Do Surgeons Consult with Others?
This recent study from Medical Care is discouraging and damning in its findings that many breast surgeons do not consult with other cancer doctors (medical and radiation oncologists) in planning surgical care. Although there certainly are many instances in which the surgery is straight forward and without nuance (e.g. a "standard"--and do realize that it never feels routine or standard to the patient--wide excision and sentinel node dissection), there are many others instances in which there may be questions re the best way to proceed. The advent of neo-adjuvant chemotherapy (chemo before surgery) in some situations is a good case in point.
At BIDMC and many other institutions, there is truly an emphasis on multi-disciplinary care. We have a twice weekly Multi-Disciplinary Breast Clinic in which women with new breast cancer diagnoses are seen by a medical oncologist, a radiation oncologist, and a breast surgeon. There is a pathologist in the conference room and other specialists on call as needed. In institutions where a formalized approach like ours is not offered, you should at least be able to expect that your surgeon would talk to other doctors as needed.
Here is a summary of the study:
Few Breast Cancer Surgeons Routinely Consult Other
January 7, 2009 — Although a multidisciplinary approach is considered to offer the best quality of care, a new survey has found that many breast cancer surgeons do not routinely consult with other experts, such as medical or radiation
oncologists or plastic surgeons, when developing treatment plans. Many also do not make use of patient decisionsupport activities, such as videos, websites, and patient-support programs. The survey is reported in the January issue of Medical Care.
"Despite the mantra for multidisciplinary decision-making and care intake for patients, surgeons in the community are reporting relatively little of that in their practices," said lead author Steven Katz, MD, MPH, professor of internal medicine at the University of Michigan Comprehensive Cancer Center in Ann Arbor.
"Either doctors are not convinced that these elements matter or there are logistical constraints in terms of building these standards into their practices," he added.
However, Dr. Katz pointed out that the implications for patients are not known. The results from the survey suggest that it is the surgeons with high volumes of breast cancer patients who are most likely to have a more integrated practice.
"But we don't know whether that matters with regard to patient decision-making, quality of life and satisfaction," he said in a statement.
Surgeon Plays Primary Role
For a patient newly diagnosed with breast cancer, the surgeon plays a primary role in clinical decision-making and delivery of treatment, the authors note. Investigating how surgeons go about this "can provide key insight about how care is organized for patients with breast cancer," the researchers write.
The researchers surveyed 318 surgeons who treat breast cancer in the metropolitan areas of Detroit, Michigan and Los Angeles, California. The researchers also surveyed 2268 breast cancer patients, and found a good correlation between the 2 sets of responses.
When asked about multidisciplinary physician communication, only one quarter to one third of surgeons said they had discussed the treatment plan with medical and radiation oncologists prior to surgery for a majority of their patients treated in the previous 12 months. Only 13% had consulted with a plastic surgeon. But a substantial proportion of
surgeons reported that they frequently had outside pathology or imaging studies reviewed by their colleagues (for two thirds or more of their patients).
About two thirds of surgeons reported that few or almost none of their patients participated in patient decision-support activities arranged by the practice, such as attending a practice-based presentation, viewing web-based materials, or
participating in peer-support programs. Surgeons who treated mostly breast cancer patients were more likely to consult with other experts and to use patient decision-support tools than those who saw fewer breast cancer patients. About half of the surgeons (46.1%) surveyed said that 15% or less of their total practice was devoted to breast cancer, whereas 16.2% of surgeons said that half or more of their practice was devoted to breast cancer.
It might be that the surgeons in the more specialized practices, who reported more collaborative communication and patient decision-support activities, are more willing or have more opportunity to invest in infrastructure such as same day appointments and weekly tumor boards. Surgeons who devote only a small proportion of their total practice to breast cancer might not feel that a large investment in infrastructure targeting these patients is justified, the authors note. These surgeons might benefit from virtual approaches, such as computer-based or internet-based methods of between-physician communication, they suggest.
Being part of a teaching program increased the likelihood of multidisciplinary collaboration, and this was independent of the level of specialization of the surgeon. "Practices that participate in surgical teaching programs may be more
motivated to initiate innovations in practice, or these features may evolve more naturally due to the structure of the teaching programs," the authors write.
These results should be interpreted cautiously with regard to patient care, the authors warn. "One important caveat is that we do not know yet whether patients who received treatment from more experienced surgeons using more patient and practice management processes actually received better quality of care," they point out.
The study was supported by the Commission on Cancer of the American College of Surgeons. The researchers have
disclosed no relevant financial relationships.
Med Care. 2010;48:45-51. Abstract