Newsweek reports that according to a new study conducted in the United States, the effectiveness of breast cancer treatment can vary significantly depending on the surgeon’s skill level. According to the researchers’ estimates, if all surgeons could achieve an intermediate level of skill in achieving negative margins and administering radiation therapy, patients would be 22 percent less likely to have their cancer recur within five years. Even more surprising is the possibility that surgeons are even more important than the treatment itself. It’s hard to say the right surgeon For any woman who has undergone breast cancer surgery, the last thing they want to hear in the recovery room is “we’ve completely removed the tumor”. In other words, a negative margin. A negative margin means that there are no cancer cells within a few millimeters of the edge of the removed tissue, which reduces the likelihood of breast cancer recurrence and thus increases the patient’s chances of survival. In addition, radiation therapy after a mastectomy or other breast-conserving surgery can also improve cancer-free survival rates. However, it is not always easy for breast cancer patients to find a skilled surgeon to perform the procedure on them. As Newsweek noted in a 2009 story, the difficulty breast cancer patients face in finding the desired treatment outcome has been a major scandal for years. A new study finds that for patients with intraductal breast cancer, the difficulty in obtaining the desired treatment outcome poses a greater threat than anyone imagined, and one of the major obstacles is the refusal of the professional medical establishment and health insurance to release information about it. In addition, the professionalism of surgeons is mixed, with some having no regard for patient affordability and even ethical issues. Negative margins + radiation therapy = low risk of recurrence Non-invasive breast cancer is usually treated with breast-conserving surgery or mastectomy, and patients may or may not receive radiation therapy after breast-conserving surgery. According to a paper published Jan. 3 in the Journal of the National Cancer Institute (JNCI), treatment outcomes also depend on which surgeon performs the surgery on the patient. According to an analysis by Andrew Dick of the RAND Corporation, the two most important factors in preventing patients with intraductal breast cancer from recurring after treatment are negative tumor margins and receiving radiation therapy after breast-conserving surgery. How important are these two factors? According to researchers who analyzed the medical records of 994 patients with intraductal breast cancer, women who received radiation therapy after breast-conserving surgery had about a 5 percent chance of cancer recurrence, compared to 14 percent for women who did not receive radiation therapy. The recurrence rate was about 3% for women who achieved a negative margin and received radiotherapy, 15% for women who achieved a positive margin and received radiotherapy, 13% for women who achieved a negative margin but did not receive radiotherapy, and 25% for women who achieved a positive margin and did not receive radiotherapy. It is clear that failure to receive radiotherapy after surgery increases the risk of breast cancer recurrence, and that positive margins also have this negative effect. What is even more surprising is that these two major determinants of treatment outcome can also vary significantly from surgeon to surgeon. How big is the difference? According to the researchers’ estimates, if all surgeons were moderately skilled in achieving negative margins and administering radiation therapy, patients would be 22 percent less likely to have their cancer recur within five years. The surgeon may be more important than the treatment The researchers note in the paper, “Treatment outcomes vary significantly by surgeon skill. Differences in surgeon skill and their impact on long-term treatment outcomes is a vexing issue, and such unexplained differences can have a significant impact on treatment outcomes.” For patients, it is difficult for them to understand how their doctors administer treatment. In an editorial published with the paper, University of Minnesota epidemiologist Beth Wernig and surgeon Todd Tuttle ask the question – how should women choose a surgeon if they know that surgeons can cause up to a 35 percent difference in treatment outcomes? That choice is never easy. What’s more surprising, Wernig says, is that patients don’t have access to the information, and the surgeon may even be more important than the treatment itself. If one surgeon performs breast-conserving surgery on a patient and another performs a mastectomy, she says, “the former may result in better outcomes for the patient than the latter, although cancer-free survival rates are typically higher for patients who undergo mastectomy.” Information disclosure still needs to wait One way to help patients choose the ideal surgeon is to make the number of breast cancer surgeries performed by all surgeons available to the public, Wernig noted. But compiling that information would be a daunting task for anyone. The U.S. Department of Health Care refuses to release any information related to the number of cases a doctor has treated for a specific disease or the number of surgeries performed. The nonprofit Consumers’ Checkbook tried to get Medicare to release this information, but the request was ultimately rebuffed in a court battle in 2009. Newsweek also tried to persuade the American Society of Clinical Oncology to create a database for patients in 2010, providing information on the number of cases of specific cancers treated by society members over the past few years, whether they were professionally certified, and how long they had had clinical practice. Newsweek spent months negotiating with the Society of Clinical Oncology, but was ultimately turned away. On this issue, Consumers Union, the publisher of Consumer Reports, made a major breakthrough. John Santa of Consumers Union told Newsweek that in 2010, they succeeded in convincing the Society of Thoracic Surgeons to publish key information, including 30-day mortality rates, complications such as serious infections, the number of surgeries performed, and whether patients were receiving appropriate medications. They worked for two years to convince the Society of Thoracic Surgeons to release this information. But of its 950 member groups (where “group” stands for one or more surgeons), only 221 agreed to release their data. Patients will remain in the dark until the government or medical institutions release information about their doctors. For cancer surgery, the best current database is one created by the American College of Surgeons Commission on Cancer. By going to this database and selecting “Details,” one can see specific city, state or zip code information, as well as find nearby cancer treatment facilities and the number of cases of different types and stages of cancer they treat each year through surgery. Knowing this information, patients will at least be less likely to have treatment performed by doctors who have never treated the cancer they have. But this database still does not provide the information that patients most want, namely all the information they need to know before choosing a surgeon to treat their cancer.