Surgeons and Sex

Well, here's a new one: it's reported that women who have lumpectomy for breast cancer are more likely to have radiation therapy afterwards if their surgeon is female. Once again, I'm stumped. As a surgeon of the scrotumnal sort, I'm trying to figure it out. In the article, you'd see the differences weren't huge; and that there were other independent characteristics which seemed to matter at about the same level: that the surgeon was an MD, and that s/he was US-trained. (Chauvinistic in ways other than sexual, I'm not surprised by those two.)

It's hard to imagine any properly-trained surgeon who doesn't know of the need for adjunctive breast irradiation after lumpectomy. As always, there's room for some judgment: from a few very elderly and frail women I've removed a cancerous lump under local anesthesia and elected -- fully consulting with patient and family about options -- simply to follow along with no other treatment except, for some, hormone therapy. But the study is said to have controlled for age and other factors. So what can it mean? Are female surgeons more interested in saving the lives of their patients than males? Is it that we males prefer the feel and look of uncooked and unbrowned breasts (truth be told, I've heard it said more than a few times that the irradiated breast is preferred by its owner, because of youthful firmness)? After a night of carousing and piggish behavior, did the menfolk sleep through the lecture on complete breast treatment?

Maybe it's patient self-direction: women who don't want "all that fuss" (ie, radiation) gravitate toward male surgeons. It could even be, I suppose, that males are more open to modifying treatment for the frail and very elderly to whom I referred above. Or maybe it's about the age of surgeons: could older ones not be up to date? I doubt it; but if it's true, there are a lot more old male surgeons than female ones, since the demographics have only somewhat recently shifted toward the ovarian model.

At the end of the article it's stated that more work is needed to figure it all out. Meanwhile, it has me mystified. In most ways I think women are more admirable than males. Still, I'd hate to have to hang my nuts on a nail to practice my craft.

A Step Forward

(This is one of several posts I wrote in the last few weeks, but never published, for a variety of reasons.)

In an ideal world (or, it could be said, a well-designed one) there'd be no cancer. Failing that, we'd have perfect treatment: one that destroyed every bit of cancer with no damage at all to normal cells and organs. That is at least imaginable at some point in the future. Even the not-too-impossibly-distant future. Meanwhile, we're stuck with imperfect treatments and we lack the ability accurately to determine who needs how much; who will get along just fine without extensive treatment (and, for that matter, who will succumb even with maximal therapy.) Recently there was news about some progress on that front.

As a surgeon who dealt extensively with breast cancer, I can say one of the most frustrating categories has been the entity known as DCIS, or "ductal-carcinoma-in-situ." It refers to the earliest possible form of breast cancer, wherein the abnormal cells are confined to the inside of the milk-ducts; as such, because it hasn't invaded across any blood or lymph vessels, it presents no danger at all, as long as it stays in that stage. A very rare diagnosis only a few decades ago, it's become increasingly discovered as mammography is more widely done and is of better and better quality. And it's become a therapeutic dilemma: how much treatment -- and what sort -- is necessary for this entity, not dangerous in itself but which has the potential to become so? As DCIS has been more and more frequently dealt with, it's become apparent that not all forms are of equal potential: some women who have it will never develop invasive cancer; others will. And whereas it's still not universally agreed what treatments are indicated for which types of DCIS in what sort of women, it looks like there's progress toward figuring out which women need treatment, and which don't. That's a good thing.

At a national meeting in San Antonio, a recently published paper was reported (by researchers at UCSF, where I learned to be a surgeon) showing that molecular markers have been discovered which can be used to predict when a given woman with DCIS will go on to develop invasive cancer, and which won't. As is the case with early results, confirmation is needed and the testing is not yet widely available. Still, it strikes me as a really significant finding -- one which will lead to much more precise decision-making, conferring confidence on both sides of the equation. Women who need treatment will really need it, and those that don't can safely be excluded. I hope it turns out to be the case; and I wish I'd had such testing available when I saw all those women, all those years.

The Old Man and the C

I expressed this particular opinion on another medical site, and was -- gently -- told I was an old guy, of a generation that was out of touch. It could be true. But having treated many hundreds of women with breast cancer (I lost count a long time ago) and having been (so I was told) more sensitive to the horror and fear than the "typical" surgeon, I feel qualified to express myself. My thoughts are based in the reality I saw in my practice. So here it is: though not opposed, and having participated in many cases of it, I'm not a big fan of immediate breast reconstruction after mastectomy.

