Susan is a 40-year-old woman with a breast lump. Unfortunately, Susan’s biopsy revealed that the lump was indeed breast cancer, and she is going to need treatment. Although several health care professionals will be involved in her care and treatment, as with most women diagnosed with breast cancer, Susan will start by seeing a breast cancer surgeon. She feels comfortable about the cancer center she was referred to, but how will she know which surgeon to go with?
An important decision facing patients with breast cancer is how to decide upon a surgeon. Studies have indicated that the quality of initial breast cancer surgery has a dramatic impact on all subsequent breast cancer care as well as overall clinical outcome. Given the importance of high quality breast surgery, I want to share some tips and resources to help patients get the most out of their breast cancer surgeon.
Start with a certificate of quality: Board certification is an important initial credential to look for in a surgeon. Surgeons who are board-certified in a surgical specialty have successfully completed the required number of years of residency training and have demonstrated a certain level of knowledge and competence by successfully completing a rigorous examination process. Most surgical boards now require surgeons to demonstrate ongoing education and quality monitoring through a process called maintenance of certification. This helps to ensure that your surgeon is committed to lifelong learning.
You should consider choosing a surgeon who has obtained and maintained board certification in their specialty. For breast cancer surgeons, the appropriate certification is through the American Board of Surgery. For reconstructive surgeons, the appropriate certification is through the American Board of Plastic Surgery. It is important to note that the term ‘cosmetic surgeon’ does not in itself imply any board certification, as there is no approved board of ‘cosmetic surgery.’ Certification through the American Board of Plastic surgery applies to both reconstructive and cosmetic surgical procedures.
The right fit: In his best-selling business book ‘Good to Great,’ Jim Collins describes how leaders of great businesses recognize the importance of having the right people on the team as a key factor of success. Answering the question of ‘who’ sets the stage for everything else. A similar parallel exists for getting the most out of your breast cancer surgeon. It is important to have a surgeon who not only has the appropriate qualifications, but who is also a good fit for your preferences.
Of course word of mouth is great, and getting a good recommendation about a surgeon from a former patient can be reassuring. However, this is not always possible, and one person’s experience may not predict your experience. Some patients prefer a surgeon with a more casual, easygoing personality while others prefer a surgeon who is more frank and gets straight to the point. Whether your primary care provider has recommended a surgeon or you decide to select one on your own, it’s important to make sure you have the right surgeon for you. If you feel you don’t have a good fit, you can always consider a second opinion.
Membership has its benefits: The American College of Surgeons is a scientific and professional organization of surgeons dedicated to quality in the care of the surgical patient, and does so by setting high standards for surgical education and practice. Surgeons who are approved members of the American College of Surgeons are designated as a ‘Fellow’ of the college.
Being a Fellow of the American College of Surgeons indicates that a surgeon’s education, training, professional qualifications, surgical competence, and ethical conduct have passed a rigorous evaluation, and have been found to be consistent with standards established and demanded by the American College of Surgeons. Many surgeons will display the letters FACS after their name to indicate their status as a Fellow of the American College of Surgeons, and/or mention list their membership as a Fellow of the College in their bios.
Experience matters: The more someone does something, the better they tend to get at it. It generally helps to look for a surgeon who does a large number of breast cancer cases to help ensure quality. Research suggests that surgical outcomes tend to be better when surgical volume is highest. In fact, recent studies demonstrate that high volume breast cancer surgeons had fewer complications and greater cancer-related outcomes compared to low volume surgeons. Of note, survival after breast cancer surgery was significantly associated with high volume surgeons. This may in part reflect that high volume surgeons tend to work in high volume centers offering patients the latest evidence-based treatments and clinical trials.
As a general tip, if a surgeon is not performing your specific operation at least every few weeks, you may have reason to consider whether a more experienced and practiced surgeon might lead to a better outcome. Surgical volume may be inferred by looking at the nature of their practice. For example, do they work at a breast cancer center; are they part of the dedicated breast cancer team? You can also take the more direct approach and consider asking your surgeon how many of this operation did they perform in the past year. The bottom line is that a surgeon who performs a lot breast cancer procedures will most likely be a better choice in the management of your breast cancer than one who does very few.
It’s all about relationships: There is an old question that asks whether it is better to have a highly skilled surgeon or one with a great bedside manner. The truth is that these qualities are not mutually exclusive and the best option is to have both! I’ve always been impressed with surgeons who take time to speak with patients and families, listen to their concerns, and incorporate their priorities into the surgical treatment plan. The physician and patient establish a relationship of mutual respect and participation.
