken brick buildings in Mexico that lead to delightful, enchanting, plant-strewn courtyards that bear absolutely no resemblance to the filth outside. Enter any door in our place, and you are surrounded with cedar. Every wall is cedar, the ceiling is pine: wood everywhere. Dark wooden beams support the fifteen foot barely sloping ceilings. Colour it rich and warm. There is a big stone fireplace dominating the living room, and the view from the front windows is mountains and forest. The view from the back ones is somebody’s boat on the other side of a not-high-enough fence, but that is another story. Anyway, the inside of our house is what led us to live with the outside -until recently.

Linda decided she wanted to remodel the kitchen first -not a bad idea, except that it encourages nestlings. That led to six weeks or so of unremitting stress while we cooked in the living room. Oh, and did I mention she figured the bathroom should be done at the same time, so for a week or so, we showered at work? Fortunately, the nestlings moved out for a while at that inconvenience. It also disturbed the resident mouse population, so where there was a bathtub, it usually sported a frantic mouse in the morning which I duly disposed of by flinging it across the road into a field. Deer mice are so cute with their big ears, and tiny little feet... I found out only later that Hanta virus had been isolated in one on the nearby mainland. I suppose I didn’t mention that we live on an island either, did I? Anyway, neither Linda or I got Hanta, and I assume the nestlings didn’t either, because as soon as the kitchen was finished, and the stove was up and running, one of them moved back into the basement -just until he started college in a month or so, mind you.

Why is this important? Linda is a cleanomaniac. Whereas I and the nestlings can live quite comfortably in a certain amount of deshevility -the basement troglodyte achieving record-breaking levels- Linda cannot. If we are sitting in the kitchen talking, she will get up like a hot-wired automaton and wipe a fingerprint off the glass cupboard door, or burst into sweeping the floor at the slightest light deflection. The bed has to be made just-so, lint is not allowed on accessible surfaces, no laundry is allowed to accumulate. Triple-A: that’s my Linda. Me? I’m double-B. A dusty carpet does not elicit a vacuum cleaner response in me, although I have to say I don’t appreciate it when the nestling puts dirty, food-caked, unrinsed dishes in the dishwasher and then disappears downstairs again. I suppose it’s better than leaving them under his bed like he usually does after his late night TV snacks, though.

Anyway, we survived Renovations I by the skin of our stove, and you would have thought we’d have learned. After all, most of us live inside, not outside our houses, right? Especially when there are animals that leave stuff on the lawn -hereafter referred to as pastures. Animals? Well, I said it was a farm. We have sheep in various states of disrepair, goats that, depending on the season and probably the amount we contribute to charitable causes, smell worse than the inside of the chicken coop, geese that we could never bring ourselves to eat for fear of gander-poisoning and which do nothing all night long but strut back and forth on the other side of a fence and cackle whenever they bump into each other. I put them on the other side, because they kept attacking the lambs.

And then there are the chickens. Stupid, smelly, foul-mouthed creatures that spend most of their time fighting with each other over who gets the rooster. If it weren’t for the eggs which I sell at the hospital, I’d boil the lot of them. The rooster first! Nobody in their right mind goes off at four A.M. Winter and summer, his alarm is rusted on four A.M. He switches when we go on standard time, but that’s his only capitulation to civilization. Useless thing! Oh yes, and where there are chickens, there are flies -swallows notwithstanding. I understand it is natural for flies to seek windows to bump into, but how they get on the inside of them