Surgeon Preferences and Surgical Options
Another study has just concluded that a woman's particular choice of her breast surgeon can have a profound impact on whether she is offered lumpectomy or mastectomy as a primary treatment-even when both surgical procedures would be medically equivalent.
However, this new study, by Dr. Elizabeth Cyran of the University of Colorado Health Sciences Center in Denver and colleagues, found that the surgeon's gender can play a role.
Writing in the journal Archives of Surgery, Cyran's team reported on a survey of 198 women aged 65 to 84. Ninety six of the women were treated with lumpectomy and 102 with mastectomy. All had stage I or II breast cancer.
The researchers found that female physicians were more likely than their male counterparts to recommend lumpectomy to their older patients, particularly in patients over age 75. They also found that 45 percent of the women who underwent mastectomy had no medical reason not to consider lumpectomy as a surgical option.
Cyran's study comes on the heels of previous research by Dr. Lillian Rinker of Methodist Healthcare-Central Hospital in Memphis and colleagues which concluded that a surgeon's "comfort level" with either lumpectomy or mastectomy was a defining factor for which surgical option would be recommended to her.
Rinker's team evaluated the treatment records for 142 women at her hospital with early-stage breast cancer, all of whom were eligible for lumpectomy with adjuvant (additional) radiation therapy. However, only 47 percent of the women had breast-conserving surgery, while the balance underwent mastectomies.
The researchers concluded that the discrepancy in treatment was based primarily on an individual surgeon's experience with one procedure over the other. For example, one surgeon at the hospital treated 81 percent of his patients with lumpectomy while another treated only 9 percent of his patients with this breast-conserving option.
They suggested that doctors often perform procedures that they feel more comfortable with, rather than basing their treatment decisions on the actual medical evidence at hand.
Furthermore, they found that those surgeons who attended regular interdepartmental conferences to discuss patient cases were more likely to perform lumpectomies than surgeons who did not participate in such collaborative discussions. In effect, peer pressure and input from medical colleagues seemed to play a major behind-the-scenes role in opening up treatment opportunities for patients, they said.
And it is not just breast cancer patients that can be affected by physician bias. According to a report published in The Journal of the American Medical Association, urologists and radiation oncologists often agree on treatment options for prostate cancer. However, for men with moderately differentiated, localized cancer who had a life expectancy greater than 10 years, 93 percent of urologists preferred to treat the patient with radical prostatectomy, while 72 percent of radiation oncologists saw no difference between surgery and external beam radiation as treatment options.
Drs. Michael Barry and Mary McNaughton Collins of Massachusetts General Hospital in Boston wrote that for most tumor grades and PSA levels, the physicians were significantly more likely to recommend a treatment in their own specialty than any other treatment. This reiterated the findings of a similar survey undertaken in 1988 that documented equally skewed treatment recommendations.
The researchers also noted that a similarly low percentage of both specialists would recommend "watchful waiting," even though this option might be the best treatment for patients in some cases. They said that the best thing for prostate-and other cancer patients-to do is to seek multiple opinions before deciding on a course of treatment.
Patients should always seek a second opinion on procedures for which there is any difference in medical opinion. Even when there are no treatment alternatives to sort out, a second opinion can offer a fresh perspective if there's a vexing clinical problem. Or it can confirm a diagnosis or the wisdom of a course of treatment, and thus ease any doubts that you, or your physician, may have.
When seeking another opinion, make sure to discuss this with your primary physician. If you sense reluctance or defensiveness on your doctor's part, that's all the more reason to get a second opinion. Walking away from a physician who leaves you frustrated or angry, or just uncomfortable, may be one of the most important things you can do to take charge of your health.
Unfortunately, many patients are hesitant to get a second opinion because they are afraid of damaging their relationship with their doctor. Yet all patients are entitled to an independent second opinion and to get a copy of their medical records. Your primary physician should not only support this process, but should provide you with a list of specialists that he or she would personally recommend.
SOURCES:
Archives of Surgery, February 2001; 136:185-191
Presentation by Dr. Lillian Rinker, Radiological Society of North America, November 28, 2000, Chicago, Illinois
Journal of the American Medical Association, 2000; 283:3217-3222, 3258-3260
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