Vocapedia > Media > USA > NYT > Illustrations > 2008-2009

Loren Capelli

Letters

Who Should Treat Breast Cancer?

October 18, 2009
The New York Times

To the Editor:

In “Wanted: Mammologists” (Op-Ed, Oct. 10), Ann V. Bell, Mark Pearlman and Raymond De Vries argue that women with breast cancer need doctors “devoted to shepherding them through surgery, therapy and healing.” But introducing a “mammologist” would create yet another specialist to whom generalists would refer patients.

Mammologists would not necessarily reduce communication errors, which are often institutional issues. Besides, many women use a family doctor, internist, physician’s assistant or nurse practitioner as an initial care provider.

Coordination of care is a high priority, but why not turn to multidisciplinary breast care centers that can, in a single visit, marshal the expertise of subspecialists and ancillary services?

Edwin Wang
Wilsonville, Ore., Oct. 10, 2009

The writer is a radiologist.

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To the Editor:

It is true that breast cancer treatment has become too complex for the current models of care. The multiple specialties required make it impossible for a single individual, no matter how well trained, to deliver that care.

The only solution is to put the patient at the center of the process. At many leading institutions, a multidisciplinary approach allows all relevant specialists to come together to see patients on the same day. Such an approach leads to improved communication and better care for breast cancer, and should be applied throughout medicine as care becomes more complex.

James P. Evans
Chapel Hill, N.C., Oct. 10, 2009

The writer, a doctor, is director of clinical cancer genetics at the Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill.

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To the Editor:

I am a nurse practitioner in internal medicine and have been practicing for 11 years, so I feel I have experience with breast-lump palpation and cancer detection.

If a woman has not had a clinical breast exam in the past year or mentions a lump, I do a breast exam. If we agree that there is a lump, she is immediately sent to our breast imaging clinic, where a mammogram and an ultrasound are done that day.

If the radiologist tells me the results are worrisome, the patient can immediately see one of our breast surgeons.

A woman does not have to go to a gynecologist for this care. In fact, men or women in our internal medicine clinic who mention a worrisome lump can be seen that day, whether it is in the breast, neck or testicle. We have been doing it this way for as long as I can remember.

Chris Keeney
Sayre, Pa., Oct. 10, 2009

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To the Editor:

Your article describes the challenges for breast cancer patients who are shuttled between specialists. As long as our system fixes us one piece at a time, we will suffer the costs of miscommunication, and miss out on the benefits of holistic care.

This à la carte health care surely helps explain why we spend more yet have a shorter life expectancy than our European counterparts. As we consider health care access for all, let’s make sure we treat all of each person.

Necia Hobbes
Pittsburgh, Oct. 10, 2009

The writer is a student in the health law program at the University of Pittsburgh School of Law.

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To the Editor:

While the tone of “Wanted: Mammologists” seems conciliatory, the text is a subtle rally to turf warfare, advocating that obstetrician-gynecologists learn to do breast biopsies.

Collaborative efforts to help patients through breast cancer treatment are well under way. In my hospital, these include a program that helps navigate patients from radiology to surgery to radiation, as well as interdepartmental teaching conferences and courses stressing comprehensive approaches.

Breast Cancer Awareness Month is as good a time as any to encourage better communication.

Miriam David
Bronx, Oct. 10, 2009

The writer is a radiologist at Jacobi Hospital specializing in breast imaging.

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To the Editor:

The decreasing mortality from breast cancer is due to earlier diagnosis because of mammography and to multidisciplinary, innovative treatments.

Women should still have breast examinations by their primary-care doctors, and be taught self-examination. But breast cancers are more frequently detected by mammograms.

The diagnosis should then be established not by surgical biopsy, but by a less invasive technique, like a needle biopsy by a radiologist or surgeon.

There is no reason to go back a century to when breast biopsies were performed by gynecologists. The diagnosis and treatment of breast disease are taught within the specialty of general surgery, and there are fellowships that train specialists in all aspects of treating breast cancer.

We have too often seen the bad results of what the writers call “minimal” surgery to diagnose breast disease. Surgery should be performed only by those specifically trained to complete whatever additional procedures are deemed necessary at the time — for example, the removal of lymph nodes. This is state-of-the-art, optimal care.

Peter I. Pressman
Gordon F. Schwartz
New York, Oct. 10, 2009

The writers are, respectively, clinical professor of surgery at Weill Cornell Medical College and a professor of surgery at Jefferson Medical College. Dr. Pressman is co-author of “Breast Cancer: The Complete Guide.”

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To the Editor:

It fell to general surgeons to treat breast cancer in the late 19th century when William Stewart Halsted devised the first effective treatment for it.

As medicine has advanced, the skills of radiation oncologists and radiologists have become far greater than those of practitioners who don’t do this work full time.

