Choosing Your Breast Surgeon

What are the usual qualifications for a surgeon?

All surgeons must first qualify as doctors, so they all have a basic medical degree which includes the principles of medicine and surgery. The title of this degree varies according to the university attended. Examples such as at the University of Melbourne are MB (Bachelor of Medicine) and BS (Bachelor of Surgery) ie MBBS

Surgeons then go on to do years of further training in surgical specialities. On completion of this training they acquire a specific surgical qualification ie FRACS (Fellowship of The Royal Australasian College of Surgeons)

Some surgeons then undergo further additional “super” specialist training in a particular discipline, known as a fellowship. Fellowship training programs are available in breast surgery such as the breast fellowship completed by Miss Jane O’Brien. A breast fellowship provides comprehensive and specific training in all aspects of screening, diagnosis and treatment of benign and malignant breast conditions.

How can I find out if my surgeon is appropriately qualified and registered?

All doctors require current registration with the Medical Practitioners Board of Victoria in order to practice in Victoria. You can check that your doctor has current registration (not suspended or cancelled) on the register- secure.medicalboardvic.org.au
The Royal Australasian College of Surgeons (RACS) has an online directory listing of Fellows of the Royal Australasian College of Surgeons who meet the requirements of the College’s Continuing Professional Development (CPD) program
RACS “Find a Surgeon” Directory- www.surgeons.org

Why are most surgeons in Victoria known as Mr or Miss, rather than Dr?

illustrated history of surgery The tradition of addressing surgeons as “Mister” or “Miss” rather than “Doctor” is firmly entrenched in English surgical practice. Female surgeons in the United Kingdom are traditionally addressed as “Miss”, regardless of marital status. The strong influence of the Royal College of Surgeons of England in the formative years of the Royal Australasian College of Surgeons (RACS) has led to the persistence of the term in Australia. The tradition is generally thought to have had its origins in the days of the “barber-surgeons”. The blade-wielding skills of barbers had given them opportunities for surgical practice, and “surgeons” at that time seldom had formal qualifications. With the separation of the surgeons from the Great Company of Barbers and Surgeons in 1745 and the establishment of the Royal College of Surgeons of London, the title “Mr” was retained and began to be seen as a label of status, as it marked the completion of formal examinations.

In most other parts of the world all medical practitioners, physicians and surgeons alike, are referred to as ‘Dr’. Locally, the use of the terms Mr/Miss appears to be losing favour, at least in New South Wales. When researchers quizzed urologists, they found that 91% of urologists in New South Wales preferred Dr, while 85.7% in Victoria opted for Mr.

What is a breast surgeon?

Breast Surgery is now regarded as a surgical subspecialty in Australia and internationally. The Section of Breast Surgery of the Royal Australasian College of Surgeons has done much to encourage the development of breast surgery as a specialty and the increasing availability of breast fellowships, such as completed by Jane O’Brien, reflects the emergence of breast disease as an area of specialization for surgeons.

Breast surgeons treat women and men with all forms of breast disease, both benign and malignant. They also have an important role in the surveillance of women at increased risk of breast cancer, both for the purposes of early detection and sometimes even for consideration of prophylactic surgery in this setting. In addition to technical skills, surgeons who treat women with breast disease should be good communicators and surgeons who practice in this field must now have some formal training in communication. There is reliable evidence to show that good communication enhances a woman’s ability to deal with the crisis of breast cancer, and that it has a role in reducing post-treatment morbidity, including anxiety and depression. Breast surgeons must also be surgical oncologists. They must have a detailed understanding of tumour biology, particularly at this time of rapid expansion of knowledge in molecular biology and genetics, or they will be unable to identify opportunities for innovative treatment methods in the future. Breast specialization requires a broad knowledge of cancer biology, molecular genetics and an understanding of non-surgical oncology fields including pathology, radiation oncology and medical oncology. Breast cancer nowadays is managed by a therapeutic consortium of breast surgeons, breast care nurses, radiation and medical oncologists who work closely with their colleagues in pathology and diagnostic radiology. The multidisciplinary meeting is more than a management team meeting − it is a forum for peer review in which opinions are frequently challenged.

As in all branches of specialist surgical training, breast surgeons should be strongly encouraged to travel and work overseas as part of their training. The facilities for training in Australia and New Zealand are now amongst the best in the world, but there is still an opportunity to enhance surgical skills by spending an extended period of time overseas at centres of excellence. Jane O’Brien herself spent nine years working as a specialist breast surgeon in the United Kingdom and feels strongly that the acquisition of new and advanced techniques such as oncoplastic breast surgery and the experience of different medical systems broadens the vision of breast surgical practice.

