Should breast surgery be his own medical specialty?

By 2018, breast cancer will be the most common newly diagnosed cancer in the United States, with 286,670 new cases, outpacing lung cancer (in both men and women) by more than 50,000 new cases, according to projections from the American Cancer Society.

For almost all of these breast cancers, patients will undergo surgery to eliminate malignant or premalignant tumors.

The large number of mastectomies and lumpectomies performed makes breast cancer surgery one of the top 20 types of surgery in the United States. And that does not take into account breast biopsies, which are even more common.

Despite the volume of breast surgeries, there is no specific American certification chart that is exclusive to breast surgery, as it is the case, for example, for surgery of the colon and rectum, of the breast, blood vessels, joints and bones.

In the United States, doctors practicing breast surgery are certified by the American Board of Surgery, based in Philadelphia and founded in 1937 by general surgeons. Thus, breast surgeons are certified in general surgery, a specialty that includes a wide range of operations including removal of appendages and hernia repair.

Historically, general surgeons began practicing after five years of general surgery residency, including breast surgeries. They have also benefited from "on-the-job training" with breasts, a process that continues today for many surgeons, explained Mark A. Malangoni, MD, a university and long-time surgeon. Malagoni was associate executive director of the American Board of Surgery, but recently left the organization.

Although not all surgeons in the United States are certified by a board, certification by a recognized board is a seal of approval that helps ensure competence and quality of care. It also contributes to professional reputation and provides crucial access to hospital operating rooms.

Despite the guarantees, the quality of breast cancer surgery in the United States could be further improved, suggest recent studies that have documented an "epidemic" of reinterventions, a weak adoption of recommendations for axillary lymph node surgery, and an increasing number of questionable mastectomies.

So, looking at the big picture of breast surgery in America, the question arises: Should breast surgery be a medical specialty, with its own board of directors and a related certification?

Perhaps, suggested Peter Beitsch, MD, a surgeon at Dallas Surgical Group in Texas and former president of the American Society of Breast Surgeons, a professional group that has no authority in matters of certification.

Sounding like an oriental contemplative, Beitsch offered an enigmatic commentary to Medscape Medical News: "When things are designated as a specialty, it's like everything in the world – it's a good and a bad thing.There's a ying and a yang to that." a pebble thrown into a pond, and the ripples – you do not always see them coming. "

But Beitsh also spoke clearly: "I would say that the main reason why there is no American Board of Breast Surgery [or a breast specialty within the American Board of Surgeons] This is the opposition of the general surgeons of this country "who fear a loss of patients and income.

Beitsch did not delay in hiring general surgeons and their work in breast surgery: "Breast surgeons in the United States are very knowledgeable and well trained, including those who undergo training in general surgery."

He also explained that general surgeons with a "partial practice" in breast surgery represent about 50% of the members of the American Society of Breast Surgeons. In short, general surgeons are indispensable in breast surgery.

But the other 50% of this company is made up of "exclusively breast" surgeons, many of whom have benefited from special fellowships, either in surgical oncology or in breast surgery. This group, suggested Beitsch, would like their expertise to be fully recognized and recognized in the medical market and turn to a specialty or subspecialty designation.

Malangoni sees things a little differently.

Each type of surgery does not have his own chart, he explained. There is no advice for appendectomies or bariatric surgery.

He also pointed out a "similar situation" for breast surgery in another form of cancer treatment.

Malangoni said that within the American Board of Internal Medicine, there is a specialized certification in hematology / oncology. Among this group, there are medical oncologists who only treat breast cancer, but they do not have a separate board of directors.

"Much of the care for breast disease in this country is provided by people who have not yet benefited from a breast surgery fellowship," he said at the time. ;a meeting. "It is provided by general surgeons, often in remote communities in large urban areas where there is not a huge consolidation of specialist surgeons."

