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Breast Cancer: Making the Right Choices for You
Choosing a Doctor
Breast surgery, whether it be in the form of a lumpectomy
or mastectomy has historically been thought to be a "simple" surgical
procedure to do. Well, if it is your breast it might not sound so simple.
There are many general surgeons who perform breast cancer
surgery. They might do one case a year or perhaps as many as twenty.
You want to go and be seen by a surgeon who IS a breast surgeon... who
has chosen this to be his or her surgical specialty and who does a lot
of breast surgeries every year. These are physicians with the surgical
experience you are seeking. They have chosen this as their field of
specialty and will be probably more up to date on the latest surgical
techniques.
High volume surgeons tend to have better results and
are more attuned to subtle differences in individual cases. Seek out
a physician who does fifty or more breast cancer operations a year.
You can find out this kind of information from several
sources: call the hospital where the doctor is in practice and ask for
information about case volume. His or her office should be more than
willing to provide this type of information to you. Call your state
board of quality assurance and ask for information on file about the
physician you are considering seeing. They will also have information
about any malpractice cases he has had and other quality of care complaints
that have been filed against him. This information isn't published data
but is available by making a simple call. (Keep in mind however that
physicians who treat large numbers of women with breast cancer may have
some information on file where as a physician who only treats a handful
of patients a year may have nothing on file.)
You also want to know about the credentialling of the
physicians you choose; this includes your breast surgeon, medical oncologist,
radiation oncologist, radiologist and others involved in your care.
Your wisest choice is to choose a physician board certified by The American
Board of Surgery as your breast surgeon. He or she had to be trained
in a recognized approved training program and pass rigorous exams after
training. The American Board of Medical Specialists can be reached by
calling 1-847-491-9091 or by going to their web site which is: www.certifieddoctor.org/.
They can provide you information regarding who in your region meets
this criteria. Surgeons of this specialty also frequently are members
of the American College of Surgeons. This distinction comes only after
having become board certified and practicing in a community for greater
than 3 years. These surgeons are considered by their peers to be above
average in the care of surgical patients.
Finally, most true breast surgeons are also members of
The Society of Surgical Oncology. This society only accepts as members
those with substantially greater training and/or experience in the management
of cancer. Most of the latest developments in the surgical management
of breast cancer are presented at annual educational meetings of this
society. The standards for the surgical care of breast cancer patients
are developed by the American College of Surgeons and The Society of
Surgical Oncology jointly. Not all breast surgeons do breast cancer
surgeries 100% of the time. But consider this - some full time breast
surgeons do surgery on only 25-30 new cancer cases each year but others
who do only 75% breast surgery treat over 200 new cases a year!
The same criteria applies for each other specialty physicians
who will be providing your care. They should be board certified for
their specialty with a subspecialty in breast cancer. There are lots
of physicians for example who are medical oncologists and provide treatment
to cancer patients. You want to receive your care however from someone
whose specialty or major interest is "breast cancer."
Physician attitude
Seek out someone who is going to be very frank and honest
with you. This is not a time to have a sugared version of what your
situation is. You need the facts and you want them presented to you
candidly. This can be emotionally difficult for some physicians so you
never really end up with the whole unvarnished truth. Seek out a physician
who is willing to spend time with you and answer all your questions.
No physician knows all - they should be willing to discuss the uncertainties
in treatment and results. Beware of the omniscient doctor. That person
may not be able to recognize their shortcomings or see alternatives
in treatment that may not be the usual local treatment policy.
Seek a physician who wants to help educate you about this
disease and your treatment options and not someone who wants to make
the decisions for you. You need to be part of your own treatment team
remember. That is important. It can be tempting to just have the doctor
tell you what to do but that really isn't in your best interest. There
are critical choices that you must make which need to be your decision
alone. An example is whether to have mastectomy or breast conservation
surgery (lumpectomy with lymph node removal). Depending on your clinical
condition and the size of the tumor along with some other factors, it
may very well be that from a survival perspective, you will be given
the choice of having one type of surgery or the other, both having equal
outcomes regarding your survival rate. This is a decision that should
be left for you to decide based on many factors including your emotional
well being and the feelings you have about your self image. You, not
the doctor, will face the consequences of these decisions for the rest
of your life. Make sure these decisions and treatments have your seal
of approval.
