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Deciding on surgical treatment for breast cancer

A recent article in the Seattle Times references the 2012 Dartmouth Atlas Report: Improving Patient Decision-Making in Health Care. Unfortunately their take home line, "A new report that found wide geographical variation in the use of elective surgical procedures in Pacific states reflects the preferences of physicians – not what patients want or need, the authors say,” oversimplifies a complicated situation.

On my reading of the report, it stresses the values that an individual woman brings to the decision:

“Different women will prefer one option or the other, depending upon how much they value preserving their breast, their willingness to undergo radiation or more invasive surgery, and the level of uncertainty they are willing to live with in terms of their cancer recurring.”

As a breast surgeon who has practiced in Seattle for almost 40 years, I don’t believe that “the preferences of physicians” are the driving factor. I have a few observations to make.

It is clear that wide variations in treatment of early stage breast cancer can be seen across the USA, as the Dartmouth-Atlas data confirms. Some factors that influence this are physician related – for example, what % of their surgical practice involves treating women with breast cancer. Specialists in breast cancer or general surgeons who treat large numbers of women with breast cancer are motivated to be current in their practice patterns and to make sure that their patients are making considered decisions. The utilization of breast MRI has been shown to influence the mastectomy rates and there is regional variation in the use of that study. Distance to a radiation oncology treatment center is a factor for some women as are potential differences in out of pocket costs between mastectomy and breast conservation.

All of the local breast surgeons that I know strongly value shared decision making with their patients. We all work hard to present treatment options fairly and as neutrally as possible. If we have a patient that we think is choosing mastectomy over breast conservation out of fear – for example, fear of radiation therapy – we will encourage her to consult with a radiation oncology specialist prior to making a final decision. We believe that one of our roles is to help our patients make informed decisions. If there are clear medical reasons why one treatment is preferred, we will state that but otherwise encourage the patient to make the best decision for herself.

For example...

Two key questions to answer in a suspected cancer workup

There are two questions to be answered if cancer is suspected:

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The Story Behind the Voice of 1-855-XCANCER (1-855-922-6237)

Being diagnosed with cancer is the beginning of a difficult time. The entire process – from diagnosis to treatment to survivorship – can be exhausting. And, I am sure that when you have questions that come up, you would like to have them answered, respectfully and responsively.

As health professionals we want to ensure that you, your family, friends and caregivers have access to all resources available at the Swedish Cancer Institute (SCI). For this reason, Swedish launched a customized phone line tailored to the Cancer Institute where callers can find out more information on services available.

Whether you want to know more about different treatment options, learn more about research studies or locate community cancer resources, I am here to assist you. If you are a new patient and would like to be seen by a provider at the Swedish Cancer Institute, I can help get the process started for you by connecting you with the most appropriate SCI specialist.

To put a story behind the voice over the phone, I would like to officially introduce myself to the Swedish community! I am Swedish’s Integrated Care Services Coordinator and Telephone Liaison for the Swedish Cancer Institute and True Family Women’s Cancer Center – which means I get to work with the entire network of Swedish campuses (including First Hill, Cherry Hill, Issaquah, Ballard and Edmonds) and can help you get connected to the appropriate areas of service that you may need.

I can help to answer any questions you may have, or connect you to the following:

Do Docs Miss Breast Cancer Warning Signs in Breastfeeding Mothers?

In the haze of joy and sleeplessness during the months after childbirth, thoughts about breast cancer are the last thing on a new mother’s mind. Her body is undergoing so many changes that, of course, she and her doctors would naturally assume any breast changes are related to breastfeeding.

Probably, they are. However, there is a small but real incidence of women who develop breast cancer during and following pregnancy. Often, they end up having delays in seeking evaluation and getting a diagnosis, because they or their doctors may not appreciate that risk!

So, what things should prompt an evaluation?

  • Lumps most often will be changes in the breast tissue as it revs up milk production. A distinct lump or “dominant mass” could be a clogged duct, galactocele, cyst or a common benign tumor called a fibroadenoma, but if it doesn’t resolve within a few weeks with treatment, it needs imaging.
  • Redness most often will represent infections like mastitis or an abscess, but if it doesn’t resolve within a few weeks with treatment, it will also need imaging and possibly a biopsy. At the very least, that could determine if the right antibiotics are being used. An uncommon form of breast cancer called inflammatory breast cancer can present this way.
  • Bloody milk or baby refusing one breast  most often will be due to nipple trauma, latch issues, or positioning; if so, seeing a board-certified lactation consultant is appropriate. But rarely, this can represent a form of breast cancer within the milk ducts.
  • “Something’s not right”. You are the most knowledgeable person about your own breasts. Even if it doesn’t neatly fit one of the categories above, if something really seems wrong to you, your doctors should take that seriously.

