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CLINICAL OBSTETRICS AND GYNECOLOGY Volume 54, Number 1, 85–90 r 2011, Lippincott Williams & Wilkins

Improving Breast Care: Providing, Guiding, Expertise, and Leadership CORNELIUS O. GRANAI, MD, FACOG, FACS* and JAMES W. ORR, JR, MD, FACOG, FACSw *The Warren Alpert Medical School of Brown University, Program in Women’s Oncology, Women and Infants Hospital, Providence, Rhode Island; and w Florida Gynecologic Oncology and Lee Cancer Care, Fort Myers, Florida

Abstract: Optimal healthcare blends timeless doctorpatient values with state-of-the-art medical knowledge. The physician’s role varies from delivering therapies to guiding patients through the healthcare maze to their best decisions. Breast care should not be parceling out of anatomic parts, as if biological relationships do not exist. Instead, it should stem from an understanding of the ‘‘total woman’’—biological and otherwise—and how important that unity is for quality of life, even when confronting breast cancer. Breast fellowships for gynecologic and general surgeons create superior clinicians and better patient advocates — essential in advancing women-centric care and healthcare leadership. Key words: fellowships, breast fellowships, breast cancer, improved healthcare, healthcare change

the complexities of real life make enactment of this simple idea, difficult. The morass of breast care delivery is a case in point. It highlights important medical services that are disjointed, idiosyncratic, and entangled in the politics of medical turfs, rather than care emanating naturally from women-centric priorities as basic as the female anatomy, physiology, and psychology. Whatever its historic explanation, today’s breast care assortment has unintended consequences. One of the most unfortunate is that the ‘‘nonsystem’’ can leave patients, facing life and death decisions, confused, afraid, and feeling alone.1 Ironically, despite the widely available, massive internet search engines of the ‘‘information age,’’ cancer patients and families often feel more overwhelmed than ever, as they desperately try to sort through the reams of online scientific abstracts, conflicting video opinions, and Las Vegas styled institutional web

It stands to reason that medical services would be optimized if coordinated by experts in an organized system that flowed logically. A few would disagree, yet Correspondence: James W. Orr, JR, MD, FACOG, FACS, Florida Gynecologic Oncology and Lee Cancer Care, 8931 Colonial Center Drive, Suite 400, Fort Myers, FL. E-mail: CLINICAL OBSTETRICS AND GYNECOLOGY






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sites flashing dazzling statistics and thinly veiled promises of special treatment options ‘‘only available here.’’ Given the magnitude of what is at stake, and facing such complexity without a professional escort, simply ascertaining where to safely ‘‘start’’ can be paralyzing. Consider the typical woman suddenly confronted with an abnormal screening mammogram. Scared of course, she intuitively seeks the advice of her obstetricians and gynecologists (OB/GYNs). Most OB/GYNs, however, do not manage breast problems. Thus, they refer her to a general surgeon. Frequently, the general surgeon is not comprehensively trained in contemporary breast disease management. Nonetheless, with or without the consultation of a radiologist–let alone the considered input of a Breast Tumor Board– an invasive procedure is often performed. Depending on the final pathology, radiation and medical oncologists are often added to the group. Indeed, the latter may assume parts of further cancer management and some aspects of longterm surveillance. But for the other aspects and for her additional healthcare needs, which often go uncoordinated with her ongoing breast cancer history and risk of recurrence, the patient is left to look elsewhere. In some ways, this fragmented chain of events can sound strangely logical. But if there is a general acceptance, does it come from pride or complacency? Do we truly believe that our current breast care consistently uses the best therapeutic strategies for each patient’s specific circumstances, while it also meets each patient’s overall needs as a woman? How can we determine the answer? Asked differently, how can cancer care effectiveness be judged? Letting the statistics speak, which seems to be the obvious solution, and, in that, high-profile data, such as ‘‘the 5-year survival rates’’ have become the parameters by which cancer treatments are often ‘‘objectively’’ compared. Maybe

