ACP American College of Physicians - Internal Medicine - Doctors for Adults

Effective Clinical Practice

LETTER TO THE EDITOR

Who Cares What Surgeons Think?

I have serious concerns about the conclusion of the article on the surgical treatment of early breast cancer1: "The assumption that BCS [breast-conserving surgery] is the 'right' choice for early-stage cancer may be unwarranted because many patients may have an informed preference for mastectomy." This conclusion is self-serving and severely flawed. The female surgeons surveyed were not patients. The decision of female surgeons when actually faced with a mastectomy or breast-conserving surgery may be very different from an off-the-cuff, hypothetical survey question. Male nonpatient surgeons are an inappropriate study sample.

"Real" Surgeons Like Big Surgery

What the survey documents is that surgeons prefer mastectomy over breast-conserving surgery for early breast cancer. The gynecology literature is replete with such statements as "The gynecologist prefers the more definitive (destructive) total hysterectomy rather than partial one in order to feel like a 'real' gynecologist." The surgeon's need to perform the more invasive and disfiguring procedure to feel like a 'real' surgeon needs elucidation, elaboration, and further study.

"Real" Patients Prefer Little Lumpectomies

My experience is that, in general, fully informed female patients prefer breast-conserving surgery, although they are rarely informed about this option. If they are informed, they are almost never told that the 10-year survival statistics for the less-invasive breast-conserving surgery are equivalent to those for mastectomy. The study required to answer your question is a study of fully informed patients as they are facing the surgery decision and a follow-up of whether they are satisfied with their decision after surgery.

Eileen Marie Wayne, MD
InformedConsent.com Foundation, Inc.
Moline, Illinois

Reference

1. Surgical treatment of early breast cancer: what would surgeons choose for themselves? Eff Clin Pract. 1999;2:149-51.

THE AUTHORS RESPOND

We agree with Dr. Wayne that the ideal study would incorporate actual patient preferences from a pool of fully informed patients. We also agree that our survey had limitations, many of which were addressed in our discussion of the findings. The surgeons surveyed were asked to make a hypothetical choice, which is clearly a different experience from that of patients who are actually faced with the choice of mastectomy or breast-conserving surgery.

We should be clear, however, about our rationale for asking surgeons what they would choose for themselves. Surgeons are a good proxy for "fully-informed" patients. If they make different choices when faced with the same data, then it is reasonable to expect that others will as well. We also disagree that our study suggests that surgeons, male or female, prefer mastectomy to breast-conserving surgery. Indeed, we clearly state that the decision was split equally, for both male and female surgeons.

For the record, none of the authors of this paper feel that one choice is more appropriate than the other. To the contrary, our message is that every woman must be given the information needed to make this decision and that the final choice is hers to make.

E. Dale Collins, MD, MS
Carolyn Kerrigan, MD, MS
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire