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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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What patients should know about small cell lung cancer

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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:

What is the treatment of choice for patients whose advanced lung cancer has progressed?

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Might some lung cancers not require treatment?

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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?


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