Whether a woman receives radiation treatment after breast cancer surgery may be influenced by the gender of her surgeon, according to a new report from The Journal of the National Cancer Institute.
The gender of your surgeon may impact your treatment. (Fred Conrad/The New York Times)The study, from researchers at Columbia University, set out to determine why breast cancer treatment still varies among similar patients. In particular, they looked at radiation treatment given to women after lumpectomy. The treatment is considered a standard of quality cancer care and has been shown to reduce breast cancer recurrence and mortality. However, many women still don’t receive it.
Earlier studies have suggested that demographic characteristics influence whether a woman receives postsurgical radiation. A patient’s race, age and how far she lives from a radiation therapy facility all are factors that affect her chance of receiving the treatment.
But the latest report looked at the doctors behind the decisions. The researchers analyzed data on nearly 30,000 women aged 65 and older who were diagnosed with breast cancer between 1991 and 2002 and who received lumpectomy. They also analyzed data on the 4,453 surgeons who operated on the women.
About one in four women were not treated with radiation after surgery. Older women, black women, unmarried women and those living outside urban areas were less likely to receive radiation. But after controlling for those factors as well as characteristics of each woman’s cancer, the Columbia researchers spotted other trends.
Women who received radiation were more likely to have a female surgeon. Women who were treated by more experienced surgeons were also more likely to receive radiation treatment, as were women treated by doctors trained in the United States.
Dr. Dawn L. Hershman, co-director of the breast program at the Herbert Irving Comprehensive Cancer Center at Columbia University, said it’s not clear why women treated by female surgeons were more likely to receive radiation. It may have to do with the nature of a woman’s relationship with her doctor or the doctor’s communication style.
“It’s important to figure out all the factors that can contribute to improving quality of care,’’ said Dr. Hershman. “There are many fantastic male surgeons….It shouldn’t be taken that every woman should be seen by a woman, but there are some contributing factors to this difference that we need to investigate further.”
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From 1 to 25 of 122 Comments
Perhaps female surgeons are more likely to offer their patients the treatment that they themselves would want if they had breast cancer.
— Sharon R.Interesting study but there could be many other explanations.
Those affected were “older women, black women, unmarried women and those living outside urban areas” - sounds like a list of those 1) least likely to be adequately insured 2) most likely to have lower incomes 3) most likely to have burdens such as caring for children or parents which demand they get their treatment over quicker and don’t take on the debilitating ongoing treatment options.
Some of those reasons might be reflected in women REFUSING radiation that their Drs advised they should have. And if a black single mother from a rural area who also takes care of her parents and is the sole breadwinner in the family without insurance is pressured by her male surgeon to get the best treatment she’s likely to tell him to get stuffed (and I can understand that, sad as it is, it isn’t her fault or his).
To the extent there IS any cause-and-effect from the gender of the surgeon who says it isn’t lateral? Perhaps women surgeons are more likely to push the issue, pointing out that they DO in fact comprehend the difficulties but that long term lifespan and health is a huge benefit not just to the patient but to those dependents. I think that women probably take that argument better from a woman Dr…and that is completely contrary to the “men Drs are letting us down the bastards” line you’ve taken.
What you could really be saying is Women Drs are bullies and that’s good for our health. But that wouldn’t sound as catchy would it?
— JillyFlowerI wish we’d stop trying to put gender and race labels on every aspect of life. It’s counterproductive.
If you have breast cancer, and are wondering about radiation, talk to a surgeon (or better yet, a medical oncologist, which every cancer patient should have) of either gender and any race. If that person does not give you a logical reason for his/her recommendation, go somewhere else.
Don’t choose a physician (or any other provider of services) on the basis of gender or race.
— jackWe can’t help but note that some people get treated differently from others. Some people have ONE choice for getting breast cancer care–the free care for breast and cervical cancer that Illinois provides to uninsured women, for example. While it purports to guard against cervical cancer, it outright refuses to test for HPV, offering only pap smears. If that facility doesn’t offer you the treatment good luck going somewhere else. Without privilege and money, your choice and opportunity to exercise any power in participating in your own health care decision process pretty much fly out the window, Jack.
— Laurie BlackTypical.
So, even though it’s a known fact that women who’ve been treated for breast cancer need follow up radiation treatments, certain women don’t get them.
