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Screening Mammography: Debates, Guidelines, Issues
The screening mammography debate has been rekindled by the American Cancer Society’s updated guideline released in October 2015. Surgeons are now looking at yet another iteration of the optimal surveillance schedule aimed at reducing breast cancer mortality.
Nearly all breast cancer patients undergo surgery as at least one component of their care through diagnostic biopsy and/or definitive locoregional management, and many women are referred to surgeons for evaluation as well as follow-up for a variety of benign breast problems. The discussion of breast cancer screening with patients can be complicated by the many guidelines with conflicting recommendations, not to mention patient fears triggered by incompletely informed or simplistic media coverage. Surgeons are therefore obliged to remain knowledgeable regarding the status and rationale for breast cancer screening guidelines that have been developed by our colleagues in the American Cancer Society as well as other organizations.
Context of the updated guideline
The American Cancer Society and the American College of Surgeons have historically advocated in favor of annual screening mammography for average-risk women in the United States beginning at age 40 years (https://goo.gl/4W92EI). In 2009, the United States Preventive Services Task Force (USPSTF) published a recommendation that women delay initiation of screening mammography until reaching age 50, with follow-up studies performed biennially thereafter. This USPSTF guideline has remain unchanged as of 2015 (http://goo.gl/RYYWEP). Other medical societies and institutions have established their own guidelines.
The updated American Cancer Society guideline now recommends that average-risk women initiate annual mammography at age 45, but advocates in favor of availability of annual mammography beginning at age 40; the updated guideline also indicates that women can transition to biennial mammography at age 55, but should have access to continued annual mammography in accordance with personal preferences and after consideration of risks and benefits (JAMA. 2015;314[15]:1599-614).
The updated guideline can basically be interpreted as a more relaxed version of the prior guideline, which featured a straightforward mandate for average-risk women to undergo annual screening mammography beginning at age 40 years. However, the increased complexity of the more flexible guideline has generated legitimate concerns regarding the potential for confusion and misinterpretation.
Updated guideline rationale and empirical basis
The Society commissioned a systematic review to evaluate the benefits and harms of mammographic screening as well as clinical breast examination, based upon randomized clinical trials, and observational and modeling studies (JAMA. 2015;314[15]: 1615-34).
The Society then convened their Guideline Development Group (GDG) and GDG Breast Subgroup to interpret the systematic review for the purpose of drafting the breast cancer screening update. This process was further guided by a panel of External Expert Advisors. Mortality reductions were analyzed in the context of population-based breast cancer incidence rates by 5-year age increments.
Not surprisingly, the overall review confirmed the findings of several published studies that screening mammography in women aged 40-79 reduces breast cancer mortality rates by 20%-50%, with extent of benefit varying by age, as well as study design (randomized clinical trial versus observational). Since breast cancer incidence rates increase substantially among women by age (incidence rates per 100,000 population for women 35-39; 40-44; 45-49; 50-54; and 55-59 reported as 59.5; 122.5; 188.6; 224.0; and 266.4, respectively), the likelihood of a mammogram detecting a true cancer clearly increases with age. The American Cancer Society GDG Breast Subgroup balanced the mortality reductions and population-based incidence rates against the risks of mammography “harms” (defined as needing to be recalled for additional testing via imaging and/or biopsy).
The quality of evidence for estimating risk of “overdiagnosis” (detecting a breast cancer that was not destined to be biologically significant or life threatening) was deemed to be insufficient and so this controversial metric was omitted from the final analysis. However, data regarding the general tendency for breast cancers to have more favorable biologic features (and therefore presumed to be more indolent) in older-aged women were taken into account with regard to recommendations for age-based screening intervals.
Upon review of the above incidence and mortality-related issues, the Society generated their age- and interval-based mammography screening recommendations. The recommendations were stratified as either “strong” (defined as a screening practice that “most” patients should follow, and one that could be reasonably used as a “quality criterion or performance indicator”) or “qualified” (defined as a screening practice that is reasonable for the “majority” of patients, but encouraging a balanced discussion of possible alternatives and informed decision making). The recommendations for average-risk women are summarized as follows:
• Strong Recommendation: Women should initiate screening mammography at age 45 years.
• Qualified Recommendation: Screening mammography should be performed annually between ages 45 and 54 years.
• Qualified Recommendation: Women should have the opportunity to undergo annual screening mammography between ages 40 and 44 years.
• Qualified Recommendation: Women aged 55 and older should transition to biennial screening mammography but they should have the opportunity to continue annual screening.
• Qualified Recommendation: Women should continue screening mammography until they no longer have a life expectancy of at least 10 years.
The updated American Cancer Society screening mammography guideline therefore continues to support availability of annual screening mammography for average-risk women beginning at age 40 years and continuing for as long as life expectancy supports the benefit of undergoing treatment for a screen-detected breast cancer. However, in acknowledging the increasing risk of breast cancer with age and the increased prevalence of biologically favorable breast cancers among older versus younger women, the Society stresses that screening mammography is a must by the time a woman reaches age 45, and that she can safely consider transitioning from annual to biennial screening at age 55.
Other components of the updated guideline:
While the mammography component of the breast cancer screening guidelines have provoked the most substantial discussion, they have also addressed other screening practices, and these are summarized as follows:
• Qualified Recommendation: Clinical breast examination is not recommended for breast cancer screening among average-risk women at any age.
• Not addressed in the update, and therefore not changed from prior American Cancer Society recommendation: Breast self-examination is not recommended for average-risk women at any age.
Additional issues in the screening mammography debate
While the American Cancer Society and other organizations attempt to synthesize and interpret the existing data regarding the benefits and risks of various screening practices, clinicians must also consider several public health issues when deciding upon their own screening recommendation practices:
• Disparities and variation in breast cancer patterns associated with racial/ethnic identity: Although white American women have historically had higher population-based incidence rates of breast cancer, compared with African American women, incidence rates have risen among African Americans, and 2012 data indicate comparable rates for both groups. Furthermore, breast cancer outcome disparities have worsened, with breast cancer mortality rates 42% higher for African Americans (CA Cancer J Clin. 2015 Oct 29. doi: 10.3322/caac.21320 [Epub ahead of print]). African American women have a twofold higher population-based incidence rate of the biologically more aggressive triple-negative breast cancers at all ages, and the rates among African American women in their forties is higher than those among white American women in their fifties (Cancer. 2011;117[12]:2747-53; J Natl Cancer Inst. 2015;107[6]: djv048). Prevalence of breast cancer in the premenopausal age range is also higher among African American patients. Delayed initiation of breast cancer screening, and more prolonged intervals between screenings is therefore likely to have a disproportionate impact on the breast cancer burden of the African American population.
• Demographics of the American female population: While overall population-based incidence rates of breast cancer have been stable among American women younger than age 45 years, U.S. Census data reveal 10 million more women in the 20-45 years age range for 2010, compared with 1980. The absolute number of breast cancer patients belonging to this young age category has therefore increased (JAMA Oncol. 2015;1[7]:877-8).
• Scenarios that are not relevant for routine screening recommendations: Clinicians must continue to aggressively counsel patients regarding the importance of overall breast health awareness. The development of a new breast mass, inflammatory skin changes, and/or bloody nipple discharge should prompt immediate medical attention regardless of the result and timing of the most recent mammogram. Furthermore, women facing increased risk of breast cancer because of family history, chest wall irradiation in adolescence/early adulthood, and high-risk breast biopsy pathology (atypia, lobular carcinoma in situ) are candidates for more intense surveillance such as breast MRI in addition to mammography. The most appropriate management of women with increased risk based upon mammographic density remains unclear. Lastly but extremely importantly, American-based breast cancer screening recommendations do not apply to low- and middle-income countries where screening mammography is not widely available. Clinical breast examination and breast self-examination may play a different role in the breast cancer burden of these populations.
Dr. Newman is an ACS Fellow, Director of the Breast Oncology Program, Multi-Hospital Henry Ford Health System, Detroit, and founding Medical Director, Henry Ford Health System International Center for the Study of Breast Cancer Subtypes. Dr. Newman has acted as a volunteer advisor to the American Cancer Society.
The screening mammography debate has been rekindled by the American Cancer Society’s updated guideline released in October 2015. Surgeons are now looking at yet another iteration of the optimal surveillance schedule aimed at reducing breast cancer mortality.
Nearly all breast cancer patients undergo surgery as at least one component of their care through diagnostic biopsy and/or definitive locoregional management, and many women are referred to surgeons for evaluation as well as follow-up for a variety of benign breast problems. The discussion of breast cancer screening with patients can be complicated by the many guidelines with conflicting recommendations, not to mention patient fears triggered by incompletely informed or simplistic media coverage. Surgeons are therefore obliged to remain knowledgeable regarding the status and rationale for breast cancer screening guidelines that have been developed by our colleagues in the American Cancer Society as well as other organizations.
Context of the updated guideline
The American Cancer Society and the American College of Surgeons have historically advocated in favor of annual screening mammography for average-risk women in the United States beginning at age 40 years (https://goo.gl/4W92EI). In 2009, the United States Preventive Services Task Force (USPSTF) published a recommendation that women delay initiation of screening mammography until reaching age 50, with follow-up studies performed biennially thereafter. This USPSTF guideline has remain unchanged as of 2015 (http://goo.gl/RYYWEP). Other medical societies and institutions have established their own guidelines.
The updated American Cancer Society guideline now recommends that average-risk women initiate annual mammography at age 45, but advocates in favor of availability of annual mammography beginning at age 40; the updated guideline also indicates that women can transition to biennial mammography at age 55, but should have access to continued annual mammography in accordance with personal preferences and after consideration of risks and benefits (JAMA. 2015;314[15]:1599-614).
The updated guideline can basically be interpreted as a more relaxed version of the prior guideline, which featured a straightforward mandate for average-risk women to undergo annual screening mammography beginning at age 40 years. However, the increased complexity of the more flexible guideline has generated legitimate concerns regarding the potential for confusion and misinterpretation.
Updated guideline rationale and empirical basis
The Society commissioned a systematic review to evaluate the benefits and harms of mammographic screening as well as clinical breast examination, based upon randomized clinical trials, and observational and modeling studies (JAMA. 2015;314[15]: 1615-34).
The Society then convened their Guideline Development Group (GDG) and GDG Breast Subgroup to interpret the systematic review for the purpose of drafting the breast cancer screening update. This process was further guided by a panel of External Expert Advisors. Mortality reductions were analyzed in the context of population-based breast cancer incidence rates by 5-year age increments.
Not surprisingly, the overall review confirmed the findings of several published studies that screening mammography in women aged 40-79 reduces breast cancer mortality rates by 20%-50%, with extent of benefit varying by age, as well as study design (randomized clinical trial versus observational). Since breast cancer incidence rates increase substantially among women by age (incidence rates per 100,000 population for women 35-39; 40-44; 45-49; 50-54; and 55-59 reported as 59.5; 122.5; 188.6; 224.0; and 266.4, respectively), the likelihood of a mammogram detecting a true cancer clearly increases with age. The American Cancer Society GDG Breast Subgroup balanced the mortality reductions and population-based incidence rates against the risks of mammography “harms” (defined as needing to be recalled for additional testing via imaging and/or biopsy).
The quality of evidence for estimating risk of “overdiagnosis” (detecting a breast cancer that was not destined to be biologically significant or life threatening) was deemed to be insufficient and so this controversial metric was omitted from the final analysis. However, data regarding the general tendency for breast cancers to have more favorable biologic features (and therefore presumed to be more indolent) in older-aged women were taken into account with regard to recommendations for age-based screening intervals.
Upon review of the above incidence and mortality-related issues, the Society generated their age- and interval-based mammography screening recommendations. The recommendations were stratified as either “strong” (defined as a screening practice that “most” patients should follow, and one that could be reasonably used as a “quality criterion or performance indicator”) or “qualified” (defined as a screening practice that is reasonable for the “majority” of patients, but encouraging a balanced discussion of possible alternatives and informed decision making). The recommendations for average-risk women are summarized as follows:
• Strong Recommendation: Women should initiate screening mammography at age 45 years.
• Qualified Recommendation: Screening mammography should be performed annually between ages 45 and 54 years.
• Qualified Recommendation: Women should have the opportunity to undergo annual screening mammography between ages 40 and 44 years.
• Qualified Recommendation: Women aged 55 and older should transition to biennial screening mammography but they should have the opportunity to continue annual screening.
• Qualified Recommendation: Women should continue screening mammography until they no longer have a life expectancy of at least 10 years.
The updated American Cancer Society screening mammography guideline therefore continues to support availability of annual screening mammography for average-risk women beginning at age 40 years and continuing for as long as life expectancy supports the benefit of undergoing treatment for a screen-detected breast cancer. However, in acknowledging the increasing risk of breast cancer with age and the increased prevalence of biologically favorable breast cancers among older versus younger women, the Society stresses that screening mammography is a must by the time a woman reaches age 45, and that she can safely consider transitioning from annual to biennial screening at age 55.
Other components of the updated guideline:
While the mammography component of the breast cancer screening guidelines have provoked the most substantial discussion, they have also addressed other screening practices, and these are summarized as follows:
• Qualified Recommendation: Clinical breast examination is not recommended for breast cancer screening among average-risk women at any age.
• Not addressed in the update, and therefore not changed from prior American Cancer Society recommendation: Breast self-examination is not recommended for average-risk women at any age.
