IN THE MONTH OF BREAST CANCER AWARENESS, RADIOLOGIST MALCOLM CROCKFORD SHEDS A RAY OF LIGHT ONTO WOMEN’S VARIED PSYCHOLOGICAL REACTIONS TO RECALL LETTERS AND THE DELICATE DETECTION OF THE DISEASE… AS WELL AS THE PSYCHOLOGICAL SIDE OF HIS OWN JOB, WHICH CAN ENTAIL BEING THE BEARER OF BAD NEWS. HE TELLS FIONA GALEA DEBONO HE IS AGAINST SCAREMONGERING WOMEN INTO BREAST CHECKS.

Dangerous Dissemination

Here we are, trying to raise awareness about breast cancer, but Dr Crockford sees through the initiative and straight into a negative aspect that is hardly ever touched on. It can actually cause anxiety in women if not done cautiously, he maintains.

Although Dr Crockford is the first to push for regular mammograms, he feels statements highlighting, for example, that one in eight women get breast cancer are scary and provoke anxiety. He can see the value of, sometimes, reminding that seven out of eight do not, because he is against “scaremongering” women into breast checks, insisting on balance in the message and that it could have the opposite effect.

“Increasing awareness has to be done in a way that women can understand relatively easily. You cannot just pontificate; it has to be done in a caring manner. This is not always the case: people go and speak on radios, without being appreciative of how different women are going to respond to their words.

“The danger lies mostly in how the message is interpreted at the receiving end and how it is scattered second hand, for example, from woman to woman. The more widespread the first-hand information, the less effective the dangerous second-hand communication.”

Common Misconceptions

Confusing stories about mammography, including whether it hurts, or causes damage, and how accurate it really is, can further contribute to keeping women away.

Dr Crockford has so many anecdotes of women who admit they weren’t going to do the test because they were anxious it would hurt them, or that it could create, or even spread cancer.

“These are all false statements, but sadly, they are out there,” he says. The problem is that the consequences can be nasty.

“Some years ago, two sisters came for a mammogram. One had wanted to come early in the year, but the other put her off on the basis that it hurt. Some months later, when they both came to the clinic, she found a lump and it turned out she had breast can­cer, which had already spread to the armpit. Eighteen months later, she passed away.

“Almost certainly, if she had come when she planned to – five months earlier than she actually did – today, she would still be living,” Dr Crockford states, pointing out that a simple misconception, which creates an­xiety, can lead to a non-test and take a life.

Setting The Painful Record Straight

Slight pressure is applied to the breasts and some are more tender than others, Dr Crockford admits. But all in all, a mammo­gram is a quick process, and the examination should have a build-up to it that would serve to reduce stress levels. Gentle handling by staff, information on the procedure by the radiographer and a relaxed environment are all vital.

“Countering any pain in mammography is not so much about the technique as it is about how well you relax the patient before. The more tranquil she is, the more she is likely to cooperate and the faster the whole process is.”

A four-view mammogram only takes 12 minutes and the two-view version takes five. Unfortunately, however, patients tend to only remember that spilt second of discomfort.

Risk factors

Although these are important – and there is a whole host, including not having children and not breastfeeding – they remain risk factors, Dr Crockford points out.

“So if mummy has a breast cancer, it does not necessarily mean you are destined to have it too.”

Risk factors, which are important to high­light, can also stir up anxiety, he maintains. “One of the most common is family history. But looking at 10 random breast cancers in Europe, only three who had it in the family contracted the disease. So women who live with the fear because their mother, or grandmother, had it, have to dilute it down to context,” Dr Crockford clarifies.

On the other hand, it does not mean that those who don’t have a risk factor don’t need to check their breasts, he adds.

Reactions To Recall Letters

Recall letters for mammography stimulate different reactions from different women: some hide it, preferring to let sleeping dogs lie; some ignore it; some respond; and others do not give it priority. Dr Crockford has seen it all – to the point of denying that they ever received it. “Then, when you probe fur­ther, they admit,” he says from experience.

The first reactions of many women when they receive a reminder is: “Oh my God, my time has come again! I have to find out whether I have breast cancer!”

A small percentage actually bin it; and some put it aside, sometimes even for months, until they see some advert, or learn of someone who has the condition and pick up the phone. And then there are those who come even before they receive the letter.

Don’t Go It Alone

Dr Crockford strongly encourages women to come for their consultation accompanied, either by their husband, or a friend. Like that, they can talk to each other and reduce the stress that does tend to build up during their wait for the appointment.

“This is important even if I have to be the bearer of bad news. It helps to deflate and deflect some of the anxiety. If a woman is beginning to crumble, having her husband by her side is supportive, even from the point of view of explaining the situation. The woman’s mind may drift in those circumstances, but her husband can reinforce what I have said when she may be calmer later.”

Even though Dr Crockford considers it important for husband and wife to be together, he would not tell the man the prognosis before the woman. Sometimes, he has to decipher the psychology of the man too: “The woman may take it all in her stride and the husband may literally crumble; whereas I thought I’d have to manage the woman, I’d actually have to handle the man.”

Not everyone would consider being accompanied, but Dr Crockford believes that “if you happen to be the woman who has a problem, having your husband next to you is a good thing… And in the eventuality of bad news, I would not want them to be driving home alone”.

