Making decisions for surgical treatment

I have always been curious about the process by which patients make decisions about their care.  I remember being in fellowship training in Hand & Microsurgery at the Massachusetts General Hospital.  I supervised 2 chief residents in plastic surgery, 2 junior residents in plastic surgery, and whichever general surgery residents were rotating on the Plastic Surgery Service that particular month.  One of the most frequently performed procedures we did on call was replantation of amputated fingers.  As a matter of course, most of these cases were done late into the night.  Sometimes I felt that we were the only replantation center for the whole city of Boston considering the volume of work we did.

Obviously, most patients WANTED everything done to save the amputated part.  But we (the community of replantation surgeons) knew from more than 2 decades of accumulated experience that just because a finger COULD be replanted, did not mean it SHOULD be replanted.  In other words, a single digit amputation through zone II (from the mid palm past the middle knuckle of the finger - where the 2 flexor tendons run through a delicate sheath where scarring can significantly effect function) may survive, but may be more of a functional hindrance than a help.  But who wants to walk around with a stump for a finger?  But if you are a manual laborer who supports their family, and return to work will be significantly prolonged with replantation and rehabilitation of a single amputated finger, and functionally one could perform their job capably without the finger replanted - what is the right choice?  In these cases, recommendations by the surgeon play a major role in the decisions ultimately made by patients.  Maybe there is a "better" choice to be made based on the available information.

Women who are diagnosed with breast cancer face several initial choices for surgical treatment - breast conservation versus mastectomy.  These treatments have been shown to lead to equivalent survival rates.  What influences what choices are made?  Shouldn't patient preference be a major part of the decision making process because of the equivalent survival rates?  I will describe some interesting findings about decision making in early stage breast cancer in my next post, but I wanted to try a reader poll about the subject.  I am sure there is nothing too scientific about the poll I have posted on the sidebar, but I am interested more in the readers' commentary than the answers per se.

Referrals for breast reconstruction

As a board certified plastic surgeon, I deal with issues surrounding breast reconstruction on a daily basis. But as I speak to most patients at their initial consultation once they have been newly diagnosed with breast cancer, it is clear that most people are unaware of most of the surgical options for treating and hopefully curing breast cancer, let alone the options for reconstruction after mastectomy. The standard primary treatments available to women with breast cancer are either lumpectomy with radiation therapy to the remaining breast (also know as breast conservation therapy) or mastectomy. Studies have shown that survival rates after either treatment are similar.

Interestingly (or sadly as I see it), only a small percentage of women who undergo mastectomy have reconstruction. The 2 studies that I reviewed (one by Monica Morrow, MD and her colleagues published in 2001 in the Journal of the American College of Surgeons, and another by Amy Alderman, MD and her colleagues published in 2007 in the journal Cancer) suggest that in the last 2 decades the rate of postmastectomy reconstruction has increased from about 3.4% in the mid 1980s to about 16% in this decade. Why is the referral rate for breast reconstruction so low?

Unfortunately, misinformation and old attitudes persist. In the early "modern period" of breast reconstruction (1980s), some were concerned that breast reconstruction would limit the ability to detect local recurrences of cancer, or that compromises in the surgical removal of the breast cancer would have to occur to ensure a better reconstructive result. Both of these misconceptions have been disproved.

What these studies revealed is that some surgeons are reluctant to refer women who are "older" for reconstruction (over 50!). I think that this attitude still persists among some general surgeons. I have performed breast reconstruction on many women in their 60s and 70s when they are medically fit and motivated to have reconstruction. There is also a lower tendency for women of lower socioeconomic status to undergo reconstruction. Alderman's study suggested that low referral surgeons cite cost of reconstruction, availability of plastic surgeons, low patient knowledge, and low patient priority for reconstruction as reasons to justify the lower referral rate. Despite the 1998 Women’s Health and Cancer Rights Act (WHCRA), a federal law establishing that insurance companies covering mastectomy must also pay for breast reconstruction, the number of reconstructions done in the USA remains low. I hope to cover the WHCRA in more detail in later posts.

There were some suggestions that high referral surgeons were more often women, with breast surgery making up a higher proportion of their practice, and often associate with a cancer center. My own experiences suggest that this may be a generalization. Most of the surgeons who refer to me are male, but I think the reason they refer as frequently as they do is that I made an effort to educate them and their staff about the surgical options for breast reconstruction after mastectomy. My staff works well with the staff in their office to coordinate surgical schedules so the patient and all physicians are accommodated promptly. Patient education is where it's at - I'll try to cover some strategies for improving decision making for patients in later posts.

I am excited about where this blog is heading....I am anxious to see comments from any one who wishes to share them!

Welcome

Welcome to Building Breasts. Blogging is something new for me, so I'm excited to see in what direction it goes. The idea behind the blog is to provide easy to understand information about breast reconstruction after mastectomy. But that is just the beginning...As a board certified Plastic Surgeon with a practice focus on breast reconstruction surgery, I evaluate patients for immediate and delayed breast reconstruction after mastectomy, but also improvement of poor results after breast conservation therapy or unfavorable breast reconstruction outcomes.

I am also hoping to share my experiences and those of my patients' (with their consent of course...) regarding the emotional impact of the decision making process. What emotional issues are the patients, their significant others, their children, and their friends experiencing? I'd love this site to be the seed for a growing community for those to share and support others walking in their shoes.

I am a board certified Plastic Surgeon practicing in West Islip, NY on the south shore of Long Island. I was fortunate to have trained in General Surgery at The New York Hospital - Cornell University Medical Center and at Emory University in Plastic Surgery. I also did fellowship training in Hand and Microsurgery at Massachusetts General Hospital - Harvard Medical School. I know that I stand on the shoulders of those who trained me in hoping to improve the care and quality of life of those women dealing with surgical options in breast cancer.