Surgical Choices (Again)
Posted 7/8/2012
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A few days ago I wrote about the growing incidence of women opting for bilateral mastectomies. This is a short article from ASTRO about another possible reason for this situation. I think that the writer is thinking primarily about single mastectomies, not bilateral, as a choice for treatment of diagnosed breast cancer--not as a hedge against a future problem. The suggestion here is that some women meet first and only with a surgeon and never have a chance to really hear about the possibility of smaller surgery/lumpectomy/wide excision and radiation.
I appreciate that there are women and situations in which daily radiation therapy for approximately six weeks is a big hardship. In rural America, a woman may have to travel miles for radiation. Near to home, women who live on Martha's Vineyard or Nantucket have to travel to the Cape to receive radiation therapy. That could be quite an undertaking for six weeks of daily ferries. There also are women who have other medical issues that complicate radiation and women who just feel they can't devote that much time and energy to weeks worth of visits.
All of that aside, this particular reason, not speaking with a radiation oncologist, had not occured to me. At BID, and certainly at all major medical centers and most smaller ones, women routinely are routed to both specialists. We have a twice weekly Multi Disciplinary Breast Clinic where women, in the course of one long visit, can meet with a surgeon, a radiation oncologist, and a medical oncologist. This is efficient although exhausting and overwhelming. Women who come into our system via a surgeon's office are certainly set up with these other specialists.
Here is the article:
Breast cancer patients choosing surgery without learning their options
Fairfax, Va., April 18, 2012
Many surgeons foregoing multidisciplinary approach when deciding treatment course
Surgeons are not always including radiation oncologists early enough in a patient's treatment decisionmaking process, leaving some patients uninformed of all of their treatment options and potentially leading to more mastectomies over breast conserving therapy, according to a study in the April issue of the International Journal of Radiation Oncology•Biology•Physics, the official scientific journal of the American Society for Radiation Oncology (ASTRO).
Multidisciplinary collaboration in cancer care is quickly becoming the standard philosophy in treating cancer patients. However, because different specialists have varying opinions on a patient's best course of treatment, not all specialists are working together.
Researchers interviewed 318 surgeons and 160 radiation oncologists on their practice patterns and attitudes toward multidisciplinary care. Almost 30 percent of radiation oncologists said their biggest challenge was other providers failing to include them in the treatment decision process early enough, and nearly half of surgeons admitted that few or almost none of the breast cancer patients they had treated in the past year had consulted with a radiation oncologist before undergoing surgery.
Almost 100 percent of both specialties indicated that they do have access to a multidisciplinary tumor board, which allows physicians from different specialties to discuss cases with one another. However, despite access to these discussions, a substantial proportion of radiation oncologists in this study reported concern that they were not involved early enough.
It was found that the desire to avoid radiation was strongly correlated with a patient's decision to undergo mastectomy, but many patients who have this procedure still need postsurgery radiation. Researchers concluded that patients weren't always aware of this, and if they had been informed before surgery that radiation may be necessary whether undergoing mastectomy or breast conservation, some might have chosen to attempt breast conservation instead.
Another underlying problem in true multidisciplinary care is differing opinions among specialties over the standard treatment in common breast cancer cases. Surgeons and radiation oncologists varied greatly in how they would treat an earlystage breast cancer and what is appropriate margin width.
Because radiation oncologists appear to be less conservative than surgeons with regard to acceptable margin width, earlier involvement of radiation oncologists in decisionmaking might lower mastectomy rates. Because of this, the researchers also called for developing institutional guidelines or national guidelines to avoid providerbased variations in care.
"If such efforts to increase multidisciplinary involvement before surgery are successful, patients may benefit from exposure to a variety of viewpoints before proceeding with definitive local therapy decisions," Reshma Jagsi, MD, DPhil, lead author of the study and a radiation oncologist at the University of Michigan Comprehensive Cancer Center in Ann Arbor, Mich., said. "This could lead to their decisionmaking process being more informed and more in accord with their preferences."
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