Additional issues in the screening mammography debate
While the American Cancer Society and other organizations attempt to synthesize and interpret the existing data regarding the benefits and risks of various screening practices, clinicians must also consider several public health issues when deciding upon their own screening recommendation practices:
• Disparities and variation in breast cancer patterns associated with racial/ethnic identity: Although white American women have historically had higher population-based incidence rates of breast cancer, compared with African American women, incidence rates have risen among African Americans, and 2012 data indicate comparable rates for both groups. Furthermore, breast cancer outcome disparities have worsened, with breast cancer mortality rates 42% higher for African Americans (CA Cancer J Clin. 2015 Oct 29. doi: 10.3322/caac.21320 [Epub ahead of print]). African American women have a twofold higher population-based incidence rate of the biologically more aggressive triple-negative breast cancers at all ages, and the rates among African American women in their forties is higher than those among white American women in their fifties (Cancer. 2011;117[12]:2747-53; J Natl Cancer Inst. 2015;107[6]: djv048). Prevalence of breast cancer in the premenopausal age range is also higher among African American patients. Delayed initiation of breast cancer screening, and more prolonged intervals between screenings is therefore likely to have a disproportionate impact on the breast cancer burden of the African American population.
• Demographics of the American female population: While overall population-based incidence rates of breast cancer have been stable among American women younger than age 45 years, U.S. Census data reveal 10 million more women in the 20-45 years age range for 2010, compared with 1980. The absolute number of breast cancer patients belonging to this young age category has therefore increased (JAMA Oncol. 2015;1[7]:877-8).
• Scenarios that are not relevant for routine screening recommendations: Clinicians must continue to aggressively counsel patients regarding the importance of overall breast health awareness. The development of a new breast mass, inflammatory skin changes, and/or bloody nipple discharge should prompt immediate medical attention regardless of the result and timing of the most recent mammogram. Furthermore, women facing increased risk of breast cancer because of family history, chest wall irradiation in adolescence/early adulthood, and high-risk breast biopsy pathology (atypia, lobular carcinoma in situ) are candidates for more intense surveillance such as breast MRI in addition to mammography. The most appropriate management of women with increased risk based upon mammographic density remains unclear. Lastly but extremely importantly, American-based breast cancer screening recommendations do not apply to low- and middle-income countries where screening mammography is not widely available. Clinical breast examination and breast self-examination may play a different role in the breast cancer burden of these populations.
Dr. Newman is an ACS Fellow, Director of the Breast Oncology Program, Multi-Hospital Henry Ford Health System, Detroit, and founding Medical Director, Henry Ford Health System International Center for the Study of Breast Cancer Subtypes. Dr. Newman has acted as a volunteer advisor to the American Cancer Society.
The screening mammography debate has been rekindled by the American Cancer Society’s updated guideline released in October 2015. Surgeons are now looking at yet another iteration of the optimal surveillance schedule aimed at reducing breast cancer mortality.
Nearly all breast cancer patients undergo surgery as at least one component of their care through diagnostic biopsy and/or definitive locoregional management, and many women are referred to surgeons for evaluation as well as follow-up for a variety of benign breast problems. The discussion of breast cancer screening with patients can be complicated by the many guidelines with conflicting recommendations, not to mention patient fears triggered by incompletely informed or simplistic media coverage. Surgeons are therefore obliged to remain knowledgeable regarding the status and rationale for breast cancer screening guidelines that have been developed by our colleagues in the American Cancer Society as well as other organizations.
Context of the updated guideline
The American Cancer Society and the American College of Surgeons have historically advocated in favor of annual screening mammography for average-risk women in the United States beginning at age 40 years (https://goo.gl/4W92EI). In 2009, the United States Preventive Services Task Force (USPSTF) published a recommendation that women delay initiation of screening mammography until reaching age 50, with follow-up studies performed biennially thereafter. This USPSTF guideline has remain unchanged as of 2015 (http://goo.gl/RYYWEP). Other medical societies and institutions have established their own guidelines.
The updated American Cancer Society guideline now recommends that average-risk women initiate annual mammography at age 45, but advocates in favor of availability of annual mammography beginning at age 40; the updated guideline also indicates that women can transition to biennial mammography at age 55, but should have access to continued annual mammography in accordance with personal preferences and after consideration of risks and benefits (JAMA. 2015;314[15]:1599-614).
The updated guideline can basically be interpreted as a more relaxed version of the prior guideline, which featured a straightforward mandate for average-risk women to undergo annual screening mammography beginning at age 40 years. However, the increased complexity of the more flexible guideline has generated legitimate concerns regarding the potential for confusion and misinterpretation.
Updated guideline rationale and empirical basis
The Society commissioned a systematic review to evaluate the benefits and harms of mammographic screening as well as clinical breast examination, based upon randomized clinical trials, and observational and modeling studies (JAMA. 2015;314[15]: 1615-34).
The Society then convened their Guideline Development Group (GDG) and GDG Breast Subgroup to interpret the systematic review for the purpose of drafting the breast cancer screening update. This process was further guided by a panel of External Expert Advisors. Mortality reductions were analyzed in the context of population-based breast cancer incidence rates by 5-year age increments.
Not surprisingly, the overall review confirmed the findings of several published studies that screening mammography in women aged 40-79 reduces breast cancer mortality rates by 20%-50%, with extent of benefit varying by age, as well as study design (randomized clinical trial versus observational). Since breast cancer incidence rates increase substantially among women by age (incidence rates per 100,000 population for women 35-39; 40-44; 45-49; 50-54; and 55-59 reported as 59.5; 122.5; 188.6; 224.0; and 266.4, respectively), the likelihood of a mammogram detecting a true cancer clearly increases with age. The American Cancer Society GDG Breast Subgroup balanced the mortality reductions and population-based incidence rates against the risks of mammography “harms” (defined as needing to be recalled for additional testing via imaging and/or biopsy).
The quality of evidence for estimating risk of “overdiagnosis” (detecting a breast cancer that was not destined to be biologically significant or life threatening) was deemed to be insufficient and so this controversial metric was omitted from the final analysis. However, data regarding the general tendency for breast cancers to have more favorable biologic features (and therefore presumed to be more indolent) in older-aged women were taken into account with regard to recommendations for age-based screening intervals.
Upon review of the above incidence and mortality-related issues, the Society generated their age- and interval-based mammography screening recommendations. The recommendations were stratified as either “strong” (defined as a screening practice that “most” patients should follow, and one that could be reasonably used as a “quality criterion or performance indicator”) or “qualified” (defined as a screening practice that is reasonable for the “majority” of patients, but encouraging a balanced discussion of possible alternatives and informed decision making). The recommendations for average-risk women are summarized as follows:
• Strong Recommendation: Women should initiate screening mammography at age 45 years.
• Qualified Recommendation: Screening mammography should be performed annually between ages 45 and 54 years.
• Qualified Recommendation: Women should have the opportunity to undergo annual screening mammography between ages 40 and 44 years.
• Qualified Recommendation: Women aged 55 and older should transition to biennial screening mammography but they should have the opportunity to continue annual screening.
• Qualified Recommendation: Women should continue screening mammography until they no longer have a life expectancy of at least 10 years.
The updated American Cancer Society screening mammography guideline therefore continues to support availability of annual screening mammography for average-risk women beginning at age 40 years and continuing for as long as life expectancy supports the benefit of undergoing treatment for a screen-detected breast cancer. However, in acknowledging the increasing risk of breast cancer with age and the increased prevalence of biologically favorable breast cancers among older versus younger women, the Society stresses that screening mammography is a must by the time a woman reaches age 45, and that she can safely consider transitioning from annual to biennial screening at age 55.
Other components of the updated guideline:
While the mammography component of the breast cancer screening guidelines have provoked the most substantial discussion, they have also addressed other screening practices, and these are summarized as follows:
• Qualified Recommendation: Clinical breast examination is not recommended for breast cancer screening among average-risk women at any age.
• Not addressed in the update, and therefore not changed from prior American Cancer Society recommendation: Breast self-examination is not recommended for average-risk women at any age.
Additional issues in the screening mammography debate
While the American Cancer Society and other organizations attempt to synthesize and interpret the existing data regarding the benefits and risks of various screening practices, clinicians must also consider several public health issues when deciding upon their own screening recommendation practices:
• Disparities and variation in breast cancer patterns associated with racial/ethnic identity: Although white American women have historically had higher population-based incidence rates of breast cancer, compared with African American women, incidence rates have risen among African Americans, and 2012 data indicate comparable rates for both groups. Furthermore, breast cancer outcome disparities have worsened, with breast cancer mortality rates 42% higher for African Americans (CA Cancer J Clin. 2015 Oct 29. doi: 10.3322/caac.21320 [Epub ahead of print]). African American women have a twofold higher population-based incidence rate of the biologically more aggressive triple-negative breast cancers at all ages, and the rates among African American women in their forties is higher than those among white American women in their fifties (Cancer. 2011;117[12]:2747-53; J Natl Cancer Inst. 2015;107[6]: djv048). Prevalence of breast cancer in the premenopausal age range is also higher among African American patients. Delayed initiation of breast cancer screening, and more prolonged intervals between screenings is therefore likely to have a disproportionate impact on the breast cancer burden of the African American population.
• Demographics of the American female population: While overall population-based incidence rates of breast cancer have been stable among American women younger than age 45 years, U.S. Census data reveal 10 million more women in the 20-45 years age range for 2010, compared with 1980. The absolute number of breast cancer patients belonging to this young age category has therefore increased (JAMA Oncol. 2015;1[7]:877-8).
• Scenarios that are not relevant for routine screening recommendations: Clinicians must continue to aggressively counsel patients regarding the importance of overall breast health awareness. The development of a new breast mass, inflammatory skin changes, and/or bloody nipple discharge should prompt immediate medical attention regardless of the result and timing of the most recent mammogram. Furthermore, women facing increased risk of breast cancer because of family history, chest wall irradiation in adolescence/early adulthood, and high-risk breast biopsy pathology (atypia, lobular carcinoma in situ) are candidates for more intense surveillance such as breast MRI in addition to mammography. The most appropriate management of women with increased risk based upon mammographic density remains unclear. Lastly but extremely importantly, American-based breast cancer screening recommendations do not apply to low- and middle-income countries where screening mammography is not widely available. Clinical breast examination and breast self-examination may play a different role in the breast cancer burden of these populations.
Dr. Newman is an ACS Fellow, Director of the Breast Oncology Program, Multi-Hospital Henry Ford Health System, Detroit, and founding Medical Director, Henry Ford Health System International Center for the Study of Breast Cancer Subtypes. Dr. Newman has acted as a volunteer advisor to the American Cancer Society.
Black surgeons transcend artificial barriers
The emergence of African Americans as acclaimed leaders in the field of surgery over the last century is a triumph of personal struggle, brilliant minds, and sheer determination.
Disparities in educational and professional opportunities related to racial/ethnic identity persist, but LaSalle D. Leffall, Jr., MD, FACS, fondly recalls a favorite quote from pioneering African American surgeon Charles Drew: “Excellence of performance will transcend artificial barriers created by man.” The goals and abundant talent shared by the membership of the American College of Surgeons (ACS) and Society of Black Academic Surgeons (SBAS) are testimony to the ongoing dissolution of these artificial barriers.
Parallels are evident between the history of organized surgery in America and African American efforts to achieve health care equity. While the spectrum of surgical procedures mushroomed in the late 19th century, surgical training was characterized by inconsistency and instability. The ACS was established in 1913 with the mission of “improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.”
Significant disparities in medical and surgical care existed for African Americans in this era. During the decades following the Civil War, black citizens were routinely denied care or they received substandard care delivered in segregated hospitals. Medical education opportunities for African Americans were nearly nonexistent.
Nonetheless, African Americans mobilized their talent and energy to address the same threats to quality medical care as those faced by the ACS founders, but having to overcome even greater obstacles in the form of systematic racism and exclusion.
Chicago’s Provident Hospital and Training School (the first African American-owned and -operated hospital) was established in 1891. Howard University College of Medicine in Washington, and Meharry Medical College in Nashville, Tenn., founded in 1868 and 1876, respectively, remained the predominent options for prospective African American medical students for several decades. Because African American medical professionals were denied membership in the American Medical Association, they formed their own professional society, the National Medical Association, in 1895.
In contrast, Dr. Daniel Hale Williams, founder of the Provident Hospital and founding member of the National Medical Association, was a charter member of ACS in 1913. However, more than 20 years passed before another African American surgeon (Louis Tompkins Wright, MD, FACS) became a Fellow of the College.
The number of African American surgeons in the College grew steadily after World War II, and in the past 3 years, approximately 6% of ACS inductees have been African Americans.
The value of race/ethnic diversity in optimizing quality of care is summarized by Dr. Otis Brawley, Chief Medical Officer for the American Cancer Society and past Director of the Office for Special Populations Research at the National Institutes of Health: “The practice of surgery is both a science and an art. Part of the art is understanding the patient’s needs and communicating well. Modern medicine has used the phrase ‘cultural competence’ to describe this. While a physician of one race certainly can and often does provide excellent service to a patient of another, diverse membership in the surgical community is essential for cultural competence of that community.”
Pioneering black surgeons
The following lists a few of the many African American surgical luminaries who fought incredible obstacles in order to improve health outcomes for all:
• Daniel Hale Williams, MD, FACS (1856-1931): Founder of Provident Hospital; performed one of the first successful open heart surgeries; charter member of the ACS.
• Louis Tompkins Wright, MD, FACS (1891-1952): Second African American admitted to ACS Fellowship (in 1934) amid much debate and controversy, despite graduating cum laude from Harvard Medical School and having an illustrious career as a decorated Army surgeon. Dr. Wright was the son of a slave (Ceah Ketcham Wright, MD) who pursued medical education at Meharry after obtaining his freedom.