And - big suprise here - Black women, older women, unmarried women and rural women are the ones being underserved.
I thought there was no more discrimination in America?
I guess not!
And, as if that wasn’t bad enough, women with male surgeons get inferior care to those who’s doctors were male.
[A side order of misogyny with your racism, ma'am?]
What’s sad is that this kind of medical discrimination is just so damned typical in this country!
— Gregory A ButlerDo female doctors tell their female patients, “If you were my mother/sister/partner I’d want you to do X”? Do they say “If it were me I’d do X?”
If so I think it would sound LESS bossy than having a man tell you “If you were my mother/sister/wife I’d want you to do X.”
— diI thought the oncologist would be the one to make this decision, no? Perhaps this has something to do with the female surgeon reporting back to the oncologist and perhaps the male counterpart is too cool or doesn’t think he has to report back to the oncologist? Aren’t surgeons notoriously arrogant or is this just another stereotype? This entire issue is based upon averages. Perhaps it varies based upon geography as well?
I wonder if this type of study has been done about other types of cancer as well? When my father had colon cancer there was a rather long delay from the diagnosis until he could have the surgery. It was like six weeks or something. Shouldn’t there be a sense of urgency?
— MattDid they contol for the age of the doctors as well? I suspect the women average younger.
— diI thought age would have an impact as well, but the article indicates that where more experienced (presumably older) surgeons did the surgery, the radiation is more likely.
— MattMy wife had breast cancer this past year. I found the lump, we went to our primary care doctor who got the referral to the surgeon, all doctors were male. He looked at the lump and immediately scheduled surgery, no biopsy, no more mammograms (the one six months before didn’t show anything). Out came the lump, it was cancerous so a week later he went back in and took out a lymph node, it had not spread. She started chemo a month later and took that as long as she could (four times before the blood-count got too low). Then radiation started a month later and lasted for 6 weeks. We were told by all doctors that this was the standard procedure and were not asked if it was what she wanted. My internet studies showed this to be true. If this is the protocol why all the problems. Am I missing something? Sure the insurance and all the referrals were a problem but the result seems to be fine for now. The surgeon couldn’t have been better or more patient friendly. Maybe it is because he specializes in breast cancer surgery. The oncologist was at his recommendation and the radiologist the same.
From TPP — You’d be surprised how much breast cancer care varies across the nation. Radiation after lumpectomy is standard of care, and that’s why your doctor didn’t suggest that it was optional. But the fact is that 25% of women in this particular study didn’t get standard care. I find that pretty amazing and terrible. I hope your wife is doing well now.
— RichObviously women make better doctors.
— dr fernandezPerhaps, the study should take into account that women doctors generally tend to be younger than male doctors and the difference could be due to the different styles of teaching now and 20 years ago.
The trend today is for patients to have more autonomy compared to a more paternalistic past. This may be preferred for breast cancer patients.
— Jasmine WongCould be just a coincidental finding, but nice to publish from an author’s point of view because of the attention the paper receives. Why not spend money on those who lack adequate care and on how to provide them better care? As a physician, it is still a challenge I face everyday trying to provide equal access to health care for all. By the way, it saddens me to see such a comment by Dr. Fernandez.
From TPP — Thanks for the comment. Between you and me (and everyone else reading I guess) I doubt “Dr. Fernandez” is a real name or that the poster is a doctor. As for whether the data cited in this study is just a coincidence, the findings are statistically significant. But you are right — the real issue here, as noted by Dr. Hershman, is making sure every woman gets the best care available.
— KenThis is an interesting study, but scientifically meaningless. It’s like the study that shows that large shoe size causes people to buy bigger cars. It fails to take into account the fact that people with bigger shoes may be taller and therefore want bigger cars.
In this study, for example, foreign medical grads (who are more likely to be male), were less likely to recommend radiation. Similarly, do we know the gender spread on male versus female doctors practicing in rural vs. urban vs. suburban locations? If it turns out that there are males practicing in rural settings, the data would be swayed.
For anyone with a problem like this, find the best doctor, male or female, in your area. Get a second opinion. Take your doctor’s advice.
Eric
— EricI think jumping to conclusions about why one group of surgeons treats differently is completely unwarranted. In fact, it’s not entirely clear which group is treating their patients correctly.