so, but although it is frequently touted as supporting the status quo, does the relatively greater 5-year survival of breast cancer patients–or any other statistical parameter for that matter2–validate our current breast care as being the best it can be? Obviously not and nothing can, but considering various outcome measures as part of a broader context that inspires continuous improvement, is worthwhile.3 Deferring an appraisal of clinical management per se, an assessment of how breast care services are currently administered readily finds deficits, including what might bureaucratically be termed ‘‘inefficiencies’’ and ‘‘misdirections.’’ Patients, however, may experience these administrative flaws more personally, as chaotic, cold, and uncaring. For example, because of their understanding of the female patient, OB/GYNs are often the physicians who are first consulted for breast problems. Their holistic perspective is important to be sure,4 but typically OB/GYNs are ill trained in breast management, and thus are unable to contribute clinically, or even to aid by supportively escorting the patient through the process. This void is disconcerting to patients and inefficiently forces them to pursue alternative expertise, which is not necessarily easy to find. In the changing, highly nuanced data of breast oncology, finding a general surgeon, medical oncologist, and radiation oncologist who is up–to date with special expertise in breast cancer is difficult enough, but finding such specialists, who also have expertise in female wholeness and quality of life, is more difficult as of now. The frenzied search leaves patients with breast cancer wondering: who is my real doctor and do they fully understand and care about what I am going through? And it begs doctors to ask of themselves, what philosophic, educational, and organizational changes can be made that would result in better care for the whole woman with breast disease, from

Improving Breast Care diagnosis through long-term follow-up? And, overall, where is the leadership to make this happen now and going forward?5 Optimal care depends on many ingredients. Possibly the most important is for physicians to have knowledge, expert skills, and a patient-centered passion to prevail. Fundamental to treating breast disease, is an understanding how profound breasts are in terms of a woman’s physiology, self-image, sexuality, and basic well being. As universally depicted in art, breasts have been a defining form of female beauty and a symbol of female nurturing behavior. Although the status of women in society has changed over time, the imagery and culture linking womanhood and breasts continues. It follows then, that just as society places breasts in a special status, breast diseases are also accorded a distinction that is separate from other organic diseases. The medical concerns unique to women, such as those of breast disease, present health care with special clinical and social challenges. Complex in nature, those needs are more likely to be fulfilled by specifically trained care teams, working in environments dedicated to women,6 just as children with diseases are best cared for in environments specifically dedicated to children. The benefit coming to children from ‘‘children’s hospitals’’ is not solely the result of the institution’s greater familiarity with childhood illness. It also derives more broadly from the institution’s child-centric environment, intentionally created to address the uniqueness of kids that underlie the quality of their experiences.7 Similarly, womenspecific environments can be created that bring meaningful improvement to the healthcare experience of women, even if the value is mathematically unmeasurable by standard ‘‘quality’’ statistics. As mentioned, many women in the United States intuitively look to OB/ GYNs as their primary women health


resource, particularly as relates to ‘‘female organs.’’ The trust implicit in the OB/ GYN-patient relationship was earned over many generations and remains today. But what was once a clinical discipline that could be fully mastered is no longer so. The explosion of medical knowledge has made the romantic notion of the all-knowing doctor, even as concerns ‘‘just’’ the female organs, long since impossible. The necessity for further (AKA ‘‘sub’’) specialization has been true across all medical disciplines, of course (and it’s not likely to diminish).8 Consequently, the modern day fulfillment of the physician-patient relationship has, at times, shifted from a metaphor of ‘‘all knowing and all treating’’ to one of ‘‘connection and shepherding.’’ With serious illness, such as breast cancer, patients can not find all they need from a single physician; but, while patients make all final decisions, they need and deserve knowledgeable guidance through the complexities of the disease and the confusing means by which its care is provided—that ultimately they come to sincerely understand their best medical options, and are then supported in their choices. The historic service of social workers and the more recent use of ‘‘nurse navigators,’’ are examples of such patient-centered efforts. Nevertheless, physician leadership is the irreplaceable core, essential for having the best possible healthcare. Patients and society depend on doctors in that central role. Thus, despite the many intended-or-not obstacles impeding optimal breast care, for the sake of patients, physicians must again stand and prevail. This can mean generating the will to take on difficult political battles, inside and outside organized medicine. It can also mean changes in how physicians serve, sometimes providing, sometimes guiding, but always championing and advocating.5 One tangible action that can be taken is to train physicians who are specifically committed to improving breast care and