As I recall, the thread in which I commented on that other site was regarding yet another study showing that surgeons had a poor record of offering reconstruction to their mastectomy patients. Of that I was never guilty. I think it's wonderful that it's available. It's a timing thing, to me. To my patients undergoing mastectomy, I always brought up breast reconstruction; among other things, I made sure they understood it was not considered "cosmetic," and was (by law!) covered by insurance. I discussed both immediate and delayed reconstruction, and did not try to talk women out of the former choice if that's what they preferred. But I was glad when they didn't. At the risk of being misunderstood, let me try to explain.

The blanched face, the terrified glaze of the eyes, the tears. The jumbled words cascading past a trembling jaw, the grip of hand upon hand, fingers compressed white and shaking. Witnessing thoughts tumbling almost visibly through the mind, randomly, out of control, one, two, three after another, splashing through pools of panic. Endlessly, I've seen it, over and over, to the point of hating it above all, to the point of looking at my schedule and feeling a physical tightening in my gut when I saw such a consultation there. That's the reality in which such conversations take place. No matter how carefully, how gently or insistently; despite taking time, providing reassurance that we can deal with it, handing out personally-written booklets; my attempt at informing, explaining, supporting the woman and her family to whom I give the news often feels futile, as I try to breach the wall of stunned disarray.

Mastectomy is always a treatment option for breast cancer. As understanding has evolved, it's uncommon that it's the only one. By far the majority of women undergoing treatment for breast cancer have the option of breast preservation, via lumpectomy and radiation therapy. For reasons I've dealt with before (here, plus 1, 2 , 3 , 4 following), some choose -- or need -- mastectomy. More than any other cancer, I'd say, there are branching decision trees to be understood, choices to be made: lumpectomy vs. mastectomy, how and where radiation fits in, when and what kind of chemotherapy is used, the need for lymph node sampling, when and if full axillary dissection would be used instead of or in addition to sentinel node biopsy. And for women who will undergo mastectomy, the issue of prosthesis vs. reconstruction: what type -- among many varieties -- and when. It's a lot to assimilate.

So my first concern is simply about overload: the need to wade through an enormous amount of information and sort it all out, at a time when you are bordering on panic. In the midst of that, adding another very thick layer of fog, requiring visits to a plastic surgeon and the full consideration of several very different options, making a realistic decision about reconstruction seems, sometimes, like piling on. First things first. Let's focus all our energy on getting through the cure. Let's know that this option awaits, and be reassured by it; and get back to it later.

I suppose that sounds condescending. Poor little women, can't handle all that stuff. Hardly. Women are tough as nails. They have to be. And let me say again: I've always brought up, and haven't tried overtly to steer women away from immediate reconstruction. (Does my mind-set affect the outcome? Could be, in some cases.) But condescension (if that's what it is) cuts both ways. At least one famous female surgeon used to go around the country claiming that the only reason mastectomy was invented was because men like to mutilate women. And, by inference, a woman who'd choose it, and not have reconstruction, was somehow succumbing to that mindset. Mastectomy is mutilation. But how one responds to it is -- and ought to be -- very individual. The time, it seems to me, to decide about reconstruction is after the enormous stresses of facing the cancer are dealt with. Many major centers publish with pride that immediate reconstruction is their standard of care, their treatment of choice. I can't help but think that many women are pushed (is that too strong a term?) into it when they'd rather just take their time.

Depending on the method, breast reconstruction is a very big deal. The operation can take several hours, and may subsequently require a couple of much smaller touch-ups. Clear-headed choice is mandatory. And here's a related issue: lying in an operating room for another four hours -- turning a forty-five minute operation into a five hour one -- anesthetized, then having one's body deal with all the required healing, while asking the body also to deal with as yet not-fully-treated cancer seems physiologically iffy. I know of one study that found no average delay in starting chemotherapy for women undergoing immediate reconstruction, and that's good. What haven't happened yet -- and likely won't, for practical reasons -- are studies that randomize women into immediate versus delayed reconstruction and follow for several years to evaluate any effect on long-term cure, segregated by stage at diagnosis. It'd be important, I'd think. Related are the delays from diagnosis to treatment that come with the need for arranging the consults and coordinating operating time. Maybe centers who promote immediate reconstruction have streamlined that part.