• Charles Richard Drew, MD, FACS (1904-1950): Pioneer transfusion researcher; first American Red Cross Blood Bank director. Dr. Leffall, a Drew trainee, recalls, “After several applications for fellowship in ACS, Drew was approved for admission at the annual convocation October 1950. He was killed in an automobile accident April 1, 1950, en route to a medical meeting in Tuskegee, Ala. In a highly unusual action, the College’s Board of Regents approved him for posthumous fellowship October 1951.”
• Vivien Thomas (1910-1985): surgical technical assistant to Dr. Alfred Blalock at Vanderbilt, and supervisor of surgical laboratories at Johns Hopkins for 35 years; became pioneer in cardiac surgery despite having no formal education beyond high school and awarded honorary doctorate at Hopkins in 1976.
• Samuel Kountz, MD, FACS (1930-1981): Pioneer transplant surgeon; performed first successful human non-identical twin kidney transplant; developed Belzer kidney perfusion prototype.
• Claude Organ, MD, FACS (1926-2005): Professor of surgery at the University of California, Davis, and University of California, San Francisco East; editor of JAMA Archives of Surgery; founding member and President of SBAS (1995-1997) and second African American President of ACS (2003-2004).
• LaSalle D. Leffall, Jr., MD, FACS: Charles R. Drew Professor of Surgery and former chairman of surgery at Howard University; former chairman of the President’s Cancer Panel; SBAS president (1997-1998); first African American president of the American Cancer Society; first African American president of the ACS (1995-1996).
• Levi Watkins, MD: Professor of cardiac surgery, Johns Hopkins University; performed first human implantation of automatic implantable defibrillator; carried out landmark efforts to strengthen diversity among health care professionals. Dr. Watkins commented: “On the occasion of the national holiday of my former pastor, Dr. Martin Luther King, Jr., I am happy to say that given the opportunity the African American surgeon has shown very well that he or she is capable and worthy to serve and lead this nation in health equity and well-being. We must, however, not allow this progress and opportunity to slip from us using slogans to replace direct action on our part. I must compliment the ACS for its role in helping to bring about change in this area.”
• Harold P. Freeman, MD, FACS: Past president, American Cancer Society; past chairman, President’s Cancer Panel; pioneer architect of patient navigation programs; founder and president/CEO, Harold P. Freeman Patient Navigation Institute.
• Haile Debas, MD, FACS: Past chairman, University of California, San Francisco (UCSF) department of surgery; past dean, School of Medicine; founding executive director, UCSF Global Health Sciences; president, the American Surgical Association (2002-2003).
• Benjamin S. Carson, Sr., MD: Emeritus professor of neurosurgery, Johns Hopkins School of Medicine; president/CEO American Business Collaborative, LLC; awarded Presidential Medal of Freedom; renowned for historic 1987 surgical procedure separating craniopagus conjoined twins.
He recalled: “Twins joined at the back of the head had never before been separated with both surviving. The 22-hour operation which combined advanced neurosurgical techniques with hypothermic cardiac arrest proved successful. I intentionally remained in the background and did not reveal my role as the primary neurosurgeon until the press conference several hours after the completion of the operation. Historically, the accomplishments of Blacks in scientific endeavors have not been heavily covered by the news media. In order to inspire millions of Black youngsters who lacked scientific role models, I waited until the story was so big that the media could not back off. Thankfully our society has advanced to the point that this kind of thing is no longer necessary.”
• Alexa Canady, MD, FACS: First African American female neurosurgery resident (University of Minnesota); became chief of neurosurgery at the Children’s Hospital of Detroit at age 36.
• Henri R. Ford, MD, FACS: Past surgeon-in-chief, Children’s Hospital of Pittsburgh; past vice-president, chief of surgery, University of California, Los Angeles (UCLA); vice-dean for Medical Education, Keck School/UCLA; SBAS president (2010-2011).
• L.D. Britt, MD, MPH, D.Sc (Hon), FACS, FCCM, FRCSEng (Hon), FRCSEd (Hon), FWACS (Hon), FRCSI (Hon), FCS(SA) (Hon), FRCS(Glasg) (Hon):
Chairman, department of surgery at Eastern Virginia Medical School; past president of numerous academic societies (American College of Surgeons, 2010-2011; Southern Surgical Congress; American Association of Trauma; Halsted Society, SBAS 1999-2001; American Surgical Association; Society of Surgical Chairs); current SBAS executive director; Robert J. Glaser Distinguished Educator Award recipient (highest teaching award granted by Association of American Medical Colleges).
Professional and personal challenges
Many of these African American professionals tackle the same barriers to productive longevity as the African American general population – disparities in professional promotion opportunities, socioeconomic disadvantages, and reduced life expectancy (National Vital Statistics Reports; vol. 61 no. 4., National Center for Health Statistics 2013).
Black physicians are less likely to receive academic promotion in university programs and are underrepresented within the full professorship rank (JAMA 2000; 284:1085-92); African American researchers are less likely to receive NIH research funding (Science 2011;333:1015-19); and society has lost many academically accomplished African American surgeons to premature death from cancer and other illnesses as well as trauma. Icons Dr. Charles Drew and Dr. Sam Kountz both died in the prime of their professional careers. More recently, the surgical oncology community mourned the losses of Keith Amos, MD, FACS, assistant professor of surgery, University of North Carolina and Yvedt Matory, MD, FACS, assistant professor of surgery, Harvard Medical School. Both of these talented surgeons died before reaching age 50.
Socioeconomic disparities and downstream effects on the pipeline of African American students and trainees remain apparent in the pool of surgeons available to pursue academic careers. These inequities are poignantly described by Sha’shonda Revels, MD, chief resident in general surgery at the University of Michigan, Ann Arbor, with plans to pursue an academic career in cardiothoracic surgery: “I consider myself truly blessed to have the opportunity to learn a tangible skill that I can use to effect change in the lives of others. … I appreciate the struggles that others have made for me to have this opportunity. Those not so well known ‘others’ include my grandmother who cleaned houses, and took care of me so that my mother could finish high school and attend college. They also include my parents who were tenacious about academics and would not accept a B average.”
The SBAS is born
Despite post-WWII gains, opportunities remained limited for black surgeons to achieve prominence and recognition in academic surgical societies. The Society for Black Academic Surgeons was therefore established as a network that would promote the careers of African American surgeons in academia and accelerate their upward professional trajectory.
SBAS founding member and President (1993-1995) Eddie Hoover, MD, FACS, professor of surgery at the State University of New York Buffalo, and Editor-in-Chief for the Journal of the National Medical Association, provides this passionate account of its history and accomplishments: “SBAS was created in a hotel room at the Marriott in New Orleans in 1987 to address the paucity of academic African American surgeons; their poor retention, promotion, and research funding; and lack of a leadership role in American surgery. The hero of academic African American surgeons, Dr. Charles Drew, adorns the shield of SBAS as much for his defiance of ACS for refusing to accept other well-qualified African American surgeons in the 1940’s as for his scientific contributions …With strong ACS support, SBAS has been stunningly successful over the past 27 years with a dozen SBAS members serving as surgical chairs and four as deans of majority schools.”
Dr. Britt, first African American chair of the ACS Board of Regents and later SBAS president, emphasizes that these two organizations have shared goals. “The evolution of the American College of Surgeons, the world’s largest organization for surgeons, and its growing partnership with the Society of Black Academic Surgeons (demonstrated formally, informally, and sometimes tacitly) needs to be recognized, underscored, and continually enhanced. Many of the ideals of SBAS now mirror the ideals and achievements of the ACS, including an ever growing diverse membership, improved diversity at all levels of leadership, meaningful mentorships for underrepresented minorities, and the establishment of several initiatives to address severe health care disparities in the world’s wealthiest nation.”
The 25th Annual Scientific Meeting of the SBAS will be hosted by the University of North Carolina, Chapel Hill, April 9-11, 2015.
Frederick Cason, MD, FACS, professor of surgery and chief, Division of Surgical Education at Morehouse School of Medicine and the SBAS historian and archivist, stated, “With the strong academic activities of SBAS, the networking it fosters, and the partnerships with numerous academic institutions and members of the College… there developed some 10 academic chairmen and at least 4 deans leading our major medical centers in America.”
Andrea Hayes-Jordan, MD, SBAS 2015 Annual Meeting program chair and associate professor of surgery and Pediatrics and Director of Pediatric Surgical Oncology at the University of Texas M.D. Anderson Cancer Center, notes, “At the annual meeting we are not only able to see the results of excellent research efforts from minority surgeons from around the country, but one has the unique opportunity to interact with them on a personal level, at an intimate meeting. This personal interaction with successful chair persons of color is invaluable in receiving pearls of advice, and understanding the nuances of successful academic practice. We hope in the future to increase the membership of SBAS and continue to promote the timely advancement of our members.”
Robert Higgins, MD, FACS, Professor and Chairman of the Department of Surgery, Ohio State University and past SBAS president (2008-2009), commented, “As someone who has benefitted from the progress that the SBAS/ACS relationship has fostered, I think the critical strength of this effort in the future is based upon its ability to create foundations for the development of underrepresented men and women of diverse backgrounds to reach new heights in surgery.”
Gender diversity addressed
Health equity efforts must also address gender imbalance. Edward E. Cornwell III, MD, FACS, LaSalle D. Leffall, Jr. Professor and Chairman of Surgery, Howard University, and SBAS president (2003-2004), reminisced about the first national meeting photo (above) of SBAS leadership and notes the “most obvious sign of the times in April 1989 … no women surgeons in that photo (the woman in the top row wasn’t a physician). Today, at a time when 14 of my 25 categorical surgical residents are women … we stand on the precipice of the next 25 years of career milestones trumpeting gender diversity – that will surpass the explosion we saw over the last 25 years with male surgeons of color.”
Dr. Brawley also commented on the meteoric rise of African American women surgeons: “I take particular pride in the contribution today of black women who have come on strong in the past half-century. I appreciate and celebrate their achievement.”
Patricia Turner, MD, FACS, Director, ACS Division of Member Services, and Associate Professor of Surgery at the University of Chicago, summarized the African American female experience in surgery: “It is indeed a pleasure to note that in the years since the first SBAS photograph in 1989 … the number of women in medicine and surgery continues to surge. This recent growth is as much a reflection of an increased interest in surgery among women who may have been discouraged previously, as it is of a profession that has realized that previously accepted constraints around gender, race, and other factors limited access to colleagues exemplifying excellence in surgery. ACS and SBAS have consistently placed excellence, integrity, and outcomes at the forefront of their mission. Diversity brings quality, and the house of surgery is no different.”
Mentorship and Giving Back
Despite facing myriad obstacles, successful contemporary African American surgeons that are testimony to the mentorship and outreach efforts of SBAS as well as the ACS leadership have been acknowledged by an exhibit developed by the National Library of Medicine titled “Opening Doors: Contemporary African American Academic Surgeons,” and by a chapter contributed by Dr. Britt for the ACS Centennial textbook, “Setting the Course and Establishing Alliances: Fellows of the American College of Surgeons with African American Heritage.” The NLM exhibit specifically highlights the achievements of contemporary surgeons Drs. Alexa Canady; LaSalle Lefall; Claude Organ (1926-2005); Rosalyn Scott; L.D. Britt; Malcolm V. Brock; Karyn L.Butler; Benjamin Carson; Edward Cornwell; Kenneth Davis; Sharon Henry; Carla Pugh; Velma Scantlebury; Claudia Thomas; Errington Thompson; Levi Watkins; Patricia Bath; and Richard Scott. Dr. Britt (a legend in his own right as well as a contemporary icon) also acknowledges the accomplishments of the recent generations of academic surgeons (many of which overlap with the notables listed by the NLM), including Drs. Levi Watkins; Kenneth Forde; Alexa Canady; Clive Callender; Arthur Fleming; Lenworth Jacobs; Velma Scantlebury; Sharon Henry; Patricia Turner; Cato Laurencin; Butch Rossner; Kimberly Joseph; Debra Ford; Robert Higgins; Lisa Newman; Carla Pugh; Electron Kebenew; Terrence Fullum; David Jacobs; Andre Campbell; Kenneth Davis; Rhonda Henry-Tillman; Sherilyn Gordon-Burroughs; Hobart Harris; Michael Watkins; Raphael Lee; Karyn Butler; Edward Barksdale; Orlando Kirton; Jeffrey Upperman; Frederick Cason; Malcolm Brock; and Raymond Bynoe.
African Americans in medicine and surgery remain committed to improving the landscape of health care for underrepresented minority patients, students, and trainees today as in the past. This dedication was expressed by Dr. Daniel Hale Williams many decades ago: “My greatest reward is knowing that I can help my fellow man, especially those of my own race, who so deserve a better way of life.”
Today, trainee Dr. Revels echoes a similar allegiance to eradicating health care disparities by strengthening gender balance as well as racial/ethnic diversity in the health care profession: “I have a responsibility to stand for the next generation of young women of color who may be told that they didn’t need to take that algebra class or that AP classes would be too hard for them.”
Data continue to document that African American physicians are substantially more likely to establish practices that provide care to minority and impoverished patient populations (The Rationale for Diversity in the Health Professions: A Review of the Evidence. Washington, DC: U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions, October 2006).
Transcending artificial barriers
The ACS and the SBAS are in many ways bound together by their shared history, goals, and membership, and both have a critical role to play in the continuing struggle for equity and diversity in the surgical profession. Dr. Britt eloquently stated: “The month of February should not be the only time to highlight these milestones. On the contrary, there should be around-the-clock recognition, along with continual emphasis on even more advances. Let me be one of the first to toast this special partnership.”
