What is important in choosing your Breast Surgeon?

Benefits and outcomes of a Breast Specialists

Evidence has consistently and repeatedly shown that patients who are treated by surgeons with a higher caseload of breast cancer patients each year, have better survival than those who are treated by surgeons who see fewer cases. This evidence reinforces the specialised nature of breast surgery. Patients treated by a specialist breast surgeon are more likely to have breast-conserving surgery, and are more likely to receive adjuvant treatments such as radiotherapy.

There are three possible reasons for this

  1. Pure Surgical skill (advanced training able to perform a technically superior operation)
  2. More appropriate use of adjuvant additional pre, and post, surgical therapies. (a Specialist is not only trained in surgery but also in cancer biology, the role of radiation, hormonal and chemotherapy treatment and will refer appropriately and work within a multidisciplinary team)
  3. Volume effect better results may be related to more volume than the occasional surgeon

Does the breast surgeon offer surgeon performed ultrasound at consultation?

Our breast specialist, Ms Ruth Bollard, holds a certificate of accreditation for breast ultrasound (having fulfilled the requirements of the Diagnostic Imaging Accreditation Scheme Standards), and is therefore able to offer patients the  additional service of surgeon-performed ultrasound using a mobile, portable ultrasound machine.

Used as an extension of the clinical examination, it increases diagnostic accuracy and most importantly for the patient helps to streamline the process during what is an anxious time. Breast ultrasound is rapidly becoming an indispensable component of the surgeon’s equipment, methods, and techniques for the diagnosis and treatment of breast disease. It is not a substitute for a formal radiologist performed ultrasound; it is complementary, enabling the surgeon to correlate the clinical examination with the ultrasound findings by palpating the lump or clinical region of concern while scanning. This skill can also assist in the removal of cancers whilst operating.

Patient satisfaction

Patient satisfaction can be related to many factors but correlation with surgeon specialisation and satisfaction does occur. It may be related to better technical and cosmetic outcomes, better planning and reduction in re operation rates, practice support such as a nurse qualified to provide breast cancer care along with information and literature, and on site diagnostic services. This can all help  to make the patient journey easier. It may also be that specialist breast surgeons have developed better interpersonal and patient communication skills.

2nd Opinions

There is often more than one option for breast cancer surgery and this can be initially confusing. It is normal to need time and several explanations to enable you to make the right choice for you. Not all surgeons offer all breast specialist procedures. Overall satisfaction and acceptance of your cancer journey is dependant on the feeling of empowerment for these decisions that are made at the start, at the time of diagnosis. Your breast care nurse can often assist you with this process. Rushing into surgery uncertain is not advised.

It is therefore not uncommon to seek a second opinion.

It is a courtesy to let your surgeon know you need this and they may recommend an appropriate opinion for you or this can be done by your GP. Having more than one operating time scheduled is not fair on other patients.

Your GP can provide the required referral letter for the second opinion (the initial surgeon will have sent your GP all the relevant information). You need to ensure you bring to that appointment all the relevant information.

2nd Opinions Checklist:

  • Breast imaging (i.e. mammogram, ultrasound, MRI) reports and films
  • Pathology report from breast needle biopsy and/or breast surgery
  • Previous breast operation reports
  • Other imaging reports (i.e. CT, bone scan, chest x-ray, PET scan)
  • Any previous treatment records, if applicable

These consultations are often more complex and will require more time.

References

Breast cancer: do specialists make a difference? Skinner, K. A., Helsper, J.T., Deapen, D., Ye, W., & Sposto, R. Annals of Surgical Oncology, 2003 Jul, Vol 10(6), 606-15

Effects of specialisation on treatment and outcomes in screen-detected breast cancers in Wales: cohort study. Allgood, P. C., & Bachmann, M.O. British Journal of Cancer, 2006 Jan 16, Vol 94(1), 36-42

Effect of surgical subspecialization on breast cancer outcome. Golledge, J., Wiggins, J.E., & Callam, M.J. The British Journal of Surgery, 2000 Oct, Vol 87(10), 1420-5

