Related topics: •  Breast Cancer Center •  Breast Cancer Treatment Overview •  Finally Choosing Your Doctor •  What to Look for in a Breast Cancer Doctor

The treatment of breast cancer is a cooperative effort -- with you in charge. This is the first article in a series on how to find the right breast cancer doctor for you.

A doctor may have been the one who first felt the lump in your breast or saw something suspicious on a mammogram. If you found a lump yourself, you may have gone to your own physician or to someone at a group practice. Isn't the doctor already found by now? Maybe, but not necessarily. Probably, to get the very best diagnosis and care possible, you should look beyond this first person you've seen, even though you may decide in the end that she is the best person to treat you. No matter where you live, no matter what your experience with medical problems, no matter what access to specialists and medical centers you've had up to now -- you want to find the very best physicians possible for each aspect of your diagnosis, treatment, and follow-up. That search for a team of doctors -- usually beginning with a surgeon -- is what you and the people who are supporting you must now undertake. And if you consider the factors below, one by one, the task can be accomplished without too much difficulty and your choices will fall into place.

The place most people start this search is at the office of their gynecologist or their family doctor, who is sometimes an internist, a specialist in internal medicine.

You will have to ask yourself now whether you feel comfortable with the advice of this physician whom, up until now, you may have consulted only for fairly routine matters. Certainly you should consider the cancer specialist to whom she refers you, but you should also feel free to do a careful search of your own to be sure you are getting the best advice and care.

If, in other family health crises, you were pleased with your physician's referrals, you can proceed more confidently. Your doctor has probably already sent patients to this breast cancer specialist and has had a chance to see favorable results. If your own physician is a caring and intelligent human being, there's a good chance she will at least get you started on the right track.

Unless your illness is already in an extremely advanced stage, it is almost certainly to a surgeon that you will be sent next for the purpose of diagnosis. Why is that? Isn't a surgeon most likely to want to "cut"? As you will see, an essential early step in finding out what's wrong is often a biopsy-and a biopsy is surgery. It is a small operation, but a surgeon is best suited to perform it, not only because of his surgical skill, but because he has unique training that makes his opinion at both the diagnostic stage and the treatment stage invaluable.

Here's a helpful analogy: Trying to accurately assess a small mass that is deep in the breast is like trying to feel a pea hidden behind the think folds of a curtain. Unless you draw the curtain aside, you can't be sure that something is really there, much less what exactly it is. A good breast surgeon, because he has so much experience, is probably better at feeling what is behind the curtain than most other physicians. And he is the only one who, if it is necessary, should draw the curtain open, that is, perform the biopsy.

The surgeons who specialize in breast cancer have board certification in general surgery. They may have taken special training in breast surgery and they have certainly devoted their practices primarily to this disorder.

An important member of the diagnostic team is the radiologist, a specialist who has been trained and certified in the use of X rays and other forms of imaging that are used to look inside the body. This specialist has become an extremely important player in the diagnosis process. That is in part because of recent dramatic improvements in mammography, the X-ray procedure that produces "pictures" of the breast called mammograms. Since mammograms are now routinely used for preventive as well as diagnostic purposes, and since the results are now so refined, it is very important to consult a particularly expert mammographer. Excellence in performing the examination and in interpreting its results is a very special skill not shared by all those who do this procedure.

The radiotherapist uses radiation after a lumpectomy is performed and sometimes following a mastectomy. Radiation therapy may also be used locally to control advanced disease. (The radiotherapist is usually not involved in the diagnostic process.) Since breast tissue is extremely sensitive to damage by radiation, it is crucial to find competent and experienced practitioners who have at their disposal the best (and usually, unfortunately, most expensive) equipment possible for the planning and delivery of radiation treatment.

The medical oncologist generally sees breast cancer patients after the diagnosis and, usually after any necessary surgery that follows. Medical oncologists are internists who specialize in the diagnosis and treatment of cancer. They most commonly use systemic therapy; that is, hormone therapy and chemotherapy, which act throughout the body in the prevention of the recurrence of the disease as well as in long-term care. Briefly, chemotherapy is the use of special drugs that have a specific destructive effect on cancerous tissue. The hormones used in treatment cause tumor shrinkage. If a patient comes for treatment in a very advanced stage of breast cancer, the judgment may be made that surgery should not be used. In that case, the oncologist will treat the patient from the start. (I have in my own practice many women who came to me with advanced cancer but who, nevertheless, have done well. One woman came to my office eighteen years ago with a cancer so extensive that there seemed no reason to subject her to useless surgery. She has had a course of medical therapy and is not only still alive, but seems fine.)

A plastic surgeon repairs skin and tissue. After a mastectomy, he may be called upon to reconstruct a treated breast. (Plastic surgeons') results are strikingly better than they were only a few years ago.

You are in charge, in the sense that you will have to get enough information to be able to put together the team of specialists that is required for the best treatment of breast cancer. You should choose the best person you can find in each specialty. Who becomes the leader of the team depends on the nature of the illness, which doctor you need to see most frequently, who knows you best, and who is willing to act as leader. Ideally, the treatment of breast cancer is a cooperative effort with the command shifting as the need arises.

It is usually the surgeon who, at least initially is the leader. It is he who must perform the biopsy. Furthermore, in most cases the other treatments of breast cancer are used to supplement the effects of surgery. Nevertheless, the radiologist, the radiotherapist, the oncologist, the plastic surgeon, and the family doctor or gynecologist all play crucial roles, and each of these team members should be the very best physician available. What follows are guidelines to help you judge what "the very best" is, and then how to find it.

Click here to read Part Two.

-- Adapted from BREAST CANCER: THE COMPLETE GUIDE by Yashar Hirshaut, MD, FACP; and Peter I. Pressman, MD, FACS; © 1992 by Yashir Hirshaut. Used by permission of Bantam Books, a division of Random House, Inc. For online information about other Random House, Inc. books and authors, see the Internet Web Site at http://www.randomhouse.com.

First published May 17, 2001
Last updated March 12, 2008

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