Lisa Newman MD, MPH, FACS, FASCO, is Professor of Surgery and Director of the Breast Care Center at the University of Michigan in Ann Arbor.
Her research focus includes studies of high-risk/triple negative breast cancer and breast cancer disparities related to African ancestry. This research involves an international breast cancer registry. Dr. Newman also serves on the Program Committee for the Society of Black Academic Surgeons.
Several resources are available to those interested in learning more about the history of African Americans in medicine and surgery in particular:
“Opening Doors: Contemporary African American Academic Surgeons”; exhibit developed by the National Library of Medicine and the Reginald F. Lewis Museum of Maryland African American History and Culture” (http://www.nlm.nih.gov/exhibition/aframsurgeons/)
Organ, Claude, A Century of Black Surgeons: The USA Experience. Norman, OK: Transcript Press, 1987.
Leffall, LaSalle D., No Boundaries: A Cancer Surgeon’s Odyssey. Washington DC: Howard University Press, 2005.
O’Shea, JS., “Louis T. Wright and Henry W. Cave: How they paved the way for fellowships for black surgeons.” Bulletin of the American College of Surgeons 2005; 90(10):22-29.
Stain, SC, “Presidential Address: Dr. Organ, how are we doing”, American Journal of Surgery 2009; 197:137-41.
ACS Centennial textbook, pages 34-41, by Dr. L.D. Britt “Setting the Course and Establishing Alliances: Fellows of the American College of Surgeons with an African American Heritage”
Several resources are available to those interested in learning more about the history of African Americans in medicine and surgery in particular:
“Opening Doors: Contemporary African American Academic Surgeons”; exhibit developed by the National Library of Medicine and the Reginald F. Lewis Museum of Maryland African American History and Culture” (http://www.nlm.nih.gov/exhibition/aframsurgeons/)
Organ, Claude, A Century of Black Surgeons: The USA Experience. Norman, OK: Transcript Press, 1987.
Leffall, LaSalle D., No Boundaries: A Cancer Surgeon’s Odyssey. Washington DC: Howard University Press, 2005.
O’Shea, JS., “Louis T. Wright and Henry W. Cave: How they paved the way for fellowships for black surgeons.” Bulletin of the American College of Surgeons 2005; 90(10):22-29.
Stain, SC, “Presidential Address: Dr. Organ, how are we doing”, American Journal of Surgery 2009; 197:137-41.
ACS Centennial textbook, pages 34-41, by Dr. L.D. Britt “Setting the Course and Establishing Alliances: Fellows of the American College of Surgeons with an African American Heritage”
Several resources are available to those interested in learning more about the history of African Americans in medicine and surgery in particular:
“Opening Doors: Contemporary African American Academic Surgeons”; exhibit developed by the National Library of Medicine and the Reginald F. Lewis Museum of Maryland African American History and Culture” (http://www.nlm.nih.gov/exhibition/aframsurgeons/)
Organ, Claude, A Century of Black Surgeons: The USA Experience. Norman, OK: Transcript Press, 1987.
Leffall, LaSalle D., No Boundaries: A Cancer Surgeon’s Odyssey. Washington DC: Howard University Press, 2005.
O’Shea, JS., “Louis T. Wright and Henry W. Cave: How they paved the way for fellowships for black surgeons.” Bulletin of the American College of Surgeons 2005; 90(10):22-29.
Stain, SC, “Presidential Address: Dr. Organ, how are we doing”, American Journal of Surgery 2009; 197:137-41.
ACS Centennial textbook, pages 34-41, by Dr. L.D. Britt “Setting the Course and Establishing Alliances: Fellows of the American College of Surgeons with an African American Heritage”
The emergence of African Americans as acclaimed leaders in the field of surgery over the last century is a triumph of personal struggle, brilliant minds, and sheer determination.
Disparities in educational and professional opportunities related to racial/ethnic identity persist, but LaSalle D. Leffall, Jr., MD, FACS, fondly recalls a favorite quote from pioneering African American surgeon Charles Drew: “Excellence of performance will transcend artificial barriers created by man.” The goals and abundant talent shared by the membership of the American College of Surgeons (ACS) and Society of Black Academic Surgeons (SBAS) are testimony to the ongoing dissolution of these artificial barriers.
Parallels are evident between the history of organized surgery in America and African American efforts to achieve health care equity. While the spectrum of surgical procedures mushroomed in the late 19th century, surgical training was characterized by inconsistency and instability. The ACS was established in 1913 with the mission of “improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.”
Significant disparities in medical and surgical care existed for African Americans in this era. During the decades following the Civil War, black citizens were routinely denied care or they received substandard care delivered in segregated hospitals. Medical education opportunities for African Americans were nearly nonexistent.
Nonetheless, African Americans mobilized their talent and energy to address the same threats to quality medical care as those faced by the ACS founders, but having to overcome even greater obstacles in the form of systematic racism and exclusion.
Chicago’s Provident Hospital and Training School (the first African American-owned and -operated hospital) was established in 1891. Howard University College of Medicine in Washington, and Meharry Medical College in Nashville, Tenn., founded in 1868 and 1876, respectively, remained the predominent options for prospective African American medical students for several decades. Because African American medical professionals were denied membership in the American Medical Association, they formed their own professional society, the National Medical Association, in 1895.
In contrast, Dr. Daniel Hale Williams, founder of the Provident Hospital and founding member of the National Medical Association, was a charter member of ACS in 1913. However, more than 20 years passed before another African American surgeon (Louis Tompkins Wright, MD, FACS) became a Fellow of the College.
The number of African American surgeons in the College grew steadily after World War II, and in the past 3 years, approximately 6% of ACS inductees have been African Americans.
The value of race/ethnic diversity in optimizing quality of care is summarized by Dr. Otis Brawley, Chief Medical Officer for the American Cancer Society and past Director of the Office for Special Populations Research at the National Institutes of Health: “The practice of surgery is both a science and an art. Part of the art is understanding the patient’s needs and communicating well. Modern medicine has used the phrase ‘cultural competence’ to describe this. While a physician of one race certainly can and often does provide excellent service to a patient of another, diverse membership in the surgical community is essential for cultural competence of that community.”
Pioneering black surgeons
The following lists a few of the many African American surgical luminaries who fought incredible obstacles in order to improve health outcomes for all:
• Daniel Hale Williams, MD, FACS (1856-1931): Founder of Provident Hospital; performed one of the first successful open heart surgeries; charter member of the ACS.
• Louis Tompkins Wright, MD, FACS (1891-1952): Second African American admitted to ACS Fellowship (in 1934) amid much debate and controversy, despite graduating cum laude from Harvard Medical School and having an illustrious career as a decorated Army surgeon. Dr. Wright was the son of a slave (Ceah Ketcham Wright, MD) who pursued medical education at Meharry after obtaining his freedom.
• Charles Richard Drew, MD, FACS (1904-1950): Pioneer transfusion researcher; first American Red Cross Blood Bank director. Dr. Leffall, a Drew trainee, recalls, “After several applications for fellowship in ACS, Drew was approved for admission at the annual convocation October 1950. He was killed in an automobile accident April 1, 1950, en route to a medical meeting in Tuskegee, Ala. In a highly unusual action, the College’s Board of Regents approved him for posthumous fellowship October 1951.”
• Vivien Thomas (1910-1985): surgical technical assistant to Dr. Alfred Blalock at Vanderbilt, and supervisor of surgical laboratories at Johns Hopkins for 35 years; became pioneer in cardiac surgery despite having no formal education beyond high school and awarded honorary doctorate at Hopkins in 1976.
• Samuel Kountz, MD, FACS (1930-1981): Pioneer transplant surgeon; performed first successful human non-identical twin kidney transplant; developed Belzer kidney perfusion prototype.
• Claude Organ, MD, FACS (1926-2005): Professor of surgery at the University of California, Davis, and University of California, San Francisco East; editor of JAMA Archives of Surgery; founding member and President of SBAS (1995-1997) and second African American President of ACS (2003-2004).
• LaSalle D. Leffall, Jr., MD, FACS: Charles R. Drew Professor of Surgery and former chairman of surgery at Howard University; former chairman of the President’s Cancer Panel; SBAS president (1997-1998); first African American president of the American Cancer Society; first African American president of the ACS (1995-1996).
• Levi Watkins, MD: Professor of cardiac surgery, Johns Hopkins University; performed first human implantation of automatic implantable defibrillator; carried out landmark efforts to strengthen diversity among health care professionals. Dr. Watkins commented: “On the occasion of the national holiday of my former pastor, Dr. Martin Luther King, Jr., I am happy to say that given the opportunity the African American surgeon has shown very well that he or she is capable and worthy to serve and lead this nation in health equity and well-being. We must, however, not allow this progress and opportunity to slip from us using slogans to replace direct action on our part. I must compliment the ACS for its role in helping to bring about change in this area.”
• Harold P. Freeman, MD, FACS: Past president, American Cancer Society; past chairman, President’s Cancer Panel; pioneer architect of patient navigation programs; founder and president/CEO, Harold P. Freeman Patient Navigation Institute.
• Haile Debas, MD, FACS: Past chairman, University of California, San Francisco (UCSF) department of surgery; past dean, School of Medicine; founding executive director, UCSF Global Health Sciences; president, the American Surgical Association (2002-2003).
• Benjamin S. Carson, Sr., MD: Emeritus professor of neurosurgery, Johns Hopkins School of Medicine; president/CEO American Business Collaborative, LLC; awarded Presidential Medal of Freedom; renowned for historic 1987 surgical procedure separating craniopagus conjoined twins.
He recalled: “Twins joined at the back of the head had never before been separated with both surviving. The 22-hour operation which combined advanced neurosurgical techniques with hypothermic cardiac arrest proved successful. I intentionally remained in the background and did not reveal my role as the primary neurosurgeon until the press conference several hours after the completion of the operation. Historically, the accomplishments of Blacks in scientific endeavors have not been heavily covered by the news media. In order to inspire millions of Black youngsters who lacked scientific role models, I waited until the story was so big that the media could not back off. Thankfully our society has advanced to the point that this kind of thing is no longer necessary.”
• Alexa Canady, MD, FACS: First African American female neurosurgery resident (University of Minnesota); became chief of neurosurgery at the Children’s Hospital of Detroit at age 36.
• Henri R. Ford, MD, FACS: Past surgeon-in-chief, Children’s Hospital of Pittsburgh; past vice-president, chief of surgery, University of California, Los Angeles (UCLA); vice-dean for Medical Education, Keck School/UCLA; SBAS president (2010-2011).
• L.D. Britt, MD, MPH, D.Sc (Hon), FACS, FCCM, FRCSEng (Hon), FRCSEd (Hon), FWACS (Hon), FRCSI (Hon), FCS(SA) (Hon), FRCS(Glasg) (Hon):
Chairman, department of surgery at Eastern Virginia Medical School; past president of numerous academic societies (American College of Surgeons, 2010-2011; Southern Surgical Congress; American Association of Trauma; Halsted Society, SBAS 1999-2001; American Surgical Association; Society of Surgical Chairs); current SBAS executive director; Robert J. Glaser Distinguished Educator Award recipient (highest teaching award granted by Association of American Medical Colleges).
Professional and personal challenges
Many of these African American professionals tackle the same barriers to productive longevity as the African American general population – disparities in professional promotion opportunities, socioeconomic disadvantages, and reduced life expectancy (National Vital Statistics Reports; vol. 61 no. 4., National Center for Health Statistics 2013).
Black physicians are less likely to receive academic promotion in university programs and are underrepresented within the full professorship rank (JAMA 2000; 284:1085-92); African American researchers are less likely to receive NIH research funding (Science 2011;333:1015-19); and society has lost many academically accomplished African American surgeons to premature death from cancer and other illnesses as well as trauma. Icons Dr. Charles Drew and Dr. Sam Kountz both died in the prime of their professional careers. More recently, the surgical oncology community mourned the losses of Keith Amos, MD, FACS, assistant professor of surgery, University of North Carolina and Yvedt Matory, MD, FACS, assistant professor of surgery, Harvard Medical School. Both of these talented surgeons died before reaching age 50.
Socioeconomic disparities and downstream effects on the pipeline of African American students and trainees remain apparent in the pool of surgeons available to pursue academic careers. These inequities are poignantly described by Sha’shonda Revels, MD, chief resident in general surgery at the University of Michigan, Ann Arbor, with plans to pursue an academic career in cardiothoracic surgery: “I consider myself truly blessed to have the opportunity to learn a tangible skill that I can use to effect change in the lives of others. … I appreciate the struggles that others have made for me to have this opportunity. Those not so well known ‘others’ include my grandmother who cleaned houses, and took care of me so that my mother could finish high school and attend college. They also include my parents who were tenacious about academics and would not accept a B average.”
The SBAS is born
Despite post-WWII gains, opportunities remained limited for black surgeons to achieve prominence and recognition in academic surgical societies. The Society for Black Academic Surgeons was therefore established as a network that would promote the careers of African American surgeons in academia and accelerate their upward professional trajectory.
SBAS founding member and President (1993-1995) Eddie Hoover, MD, FACS, professor of surgery at the State University of New York Buffalo, and Editor-in-Chief for the Journal of the National Medical Association, provides this passionate account of its history and accomplishments: “SBAS was created in a hotel room at the Marriott in New Orleans in 1987 to address the paucity of academic African American surgeons; their poor retention, promotion, and research funding; and lack of a leadership role in American surgery. The hero of academic African American surgeons, Dr. Charles Drew, adorns the shield of SBAS as much for his defiance of ACS for refusing to accept other well-qualified African American surgeons in the 1940’s as for his scientific contributions …With strong ACS support, SBAS has been stunningly successful over the past 27 years with a dozen SBAS members serving as surgical chairs and four as deans of majority schools.”
