Thursday, October 29, 2009


A NY Times op ed from October 10 makes the case that the management of breast cancer ought to be coordinated and run entirely by fellowship trained specialists hereafter to be known as "mammologists". The article was written by an OB/Gyn who runs the breast fellowship program at the University of Rich Rod. Basically, it's another barely camouflaged attempt by a sub-sub specialist to corner the surgical market on a type of operation that is about as straight forward and simple as it gets. (Surgical training programs assign junior residents and interns to all the breast lumpectomies). The decision-making in breast oncology is certainly complex and patients benefit from a multi-disciplinarian approach but the actual surgical procedures are not exactly enigmatic. The idea that you need to have your mastectomy done by an expert, i.e. a "breast surgeon" is rather absurd.

But the article does raise an interesting point. Specifically, why don't OB/Gynes do breast surgery? They do pap smears and pelvic exams and formal breast exams and usually are the ones who order yearly mammograms on their patients. It has always struck me as odd that once breast pathology is identified, the patient is all of a sudden shunted off to a general surgeon.

The super-specialization of surgery is an apparent inevitability. The paradigm of practicing "general surgery" is a dying ideal. I can read the writing on the wall. But these specialists are going to have to do a better job in coming up with new appellations. I mean, "mammologist"? That sounds terrible. It sounds zoologic. Just call yourself a breast surgeon, dammit.


Dr. Midlife said...

That article's suggestion that the process of cancer treatment would be eased by the addition of an ob/gyn was LUDICROUS. If the ob/gyn does nothing but cancer surgery and is part of a treatment team, sits on tumor board, fine. But the article suggests that the garden variety, primary care ob/gyn can insert him/herself into the process of surgery/chemo/radiation as a patient advocate, explaining and helping things along. How, exactly, and how would they be paid, exactly?

Ridiculous. That ob/gyn ain't getting paid to navigate, doesn't know from med or rad onc, doesn't even have an office in the same building with the infusion or radiation process in which they'd allegedly be assisting. Which part is helping the patient or his/her family (oh yeah, men get breast cancer, hmm, that's a wrinkle in the ob/gyn sell).

Also, I tried to find this "breast fellowship" on UMich's website, and, um, there are a few of them, none of which are run by the article's author. The weekend following the publication of this article, the UMich breast SURGERY program had a conference on how to improve primary care management of breast cancer. Awesome! But none of the article's authors are involved in that effort. Specifically, the "breast fellowship" in the ob/gyn department, which Mark Pearlman runs, DOESN'T EXIST.

As long as the attending surgeon knows what a margin is, and knows the stats about lumpectomy vs. mastectomy outcomes, has heard of lymphedema, maybe goes to a cancer conference now and then, I don't care if they're gen surg, ob/gyn or optho. But don't be thinking some yahoo random primary care provider gets to vote on chemo and radonc.

Obviously, the article pissed me off, and I thank you for mentioning it.

NikkiK said...

I can't get this to come out the way it is in my head, so I apologize if it is incoherent. But there's the whole thing out there now about women coordinating mastectomies with reconstructions, and disappointing results from lumpectomies; problems with women not being offered reconstruction at all; doctors who are only interested in removing the cancerous tissue, and not rebuilding the breasts. I'm sure things are improving all the time, but they remain issues.
I'm not a medical professional, (my only claim to a connection is that my dad is a general surgeon who now solely works in an ER) but I am a woman with a strong family history of breast cancer and I particularly like the idea of a specialized "breast surgeon," since the surgical part of breast cancer treatment is not limited to removal. I agree the name stinks, and I *think* I understand why you'd be annoyed with overspecialization, but if I am ever diagnosed with cancer and have a choice, I'd choose the superspecialist.

tom said...

next sub specialty will likely be, breast specific (L vs R) age specific, specified bra cup size, no existing co morbidities (extra work you know) and a "can pay well cohort".

The value of general surgeons will be increase as their availability decreases. Are GS residency slots still going unfilled??

Jeffrey Parks MD FACS said...

Any general surgeon worth anything will always discuss reconstruction options prior to definitive breast surgery. I involve a plastic surgeon early in the care of all my patients who require or choose a mastectomy. It's simply the right thing to do. And I didn't have to go through a "breast fellowship" to learn it.

Anonymous said...

The GYN tends to appear back in the picture if a woman takes tamoxifen.

It's an important drug for pre-menopausal women who've had breast cancer, but it might as well be labeled as full-employment act for gynecologists.

I don't know any women who've taken it for a few years who haven't ended up at their GYN with some, usually benign problem.

By that time, if a woman is lucky, her surgeon has faded away and her Oncologist has moved onto more pressing patients. The GYN gets assigned the female side effects.

Anonymous said...

C'mon Buckeye,
WHO wouldn't want to do a "Breast Fellowship"??


ER's Mom said...

Um, Mark Pearlman is an MFM (maternal-fetal medicine) subspecialist in OB.

And quite frankly, I DON'T want to add breasts to my OR procedures...we don't get training for it and therefore I don't feel comfortable doing it. It would be like you doing a crash c-section.

ER's Mom
an OB who occasionally refers to that center

Anonymous said...

I went through the whole shebang last year - double mx (I had Ca in both breasts, it wasn't prophylactic) and DIEP recon. I interviewed several surgeons (both breast/general and plastic). I can tell you, that not all breast/general surgeons take the time to fully review all the reconstruction options available.

N=5, in terms of breast/general surgeons personally interviewed. 4 of the 5 did not even bring up the option of DIEP reconstruction.

And, the plastic surgeons - I interviewed 4 of those. I had decided on a muscle-sparing free TRAM (no local PS did DIEP). I had to learn about DIEP on my own, for the most part. Not one of the first 4 breast/general surgeons explained the advantages/disadvantages of ALL the various reconstruction procedures. The general viewpoint from each of them was "here's what the plastic surgeon I partner with does - so these are your (only) option(s). I ended up going out-of-state to get the reconstruction I wanted. Once I made that decision the breast surgeon was just part of the package.

I believe you, Dr. Buckeye, when you say you (and any other surgeon worth anything) always discuss reconstruction options before surgery. I do think, however, that that discussion must include ALL OPTIONS, including those options which might mean the patient goes elsewhere for surgery.

But, back to your point about super sub-specialists - as you might imagine, I've studied the breast surgery subject extensively over the past year (from a patient's POV). I also have a background in marketing - so I am rather sensitive to language that is marketing-based rather than actually, you know - scientific. I see a trend among medical centers. They are "marketing" their services. The super sub-specialty trend seems to my untrained eye to be based mostly on marketing opportunities. It all goes back to Marketing 101 - What is your point of difference? I can see through it, but I doubt it's as obvious to others.

The commoditizing of cancer is particularly blatant (and disgusting) these days - what with all the baby boomers reaching the age of greatest risk. There's even a cancer center in my home city (with many franchises in the region) that was owned by venture capitalists. When I called to make an appointment there, the hold time was taken up with commercials for all their ancillary services. Hung up. Went elsewhere.