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women’s health. Another is having each ‘‘breast case’’ presented, prospectively, to a Tumor Board consisting of multidisciplinary, subspecialty trained, experts, focusing on breast cancer (A.K.A. the science of medicine)–without losing the broader perspective including organ systems, endocrinology, sexuality, and quality of life (A.K.A. the art of medicine).9 Unfortunately, the intuitiveness of the general public’s search for breast cancer care was not mirrored in how American medicine evolved its care delivery. Unlike our European colleagues who sensed the natural role for gynecologists, for reasons more likely related to medical politics than common sense, in the United States, treatment of breast disease was largely assumed by general surgery, thus came under it’s somewhat generalist philosophy. This amounted to breast care being based on a geographic parceling out of ‘‘anatomic parts’’ or ‘‘skin appendages’’ that disregards the unique biological and personal unity of breasts with the entire female reproductive system. Women (and men) naturally sense the importance of ‘‘the whole’’ and it’s why they look to OB/ GYNs for help—and it is why OB/GYNs and their subspecialties need to deepen their knowledge in breast care if they wish to remain central and relevant in women’s health. Improving breast care requires better training on all fronts and disciplines, and formally developing physicians/leaders with indisputable credentials and expertise as well. Considering the vast scope of practice, general surgery has claimed–in both sexes no less–and considering the major time demands it would require to be on the leading edge of merely a portion of that domain, the practical reality is that general surgeons, per se, cannot be the stand-above leaders of breast disease if they simultaneously serve the historic dimensions of their specialty. In recognition of this impossibility, postresidency training programs have been initiated to

cate surgeons more completely in breast disease and encourage their long-term interest and leadership. The Society of Surgical Oncology (SSO) has created an excellent breast fellowship curriculum imposing significant standards for completion. However, enthusiasm for this educational endeavor has not been universally shared within General Surgery; to wit ‘‘breast fellowships’’ remain unrecognized by the American Board of Surgery. This seems to imply that the national leadership of General Surgery believes that their basic residency alone is qualifying for the status of ‘‘expert’’ in breast disease. If so, that stance would be difficult to square with the pace of the scientific, medical, surgical, technological, indeed political change occurring around breast cancer and the thresholds of ongoing experience, teaching, and research needed to remain best. By common sense–supported by empiric experience from all walks of life– if individuals have additional, focused training in a defined area, and then committedly work in that ‘‘narrow’’ area, they will be relatively better in that type of work than others less specially trained and more broadly engaged. Other factors come into play as well, of course, including talent and passion.1 But extra training, coupled with a high volume and ongoing experience, is hard to beat for creating and maintaining superiority.10,11 Surgery and disease management are not exceptions to this truism. Just as surgeons and institutions that do more cardiac surgery generally have better outcomes,12 critical volumes of oncology care provided by special experts bring similar improvements. In comparison with their generalist colleagues, fellowship-trained breast surgeons have more experience and a deeper understanding of the possibilities for women with breast disease.13–15 This ‘‘extra’’ makes it possible for fellowship-trained physicians to become the here to for lacking, central connection,