Dr. Britt, first African American chair of the ACS Board of Regents and later SBAS president, emphasizes that these two organizations have shared goals. “The evolution of the American College of Surgeons, the world’s largest organization for surgeons, and its growing partnership with the Society of Black Academic Surgeons (demonstrated formally, informally, and sometimes tacitly) needs to be recognized, underscored, and continually enhanced. Many of the ideals of SBAS now mirror the ideals and achievements of the ACS, including an ever growing diverse membership, improved diversity at all levels of leadership, meaningful mentorships for underrepresented minorities, and the establishment of several initiatives to address severe health care disparities in the world’s wealthiest nation.”
The 25th Annual Scientific Meeting of the SBAS will be hosted by the University of North Carolina, Chapel Hill, April 9-11, 2015.
Frederick Cason, MD, FACS, professor of surgery and chief, Division of Surgical Education at Morehouse School of Medicine and the SBAS historian and archivist, stated, “With the strong academic activities of SBAS, the networking it fosters, and the partnerships with numerous academic institutions and members of the College… there developed some 10 academic chairmen and at least 4 deans leading our major medical centers in America.”
Andrea Hayes-Jordan, MD, SBAS 2015 Annual Meeting program chair and associate professor of surgery and Pediatrics and Director of Pediatric Surgical Oncology at the University of Texas M.D. Anderson Cancer Center, notes, “At the annual meeting we are not only able to see the results of excellent research efforts from minority surgeons from around the country, but one has the unique opportunity to interact with them on a personal level, at an intimate meeting. This personal interaction with successful chair persons of color is invaluable in receiving pearls of advice, and understanding the nuances of successful academic practice. We hope in the future to increase the membership of SBAS and continue to promote the timely advancement of our members.”
Robert Higgins, MD, FACS, Professor and Chairman of the Department of Surgery, Ohio State University and past SBAS president (2008-2009), commented, “As someone who has benefitted from the progress that the SBAS/ACS relationship has fostered, I think the critical strength of this effort in the future is based upon its ability to create foundations for the development of underrepresented men and women of diverse backgrounds to reach new heights in surgery.”
Gender diversity addressed
Health equity efforts must also address gender imbalance. Edward E. Cornwell III, MD, FACS, LaSalle D. Leffall, Jr. Professor and Chairman of Surgery, Howard University, and SBAS president (2003-2004), reminisced about the first national meeting photo (above) of SBAS leadership and notes the “most obvious sign of the times in April 1989 … no women surgeons in that photo (the woman in the top row wasn’t a physician). Today, at a time when 14 of my 25 categorical surgical residents are women … we stand on the precipice of the next 25 years of career milestones trumpeting gender diversity – that will surpass the explosion we saw over the last 25 years with male surgeons of color.”
Dr. Brawley also commented on the meteoric rise of African American women surgeons: “I take particular pride in the contribution today of black women who have come on strong in the past half-century. I appreciate and celebrate their achievement.”
Patricia Turner, MD, FACS, Director, ACS Division of Member Services, and Associate Professor of Surgery at the University of Chicago, summarized the African American female experience in surgery: “It is indeed a pleasure to note that in the years since the first SBAS photograph in 1989 … the number of women in medicine and surgery continues to surge. This recent growth is as much a reflection of an increased interest in surgery among women who may have been discouraged previously, as it is of a profession that has realized that previously accepted constraints around gender, race, and other factors limited access to colleagues exemplifying excellence in surgery. ACS and SBAS have consistently placed excellence, integrity, and outcomes at the forefront of their mission. Diversity brings quality, and the house of surgery is no different.”
Mentorship and Giving Back
Despite facing myriad obstacles, successful contemporary African American surgeons that are testimony to the mentorship and outreach efforts of SBAS as well as the ACS leadership have been acknowledged by an exhibit developed by the National Library of Medicine titled “Opening Doors: Contemporary African American Academic Surgeons,” and by a chapter contributed by Dr. Britt for the ACS Centennial textbook, “Setting the Course and Establishing Alliances: Fellows of the American College of Surgeons with African American Heritage.” The NLM exhibit specifically highlights the achievements of contemporary surgeons Drs. Alexa Canady; LaSalle Lefall; Claude Organ (1926-2005); Rosalyn Scott; L.D. Britt; Malcolm V. Brock; Karyn L.Butler; Benjamin Carson; Edward Cornwell; Kenneth Davis; Sharon Henry; Carla Pugh; Velma Scantlebury; Claudia Thomas; Errington Thompson; Levi Watkins; Patricia Bath; and Richard Scott. Dr. Britt (a legend in his own right as well as a contemporary icon) also acknowledges the accomplishments of the recent generations of academic surgeons (many of which overlap with the notables listed by the NLM), including Drs. Levi Watkins; Kenneth Forde; Alexa Canady; Clive Callender; Arthur Fleming; Lenworth Jacobs; Velma Scantlebury; Sharon Henry; Patricia Turner; Cato Laurencin; Butch Rossner; Kimberly Joseph; Debra Ford; Robert Higgins; Lisa Newman; Carla Pugh; Electron Kebenew; Terrence Fullum; David Jacobs; Andre Campbell; Kenneth Davis; Rhonda Henry-Tillman; Sherilyn Gordon-Burroughs; Hobart Harris; Michael Watkins; Raphael Lee; Karyn Butler; Edward Barksdale; Orlando Kirton; Jeffrey Upperman; Frederick Cason; Malcolm Brock; and Raymond Bynoe.
African Americans in medicine and surgery remain committed to improving the landscape of health care for underrepresented minority patients, students, and trainees today as in the past. This dedication was expressed by Dr. Daniel Hale Williams many decades ago: “My greatest reward is knowing that I can help my fellow man, especially those of my own race, who so deserve a better way of life.”
Today, trainee Dr. Revels echoes a similar allegiance to eradicating health care disparities by strengthening gender balance as well as racial/ethnic diversity in the health care profession: “I have a responsibility to stand for the next generation of young women of color who may be told that they didn’t need to take that algebra class or that AP classes would be too hard for them.”
Data continue to document that African American physicians are substantially more likely to establish practices that provide care to minority and impoverished patient populations (The Rationale for Diversity in the Health Professions: A Review of the Evidence. Washington, DC: U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions, October 2006).
Transcending artificial barriers
The ACS and the SBAS are in many ways bound together by their shared history, goals, and membership, and both have a critical role to play in the continuing struggle for equity and diversity in the surgical profession. Dr. Britt eloquently stated: “The month of February should not be the only time to highlight these milestones. On the contrary, there should be around-the-clock recognition, along with continual emphasis on even more advances. Let me be one of the first to toast this special partnership.”
Lisa Newman MD, MPH, FACS, FASCO, is Professor of Surgery and Director of the Breast Care Center at the University of Michigan in Ann Arbor.
Her research focus includes studies of high-risk/triple negative breast cancer and breast cancer disparities related to African ancestry. This research involves an international breast cancer registry. Dr. Newman also serves on the Program Committee for the Society of Black Academic Surgeons.
The emergence of African Americans as acclaimed leaders in the field of surgery over the last century is a triumph of personal struggle, brilliant minds, and sheer determination.
Disparities in educational and professional opportunities related to racial/ethnic identity persist, but LaSalle D. Leffall, Jr., MD, FACS, fondly recalls a favorite quote from pioneering African American surgeon Charles Drew: “Excellence of performance will transcend artificial barriers created by man.” The goals and abundant talent shared by the membership of the American College of Surgeons (ACS) and Society of Black Academic Surgeons (SBAS) are testimony to the ongoing dissolution of these artificial barriers.
Parallels are evident between the history of organized surgery in America and African American efforts to achieve health care equity. While the spectrum of surgical procedures mushroomed in the late 19th century, surgical training was characterized by inconsistency and instability. The ACS was established in 1913 with the mission of “improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.”
Significant disparities in medical and surgical care existed for African Americans in this era. During the decades following the Civil War, black citizens were routinely denied care or they received substandard care delivered in segregated hospitals. Medical education opportunities for African Americans were nearly nonexistent.
Nonetheless, African Americans mobilized their talent and energy to address the same threats to quality medical care as those faced by the ACS founders, but having to overcome even greater obstacles in the form of systematic racism and exclusion.
Chicago’s Provident Hospital and Training School (the first African American-owned and -operated hospital) was established in 1891. Howard University College of Medicine in Washington, and Meharry Medical College in Nashville, Tenn., founded in 1868 and 1876, respectively, remained the predominent options for prospective African American medical students for several decades. Because African American medical professionals were denied membership in the American Medical Association, they formed their own professional society, the National Medical Association, in 1895.
In contrast, Dr. Daniel Hale Williams, founder of the Provident Hospital and founding member of the National Medical Association, was a charter member of ACS in 1913. However, more than 20 years passed before another African American surgeon (Louis Tompkins Wright, MD, FACS) became a Fellow of the College.
The number of African American surgeons in the College grew steadily after World War II, and in the past 3 years, approximately 6% of ACS inductees have been African Americans.
The value of race/ethnic diversity in optimizing quality of care is summarized by Dr. Otis Brawley, Chief Medical Officer for the American Cancer Society and past Director of the Office for Special Populations Research at the National Institutes of Health: “The practice of surgery is both a science and an art. Part of the art is understanding the patient’s needs and communicating well. Modern medicine has used the phrase ‘cultural competence’ to describe this. While a physician of one race certainly can and often does provide excellent service to a patient of another, diverse membership in the surgical community is essential for cultural competence of that community.”
Pioneering black surgeons
The following lists a few of the many African American surgical luminaries who fought incredible obstacles in order to improve health outcomes for all:
• Daniel Hale Williams, MD, FACS (1856-1931): Founder of Provident Hospital; performed one of the first successful open heart surgeries; charter member of the ACS.
• Louis Tompkins Wright, MD, FACS (1891-1952): Second African American admitted to ACS Fellowship (in 1934) amid much debate and controversy, despite graduating cum laude from Harvard Medical School and having an illustrious career as a decorated Army surgeon. Dr. Wright was the son of a slave (Ceah Ketcham Wright, MD) who pursued medical education at Meharry after obtaining his freedom.
• Charles Richard Drew, MD, FACS (1904-1950): Pioneer transfusion researcher; first American Red Cross Blood Bank director. Dr. Leffall, a Drew trainee, recalls, “After several applications for fellowship in ACS, Drew was approved for admission at the annual convocation October 1950. He was killed in an automobile accident April 1, 1950, en route to a medical meeting in Tuskegee, Ala. In a highly unusual action, the College’s Board of Regents approved him for posthumous fellowship October 1951.”
• Vivien Thomas (1910-1985): surgical technical assistant to Dr. Alfred Blalock at Vanderbilt, and supervisor of surgical laboratories at Johns Hopkins for 35 years; became pioneer in cardiac surgery despite having no formal education beyond high school and awarded honorary doctorate at Hopkins in 1976.
• Samuel Kountz, MD, FACS (1930-1981): Pioneer transplant surgeon; performed first successful human non-identical twin kidney transplant; developed Belzer kidney perfusion prototype.
• Claude Organ, MD, FACS (1926-2005): Professor of surgery at the University of California, Davis, and University of California, San Francisco East; editor of JAMA Archives of Surgery; founding member and President of SBAS (1995-1997) and second African American President of ACS (2003-2004).
• LaSalle D. Leffall, Jr., MD, FACS: Charles R. Drew Professor of Surgery and former chairman of surgery at Howard University; former chairman of the President’s Cancer Panel; SBAS president (1997-1998); first African American president of the American Cancer Society; first African American president of the ACS (1995-1996).
• Levi Watkins, MD: Professor of cardiac surgery, Johns Hopkins University; performed first human implantation of automatic implantable defibrillator; carried out landmark efforts to strengthen diversity among health care professionals. Dr. Watkins commented: “On the occasion of the national holiday of my former pastor, Dr. Martin Luther King, Jr., I am happy to say that given the opportunity the African American surgeon has shown very well that he or she is capable and worthy to serve and lead this nation in health equity and well-being. We must, however, not allow this progress and opportunity to slip from us using slogans to replace direct action on our part. I must compliment the ACS for its role in helping to bring about change in this area.”
• Harold P. Freeman, MD, FACS: Past president, American Cancer Society; past chairman, President’s Cancer Panel; pioneer architect of patient navigation programs; founder and president/CEO, Harold P. Freeman Patient Navigation Institute.
• Haile Debas, MD, FACS: Past chairman, University of California, San Francisco (UCSF) department of surgery; past dean, School of Medicine; founding executive director, UCSF Global Health Sciences; president, the American Surgical Association (2002-2003).
• Benjamin S. Carson, Sr., MD: Emeritus professor of neurosurgery, Johns Hopkins School of Medicine; president/CEO American Business Collaborative, LLC; awarded Presidential Medal of Freedom; renowned for historic 1987 surgical procedure separating craniopagus conjoined twins.
He recalled: “Twins joined at the back of the head had never before been separated with both surviving. The 22-hour operation which combined advanced neurosurgical techniques with hypothermic cardiac arrest proved successful. I intentionally remained in the background and did not reveal my role as the primary neurosurgeon until the press conference several hours after the completion of the operation. Historically, the accomplishments of Blacks in scientific endeavors have not been heavily covered by the news media. In order to inspire millions of Black youngsters who lacked scientific role models, I waited until the story was so big that the media could not back off. Thankfully our society has advanced to the point that this kind of thing is no longer necessary.”