Radiation Therapy (RT) after breast conservign surgery may be the current standard of care, but it’s far from set in stone.
The data supporting RT is semi-equivocal. While the registry data provides strong survival benefit, many randomized controlled studies have failed to show survival benefit. When the studies are pooled and subjected to meta-analysis a small survival benefit is shown. Verschraegen calculates the increased mortality risk after not gettting RT at 8.6%. That said the recurrence risk after skipping RT is very high.
This is very complicated territory because of the type of statistical analysis used, the length of time that women were followed, the differences between patients in the registries vs. the study population, etc, etc.
What I will say is that it’s something you should discuss with your surgeon. If you are very low risk, e.g., ductal carcinoma in situ with clean margins and no positive nodes, or an older (70yo+) woman with a small (
— Adam SThe thought occurred to me that it could very well just be unrecognized sexism and racism on the part of the male doctors. If a woman is perceived as past her sexually attractive prime, then these male doctors may very well not see any reason for the treatment. I was onced asked by a surgeon I was interviewing “why I wanted to keep my uterus”? I very nearly asked him why he wanted to keep his balls, but I refrained. I then chose a woman surgeon for my procedure, and kept my uterus.
— LisaRadiation therapy to the breast after lumpectomy is one of the standards of care for early stage breast cancer. A simple mastectomy with lymph node biopsy is another option, with or without breast reconstruction.
The application of radiation to the breast after lumpectomy has been shown to reduce the risk of a recurrence of breast cancer within the breast. Approximately three out of ten women may experience a recurrence of cancer within the breast within ten years of a lumpectomy if they do not get radiation o the breast compared with around one in ten who do get radiation. Put a different way, seven out of ten women will not have a local recurrence of their disease if they do not get radiation vs. nine in ten who do get radiation.
While radiation in this situation is a standard of care, some patients may choose not to take treatment for a variety of reasons—among others, she may think that a seven out of ten chance of no local recurrence is a good enough outcome for her. Most will choose to get radiation.
Careful education of the breast cancer patient by a team that would include a radiation oncologist as well as surgeon and medical oncologist about the rationale for the use of any modality in the treatment of her breast cancer is important. Education about the options available and empowerment to make choices is essential for the vulnerable patient.
— David Howell, MDI had breast cancer and several treatments of chemotherapy…but no radiation. Mastectomy done in 2001. I think I’m still alive…I see a survivor when I look in the mirror…could that be me? Yep…with added lbs. and less hair…but then I’m about to be 71. Yes, I’ll accept greetings & birthday wishes…on Feb. 6. Cheers..to bloggers!
— kathleen claireF.Y.I.: My oncologist & surgeon were both male.
20+ years ago, ninety percent of all surgeons were male. Now, 60% are male. Since most male surgeons are older, if you don’t control for surgeon age, you will be statistically skewed. Look at decision making by male and female surgeons under the age of 45, adjusting for fellowwship training in surgical oncology and I am sure the numbers will be the same.
Remember: Lies, Dam Lies, and Statistics.
From TPP — the researchers controlled for this issue.
— veritasI think it is the nurturing nature of female surgeons that may have made them more melticulous in ordering a treatment course.
— Khanh ngostatistic are open for interpretation,it can be twisted,manipulated,and percept into a philosophical intellectual concept of one’s own ideology (idiosyncrasy).NB.ME LOW IQ.ME USE DICTIONARY FOR THIS COMMENT.
— james christensen,danish in thailandBased on the abstract of the article, as well as the methods (retrospective review of large database), it does not appear that they controlled for the age of the surgeon at all, so I think you may be incorrect, TPP. Also they did not control for who did a fellowship or not. I cannot help but think that the experience of a surgeon (which is under his or her control) matters far more than the sex of aeon surgeon (which is not). The importance of the article is clearly that the care of patients with breast cancer could and should be improved, not that the sex of the surgeon matters for each individual patient
From TPP — I was referring to the fact that there has been an increase in female surgeons. According to Dr.Hershman the number of female surgeons in the study group increased significantly over time. In the early 1990s, less than 10 percent of surgeons were female but by 2002 close to 25% were female. But if you look at the overall data set, there was a 13% increase associated with female gender.