At the same time, Malangoni said something that somewhat supports the idea that breast surgery should be a specialty with a chart. "The purpose of the counseling was to distinguish people who had special training, special expertise" – otherwise, other surgeons would have "results judged to be less good," he said.

Who gets advice?

The creation of various surgical boards has been "scalable," said Malangoni Medscape Medical News. For example, the specialties of thoracic, plastic and neurological surgery all emerged from the American Board of Surgery "as these disciplines evolved and more individuals practiced in these areas," he said. Explain.

This evolution is often motivated by the growth of the number of practitioners in a specific field.

"To have a certification committee, a certain number of people must be certified in this discipline," he added. The complexity of any type of surgery is also part of it: as the field evolves, complexity often intensifies.

"The complexity of breast surgery has exploded, it's a lot more complicated than it was before," Breitsch agreed.

Breast cancer is now more and more complex, Malangoni said. "In the past, there were very few types of breast cancer, whereas today, with genetic testing and molecular assessments, breast cancer is a slogan for many types of cancer." . "

Different subtypes of breast cancer are associated with different prognoses and have different treatments and outcomes, he added.

Does this qualify for having his own advice? "I do not have a good answer to that," Malangoni said.

In the end, any new board must be approved by the American Board of Medical Specialties, which oversees 24 different medical specialty boards.

In an email to Medscape Medical NewsMira Irons, MD, Executive Vice-President of the Group's Academic Affairs Group, noted that the adoption of new specialties and subspecialties involved a process that included the creation of a Council of Europe Medical Scholarship Program. accreditation of graduates in medical education.

American Board of Surgery winks at breast surgery

The American Board of Surgery has a new executive director, Jo Buyske, MD, a Philadelphia surgeon who "rotates the aircraft carrier, but it takes a bit of time," said Beitsch.

Since 1976, after the initial certification, surgeons have to pass a complete recertification examination every 10 years. It has changed this year. There is now a shorter interview on the certification exam – 40 questions, to be completed every two years – which is supposed to be more practice-oriented. The window to pass this year's exam extends until November 5th.

Half of the examination consists of "basic surgical principles", such as preoperative assessment and management of common complications in all types of surgery. The other half of the exam is divided into four areas / modules to choose from which surgeons can choose, including digestive tract surgery and breast surgery.

The four areas were chosen based on past operations volume data.

By adopting a "continuous certification process", the American Board of Surgeons "is trying to adapt to the [changing] circumstances, "said Malangoni.

"The initiation of a modular-type exam that focuses your knowledge in a specific area is a first step in that direction," he said.

It seems unlikely that the American Board of Surgeons currently grants specialty or subspecialty status for breast surgery, suggested Beitsch.

He told the story of the latest bold initiative of the board of directors a few decades ago, aimed at making vascular surgery a major specialty certification area.

"At that time, most general surgeons practiced vascular surgery," said Beitsch.

What happened next is that general surgeons have been squeezed out of the surgery market – usually in hospitals.

"Hospitals would say to the general surgeon:" Where is your certificate of vascular surgery? "" explained Beitsch.

"The surgeon replied," Well, I do not have one, I learned it during my 10 or 20 year training in general surgery, and I've done it in this hospital for 10 or 20 years. "Then the hospital said," The other doctors have it, and if you want to come back and get your certification [a 1- to 2-year process]so great. Otherwise, we use certified surgeons. "

General surgeons are concerned that breast surgery, if given a special designation, results in a repeat of the debacle of vascular surgery, said Beitsch. For general surgeons, the history of vascular surgery is a telling tale, he said.

"The vast majority of breasts are taken care of by general surgeons in the United States, and the vast majority do excellent work at excellent … I think they're careful enough because they do a good job in the field of surgery breasts and want to continue to do so, "concluded Breitsch.

Drs Breitsch, Malagnoni and Irons did not reveal any relevant financial relationship.

Follow Nick Mulcahy, Senior Medscape Reporter, on Twitter: @MulcahyNick

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