• Alexa Canady, MD, FACS: First African American female neurosurgery resident (University of Minnesota); became chief of neurosurgery at the Children’s Hospital of Detroit at age 36.
• Henri R. Ford, MD, FACS: Past surgeon-in-chief, Children’s Hospital of Pittsburgh; past vice-president, chief of surgery, University of California, Los Angeles (UCLA); vice-dean for Medical Education, Keck School/UCLA; SBAS president (2010-2011).
• L.D. Britt, MD, MPH, D.Sc (Hon), FACS, FCCM, FRCSEng (Hon), FRCSEd (Hon), FWACS (Hon), FRCSI (Hon), FCS(SA) (Hon), FRCS(Glasg) (Hon):
Chairman, department of surgery at Eastern Virginia Medical School; past president of numerous academic societies (American College of Surgeons, 2010-2011; Southern Surgical Congress; American Association of Trauma; Halsted Society, SBAS 1999-2001; American Surgical Association; Society of Surgical Chairs); current SBAS executive director; Robert J. Glaser Distinguished Educator Award recipient (highest teaching award granted by Association of American Medical Colleges).
Professional and personal challenges
Many of these African American professionals tackle the same barriers to productive longevity as the African American general population – disparities in professional promotion opportunities, socioeconomic disadvantages, and reduced life expectancy (National Vital Statistics Reports; vol. 61 no. 4., National Center for Health Statistics 2013).
Black physicians are less likely to receive academic promotion in university programs and are underrepresented within the full professorship rank (JAMA 2000; 284:1085-92); African American researchers are less likely to receive NIH research funding (Science 2011;333:1015-19); and society has lost many academically accomplished African American surgeons to premature death from cancer and other illnesses as well as trauma. Icons Dr. Charles Drew and Dr. Sam Kountz both died in the prime of their professional careers. More recently, the surgical oncology community mourned the losses of Keith Amos, MD, FACS, assistant professor of surgery, University of North Carolina and Yvedt Matory, MD, FACS, assistant professor of surgery, Harvard Medical School. Both of these talented surgeons died before reaching age 50.
Socioeconomic disparities and downstream effects on the pipeline of African American students and trainees remain apparent in the pool of surgeons available to pursue academic careers. These inequities are poignantly described by Sha’shonda Revels, MD, chief resident in general surgery at the University of Michigan, Ann Arbor, with plans to pursue an academic career in cardiothoracic surgery: “I consider myself truly blessed to have the opportunity to learn a tangible skill that I can use to effect change in the lives of others. … I appreciate the struggles that others have made for me to have this opportunity. Those not so well known ‘others’ include my grandmother who cleaned houses, and took care of me so that my mother could finish high school and attend college. They also include my parents who were tenacious about academics and would not accept a B average.”
The SBAS is born
Despite post-WWII gains, opportunities remained limited for black surgeons to achieve prominence and recognition in academic surgical societies. The Society for Black Academic Surgeons was therefore established as a network that would promote the careers of African American surgeons in academia and accelerate their upward professional trajectory.
SBAS founding member and President (1993-1995) Eddie Hoover, MD, FACS, professor of surgery at the State University of New York Buffalo, and Editor-in-Chief for the Journal of the National Medical Association, provides this passionate account of its history and accomplishments: “SBAS was created in a hotel room at the Marriott in New Orleans in 1987 to address the paucity of academic African American surgeons; their poor retention, promotion, and research funding; and lack of a leadership role in American surgery. The hero of academic African American surgeons, Dr. Charles Drew, adorns the shield of SBAS as much for his defiance of ACS for refusing to accept other well-qualified African American surgeons in the 1940’s as for his scientific contributions …With strong ACS support, SBAS has been stunningly successful over the past 27 years with a dozen SBAS members serving as surgical chairs and four as deans of majority schools.”
Dr. Britt, first African American chair of the ACS Board of Regents and later SBAS president, emphasizes that these two organizations have shared goals. “The evolution of the American College of Surgeons, the world’s largest organization for surgeons, and its growing partnership with the Society of Black Academic Surgeons (demonstrated formally, informally, and sometimes tacitly) needs to be recognized, underscored, and continually enhanced. Many of the ideals of SBAS now mirror the ideals and achievements of the ACS, including an ever growing diverse membership, improved diversity at all levels of leadership, meaningful mentorships for underrepresented minorities, and the establishment of several initiatives to address severe health care disparities in the world’s wealthiest nation.”
The 25th Annual Scientific Meeting of the SBAS will be hosted by the University of North Carolina, Chapel Hill, April 9-11, 2015.
Frederick Cason, MD, FACS, professor of surgery and chief, Division of Surgical Education at Morehouse School of Medicine and the SBAS historian and archivist, stated, “With the strong academic activities of SBAS, the networking it fosters, and the partnerships with numerous academic institutions and members of the College… there developed some 10 academic chairmen and at least 4 deans leading our major medical centers in America.”
Andrea Hayes-Jordan, MD, SBAS 2015 Annual Meeting program chair and associate professor of surgery and Pediatrics and Director of Pediatric Surgical Oncology at the University of Texas M.D. Anderson Cancer Center, notes, “At the annual meeting we are not only able to see the results of excellent research efforts from minority surgeons from around the country, but one has the unique opportunity to interact with them on a personal level, at an intimate meeting. This personal interaction with successful chair persons of color is invaluable in receiving pearls of advice, and understanding the nuances of successful academic practice. We hope in the future to increase the membership of SBAS and continue to promote the timely advancement of our members.”
Robert Higgins, MD, FACS, Professor and Chairman of the Department of Surgery, Ohio State University and past SBAS president (2008-2009), commented, “As someone who has benefitted from the progress that the SBAS/ACS relationship has fostered, I think the critical strength of this effort in the future is based upon its ability to create foundations for the development of underrepresented men and women of diverse backgrounds to reach new heights in surgery.”
Gender diversity addressed
Health equity efforts must also address gender imbalance. Edward E. Cornwell III, MD, FACS, LaSalle D. Leffall, Jr. Professor and Chairman of Surgery, Howard University, and SBAS president (2003-2004), reminisced about the first national meeting photo (above) of SBAS leadership and notes the “most obvious sign of the times in April 1989 … no women surgeons in that photo (the woman in the top row wasn’t a physician). Today, at a time when 14 of my 25 categorical surgical residents are women … we stand on the precipice of the next 25 years of career milestones trumpeting gender diversity – that will surpass the explosion we saw over the last 25 years with male surgeons of color.”
Dr. Brawley also commented on the meteoric rise of African American women surgeons: “I take particular pride in the contribution today of black women who have come on strong in the past half-century. I appreciate and celebrate their achievement.”
Patricia Turner, MD, FACS, Director, ACS Division of Member Services, and Associate Professor of Surgery at the University of Chicago, summarized the African American female experience in surgery: “It is indeed a pleasure to note that in the years since the first SBAS photograph in 1989 … the number of women in medicine and surgery continues to surge. This recent growth is as much a reflection of an increased interest in surgery among women who may have been discouraged previously, as it is of a profession that has realized that previously accepted constraints around gender, race, and other factors limited access to colleagues exemplifying excellence in surgery. ACS and SBAS have consistently placed excellence, integrity, and outcomes at the forefront of their mission. Diversity brings quality, and the house of surgery is no different.”
Mentorship and Giving Back
Despite facing myriad obstacles, successful contemporary African American surgeons that are testimony to the mentorship and outreach efforts of SBAS as well as the ACS leadership have been acknowledged by an exhibit developed by the National Library of Medicine titled “Opening Doors: Contemporary African American Academic Surgeons,” and by a chapter contributed by Dr. Britt for the ACS Centennial textbook, “Setting the Course and Establishing Alliances: Fellows of the American College of Surgeons with African American Heritage.” The NLM exhibit specifically highlights the achievements of contemporary surgeons Drs. Alexa Canady; LaSalle Lefall; Claude Organ (1926-2005); Rosalyn Scott; L.D. Britt; Malcolm V. Brock; Karyn L.Butler; Benjamin Carson; Edward Cornwell; Kenneth Davis; Sharon Henry; Carla Pugh; Velma Scantlebury; Claudia Thomas; Errington Thompson; Levi Watkins; Patricia Bath; and Richard Scott. Dr. Britt (a legend in his own right as well as a contemporary icon) also acknowledges the accomplishments of the recent generations of academic surgeons (many of which overlap with the notables listed by the NLM), including Drs. Levi Watkins; Kenneth Forde; Alexa Canady; Clive Callender; Arthur Fleming; Lenworth Jacobs; Velma Scantlebury; Sharon Henry; Patricia Turner; Cato Laurencin; Butch Rossner; Kimberly Joseph; Debra Ford; Robert Higgins; Lisa Newman; Carla Pugh; Electron Kebenew; Terrence Fullum; David Jacobs; Andre Campbell; Kenneth Davis; Rhonda Henry-Tillman; Sherilyn Gordon-Burroughs; Hobart Harris; Michael Watkins; Raphael Lee; Karyn Butler; Edward Barksdale; Orlando Kirton; Jeffrey Upperman; Frederick Cason; Malcolm Brock; and Raymond Bynoe.
African Americans in medicine and surgery remain committed to improving the landscape of health care for underrepresented minority patients, students, and trainees today as in the past. This dedication was expressed by Dr. Daniel Hale Williams many decades ago: “My greatest reward is knowing that I can help my fellow man, especially those of my own race, who so deserve a better way of life.”
Today, trainee Dr. Revels echoes a similar allegiance to eradicating health care disparities by strengthening gender balance as well as racial/ethnic diversity in the health care profession: “I have a responsibility to stand for the next generation of young women of color who may be told that they didn’t need to take that algebra class or that AP classes would be too hard for them.”
Data continue to document that African American physicians are substantially more likely to establish practices that provide care to minority and impoverished patient populations (The Rationale for Diversity in the Health Professions: A Review of the Evidence. Washington, DC: U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions, October 2006).
Transcending artificial barriers
The ACS and the SBAS are in many ways bound together by their shared history, goals, and membership, and both have a critical role to play in the continuing struggle for equity and diversity in the surgical profession. Dr. Britt eloquently stated: “The month of February should not be the only time to highlight these milestones. On the contrary, there should be around-the-clock recognition, along with continual emphasis on even more advances. Let me be one of the first to toast this special partnership.”
Lisa Newman MD, MPH, FACS, FASCO, is Professor of Surgery and Director of the Breast Care Center at the University of Michigan in Ann Arbor.
Her research focus includes studies of high-risk/triple negative breast cancer and breast cancer disparities related to African ancestry. This research involves an international breast cancer registry. Dr. Newman also serves on the Program Committee for the Society of Black Academic Surgeons.
Helping breast cancer patients analyze risk
Dr. Sarah Hawley and her coinvestigators are to be applauded for generating insightful data regarding factors and concerns that motivate a woman to undergo contralateral prophylactic mastectomy in the setting of unilateral breast cancer (JAMA Surgery 2014 May 21 [doi:10.1001/jamasurg.2013.5689]).
Hawley et al. found that fear of recurrence was one of the strongest factors leading women to choose contralateral prophylactic mastectomy (CPM). This finding clearly demonstrates that we need to do a better job of explaining and defining the significance of (i) breast cancer local recurrence; (ii) breast cancer distant recurrence; and (iii) the development of a new/second primary breast cancer. Since cross-metastasis of a primary breast cancer to the contralateral breast is an extremely rare event, and since distant metastasis from the initial primary breast cancer tends to determine survival rates, CPM by definition will influence the incidence of only the third pattern. Furthermore, since the risk of experiencing a new contralateral malignancy is less than 1% per year for the general population of breast cancer patients, only a minority of these women will actually become bilateral breast cancer patients. Fear of recurrence is therefore a totally inappropriate reason for patients to pursue CPM, and the reasonableness of CPM to reduce the risk of a contralateral new primary breast cancer is debatable.
It can be reasonably stated that prophylactic surgery by definition is never a medically indicated necessity. Furthermore, despite the fact that a personal history of breast cancer is indeed a risk factor for developing a second primary cancer in the contralateral breast, numerous studies have demonstrated equivalent survival rates for women with unilateral breast cancer, compared with those diagnosed with bilateral/metachronous breast cancer (Cancer 2001;91:1845-53; Am. J. Clin. Oncol. 1997;20:541-5). Survival tends to be driven by the stage and effectiveness of treatment for the first cancer. By virtue of its earlier presentation, it is likely that the initially diagnosed cancer has established itself as the faster-growing malignancy with a lead time advantage in establishing distant organ micrometastatic disease; furthermore, patients with a unilateral breast cancer diagnosis are generally undergoing diligent surveillance and a contralateral malignancy is more often detected at an early stage.
Messages to our patients
It is essential for those of us who manage breast cancer to clearly emphasize several messages to our newly diagnosed breast cancer patients: First, although unilateral breast cancer increases the likelihood of developing a second primary tumor, it is certainly not inevitable, and in fact, the majority of patients are not destined to develop contralateral disease. Second, reducing the risk of being diagnosed with a contralateral breast cancer does not mitigate the mortality risk associated with the first cancer. And, finally, prophylactic mastectomy is the most aggressive and effective strategy for reducing the incidence of primary breast cancer (by approximately 90%), but it does not confer complete protection, as microscopic foci of breast tissue may be left behind in the mastectomy skin flaps, along the pectoralis, or in the axilla.