Talk with other survivors
Getting information from other women who are breast cancer
survivors can be very valuable. Also take comfort in knowing that there
are many of us who HAVE survived this disease ( there are greater than 2 million
breast cancer survivors in the US today). These women can give you candid
information about their own experiences with physicians who provided
them care and treatment when they were diagnosed. It is best to talk
with someone who has been treated fairly recently though because treatment
modalities change. For example if you spoke to someone who had a mastectomy
7 years ago she would tell you that she spent several days in the hospital
and suffered with nausea and vomiting and a lot of pain. Physicians
who have chosen to continuously improve care for women battling breast
cancer will make changes in their surgical care to prevent the side
effects that women in the past had to overcome. There are various types
of surgical treatments for breast cancer too and you will find that
the experiences women share with you based on the type of surgery they
had will also vary. The results also vary dramatically between hospitals
and individual doctors. Do not expect the good results from one hospital
to translate into similar results at others.
For example, women having mastectomies or lumpectomies
with lymph node removal and not having reconstruction at the same time
should describe an experience free of severe pain and absence of nausea
and vomiting. However the reported rates of nausea and vomiting in most
hospitals in the country exceed 85%. Several years ago, we at Johns
Hopkins pioneered improvements in anesthesia management and other peri-operative
surgical care so that the majority of our women patients can awaken
from this type of surgery and feel relatively normal from a physical
perspective. I know our own experience here at Hopkins since 1995 has
been that women undergoing one of these two procedures without reconstruction
feel well enough to go home the same day. The emotional aspects of this
disease and its treatment cannot be underplayed. We want patients to
focus on addressing their emotional needs as a priority and not have
to worry with feeling ill from surgery. If you find that previous patients
you speak to are describing unpleasant experiences from their surgical
event, then you might want to get more information before selecting
the same doctor that they chose to see. There will be other important
services to ask former patients about too which will be described in
more detail below such as the ease of reaching a health care professional
in an urgent way after you go home.
Multi disciplinary care
Lots of facilities boast that they offer this. What does
it really mean though? Multi disciplinary means that you are being seen
and cared for by a team of breast cancer specialists with expertise
in breast surgery, medical oncology, radiation oncology, plastic surgery,
cytopathology, and mammography with diagnostic imaging. Some hospitals
or breast centers have such a team. This team may be however the only
team, meaning that they only have one medical oncologist or one breast
surgeon. Ideally you want to go to a place where there are several physicians
of each specialty and where your specific case gets discussed and reviewed
by the specific team caring for you as well as well by the other physicians
there who can offer second opinions on an ongoing basis. In most cases
the types of facilities that offer this level of faculty staffing are
at larger teaching hospitals. It is important to have this type of specialized
care and expertise however. Each step of the care of you is too important
to delegate to a single individual - only through open review and debate
of each step in the treatment process, can the ideal treatment and management
be certain.
Skill, knowledge and technology
The effective treatment of your breast cancer is critical
for you. You deserve to receive your care in the most up to date facility
where the latest and newest technology for diagnosing and treating breast
cancer is available. The physicians and nurses who care for you should
be specialized in the diagnosis and treatment of breast cancer. There
is always new research and innovative treatments being developed for
this disease. Having your care at a facility that can offer state of
the art diagnostic evaluation and treatments should be your priority.
Being able to have access to the latest treatment modalities including
clinical trials for treatment of breast cancer will be valuable for
you. Don't settle for a program that is limiting in its offerings as
to what it can provide to you. Facilities for example that offer state
of the art biopsies in the form of "percutaneous biopsies" means that
you can be biopsied in mammography by a radiologist who has been specially
trained and credentialed to perform such a procedure. The physician
can remove tissue for further examination by a pathologist without having
to make an incision in the breast or having to put you to sleep. Doing
the procedure this way is less painful, allows most women to do it on
their lunch hour and get the results within 24 hours. If the facility
you have chosen doesn't have such equipment or professional expertise
then you expose yourself to having procedures done the old fashioned
way which may limit some of the future treatment options.
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