Improving Breast Care breast experts, who, in addition to providing aspects of the direct patient care, can also fulfill the role of ‘‘shepherd’’ through care and follow-up. Fellowship training also helps surgeons become better educators, researchers, and the leaders of the multidisciplinary oncology teams, themselves needed to continually evolve the best cancer care. As is so of our General Surgery colleagues, gynecologists and gynecologic oncologists are excellent surgeons themselves. The unique medical and philosophic foundation of obstetrics and gynecology forms an unparalleled starting point for providing improved breast care. The above-mentioned SSO fellowship, recognizing that both general surgeons and gynecologic oncologists are worthy candidates for their educational programs, is a major step in the right direction of better patient care and teams. But the value and ability of OB/GYN surgeons overall, also provides a pool of worthy fellowship students whose proven passion for women’s health could make a meaningful difference. Similar to the SSO, the American Board of Obstetrics and Gynecology and its Division of Gynecologic Oncology, the Society of Gynecologic Oncologists, and the American College of Obstetrics and Gynecology are all committed to improving breast care and have stepped forward to provide increased breast cancer education for its fellows and members. Each of these actions has positive implications for the health of women and they serve as a model and inspiration for improving care overall.

References 1. Grady D. Cancer Patients, Lost in a Maze of Uneven Care [NY Times web site]. July 29, 2007. Available at: http://www.nytimes. com/2007/07/29/health/29Cancer.html 2. Ho V, Aloia T. Hospital volume, surgeon volume, and patient costs for cancer surgery: a case report. Med Care. 2008;46: 718–725.


3. Hillner BE, Smith TJ, Desch CE, et al. Hospital and physician volume of specialization and outcomes in cancer treatment: importance in quality of cancer care: a case report. J Clin Oncol. 2000;18: 2327–2340. 4. Parker WH, Broder MS, Chang E, et al. Ovarian conservation at the time of hysterectomy and long-term health outcomes in the nurses’ health study: a case report. Obstet Gynecol. 2009;113: 1027–1034. 5. BuckII DW, Brittner JG IV, Hayanga JA, et al. Preparing surgeons for a seat at the health care policy table: a proposal for a longitudinal health care policy curriculum during surgical training: a case report. Am Coll Surg. 2010;95: 21–26. 6. Bentrem DJ, Brennan MF. Outcomes in oncology surgery: does volume make a difference. World J Surg. 2005;29: 1210–1206. 7. Adams A, Theodore D, Goldenberg E, et al. Kids in the atrium: comparing architectural intentions and children’s experiences in a pediatric hospital lobby. Soc Sci Med. 2010;70: 658–667. 8. Glazer J. Specialization in Family Medicine Education: Abandoning our Generalist Roots [AAFP web site]. February 2007. Available at: fpm/2007/0200/p13.html 9. Kuroki L, Stuckey A, Hirway P, et al. Addressing clinical trials: can multidisciplinary tumor board improve participation? A study from an academic women’s cancer program: a case report. Gynecol Oncol. 2010;116:295–300. 10. Chowdhury MM, Dagash H, Pierro A, et al. A systematic review of the impact of volume of surgery and specialization on patient outcome: a case report. Br J Surg. 2007;94:145–161. 11. Halm EA, Lee C, Chassin MR, et al. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature: a case report. Ann Intern Med. 2002;137: 511–520. 12. Chen CS, Liu TC, Lin HC, et al. Does high surgeon and hospital volume raise


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the five-year survival rate for breast cancer? A population-based study: a case report. Breast Cancer Res Treat. 2008; 110:349–356. 13. Nattinger AB, Laud PW, Sparapani RA, et al. Exploring the surgeon volume outcome relationship among women with breast cancer: a case report. Arch Intern Med. 2007;167:1958–1963.

14. Stefoski Mikeljevic J, Haward RA, Johnson C, et al. Surgeon workload and survival from breast cancer: a case report. Br J Cancer. 2003;89:487–491. 15. Zork NM, Komenaka IK, Pennington RE Jr, et al. The effect of dedicated breast surgeons on the short-term outcomes in breast cancer: a case report. Ann Surg. 2008;248:280–285.