The messages above are critical: Our patients must understand that the priority is to address the known cancer. In this regard, appropriately selected patients should be encouraged to strongly consider breast-conserving surgery whenever feasible, as this low-morbidity treatment is equivalent to mastectomy from the perspective of overall survival. The question of CPM is most relevant for those patients that are ineligible for breast conservation or patients unwilling to undergo lumpectomy and breast radiation.
If a mastectomy for the cancerous breast is planned, we must then address the questions that routinely arise regarding bilateral surgery. In our efforts to clarify the reality of what CPM can and cannot achieve, we must also avoid being too dogmatic and paternalistic with our patients. There are clearly specific scenarios, as delineated in Dr. Hawley’s work, where the risk of a second primary breast cancer is likely to be considered excessive by most women, and where the decision to pursue CPM may be easier. Examples of such cases would be women known to harbor BRCA mutations or women with suspected hereditary susceptibility based on a strong family history of breast and/or ovarian cancer. The risk of a new contralateral breast cancer can be in the range of 4%-5% per year in cases of hereditary disease, compared with the general population of women with sporadic breast cancer, where the risk ranges from 0.25% to 1% per year.
Conveying an understanding of risk
Patients must understand that the risk to the contralateral breast is predominantly expressed in the future – the likelihood of having a clinically occult, incidentally detected cancer identified in the contralateral mastectomy specimen is only 6%, as demonstrated most recently by King et al. (Ann. Surg. 2011;254:2-7), and with ductal carcinoma in situ accounting for the high majority of these lesions.
Defining the threshold for the amount of risk that an individual woman finds to be acceptable, however, can be a very difficult and personal decision. Even after a patient comes to understand that CPM is unlikely to provide a survival advantage, she may continue to request bilateral surgery purely for the risk-reducing benefits, and out of a desire to minimize her chances of having to repeat the breast cancer diagnosis and treatment experience. In some cases this choice will be influenced by reconstruction factors. A woman may be motivated to pursue bilateral surgery if she has an adequate volume of abdominal tissue because of the fact that the autogenous TRAM (transverse rectus abdominis myocutaneous) flap can be harvested only once. In other cases the decision is influenced by body habitus, for example, a woman with large pendulous breasts who is not interested in breast reconstruction may decide that she is more comfortable with a symmetrically flat chest wall in order to avoid chest wall imbalance and the inconvenience of finding/wearing a prosthesis that matches the remaining breast.
As breast cancer surgeons we should openly discuss these issues with our patients and present viable alternatives when feasible, such as reduction mammoplasty for the large-breasted patient. Ultimately, however, the patient must decide the surgical approach that provides her with the optimal sense of treatment satisfaction, quality of life, and comfort.
Discussion strategies
In my own practice I have found two discussion strategies to be particularly useful in guiding patients through the decision about CPM.
The first approach is relevant for women who are lumpectomy candidates, but who express a "reflex" interest in bilateral mastectomy while they are still in the emotional fog of processing the new cancer diagnosis. For these women it is obviously important to stress the survival equivalence of mastectomy and breast-conserving surgery, and this is also a great opportunity to educate patients about the potential axillary surgery advantages of breast conservation. The American College of Surgeons Oncology Group Z11 trial (JAMA 2011;305:69-75) has provided strong evidence supporting the safety of avoiding an axillary lymph node dissection (ALND) in women with sentinel lymph node (SLN) metastatic disease if the primary breast cancer is managed by lumpectomy and breast radiation.
At this point in time, we do not have comparably strong data to justify avoiding the ALND in the setting of mastectomy patients with SLN metastatic disease. The mastectomy patient with SLN metastasis is usually committed to undergo the completion axillary lymph node dissection specifically so that definitive decisions can be made regarding the need for postmastectomy radiation, and many of these patients become ineligible for immediate reconstruction because of this possible radiation. I therefore accentuate the advantage of at least initiating treatment with lumpectomy and sentinel lymph node biopsy. The patient preserves all of her surgical options with the benefit of having more staging information. If she is found to have SLN metastatic disease then she is in a better position to avoid the ALND with lumpectomy and radiation, and the option of future mastectomy and immediate reconstruction would still be available to her in the future (after completing all of her cancer treatment and healing from her radiation); if the SLN is negative, she can either continue with the breast-conservation treatment plan or she can pursue mastectomy (with or without immediate breast reconstruction, since prophylactic mamillary radiation therapy is not likely to be indicated for node-negative disease).
The second approach is relevant to the patient requiring mastectomy but for whom delayed reconstruction is planned because of medical issues or anticipated postmastectomy radiation. I encourage these patients to at least consider deferring the decision for the CPM until they return for the delayed reconstruction of the cancerous mastectomy, because at that time they can undergo the prophylactic mastectomy with the cosmetic advantages of immediate reconstruction.
Cost considerations
From the public health and population-based breast cancer burden perspectives as well as for individual patients, there are additional issues to be factored into the CPM discussion. It is a basic reality that cost is relevant when it comes to sorting out the net benefit of particular medical interventions, especially those that are prophylactic. Interestingly, a cost analysis study by Zendejas et al. (J. Clin. Oncol. 2011;29:2993-3000) from the Mayo Clinic demonstrated that CPM is actually cost effective, compared with surveillance for patients diagnosed when they are younger than 70 years of age.
The Women’s Health and Cancer Rights Act was implemented in 1999, mandating insurance coverage for breast reconstruction after mastectomy performed for cancer. This legislation promoted more widespread acceptance (and reimbursement) for contralateral mastectomy/reconstruction, but patients should nonetheless be proactive about confirming that their individual policy will indeed cover the expenses of prophylactic surgery. Furthermore, we must continue to monitor outcomes in women who choose to undergo CPM, as advances in breast cancer therapies may influence the survival benefits of this surgical approach. Indeed, selected retrospective studies have recently demonstrated that patients undergoing CPM have an improved survival, compared with those focusing on unilateral breast cancer surgery (Ann. Surg. Oncol. 2010;17:2702-9; J. Natl. Cancer Inst. 2010;102:401-9; J. Clin. Oncol. 2005;23:4275-86; Am. J. Surg. 2000;180:439-45). These results suggest a survival advantage associated with avoidance of a contralateral breast cancer, in contrast to the historical data alluded to above, regarding survival equivalence for patients with unilateral compared to metachronous bilateral breast cancer. As adjuvant systemic therapies for breast cancer continue to improve in effectiveness and ability to completely eliminate distant organ micrometastases, it is likely that we will continue to increase the pool of women who are essentially "cured" of the first cancer. This in turn could potentially increase the longevity threat of a second/metachronous cancer though a renewed metastatic risk. Nonetheless, data on possible survival advantages of CPM have not yet matured to the point where it can be recommended as a medically "indicated" procedure.
Our breast cancer patients face an abundance of very legitimate fears related to the morbidity and mortality risks of the actual cancer as well as the adverse effects and toxicities of treatment for that cancer. Fortunately, we can assure them that for the majority of cases these treatments will be effective and their longevity will be protected. It is therefore understandable that the desire to avoid repeating this particular life experience may be strong. We have an obligation to explain the advantages and disadvantages, as well as the alternatives to CPM, with sensitivity and patience. We must also strive to make sure that our patients do not make premature decisions without understanding the consequences. Last, but certainly not least, we are ethically bound to offer only those treatments that we feel are medically reasonable and safe as well as oncologically sound. But we must also remember that the decision to pursue treatment and the choice between the options that we offer are ultimately rights that belong to the patient.
Dr. Newman in an ACS Fellow, professor of surgery, and director of the Breast Care Center and Multidisciplinary Breast Fellowship Program, University of Michigan Comprehensive Cancer Center, Ann Arbor.
Dr. Sarah Hawley and her coinvestigators are to be applauded for generating insightful data regarding factors and concerns that motivate a woman to undergo contralateral prophylactic mastectomy in the setting of unilateral breast cancer (JAMA Surgery 2014 May 21 [doi:10.1001/jamasurg.2013.5689]).
Hawley et al. found that fear of recurrence was one of the strongest factors leading women to choose contralateral prophylactic mastectomy (CPM). This finding clearly demonstrates that we need to do a better job of explaining and defining the significance of (i) breast cancer local recurrence; (ii) breast cancer distant recurrence; and (iii) the development of a new/second primary breast cancer. Since cross-metastasis of a primary breast cancer to the contralateral breast is an extremely rare event, and since distant metastasis from the initial primary breast cancer tends to determine survival rates, CPM by definition will influence the incidence of only the third pattern. Furthermore, since the risk of experiencing a new contralateral malignancy is less than 1% per year for the general population of breast cancer patients, only a minority of these women will actually become bilateral breast cancer patients. Fear of recurrence is therefore a totally inappropriate reason for patients to pursue CPM, and the reasonableness of CPM to reduce the risk of a contralateral new primary breast cancer is debatable.
It can be reasonably stated that prophylactic surgery by definition is never a medically indicated necessity. Furthermore, despite the fact that a personal history of breast cancer is indeed a risk factor for developing a second primary cancer in the contralateral breast, numerous studies have demonstrated equivalent survival rates for women with unilateral breast cancer, compared with those diagnosed with bilateral/metachronous breast cancer (Cancer 2001;91:1845-53; Am. J. Clin. Oncol. 1997;20:541-5). Survival tends to be driven by the stage and effectiveness of treatment for the first cancer. By virtue of its earlier presentation, it is likely that the initially diagnosed cancer has established itself as the faster-growing malignancy with a lead time advantage in establishing distant organ micrometastatic disease; furthermore, patients with a unilateral breast cancer diagnosis are generally undergoing diligent surveillance and a contralateral malignancy is more often detected at an early stage.
Messages to our patients
It is essential for those of us who manage breast cancer to clearly emphasize several messages to our newly diagnosed breast cancer patients: First, although unilateral breast cancer increases the likelihood of developing a second primary tumor, it is certainly not inevitable, and in fact, the majority of patients are not destined to develop contralateral disease. Second, reducing the risk of being diagnosed with a contralateral breast cancer does not mitigate the mortality risk associated with the first cancer. And, finally, prophylactic mastectomy is the most aggressive and effective strategy for reducing the incidence of primary breast cancer (by approximately 90%), but it does not confer complete protection, as microscopic foci of breast tissue may be left behind in the mastectomy skin flaps, along the pectoralis, or in the axilla.
The messages above are critical: Our patients must understand that the priority is to address the known cancer. In this regard, appropriately selected patients should be encouraged to strongly consider breast-conserving surgery whenever feasible, as this low-morbidity treatment is equivalent to mastectomy from the perspective of overall survival. The question of CPM is most relevant for those patients that are ineligible for breast conservation or patients unwilling to undergo lumpectomy and breast radiation.
If a mastectomy for the cancerous breast is planned, we must then address the questions that routinely arise regarding bilateral surgery. In our efforts to clarify the reality of what CPM can and cannot achieve, we must also avoid being too dogmatic and paternalistic with our patients. There are clearly specific scenarios, as delineated in Dr. Hawley’s work, where the risk of a second primary breast cancer is likely to be considered excessive by most women, and where the decision to pursue CPM may be easier. Examples of such cases would be women known to harbor BRCA mutations or women with suspected hereditary susceptibility based on a strong family history of breast and/or ovarian cancer. The risk of a new contralateral breast cancer can be in the range of 4%-5% per year in cases of hereditary disease, compared with the general population of women with sporadic breast cancer, where the risk ranges from 0.25% to 1% per year.
Conveying an understanding of risk
Patients must understand that the risk to the contralateral breast is predominantly expressed in the future – the likelihood of having a clinically occult, incidentally detected cancer identified in the contralateral mastectomy specimen is only 6%, as demonstrated most recently by King et al. (Ann. Surg. 2011;254:2-7), and with ductal carcinoma in situ accounting for the high majority of these lesions.
Defining the threshold for the amount of risk that an individual woman finds to be acceptable, however, can be a very difficult and personal decision. Even after a patient comes to understand that CPM is unlikely to provide a survival advantage, she may continue to request bilateral surgery purely for the risk-reducing benefits, and out of a desire to minimize her chances of having to repeat the breast cancer diagnosis and treatment experience. In some cases this choice will be influenced by reconstruction factors. A woman may be motivated to pursue bilateral surgery if she has an adequate volume of abdominal tissue because of the fact that the autogenous TRAM (transverse rectus abdominis myocutaneous) flap can be harvested only once. In other cases the decision is influenced by body habitus, for example, a woman with large pendulous breasts who is not interested in breast reconstruction may decide that she is more comfortable with a symmetrically flat chest wall in order to avoid chest wall imbalance and the inconvenience of finding/wearing a prosthesis that matches the remaining breast.
As breast cancer surgeons we should openly discuss these issues with our patients and present viable alternatives when feasible, such as reduction mammoplasty for the large-breasted patient. Ultimately, however, the patient must decide the surgical approach that provides her with the optimal sense of treatment satisfaction, quality of life, and comfort.
Discussion strategies
In my own practice I have found two discussion strategies to be particularly useful in guiding patients through the decision about CPM.
The first approach is relevant for women who are lumpectomy candidates, but who express a "reflex" interest in bilateral mastectomy while they are still in the emotional fog of processing the new cancer diagnosis. For these women it is obviously important to stress the survival equivalence of mastectomy and breast-conserving surgery, and this is also a great opportunity to educate patients about the potential axillary surgery advantages of breast conservation. The American College of Surgeons Oncology Group Z11 trial (JAMA 2011;305:69-75) has provided strong evidence supporting the safety of avoiding an axillary lymph node dissection (ALND) in women with sentinel lymph node (SLN) metastatic disease if the primary breast cancer is managed by lumpectomy and breast radiation.
