A woman in her mid thirties felt a breast lump a few months after she stopped breastfeeding her one-year-old child. Her doctor sent her for a mammogram.

When the technologist brought me the films, the concern on her face was evident. Together we looked at the mammogram and quickly knew that trouble lay ahead. The patient's mammogram could have come right out of a radiology textbook. There was almost no question that she had breast cancer.

We walked down the hall together to the patient, still waiting in the examination room. I shook her hand and hung her films on a view box on the wall.

"You have an abnormality, right where you feel that lump, which is in this spot here," I pointed out. "The appearance is suspicious for a possible cancer. You'll need to have a needle biopsy to know for sure."

She remained attentive and calm. A small tear ran from the corner of each eye. She wiped them away with a finger.

"But my doctor thought it might just be a cyst."

Before the study, her doctor would have probably been right statistically, but all of that changed with the mammogram.

"Unfortunately, that's not how it looks."

"I understand."

She looked down for a moment, wiping another tear.

After asking a few more questions, the young woman thanked us and left. She seemed adequately informed and responded appropriately.

I telephoned her physician, and her biopsy was arranged. Everything seemed in order to get this woman the medical attention she required. Several weeks later, I saw her surgeon in the hospital. He and I were also in our mid-thirties, about the same age as the patient.

"Hey," I asked him, "how did things turn out with the young mother with the breast lump and the abnormal mammogram?"

He ran his dark brown hand across his smooth scalp and sighed. "You won't believe it. We did her biopsy right in the clinic, since we could feel the lump, and it came back ductal carcinoma in situ. The pathologist said it was clearly cancerous, but she couldn't see any invasion of the surrounding tissue. Yet, after the biopsy results came back, the patient is refusing to have the surgery to remove it. I'm not sure that she believes she has cancer. I think she freaked out from the news, and we can't get her back into the office."

My eyes widened. If the woman waited too long before having the cancer removed, it could certainly become invasive. For someone who had to have a diagnosis of breast cancer, hers was a more fortunate diagnosis than many. Now her delay was squandering the opportunity that a relatively early diagnosis provides.

"You can't be serious. How could anybody ignore a positive biopsy result, particularly someone so young, with a small child to look after?"

"I know," he said, shaking his head again. "Our nurse has tried to get her to schedule the lumpectomy. The patient will not return our calls."

I pondered this unbelievable revelation. "Does she have any psychiatric history?"

"Not that we know of," he sighed. "As far as we can tell, she's competent to make this decision, even if she may be delusional on some level."

I could not stop thinking about this young woman or about her child, who could become orphaned due to a mother's unwillingness to admit to her illness and have it treated. On one hand, she had the right to make her own decision, but everything in me told me that her decision was simply wrong. Out of fear or misinformation, she was risking her very survival, with devastating potential consequences to her family. Such an outcome could be prevented.

I paged the surgeon several days later. "I apologize if I might be overstepping my role as a radiologist."

"It's not a problem," he said.

"I just wouldn't feel right if I didn't try to contact her myself. My interaction with her on the day of her mammogram was obviously brief, but it seemed productive, and normal. I thought we had a decent rapport. Would you object to my calling her, to discuss her treatment further?"

"Please, feel free. Anything that would bring her in for surgery would be great."

I dialed her number. When she answered the telephone I took a deep breath, reminding myself to stay reserved. I wanted her to take this seriously but not get overly scared into inaction. She might fear the pain, the cosmetic result, or risks of the operation. I wanted her to be concerned enough to undergo the surgery, but not too afraid to return to the hospital.

She sounded almost chipper. "I remember you, doctor," she exclaimed. "But I feel fine now. The lump is gone and everything is okay."

I could not believe my ears. I tried to stay cool and non-confrontational, but I was amazed at her statement.

"I understand that you had a biopsy last month. They did tell you the results, didn't they?"

"Yes, but I'm fine now. I'm telling you, it's gone. I can't feel a thing."

"But it's not all gone," I countered. "They didn't take it all out, only a little piece of it with the biopsy. The cancer is still there."

"No, I understand what you're saying, but I really don't think so," she said.

Her voice sounded rational, but her statements were far from it. I didn't know what to say.

"I don't mean to contradict you," I continued, "but I have to. It's really important to me, and to you, that you understand your situation here. It must be difficult to hear news like yours, but your biopsy showed breast cancer. If you have it removed now, you have a good chance of doing just fine. The longer you wait, the greater the chance that it could spread."

"You've all been very nice, and I appreciate your concern," she said, "but I'm doing well now."

The level of exchanged information progressed little further from this point. The more I tried to explain that she still had a cancer in her breast, the more emphatically she stated that she no longer had a problem. She thanked me for calling, but she did not budge in her conviction. I gave her my telephone number at work and encouraged her to call the surgeon, or me, if she had any questions.

After I hung up the phone, I envisioned other patients I had known with breast cancer diagnosed later than hers. Many had ended up with metastases and suffered from the pain and debilitation of their disease, not to mention the side effects of radiation and chemotherapy. Some did not survive. Would this woman end up like one of those patients because she insisted on blowing her opportunity for early treatment and potential cure?

The surgeon was disappointed when I told him of my telephone interaction with the patient, but he was not surprised.

With my conscience continuing to haunt me for several weeks, I tried to communicate with her one more time, if for no other reason than to convince myself that I had done everything I knew to do. If the telephone conversation was not fruitful, then perhaps a written letter might be more productive. She could read it and reread it on her own time. Maybe the weight of her diagnosis, and the severity of consequences by refusing treatment, could sink in eventually.

The surgeon had already written a letter, but he welcomed my trying once more. I sent a letter that was informative and simple to understand, and included the telephone numbers for the surgeon and myself.

Months passed. She never returned or called. Her inaction was presumably based on fear--of surgery, of dying, or maybe just of hearing the word that no patient ever wants to hear. Maybe by ignoring it all, she could pretend that her cancer did not really exist, slowly but continually growing inside her. At times I wished I could have her brought straight from home to the operating room, forcibly if necessary. I imagined her telling us afterward that the surgery was not as bad as she had feared. She would thank us for persisting, for caring, and for guiding her when she was too scared to face the ugliness of her illness, even if it was only temporary.

All of that thought remains fantasy. I could not force her to have surgery without her consent, any more than I could understand her decision to forego treatment.

She had all of the information I could provide for her. The surgeon and I both assured her that we would wait for her to make an appointment at the clinic, or to contact one of us.

Several years now have passed. We are still waiting.

Dr. Cullen Ruff is the author of the forthcoming book "Looking Within," the first collection of medical stories written by a radiologist. He is a professor of radiology at Virginia Commonwealth University in Fairfax, VA, and a radiologist in the Washington, DC area.