Bilateral mastectomy: Driven by
fear or real desire for prevention?
Talking with elderly
BY MARY ANN MOON
Frontline Medical News
An expert panel has developed a communication frame- work to improve treatment of older, seriously ill pa- tients who have surgical emergencies, which has been
published online in Annals of Surgery.
A substantial portion of older patients who undergo
emergency surgeries already have serious life-limiting ill-nesses such as cardiopulmonary disease, renal failure, liver
failure, dementia, severe neurological impairment, or malignancy. The advisory panel based its work on the premise
that surgery in these circumstances can lead to signifcant
further morbidity, health care utilization, functional decline, prolonged hospital stay or institutionalization, and
death, with attendant physical discomfort and psychological distress at the end of these patients’ lives.
Surgeons consulted in the emergency setting for these
patients are hampered by patients unable to communicate
well because they are in extremis, by surrogates who are
unprepared for their role, and by time constraints, lack
of familiarity with the patient, poor understanding of the
illness by patients and families, prognostic uncertainty,
and inadequate advance care planning. In addition, “many
surgeons lack skills to engage in conversations about end-of-life care, or are too unfamiliar with palliative options to
VOL. 12 • NO. 1
See Elderly Ü page 6
5 l Commentary
Dr. Patrick Bailey gives the
inside story on how the ACS
Online & In-Depth
BY BRUCE JANCIN
Frontline Medical News
SAN ANTONIO – The worldwide upsurge in
the past decade in bilateral mastectomy for
unilateral breast cancer came under withering
fre from prominent breast surgeons at the
San Antonio Breast Cancer Symposium.
“It seems crazy, doesn’t it, that we’re spend-
ing all this time trying to conserve the breast,
yet we’re facing a tsunami of requests for bi-
lateral mastectomy,” observed Dr. Fiona Mac-
Neill, chairman of the education and training
committee of the Royal College of Surgeons
“A contralateral risk–reducing prophylactic
mastectomy undoubtedly will reduce the risk
of contralateral breast cancer, since you’re
removing the breast, but this is overtreatment for the vast majority of women who
request it. At 20 years we haven’t been able
to demonstrate that it ofers a signifcant survival advantage. I think a lot of what’s driving
bilateral mastectomy is fear and ignorance, a
failure to understand risk by patients and of-
See Mastectomy Ü page 9
Panel proposes structured conversation.
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Top take-homes from SABCS
View a video round table of Cleveland Clinic
experts discussing the highlights of the meeting.
FROM THE EDITOR:
Is surgical research still ‘comic opera’?
Dr. Layton F. Rikkers argues that surgical research has come
a long way in the past 20 years as more surgeons conduct
randomized controlled trials and publish results in
Ü Page 4
Dr. Ismail Jatoi, Dr. Fiona MacNeill, and Dr. Benjamin D. Smith challenged conventional wisdom
on breast cancer surgery at the San Antonio Breast Cancer Symposium.
16 l General Surgery
Dr. Samuel W. Ross and his
colleagues offer a definition of
massive ventral hernia.
23 l Surgical Oncology
A study compares lymphazurin
with methylene blue dye.