Sadly, studies show that despite the availability of existing decision-making tools, many breast cancer patients seem to lack knowledge about their diagnosis and are not meaningfully involved in treatment discussions or asked their preferences regarding the approach to treatment. It is interesting to note the research which demonstrates that patient satisfaction is not associated with the receipt of any one particular surgical treatment option, but rather on achieving the desired level of involvement in the decision-making process.
Therefore, the purpose of shared decision-making in breast cancer surgery is not to steer treatment decisions to a presumed best choice, but rather to ensure that patients receive the care they actually want in situations where there is more than one choice among treatment options. Of course it is still fine to seek the surgeon’s opinion in treatment or to prefer the surgeon to take a more authoritative role in decision-making. It is all about personal preference, and it is good to have a surgeon who meets your style preference or who can be flexible to your needs.
Don’t be afraid to ask questions: One of the duties of a surgeon is to inform patients about their diagnosis and the available surgical options. If you have lingering questions and feel that you need further explanation then you have every right to ask your surgeon additional questions so that you are satisfied that you have the information you require. Sometimes questions may arise after you leave the office and these can be addressed with a follow-up phone call to the office, email if your surgeon communicates with patients that way, or another scheduled visit if necessary. Try not to have an over extensive list of questions that turns the office visit into an interrogation of your surgeon as this may interfere with having an open dialogue and productive discussion about your surgery.
As a guide to help patients in this dialogue, the American College of Surgeons provides a list of ten questions that patients can consider asking their surgeon before an operation.
Questions to Ask Before Having an Operation
- Why do I need this operation?
- How will the operation be performed?
- Are there other treatment options, and is this operation the best option for me?
- What are the risks, benefits, and possible complications for this operation? Will my health history and the medications I am currently taking mean the risks, possible complications, and benefits will be different for me?
- What are my anesthesia options?
- What kind of anesthesia is best for me considering my health history, the prescription medications, and vitamins/herbs I take?
- How will I be monitored during the operation?
- What can I expect before the operation?
- Will I need any special preparation – tests, blood donation, blood thinners, or change in my routine medications?
- Will I need any special diet?
- When do I have to stop eating and drinking?
- Should I take my home medication on the day of my operation?
- What can I expect for my recovery in terms of treatment, medication, diet, and home care?
- What type of care will I have to provide for myself at home?
- When will I be able to return to my regular activities (work, lifting, driving, and exercise)?
- Will I need any medication—antibiotics, pain medication?
- What can I do to help with my recovery?
- Could you tell me about your experience with this operation?
- Do you perform this operation regularly?
- What is your success rate, and how often do your patients experience any problems?
- Are you board certified?
- Are you a member of the American College of Surgeons?
- How can I contact you if I have more questions?
- Is the surgical facility accredited and properly staffed?
- How much will the operation cost me, and what type of insurance do you take?
- I Need and Operation. . . Now What? Russell, TR. American College of Surgeons. Chicago, IL. 2008
Be prepared: It is important to do your research. Knowing something about the various options with breast cancer surgery means that you can have a meaningful conversation with your surgeon. Many surgeons appreciate a well-informed patient to work with them as a team rather than a passive bystander.
- Bring a list of your medications, allergies, medical conditions, prior surgeries and family history. This will help the surgeon go through these important items quickly and allow more time to discuss your surgical care.
- Bring a friend or family member to take notes and to act as a second pair of ears. It is also helpful for that friend or family member to be present during the surgical consultation if they will be the one helping you at home after surgery. You and/or your friend should also bring a note pad to write down the information being discussed.
- After the visit ask for any handouts, written information or web sites recommended by your surgeon.
- Know what to expect after surgery and be sure to call your surgeon with any problems after your operation. I’ve been surprised with some of the post-surgical care issues that patients try to handle on their own instead of simply calling the office to have us address. Call your surgeon as soon as you suspect there may be a problem. It is much better to have your surgeon’s office or clinic nip a potential problem in the bud 9 AM on a Wednesday morning rather that waiting until 7 PM on a Friday night after the clinic/office is closed and the problem now requires you to go to the emergency department.
Final thoughts: In summary, getting the most from your breast cancer surgeon is important not only for your comfort and satisfaction with the surgical treatment process, but also for your immediate and long term breast cancer outcomes. Choose a surgeon based on qualifications, volume, and relationship. Ideally your surgeon should be a certified specialist with experience in breast surgery, working in an accredited center of excellence within a defined multidisciplinary breast cancer team. The surgeon-patient relationship is an important one and you deserve to have the right fit as you go through the treatment journey.
Ted James, MD, MS, FACS, is a surgical oncologist and Director of the Skin and Soft Tissue Surgical Oncology program at the University of Vermont Medical Center. He also serves as Vermont State Chair for the Commission on Cancer and is an Associate Professor of Surgery at the Larner College of Medicine at UVM.