— Chet Morrison MDNone of the respondents so far mention that the article says, “… as were women treated by doctors trained in the United States.”
I’ve just lost two family members to cancer, spent months with each one as death approached, spent days and weeks in hospitals with them, gone to countless doctor appointments at which I was in the examining rooms with them. I watched many doctors do their work. Yes, doctors from a different culture do seem to view death of elderly women differently than doctors from this western culture. Sad, but that was very obvious as soon as we went into these two situations. I was shocked because I had no warning about this. These non-western doctors are good, intelligent, hard-working and often even Christian (not that that matters to me, but it’s true). They often pray with and for the patient and that is so much appreciated by Christian patients. And yet, even then, there is a difference. One doctor from India told us, “In my country we take care of our elderly at home.” He was indicating that she should not go to a nursing home or should not stay in the hospital when she was dying. She wanted to be near medical help and knew there was nobody in her family strong enough to care for her at home. So she felt guilty no matter which choice she made because he basically told her that to choose care outside the home meant she was a “westerner” who has no sense of family. Another doctor from India told her in his examining room that she was costing him money - that Medicaid was not paying him enough - and that she would need to pay his office $100 every time she came in for radiation. He often made pointed remarks to me that I should not try to influence her, that she should make up her own mind, that she had at first opted not to be treated for the cancer and then changed her mind due to my influence. I only told her that she had a right to treatment if she wanted it. He had led her, early on, to think that she was stupid if she did opt for treatment. Note, this was a man who seemed to be a man of intelligence and dedication to his profession and who was a practicing Christian. I mention that because it’s a Western thing - not because I cared if he was or was not.
With the two experiences I’ve had and watched my family have in 2007 I will do all I can to be sure my doctor, male or female, is from the same culture that I am and therefore, hopefully, shares my values where my life is concerned. And no, I don’t think ALL doctors from India have allowed themselves to make constant comparisons between their “home” culture and that of the patients he or she sees here. But I simply will not be able to trust a doctor from outside my culture anymore to treat me with dignity concerning my values.
From TPP — The issue in this study was not nationality. It was whether the doctor was trained in the U.S. That’s an important distinction. Personally, I think having doctors of many nationalities is good for the U.S. healthcare system and good for patients. I also think patients and doctors alike have much to learn from “non-Western” cultures that take a more holistic approach to medicine.
— PatsyThe answer is right here: “Women who received radiation were more likely to have a female surgeon. Women who were treated by more experienced surgeons were also more likely to receive radiation treatment, as were women treated by doctors trained in the United States.”
It is about the attitude of the surgeon (empathy and concern for a woman). Female surgeons obviously are more likely to identify with a female patient. Female surgeons even from overseas, even from countries such as those in the middle east and west Asia where women are treated as second class citizens and beings than men, are still women themselves. On the other hand, male surgeons from these non-western cultures, in particular ones who have not been trained and to some degree resocialized in the United States, are going to be more likely to carry with them the traditional disregard for women in their cultures of origin. These foreign surgeons are just as capable as any other educated professional to access the latest protocols and clinical research as any other physician or surgeon here. It is about attitude and values. The experienced surgeon part has two aspects to it–1)these surgeons who were more likely to use radiation also were probably more like to be American or American trained, and also to have a much longer experience curve with outcomes–so even if they intially were trained overseas, the combination of being here longer and seeing the differential effect of post surgical treatment would impact their practice.
— RickAnalystHaving worked 32 years in healthcare–hospitals and private offices of my own and as an employee–I think the study may totally miss the critical issue.
Women on average tend to be more detail oriented and more cooperative in their work styles.
Men doctors–not only surgeons–tend to expect care to happen bacause of their intention, not because they carefully put the procedures in place to make it happen.
Women doctors (as well as other professions) tend to have more collegial relationships with their staff members who make the arrangements–they make their intentions clear and expect and reward (say thank you) follow-through.
If I were to design a study to clarify this issue I would look at the psychodynamics of the doctor-ancillary staff relationships.
I’ll bet it affects the standard of care after men’s surgeries also.
If the standards of care were assembled into easy to follow procedures for staff members to follow–prepare referrals, schedule appointments, etc–the quality of care in the US would increase tremendously.
— Marla Scripter RN DC