Should Breast Surgery Be Its Own Medical Specialty?
TME Breast Care Network doctor Peter Beitsch was one of the doctors discussing whether or not breast cancer surgery should be a specialty of general surgery.
In 2018, breast cancer will be the most common newly diagnosed cancer in the United States, with 286,670 new cases, outstripping lung cancer (in both men and women) by more than 50,000 new cases, according to projections from the American Cancer Society.
For nearly all of those breast cancers, patients will undergo surgery to remove malignancies or premaligancies.
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 factor in breast biopsies, which are even more common.
Despite the volume of breast surgeries, there is no American certifying board specific and exclusive to surgery of the breast, such as there is, for example, for surgery of the colon and rectum, chest, vasculature, and joints and bones.
Instead, in the United States, physicians who perform breast surgery are certified by the American Board of Surgery, which is headquarted in Philadelphia and was founded in 1937 by general surgeons. Thus, breast surgeons are certified in general surgery, a specialty that comprises a wide range of operations, including removing appendixes and fixing hernias.
General surgeons typically begin practicing after completing 5 years of general surgery residency, which includes breast surgeries. They then receive further "on the job training" with breasts, explained Mark A. Malangoni, MD, a long-time academic and 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 board certified, certification from a recognized board is a stamp of approval that helps ensure competence and quality care. It also aids one's professional reputation and helps with crucial access to hospital operating rooms.
Despite safeguards, the quality of breast cancer surgery in United States has room for improvement, suggest recent studies that have documented, among other things, an "epidemic" of resurgeries, poor uptake of axillary lymph node surgery recommendations, and surging numbers 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 and related certification?
Perhaps, suggested Peter Beitsch, MD, a surgeon at the Dallas Surgical Group in Texas and past president of the American Society of Breast Surgeons, a professional group that has no authority in terms of certification.
Sounding like an Eastern contemplative, Beitsch offered an enigmatic comment to Medscape Medical News: "When things get designated as a specialty, that's like everything in the world — it's a good and a bad thing. There's a ying and yang to it. It's a pebble thrown into a pond, and the ripples —you don't always see them coming."
But Beistch also spoke plainly: "I would say that the main reason there's not an American Board of Breast Surgery [or a breast specialty within the American Board of Surgeons] is opposition from general surgeons in this country" who fear a loss of patients and revenue.
Beitsch was quick to praise general surgeons and their work in breast surgery: "Breast surgeons in the United States are very competent and well trained, including those who go through general surgery training."
He also explained that general surgeons who have a "partial practice" in breast surgery make up about 50% of the membership American Society of Breast Surgeons. In short, general surgeons are indispensable in breast surgery.
But the other 50% of that society consists of "breast-only" surgeons, many of whom underwent special fellowships, either in surgical oncology or in breast surgery. That group, Beitsch suggested, would like to have their expertise fully recognized and branded in the medical marketplace and have eyes on speciality or subspecialty designation.
Malangoni sees things somewhat differently.
Not every surgery type gets its own board, he explained. There is no board for appendectomies or bariatric surgery.
He also pointed to an "analogous situation" for breast surgery in another form of cancer care.
Malangoni said that at the American Board of Internal Medicine, there is a specialty certification in hematology/oncology. Among that group, there are medical oncologists who treat only breast cancer, but they do not have a separate board.
"Much of the care for breast disease in this country is provided by individuals who have not done breast surgery fellowships," he emphasized in an interview. "It's provided by general surgeons, often in communities away from large urban areas where there is not a huge consolidation of surgical specialists."
At the same time, Malangoni said something that somewhat supports the idea that breast surgery should be a specialty with a board. "The purpose of the boards has been to distinguish individuals who had special training, special expertise" — without this, other surgeons were "thought to have results that weren't as good," he said.
Who Gets a Board?
The creation of various surgical boards has been "evolutionary," Malangoni told Medscape Medical News. For example, thoracic, plastic, and neurologic surgery specialties all evolved out of the American Board of Surgery "as those disciplines evolved and more individuals practiced in those areas," he explained.
That evolution is often driven by growth in the number practitioners in any specific area.
"To have a certification board, you have to have a certain number of people who are going to be certified in that discipline," he added. Complexity of any surgical type is also part of it — as the field advances, complexity often intensifies.
"The complexity of breast surgery has blown up. It's way more complicated than it used to be," agreed Beistch.
Breast cancer is now increasingly complex, Malangoni agreed. "In the past, there were very few types of breast cancer, whereas today, with genetic testing and molecular evaluations, breast cancer is a catch phrase for many types of cancer."
Various breast cancer subtypes are associated with different prognoses and have different treatments and outcomes, he added.
Does this qualify for having its own board? "I don't have a good answer for that," said Malangoni.
Ultimately, any new board must be agreed upon by the American Board of Medical Specialties, which oversees 24 different medical specialty boards.
In an email to Medscape Medical News, Mira Irons, MD, the group's senior vice president for academic affairs, observed that the adoption of new specialties and subspecialties involves a process, which includes the establishment of an Accreditation Council for Graduate Medical Education medical fellowship program in an area.
American Board of Surgery Makes a Nod Toward Breast Surgery
The American Board of Surgery has a new executive director, Jo Buyske, MD, a Philadelphia surgeon who "is turning the aircraft carrier around, but that takes a little time," said Beitsch.
Since 1976, after initial certification, surgeons have had to pass a comprehensive recertification exam every 10 years. That changed this year. Now, there is a shorter maintenance of certification exam — 40 questions, to be completed every other year — that is supposed to be more practice focused. The window for taking this year's exam extends to November 5.
Half of the exam consists of "core surgical principles," such as preoperative assessment and management of common complications across all surgery types. The other half of the exam is divided into four areas/elective modules that surgeons choose from, including alimentary tract surgery and breast surgery.
The four areas were chosen on the basis of past surgery volume data.
With their adoption of a "continuous certification process," the American Board of Surgeons is "trying to adapt to [changing] circumstances," said Malangoni.
"The initiation of a modular type of examination 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 will grant breast surgery speciality or subspecialty status at this time, suggested Beitsch.
He told the story of the last such bold move the board made, which was a couple of decades ago — establishing vascular surgery as an area of primary specialty certification.
"At that time, most general surgeons were doing vascular surgery," said Beitsch.
What happened next was that general surgeons were squeezed out of the surgical market — usually at hospitals.
"Hospitals would say to the general surgeon: "Where's your certificate of vascular surgery?' " explained Beitsch.
"The surgeon would answer: 'Well, I don't have one, I learned it in my training 10 or 20 years for general surgery, and I have been doing it at this hospital for 10 to 20 years.' Then the hospital would say, 'Other doctors have it, and if you want to go back and get your certification [a 1- to 2-year process], then great. Otherwise, we are using the certified surgeons.' "
General surgeons worry that breast surgery, if given a special designation, will lead to a repeat of the vascular surgery debacle, said Beitsch. For general surgeons, the story of vascular surgery is a cautionary tale, he said.
"The vast majority of breasts are taken care of by general surgeons in the United States, and the vast majority do a good to excellent job with it.... I think they are being appropriately cautious, because they do a good job in breast surgery and want to continue to do so," Beitsch concluded.
Dr Beitsch, Dr Malagnoni and Dr Irons have disclosed no relevant financial relationships.