Surgeon workload and survival from breast cancer. Stefoski Mikeljevic, J., Haward, R. A., Johnston, C., Sainsbury, R., & Forman, D. British Journal of Cancer, 2003 Aug 04, Vol 89(3), 487-91

The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire’s breast cancer patients. Morris, E., Haward, R. A., Gilthorpe, M. S., Craigs, C., & Forman, D. Annals of Oncology: Official Journal of The European Society for Medical Oncology, 2008 Feb, Vol 19(2), 284-91

Breast Cancer surgery

Surgery for treating breast cancer is aimed at removing the whole tumour with a clear margin of healthy tissue around it. This can be performed by a mastectomy but also the breast can be preserved using oncoplastic surgery techniques.

After surgery for breast cancer 20-30% of women have a residual deformity that may require surgical correction. Patients who are unhappy with the cosmetic outcome of their breast surgery have poorer psychological and social outcomes.

Traditionally trained surgeons without advance oncoplastic training are taught how to remove the cancer, but nothing about the reconstructive or cosmetic approaches to surgery.

What is Oncoplastic breast surgery? 

Oncoplastic breast surgery is a relatively new and rapidly growing field of surgery, and the number of surgeons trained in, and routinely using, oncoplastic techniques in Australia is small but increasing and was initially confined to surgeons practicing in Europe.

Oncoplastic means “oncological” (cancer controlling) and “plastic” (cosmetically pleasing).

Oncoplastic breast surgery aims to achieve good aesthetic outcomes for women with breast cancers who would have unacceptable outcomes with other Breast Cancer Surgery techniques, and in addition, enable breast-conserving surgery for larger breast cancers. Thus, many women who are treated with oncoplastic breast surgery would otherwise have had a poor aesthetic outcome from standard techniques of Breast Cancer Surgery or have been recommended a mastectomy.

For many women, oncoplastic breast conserving surgery offers the best, simplest, lowest risk, and sometimes only option for a good aesthetic and practical outcome of breast cancer surgery.

Generally, breast-conserving surgical techniques fall into four main categories:

  • Simple wide local excision (previously known as a lumpectomy)
  • Therapeutic breast reduction
  • Therapeutic Mastopexy (breast lift)
  • Volume replacement

With overall survival following breast cancer treatment improving, many women will be expected to live a long time with the cosmetic consequences of breast cancer surgery and improving cosmetic outcomes should be one of the main aims of breast cancer surgery.

Empowerment of women to make choices for their cancer surgery improves their psychological well being long after the treatment has finished.

References

Assessment of cosmetic outcome of oncoplastic breast conservation surgery in women with early breast cancer: a prospective cohort study. Adimulam, G., Challa, V. R., Dhar, A., Chumber, S., Seenu, V., & Srivastava, A. Indian Journal of Cancer, 2014 Jan-Mar, Vol 51(1), 58-62

Cosmetic Sequelae After Conservative Treatment for Breast Cancer: Classification and Results of Surgical Correction. Clough, K. B. MD; Cuminet, J. MD; Fitoussi, A. MD; Nos, C. MD; Mosseri, V. M. Annals of Plastic Surgery. November 1998, Vol 41(5):459-463

Does cosmetic outcome from treatment of primary breast cancer influence psychosocial morbidity? Al-Ghazal, S.K., Fallowfield, L., & Blamey, R. W. EJSO, December 1999, Vol 25(6), 571–573

Oncoplastic and reconstructive surgery of the breast. Hamdi, M. The Breast, Vol 22, S100 – S105

Oncoplastic Breast Surgery: What, When and for Whom? Macmillan, R. D., & McCulley S. J. Current Breast Cancer Report. 2016, Vol 8, 112-117

Ms Ruth Bollard 

I trained in the UK at world class internationally renowned breast units in the Oncoplastic approach to treating Breast cancers and can offer more options to patients, which can be less invasive, less expensive, and less traumatic. I also use a Multidisciplinary team delivery of care, which is vital to better cancer patient outcomes and is an important part of my surgical practice.

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