I don't for a second minimize the psychological effect of mastectomy. I've seen it. I know it. I've practiced through the times when reconstruction was not available; when it was technically disappointing, and when it became cosmetically fabulous; when it was done only later; and now, when it's done at the time of the mastectomy. In the pre-immediate days, I've had many patients who were very relieved to know reconstruction could be done yet who, when the time came, said they were surprised at how comfortable they were with their status and chose not to have reconstruction. (Prosthetics have also come a long way: some adhere directly to the chest so they don't need a special bra; they have lifelike texture and coloration; their nipples show through flimsy bras, if you like that sort of thing.) The numbers weren't small. From that fact, I infer that many women, under the stress of the initial diagnosis, are "encouraged" into a very big surgical deal when, given time, they'd have opted out. One can argue both ways whether that's a good or a bad thing.

Psychological well-being and body image are the bottom line issues (assuming -- which we can't quite -- no impact on survival). Studies make it clear that reconstruction serves the purpose very well, and argue for immediate reconstruction. Yet it's not simple: the "baseline" evaluations of immediate reconstruction were done in women not yet treated, who had no basis for knowing what mastectomy would be like for them; those of the women who underwent delayed reconstruction had already had mastectomy. The measured improvements were less in those with delayed surgery; but they'd had time to adjust and, in effect, raise that baseline.

I'm no crusader here. I neither expect nor desire to change minds. Recognizing that it's not clear-cut, rather than pushing a particular approach, I favor being sensitive to the individual; having feelers out to intuit what the woman sitting in front of me needs. But it appears that there's now a trend in a single direction, and that it's generated in academic centers -- the very places where, in all things, more is more. (If there's a more complicated means to an end, they find and promote it. Kidding [?]) Based on my experience, it's a steamroller for at least some women, generating what may be unnecessary anxiety and commitment to a very laborious and expensive process; forcing a quick decision at a time of great vulnerability.

When I've been asked my opinion, I've given it. When from behind those glazed eyes, from obviously overwhelmed minds the words are formed, "What do you think, doctor? Should I have reconstruction right away?" I've usually said something like this: "I have no problem with it if that's what you want to do. But if you don't want to have to decide now, you will always have the option, any time, down the road. Let's set up a consultation with a plastic surgeon if you like, to hear what's involved. But for now, let's go about curing breast cancer. Let's get all that over with, and when you're recovered, feeling good, strong, we'll take that one on and sort through the options." It's self-selecting, I'm sure: if they're asking, they're hesitant. But generally, when they hear that, a quantum of tension is dissipated, the grip relaxes, and you can sense a bit of relief fill the room.



Addendum: I'm well aware that most plastic surgeons prefer immediate reconstruction, because they don't have to deal with scar tissue. It's easier. Many claim better cosmetic results (I've seen it both ways, and -- at least with tissue-transfer techniques such as TRAM flap -- can't tell the difference. Both look great, usually.) Frankly, I think their ease is part of the push for immediate reconstruction, and I'm not sure it ought to be. Patient satisfaction is another issue, and like the whole subject is iffy and tricky and subject to claims of being patronizing. Recognizing the impossibility of accurately measuring such a thing and to subject it to a meaningful prospective study, I've heard opinions expressed on both sides of the issue by plastic surgeons. Some say that comparing a reconstructed breast to the "real" one -- which is what happens with immediate reconstruction -- has a higher chance of disappointment than when it's compared to having lived with mastectomy for a time. I'd welcome comments from my occasional plastic surgeon readers. And here is an example of what we're talking about, from the right side of the bell curve:

Surfing for Science

Google has changed healthcare delivery. Once a rarity, it's now common that patients sitting across from their doctors are primed with lots of information, largely downloaded. Medicine is not unique in this, nor is it a bad thing: if you take the time to find out dealer invoice before your automobile purchase, surely you ought to inform yourself about your gallbladder. A good doctor considers it an essential part of the relationship fully to inform a patient, whatever the subject. Eschewing the cookbook pre-packaged booklets available for most surgical problems, I wrote my own, developed a few handy visual aids, and spent as much time as it took to educate those entrusting to me their care. In general, I liked it when they came to me already well-informed. Well-informed. It won't come as a surprise, however, to learn that many had filled their heads with crap.