A team approach to most cancers, in which surgeons, oncologists, radiation therapists and radiologists diagnose and treat cancer, should be universal. My wife and I have both been cancer patients and, like others, we know that treatment is often cumbersome and unpleasant, and need not be. But construction of a new specialty won’t solve these problems.

Michael P. Kempster
Andover, Mass., Oct. 10, 2009

The writer is a retired general surgeon.

    Who Should Treat Breast Cancer?, NYT, 18.10.2009, http://www.nytimes.com/2009/10/18/opinion/l18mammo.html

Op-Ed Contributors

Wanted: Mammologists

October 10, 2009
The New York Times
By ANN V. BELL, MARK PEARLMAN and RAYMOND DE VRIES

Ann Arbor, Mich.

OCTOBER is Breast Cancer Awareness Month, but what is it we need to be aware of? We know that for women, breast cancer is the most common cancer and, after lung cancer, the leading cause of cancer death. This month, pink ribbons and yogurt containers will remind us of the need to find a cure. But equally important is improving access to life-saving therapy for women already living with breast cancer — many of whom don’t even know it.

Delayed diagnosis of breast cancer — measured from the first health care consultation for a breast complaint to a diagnosis of cancer — is the most common and the second most costly medical claim against American doctors. Moreover, the length of delays in breast cancer diagnosis in cases that lead to malpractice litigation has been increasing in recent years. According to a study by the Physician Insurers Association of America, in 1990 the average delay was 12.7 months; in 1995 it was 14 months. The most recent data, from 2002, showed the average delay had risen to 16.3 months.

Why are there such long delays, even for women who get regular examinations? The insurers association identifies five causes: a misreading of the mammogram, a false negative mammogram, findings that fail to impress the doctor, the doctor’s failure to refer the patient to a specialist and poor communication between providers. Four of these five are preventable human errors (a false negative mammogram is a machine failure) and two — failure to make a referral and poor communication — are products of the way we organize health care.

The breast is something of an orphan in our health care system. We have cardiologists, nephrologists, hepatologists, proctologists and neurologists — but we have no “mammologists.” How did the breast get lost?

To answer this question we need to look at the division of labor in medicine and the history of specialization. In 1940, 24 percent of doctors were specialists; by the late 1960s, nearly 90 percent of medical graduates were entering specialty residencies. In the 1930s, obstetrician-gynecologists attempted to define themselves as surgeons specializing in women’s reproductive organs. But general surgeons had long considered all things surgical their exclusive turf, so obstetrician-gynecologists instead created a niche for themselves as “women’s doctors,” a kind of primary care specialty. They became the point of entry to health care for most women. Some were able to diagnose breast problems, but treatment of the breast remained for the most part with general surgeons.

When radiologists — specialists who can also diagnose breast cancer — appeared on the scene, another caregiver became involved in treatment. And radiologists were followed by radiation oncologists, medical oncologists, reconstructive surgeons and medical geneticists.

Women with breast cancer get lost in the mix, forced to make several different appointments, sit in various waiting rooms and see multiple doctors. In most cases, a woman with a breast problem will start with her obstetrician-gynecologist, who will then refer her to a surgeon (for a biopsy) or a radiologist (for a mammogram). The referring obstetrician-gynecologist may never see or hear from the patient again, and may not know if she kept her appointment or got adequate care.

Contrast this with the care given to women with gynecologic cancer. Because there is a subspecialty of gynecologic oncology, women see the same doctor from diagnosis to post-surgery follow-up. Breast malignancies outnumber gynecologic cancers 10 to one, and yet we have no subspecialty for breast care.

Why don’t more obstetrician-gynecologists perform the initial, minimal surgery required to diagnose breast cancer? The answer lies in the training of medical residents. Three organizations oversee the education of future obstetrician-gynecologists: the Accreditation Council for Graduate Medical Education, the American College of Obstetricians and Gynecologists and the American Board of Obstetrics and Gynecology. All three have different requirements regarding training in breast care. At the end of their years as residents, some obstetrician-gynecologists have a great deal of experience with the minimally invasive diagnostic procedures needed to respond to breast complaints and others do not.

Women with breast cancer need obstetrician-gynecologists who have learned how to diagnose breast cancers and breast care specialists devoted to shepherding them through surgery, therapy and healing. Given the haphazard growth in medical specialties and varied training programs for obstetrician-gynecologists, it is no surprise that there is a mismatch between patient needs and caregiver skills. Campaigns to raise awareness of breast cancer must do more than push for a cure. They must also seek to improve the way we organize care for those who suffer from this illness.

 

Ann V. Bell is a graduate student in sociology at the University of Michigan. Mark Pearlman is a professor of obstetrics and gynecology and the director of the Breast Fellowship Program at the University of Michigan Medical School. Raymond De Vries is a professor of obstetrics and gynecology and bioethics there.

    Wanted: Mammologists, NYT, 10.10.2009,
    http://www.nytimes.com/2009/10/10/opinion/10DeVries.html