Historically, breast surgery in Australia and the UK has been a component of general surgery but the responsibility of the surgeon in the diagnosis and management of early breast cancer together with the rapid increase in information and technology relating to this disease, have determined the need for specialization. General surgeons frequently encountered breast problems in their practices in the past, prior to the emergence of breast surgery as a specialty, and for geographical and logistic reasons, surgical treatment of breast disease in some parts of Australia, especially in remote areas, is still undertaken by general surgeons who retain a broad range of general surgical interests. There is no reason why this practice should not continue and women should be free to make the choice themselves between the convenience of having their breast surgery performed locally, close to home compared to the advantage of having a specialist breast surgeon. Generally in major Australian capital cities, most breast surgery is performed by either general surgeons who have a breast interest, or by the small number of specialist breast surgeons, such as Jane O’Brien, whose practice is confined exclusively to breast work.

There is now good evidence from recent research that outcomes are better if treated by a specialist breast surgeon and available data supports the fact that subspecialization does result in improved overall survival of breast cancer patients. (see Benefits of Breast Surgical Specialisation ) In addition a US study found that patients treated by specialist breast surgeons (defined as high-volume surgeons) were more satisfied with the treatment decision process and with the surgeon -patient relationship than were patients treated by low volume surgeons. You should therefore check prior to referral that if possible you are being referred to a specialist breast surgeon.

If I have breast cancer diagnosed, how do I choose a surgeon?

One of the important tasks many women face when diagnosed with breast cancer is choosing a surgeon. In discussing this matter with your general practitioner, it is important that you make a decision that best meets your needs. You can always review this decision at any time or seek a second opinion. As with many decisions in life, the decision involved in choosing a surgeon may include the weighing up of several factors. With the crisis of a newly diagnosed breast cancer or even the knowledge of a suspicious finding on a mammogram, women often feel a tremendous urgency to have the lump or “lesion” immediately surgically removed immediately. The very act of doing something, anything, often alleviates the escalating anxiety. It is extremely important to realize that you don’t have to rush into treatment or a surgical procedure. Going through the process of choosing a breast surgeon can take time, and many people are tempted to rush through it to start their treatment sooner. Keep in mind, though, that most people with breast cancer have enough time to be sure that they get the best care possible. Carefully choosing the doctor you need now will pay off for years to come.

Decide what you want and need in a surgeon

Before you start looking for a doctor, think about the qualities you want your doctor to have. A few ideas are listed below, but you may want to consider others.

Choose a doctor who has extensive experience with breast cancer ( see Benefits Of Specialization) Surgeons will differ in the amount of breast surgery they perform and in their levels of experience and expertise. Particularly satisfy yourself that the surgeon treats breast cancer cases frequently and is a member of the Breast Section of the College of Surgeons (see below). Confirm that the surgeon offers a full range of breast cancer operations eg sentinel node biopsy, immediate breast reconstruction. All surgeons are not equal in terms of their surgical skills and the breast procedures they offer, especially with respect to oncoplastic breast procedures (see Oncoplastic Breast Surgery)
Pick a doctor who has privileges (ie is able to practice) at a hospital that is acceptable to you. Doctors can only send patients to facilities where they have admitting privileges/rights
The Surgeon’s Contacts. Breast surgery is often only one part of breast cancer treatment. It is important to know that there is a good working relationship between your surgeon and other health professionals who may be involved in your care and that your surgeon practices in a multidisciplinary team setting (see Multidisciplinary Breast Cancer Care) It is also beneficial to you if your surgeon is in contact with your GP. This helps your GP to answer questions you may have and to assist with your general health care. Check that the breast surgeons works with other cancer specialists and breast care nurses (see Breast Care Nurses) to address all of a woman’s needs at the time of her diagnosis and treatment
Choose a doctor you feel comfortable with. Languages spoken, gender (see Female Breast Surgeons), ethnicity, age and educational background may be important factors for you. You and your doctor don’t need to be best friends, but if you don’t get along, your care may suffer
You may have strong feelings about personality and bedside manner. Some people prefer their doctors to have a clinical, business-like manner, while others value a doctor who concentrates on emotional health as well as their medical needs. Women to whom the cosmetic outcome of their breast surgery is a major issue, may feel that a well presented surgeon, who clearly takes pride in their own appearance, may be more likely to focus their attention on this area. Many people whose illnesses require long-term treatment like a friendly relationship with their doctor. Many women find it helpful if they feel relaxed with their surgeon and find him or her easy to talk with and willing to answer any questions. It is also important that the surgeon gives you as much information as you require. Overall, while it’s crucial to be able to communicate well with your doctor, there may be limits to the amounts of information you can absorb., Being able to trust your surgeon and to know that your wishes and decisions will be respected may be a priority for you. Your relationship with this person will probably last through treatment into long-term follow-up care. For this reason many women may also take into account, amongst other things, the age of the surgeon; as breast cancer follow up continues for many years, and it therefore may not be ideal to be treated by a surgeon who is to retire within the next few years
Access and Convenience
Your choice of surgeon may depend on what is most convenient for you. The availability of a surgeon to see you and the timing of the surgery may need to fit in with other aspects of your life. Do not however over interpret the timing of the appointment offered to you. In fact, the busiest and most specialized breast surgeons, tend to be able to see urgent breast cancer referrals the most promptly, as they structure their diaries to allow it. This is because they realize that waiting can be a very anxious time for women, and regard seeing them promptly as a priority. If you have a suspected or proven breast cancer and are offered an appointment several weeks away, that does not necessarily mean the surgeon concerned is very busy and therefore very skilled; it simply reflects the fact that they do not highly prioritise the treatment of breast cancer. Equally however, if the surgeon who has been recommended to you cannot see you for a few days, for example due to leave, this certainly does not have an adverse impact on your overall long term outcome. The most specialized breast surgeons, who perform only breast surgery and no general surgery at all, do not have urgent general surgical referrals competing for their time, and most keep aside sufficient urgent appointment slots for breast cancer referrals .The surgeons rooms may also be important to you. It is much nicer to visit surroundings which are pleasant, friendly and relaxing when you are anxious and stressed