The internet, while a most remarkable source of information on every imaginable subject (and some I could never have imagined), is also an equal-opportunity fount of bullshit. Debunkery is not my mission here: others (notably Orac, who regularly and brilliantly [and respectfully!] skewers medical mendacity) do it much better than I ever could. My point is that as much as I want to inform and educate and answer all questions, it's more than irritating to have to admire a jar of stool proudly produced to show the "dissolved gallstones" resulting from a snake-oil recipe googled and then gobbled. Knowledge, as they say, is power. Misinformation kills. Failing that, it annoys.

I still haven't gotten around to posting on the subject of the gallbladder, the surgeon's best friend. I will, I will. In the interim, I can report that whereas taking lemon juice and vegetable oil, along with some herbal flavorings, can produce some sort of curdled mess that becomes indigestible enough to burble out the backside in lovely little lumps (say it out loud: it's fun), it does not a damn thing to stones in the gallbladder. I guess there's no real solution to the problem of disreputable downloads: at least they're asking me about it, as opposed to going off on their own. On the other hand, I'm not seeing the ones I'm not seeing.

In that most non-existent "best of all worlds," doctors would be entirely worthy of trust, and trusted. How nice it would be if medicine had all the answers, I knew them, and perfectly shared them. How excellent if people could happily, confidently, and realistically leave everything to their doctors, could feel they needn't arm themselves with data before the consultation. They can't, of course; and shouldn't. You'll never hear me argue that doctors have god-like omniscience, or that patients should just shut up and take what we dish out. I'm well aware of doctors who are poor communicators, and/or who (amazingly enough, in this modern world) still take a very condescending view of patients and their need for information. And yet, one wonders: is there a limit, an end-point? When does patient advocacy become an impediment to the necessary rapport between doctor and patient? How much information is too damn much? Unsurprisingly, I don't have the answers. I do, of course, have opinions. Feelings. That's the kind of guy I am.

At the extreme, I've had patients bring "advocates" to the office. Steely-jawed, humorless, with an "I've got your number, buster" look and an ostentatious finality, they've produced tape-recorders and planted them on my desk. "Now just try to bullshit us, you self-satisfied doctor, you. You establishment dick. We know about guys like you, and you're not getting away with it..." Or so it seemed. I'm a garrulous person, but that's sort of a show-stopper. I've also seen the glazed look of information overload, at a time when it's least welcome. Breast cancer is the prime paradigm, applicable as an example in both of the preceding situations.

"If your surgeon recommends mastectomy," it's been said, "find another surgeon." "No woman ever again needs to lose her breast," has been written and read, widely. And it's absolutely untrue. But tell the woman who has extensive high-grade DCIS that she ought to have mastectomy, and you might see her get up and leave. (Not really, in my experience. But it takes a long time to explain why what she'd heard is, in this fairly uncommon situation, wrong. Having watched her initially recoil at the information.) Conversely, try to enumerate all the options of primary treatment in the usual circumstances; explain the role of radiation and chemotherapy, and the types of each; the kinds of lymph node procedures, the different forms of mastectomy. List all the options for reconstruction, starting with immediate versus delayed, and get into the operative choices once that decision is made. As you watch the mind sizzle, you want nothing more than to say "here's what I think you should do, and here's why." In fact, it's not rare to be asked to do just that. Choice, it turns out, and abundant information can be -- for some people -- more than they want to handle.

I've always thought it a cop-out for a doctor to give a patient a list of options and then mutely leave the decision to her/him. Part of our job, I think, is to say what we think should happen, and to explain exactly why, yet to do it in such a way, when there are several options, that doesn't close the door to patient preference. Instinct sometimes tells me that this person or that needs more, or less, information. This person wants direction; that one doesn't. It's a subtle and somewhat mystifying thing: how different the relationship can be. But this part isn't mysterious: when there's a tape-recorder whirring on my desk, I'm highly inclined to do the list thing, and say, "let me know if you need more information, or if there are other ways I can help you with your decision.... Next."


Addendum/Update: I suppose I should clarify. This isn't really about the wisdom recording your doctor visit. I understand the desire to do so in order to remember what was said, and when I've had patients ask if it was ok, I always said yes. Likely I'd also mention I'd be giving them self-written booklets that would serve the purpose as well. In the cases I mentioned above, it was an in-your-face I-don't-trust-a-thing-you're-about-to-say encounter, initiated not by the patient but by a gun-slinging sidekick. Different animal.