What evaluation should be done?


Health Disparities and Breast Cancer

Just as all breast cancers are not alike, the impact of breast cancer is not the same for all women. African American women are less likely to get breast cancer than Caucasian women, but they are about 40% more likely to die of it when they do get it. African American women are also more likely to be diagnosed with breast cancer at a younger age than Caucasian women and to have more advanced cancers at diagnosis.

There appear to be multiple reasons for these disparities - including cultural beliefs / misperceptions about screening and cancer; lack of access to screening; inequities in healthcare delivery and treatment; concerns about being exposed to racism by healthcare institutions; and biological differences in the cancers themselves.

Let’s look at some of these more closely.

  • Cultural beliefs / misperceptions about ....

Becoming a Breast Surgeon

Surgeons are often Type A personalities, the ones who sit in the front of the class, who volunteer for everything, who stay scrubbed in the OR all day with appendicitis and do a post-op check before checking themselves into the emergency department (yes, that was me.) As such, surgeons are often dismissive of the subspecialty of breast surgery. The surgeries are not as complex as cardiac bypass surgery or Whipple procedures for pancreatic cancer. In fact, it’s often a rotation for interns. I was a Type A personality. I had no plans to do breast surgery.

Then, a funny thing happened. I had my first son during residency. Planned with military precision, of course, to coincide with the beginning of my designated research years, as I had hoped to squeeze another baby in there somewhere. After his birth, I would breastfeed, because that is what Type A mothers do these days. It’s the best! Of course, I would do the best! However, like many mothers out there, we had an incredibly rocky start. Poor latch with inadequate weight gain. Triple feeding with pumped milk. Cracked nipples leading to mastitis. As a Type A person, I threw myself into research in an effort to solve the problems. Not just the many, many baby books out there, but Medline searches on breastfeeding management. I learned more than I ever had in my surgery textbooks about the breast, the physiology of lactation that is both incredibly simple and enormously complex, and most importantly, miraculous. I was reminded constantly in my reading of the importance of preserving this ability to breastfeed my son, for his and my health, and how challenging that could be.

I would sit in my office, working on surgical infections research, as I pumped and read about normal breasts and infected breasts and cancerous breasts. Antibiotic rotations in ICUs and glucose control became less exciting than being able to offer targeted medical advice to a frustrated friend in Boston, whose refractory mastitis was being met with shrugs from some of her local doctors until we correctly identified MRSA as the source. Maybe it wasn’t saving lives, but it saved her breastfeeding relationship with her child. Who knows, maybe in the end it would be saving lives! I read more ....

What should I know about radiation if I have breast cancer?

If you’ve been diagnosed with breast cancer, you may wonder if radiation is an option for you.

Radiation is an important pillar of treatment for breast cancer and has never been safer when designed by an experienced team with state of the art technology. Radiation will be part of a standard treatment plan after breast conserving surgery (also called lumpectomy or partial mastectomy). With the addition of radiation to the breast as an insurance policy, patients will do just as well as those undergoing mastectomy. Even after a mastectomy there are indications when radiation to the chest wall and nodes are recommended for best outcome. After a lumpectomy, radiation to the whole breast is the current gold standard.

How does radiation actually work?

Radiation works by aiming it at a target. Free radicals are produced which kill cancer cells, while normal cells have the capability to repair the damage. Cancer cells don’t.

Having the most advanced technology available to precisely plan and deliver radiation to the target will protect healthy tissue for optimal outcomes and the best possible cosmetic result.

How can I make sure I receive the best radiation?

The radiation oncologists treating you should be part of an interdisciplinary team. I, for example, work closely with the patient, the breast surgeons and the medical oncologists. I then design a personalized radiation plan, tailored to the unique characteristics of the tumor and each patient’s personal preferences. The more personalized the treatment the better.

To allow patients to feel their best during and after treatment, I often work with physical therapists, naturopaths, and other support staff (social worker, dietitian etc).

What type of radiation treatment do I need?

Radiation options after a breast conserving surgery can be very confusing. Here is a list that may help you understand the different options:

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