Six out of 10 women come to the clinic accompanied. Their husbands feel they should support them, even if they have no suspicions, Dr Crockford is pleased to note.

Breaking The Bad News

This is always a challenge “because you want to be sure to handle it properly”, Dr Crockford says. He can often tell straight away if things are not looking good. But he strongly believes in not hitting someone with the bad news immediately. “Ideally, you would try to encourage the woman to start to understand that something may not be quite right.”

They soon realise it is not that straight­forward and start asking questions, although he avoids responding to details about the severity of the condition at such an early stage of diagnosis. “At the end of the day, I am not God, but I do need to give feedback when the questions start flowing in.”

Dr Crockford is constantly trying to assess the individual as you cannot have a one-size-fits-all approach. Depending on how she responds, you start to introduce the fact that she should have a biopsy, sometimes without even mentioning the word.

“On the whole, I’d like to say that it is rare for a woman to leave the clinic in tears, despite her prognosis.”

The ‘C’ Word

Dr Crockford avoids talking about cancer and prefers to refer to inflammation. “The ‘c’ word immediately impresses the notion of death, and we need to move away from this as many cancers are completely curable.”

A positive atmosphere must prevail because, nowadays, more breast cancers are caught and earlier, while treatment has improved. From experience, Dr Crockford knows that he would immediately lose his patient’s attention if he went down that road, and his priority is that she understands what he is telling her.

“There have been times when I haven’t mentioned it at all because I would have felt she would be totally devastated if I did. Some women need a bit more time.”

Much as he tries to tread carefully in these delicate situations, however, Dr Crockford is aware that one cannot always get it right.

“In one instance when I did not mention the ‘c’ word, it totally backfired. I got a call from the husband the next day, who told me it was a shame that I had not diagnosed his wife’s disease instantly. I apologised and told him I felt it was not correct to spell it out at the time. Clearly, my assessment of the man was not that good in that I assumed he would not be able to handle the news.”

Even talking about a mastectomy is a drastic thing for a woman, so Dr Crockford tends to use kid gloves there too. “Most of our work is, after all, aimed at not having to resort to one because, if you pick it up early enough, you can avoid it and require much less severe treatment, such as a lumpectomy, without even the need for radiotherapy and chemotherapy.”

The Psychological Side To Radiology

As a professional, Dr Crockford knows he cannot allow himself to feel for any individual case. Nevertheless, even he can undergo some stress, especially if he is dealing with someone he knows.

“One of my closest friends passed away this year and I was the one to find the cancer. I was doing the scans and wanting not to see them so I could push it away, but I couldn’t. Of course, I had to control myself in that case. I knew it was not a good prognosis.”

Handling the patient is part of the job. “We are usually the first to give an indication that things may be going wrong. And it isn’t something we were taught how to do. You either have it in you, or you pick it up.”

Over 24 years of mammography, Dr Crockford feels more confident in handling such situations. “I’m normally a pretty spirited person with my patients, especially when I know there is nothing wrong. The worrying thing is when, occasionally, I have been caught out with my light-hearted approach. On that rare occasion that you pick something up from the ultrasound, even though the mammogram was clear, you suddenly find you have to drastically transform your attitude and that has to be done carefully too. The moment you change your approach, alarm bells are set off.

“One episode involves a foreigner, who I was light-hearted with because I could see she was anxious. Most appreciate it, but she just wouldn’t see the humour and I was not getting through to her. I simply had to bite my tongue and get on with my work because the interaction wasn’t happening,” he admits.

The good thing about the job is that the vast majority of women who get themselves checked at the clinic are normal. And a normal result is a major psychological boost. “Seeing an anxious woman turn positive and smile is fantastic. They leave feeling they have done a chore and can move on.”

Why Should You Check?

Some women go for a check-up because the time has come; but others go because they feel something and have ‘symptoms’. That is not the idea, Dr Crockford insists. “We always recommend that the tests are done when you feel normal and not when you think you have a problem.”

These ‘symptoms’ can be pain and burning sensations, but the irony is that they are never due to cancer. The mammogram may reveal the disease, but it would have been a complete coincidence. “Fortunately, we are moving away from the scenario where a woman shows up with a large lump and has her first mammogram after about three years. These women tend to block themselves men­tally from the fact that it could be a cancer.”

Dr Crockford is particularly upset about one patient, who has a lump, won’t remove it and won’t even tell anyone about it. She comes for her check-ups regularly to see if it is growing bigger. Since it is not, she won’t do anything about it, even though it has all the makings of cancer, leaving Dr Crockford frustrated. At least, the younger women are more informed and tend to do their checks more regularly, Dr Crockford maintains. He is also pleased to note that most women, who have been through a scare, are then good at following it up. “It seems to instil the feeling of wanting to beat it. Hopefully, these women are ready to help educate others and many are, indeed, shining examples.”

Checking Yourself

There’s no excuse not too – not even the fact that you don’t know how. Dr Crockford asks his patients whether they always knew how to make lasagne, or whether they learnt with time… The answer is obvious, and in that case, they could slowly learn how to check their breasts for lumps too.

This interview was published in Pink magazine, which was distributed with The Times yesterday.