The costs involved and whether you choose to be treated within the private or public health system may also be relevant. Public patients in public hospitals do not have a choice of doctor (see Private vs Public)

The location of the surgeon’s rooms and the hospital may also be factors. For example, if you are travelling to the city from the country for your care, it may be easier to learn to negotiate a single location. Hospitals are often difficult places to find your way around, and it may be preferable to see a surgeon who like Jane O’Brien, is based on the actual hospital campus /premises. In fact, it is sometimes possible to see all your breast cancer specialists and to undergo all of your breast cancer treatment (surgery, chemotherapy and radiotherapy) under the one roof, as is available for example at the Epworth Richmond

How do I go about choosing a surgeon?

Many people with breast cancer say the most difficult part, after dealing with the shock of the diagnosis, is working out where to go for treatment and care. Your decision may be guided by a number of influences, including word of mouth, advertising, internet and your general practitioner. Usually the most reliable of these are your GP and word of mouth from a reliable source. Advertising is the least reliable. The internet can vary from being extremely useful to very poor.

Ask your GP
Ask family, friends and friends of friends and ideally aim to find someone who has been through the experience
Ask people you meet along the way, for example the radiographer who did your mammograms “What other staff say about doctors is pretty important,”
Do your own research. A US study found that women who chose their own surgeon were twice as likely to see a highly experienced surgeon. Women who were more actively involved in selecting their surgeon were more likely to be treated by a high volume surgeon in a more comprehensive treatment setting. Katz, Journal of Clinical Oncology, Jan 2007
The Cancer Council Helpline is a free, confidential telephone information and support service run by Cancer Councils in each state and territory. Specially trained staff are available to answer your questions about cancer and offer emotional or practical support. They can provide support and information on general issues to consider when choosing a surgeon. The Cancer Council Helpline can be reached on 13 11 20. www.cancervic.org.au
BreaCan is a free, confidential information and support service for people affected by breast or gynaecological cancers, their families and friends. BreaCan provides a safe and welcoming place for people to access information, participate in programs, attend information sessions and share their experiences with other women. BreaCan aims to empower women to understand and participate in decisions about their care and treatment. BreaCan also presents an opportunity for women to connect and speak with trained peer support volunteers. The volunteers have all experienced cancer themselves or cared for someone who has. BreaCan can be contacted on 1300 781 500 www.breacan.org.au A podcast of a Breacan information session presented by Jane O’Brien on making initial treatment decisions can be downloaded from their website on www.breacan.org.au
Breast Care Network Australia ( BCNA) is a national organisation for Australians personally affected by breast cancer, working to ensure that Australians diagnosed with breast cancer and their families receive the very best information, treatment, care and support possible, no matter who they are or where they live. They produce the My Journey Kit, a comprehensive information resource which has been developed by women who have had breast cancer for women newly diagnosed with breast cancer. Breast Cancer Network Australia aims to get the Kit to everyone diagnosed with breast cancer in Australia as close as possible to their diagnosis. The My Journey Information Guide provides guidance on finding a medical team to suit your needs
The Cancer Council, BreaCan and BCNA will not make specific recommendations regarding particular surgeons but will suggest you should confirm that your surgeon
1. Is a member of the Royal Australasian College of Surgeons Breast Section (see below)
2. Works as part of a multidisciplinary team which holds regular multidisciplinary meetings at which your case (with your prior consent) will be reviewed and discussed
3. Works with a Breast Care Nurse as part of the team
Look in directories such as :
Breast Care Institute, NSW has a national directory of breast cancer treatment and services- www.e-strategy.net.au

National Breast and Ovarian Cancer Centre (NBOCC) has a directory of hospital breast cancer services- www.nbcc.org.au

Is the surgeon a full member of the Breast Section of the Royal Australasian College of Surgeons?

To be a ‘full’ member of the Royal Australasian College of Surgeons Breast Section certain criteria need to be satisfied. These include full participation in the Breast Section Audit and an ongoing commitment to CPD activities in breast disease.

Attached is a list of RACS Breast Section Members

Royal Australasian College of Surgeons also has a “Find a Surgeon” search facility – www.surgeons.org