At this point in time, we do not have comparably strong data to justify avoiding the ALND in the setting of mastectomy patients with SLN metastatic disease. The mastectomy patient with SLN metastasis is usually committed to undergo the completion axillary lymph node dissection specifically so that definitive decisions can be made regarding the need for postmastectomy radiation, and many of these patients become ineligible for immediate reconstruction because of this possible radiation. I therefore accentuate the advantage of at least initiating treatment with lumpectomy and sentinel lymph node biopsy. The patient preserves all of her surgical options with the benefit of having more staging information. If she is found to have SLN metastatic disease then she is in a better position to avoid the ALND with lumpectomy and radiation, and the option of future mastectomy and immediate reconstruction would still be available to her in the future (after completing all of her cancer treatment and healing from her radiation); if the SLN is negative, she can either continue with the breast-conservation treatment plan or she can pursue mastectomy (with or without immediate breast reconstruction, since prophylactic mamillary radiation therapy is not likely to be indicated for node-negative disease).
The second approach is relevant to the patient requiring mastectomy but for whom delayed reconstruction is planned because of medical issues or anticipated postmastectomy radiation. I encourage these patients to at least consider deferring the decision for the CPM until they return for the delayed reconstruction of the cancerous mastectomy, because at that time they can undergo the prophylactic mastectomy with the cosmetic advantages of immediate reconstruction.
Cost considerations
From the public health and population-based breast cancer burden perspectives as well as for individual patients, there are additional issues to be factored into the CPM discussion. It is a basic reality that cost is relevant when it comes to sorting out the net benefit of particular medical interventions, especially those that are prophylactic. Interestingly, a cost analysis study by Zendejas et al. (J. Clin. Oncol. 2011;29:2993-3000) from the Mayo Clinic demonstrated that CPM is actually cost effective, compared with surveillance for patients diagnosed when they are younger than 70 years of age.
The Women’s Health and Cancer Rights Act was implemented in 1999, mandating insurance coverage for breast reconstruction after mastectomy performed for cancer. This legislation promoted more widespread acceptance (and reimbursement) for contralateral mastectomy/reconstruction, but patients should nonetheless be proactive about confirming that their individual policy will indeed cover the expenses of prophylactic surgery. Furthermore, we must continue to monitor outcomes in women who choose to undergo CPM, as advances in breast cancer therapies may influence the survival benefits of this surgical approach. Indeed, selected retrospective studies have recently demonstrated that patients undergoing CPM have an improved survival, compared with those focusing on unilateral breast cancer surgery (Ann. Surg. Oncol. 2010;17:2702-9; J. Natl. Cancer Inst. 2010;102:401-9; J. Clin. Oncol. 2005;23:4275-86; Am. J. Surg. 2000;180:439-45). These results suggest a survival advantage associated with avoidance of a contralateral breast cancer, in contrast to the historical data alluded to above, regarding survival equivalence for patients with unilateral compared to metachronous bilateral breast cancer. As adjuvant systemic therapies for breast cancer continue to improve in effectiveness and ability to completely eliminate distant organ micrometastases, it is likely that we will continue to increase the pool of women who are essentially "cured" of the first cancer. This in turn could potentially increase the longevity threat of a second/metachronous cancer though a renewed metastatic risk. Nonetheless, data on possible survival advantages of CPM have not yet matured to the point where it can be recommended as a medically "indicated" procedure.
Our breast cancer patients face an abundance of very legitimate fears related to the morbidity and mortality risks of the actual cancer as well as the adverse effects and toxicities of treatment for that cancer. Fortunately, we can assure them that for the majority of cases these treatments will be effective and their longevity will be protected. It is therefore understandable that the desire to avoid repeating this particular life experience may be strong. We have an obligation to explain the advantages and disadvantages, as well as the alternatives to CPM, with sensitivity and patience. We must also strive to make sure that our patients do not make premature decisions without understanding the consequences. Last, but certainly not least, we are ethically bound to offer only those treatments that we feel are medically reasonable and safe as well as oncologically sound. But we must also remember that the decision to pursue treatment and the choice between the options that we offer are ultimately rights that belong to the patient.
Dr. Newman in an ACS Fellow, professor of surgery, and director of the Breast Care Center and Multidisciplinary Breast Fellowship Program, University of Michigan Comprehensive Cancer Center, Ann Arbor.
Dr. Sarah Hawley and her coinvestigators are to be applauded for generating insightful data regarding factors and concerns that motivate a woman to undergo contralateral prophylactic mastectomy in the setting of unilateral breast cancer (JAMA Surgery 2014 May 21 [doi:10.1001/jamasurg.2013.5689]).
Hawley et al. found that fear of recurrence was one of the strongest factors leading women to choose contralateral prophylactic mastectomy (CPM). This finding clearly demonstrates that we need to do a better job of explaining and defining the significance of (i) breast cancer local recurrence; (ii) breast cancer distant recurrence; and (iii) the development of a new/second primary breast cancer. Since cross-metastasis of a primary breast cancer to the contralateral breast is an extremely rare event, and since distant metastasis from the initial primary breast cancer tends to determine survival rates, CPM by definition will influence the incidence of only the third pattern. Furthermore, since the risk of experiencing a new contralateral malignancy is less than 1% per year for the general population of breast cancer patients, only a minority of these women will actually become bilateral breast cancer patients. Fear of recurrence is therefore a totally inappropriate reason for patients to pursue CPM, and the reasonableness of CPM to reduce the risk of a contralateral new primary breast cancer is debatable.
It can be reasonably stated that prophylactic surgery by definition is never a medically indicated necessity. Furthermore, despite the fact that a personal history of breast cancer is indeed a risk factor for developing a second primary cancer in the contralateral breast, numerous studies have demonstrated equivalent survival rates for women with unilateral breast cancer, compared with those diagnosed with bilateral/metachronous breast cancer (Cancer 2001;91:1845-53; Am. J. Clin. Oncol. 1997;20:541-5). Survival tends to be driven by the stage and effectiveness of treatment for the first cancer. By virtue of its earlier presentation, it is likely that the initially diagnosed cancer has established itself as the faster-growing malignancy with a lead time advantage in establishing distant organ micrometastatic disease; furthermore, patients with a unilateral breast cancer diagnosis are generally undergoing diligent surveillance and a contralateral malignancy is more often detected at an early stage.
Messages to our patients
It is essential for those of us who manage breast cancer to clearly emphasize several messages to our newly diagnosed breast cancer patients: First, although unilateral breast cancer increases the likelihood of developing a second primary tumor, it is certainly not inevitable, and in fact, the majority of patients are not destined to develop contralateral disease. Second, reducing the risk of being diagnosed with a contralateral breast cancer does not mitigate the mortality risk associated with the first cancer. And, finally, prophylactic mastectomy is the most aggressive and effective strategy for reducing the incidence of primary breast cancer (by approximately 90%), but it does not confer complete protection, as microscopic foci of breast tissue may be left behind in the mastectomy skin flaps, along the pectoralis, or in the axilla.
The messages above are critical: Our patients must understand that the priority is to address the known cancer. In this regard, appropriately selected patients should be encouraged to strongly consider breast-conserving surgery whenever feasible, as this low-morbidity treatment is equivalent to mastectomy from the perspective of overall survival. The question of CPM is most relevant for those patients that are ineligible for breast conservation or patients unwilling to undergo lumpectomy and breast radiation.
If a mastectomy for the cancerous breast is planned, we must then address the questions that routinely arise regarding bilateral surgery. In our efforts to clarify the reality of what CPM can and cannot achieve, we must also avoid being too dogmatic and paternalistic with our patients. There are clearly specific scenarios, as delineated in Dr. Hawley’s work, where the risk of a second primary breast cancer is likely to be considered excessive by most women, and where the decision to pursue CPM may be easier. Examples of such cases would be women known to harbor BRCA mutations or women with suspected hereditary susceptibility based on a strong family history of breast and/or ovarian cancer. The risk of a new contralateral breast cancer can be in the range of 4%-5% per year in cases of hereditary disease, compared with the general population of women with sporadic breast cancer, where the risk ranges from 0.25% to 1% per year.
Conveying an understanding of risk
Patients must understand that the risk to the contralateral breast is predominantly expressed in the future – the likelihood of having a clinically occult, incidentally detected cancer identified in the contralateral mastectomy specimen is only 6%, as demonstrated most recently by King et al. (Ann. Surg. 2011;254:2-7), and with ductal carcinoma in situ accounting for the high majority of these lesions.
Defining the threshold for the amount of risk that an individual woman finds to be acceptable, however, can be a very difficult and personal decision. Even after a patient comes to understand that CPM is unlikely to provide a survival advantage, she may continue to request bilateral surgery purely for the risk-reducing benefits, and out of a desire to minimize her chances of having to repeat the breast cancer diagnosis and treatment experience. In some cases this choice will be influenced by reconstruction factors. A woman may be motivated to pursue bilateral surgery if she has an adequate volume of abdominal tissue because of the fact that the autogenous TRAM (transverse rectus abdominis myocutaneous) flap can be harvested only once. In other cases the decision is influenced by body habitus, for example, a woman with large pendulous breasts who is not interested in breast reconstruction may decide that she is more comfortable with a symmetrically flat chest wall in order to avoid chest wall imbalance and the inconvenience of finding/wearing a prosthesis that matches the remaining breast.
As breast cancer surgeons we should openly discuss these issues with our patients and present viable alternatives when feasible, such as reduction mammoplasty for the large-breasted patient. Ultimately, however, the patient must decide the surgical approach that provides her with the optimal sense of treatment satisfaction, quality of life, and comfort.
Discussion strategies
In my own practice I have found two discussion strategies to be particularly useful in guiding patients through the decision about CPM.
The first approach is relevant for women who are lumpectomy candidates, but who express a "reflex" interest in bilateral mastectomy while they are still in the emotional fog of processing the new cancer diagnosis. For these women it is obviously important to stress the survival equivalence of mastectomy and breast-conserving surgery, and this is also a great opportunity to educate patients about the potential axillary surgery advantages of breast conservation. The American College of Surgeons Oncology Group Z11 trial (JAMA 2011;305:69-75) has provided strong evidence supporting the safety of avoiding an axillary lymph node dissection (ALND) in women with sentinel lymph node (SLN) metastatic disease if the primary breast cancer is managed by lumpectomy and breast radiation.
At this point in time, we do not have comparably strong data to justify avoiding the ALND in the setting of mastectomy patients with SLN metastatic disease. The mastectomy patient with SLN metastasis is usually committed to undergo the completion axillary lymph node dissection specifically so that definitive decisions can be made regarding the need for postmastectomy radiation, and many of these patients become ineligible for immediate reconstruction because of this possible radiation. I therefore accentuate the advantage of at least initiating treatment with lumpectomy and sentinel lymph node biopsy. The patient preserves all of her surgical options with the benefit of having more staging information. If she is found to have SLN metastatic disease then she is in a better position to avoid the ALND with lumpectomy and radiation, and the option of future mastectomy and immediate reconstruction would still be available to her in the future (after completing all of her cancer treatment and healing from her radiation); if the SLN is negative, she can either continue with the breast-conservation treatment plan or she can pursue mastectomy (with or without immediate breast reconstruction, since prophylactic mamillary radiation therapy is not likely to be indicated for node-negative disease).
The second approach is relevant to the patient requiring mastectomy but for whom delayed reconstruction is planned because of medical issues or anticipated postmastectomy radiation. I encourage these patients to at least consider deferring the decision for the CPM until they return for the delayed reconstruction of the cancerous mastectomy, because at that time they can undergo the prophylactic mastectomy with the cosmetic advantages of immediate reconstruction.
Cost considerations
From the public health and population-based breast cancer burden perspectives as well as for individual patients, there are additional issues to be factored into the CPM discussion. It is a basic reality that cost is relevant when it comes to sorting out the net benefit of particular medical interventions, especially those that are prophylactic. Interestingly, a cost analysis study by Zendejas et al. (J. Clin. Oncol. 2011;29:2993-3000) from the Mayo Clinic demonstrated that CPM is actually cost effective, compared with surveillance for patients diagnosed when they are younger than 70 years of age.
The Women’s Health and Cancer Rights Act was implemented in 1999, mandating insurance coverage for breast reconstruction after mastectomy performed for cancer. This legislation promoted more widespread acceptance (and reimbursement) for contralateral mastectomy/reconstruction, but patients should nonetheless be proactive about confirming that their individual policy will indeed cover the expenses of prophylactic surgery. Furthermore, we must continue to monitor outcomes in women who choose to undergo CPM, as advances in breast cancer therapies may influence the survival benefits of this surgical approach. Indeed, selected retrospective studies have recently demonstrated that patients undergoing CPM have an improved survival, compared with those focusing on unilateral breast cancer surgery (Ann. Surg. Oncol. 2010;17:2702-9; J. Natl. Cancer Inst. 2010;102:401-9; J. Clin. Oncol. 2005;23:4275-86; Am. J. Surg. 2000;180:439-45). These results suggest a survival advantage associated with avoidance of a contralateral breast cancer, in contrast to the historical data alluded to above, regarding survival equivalence for patients with unilateral compared to metachronous bilateral breast cancer. As adjuvant systemic therapies for breast cancer continue to improve in effectiveness and ability to completely eliminate distant organ micrometastases, it is likely that we will continue to increase the pool of women who are essentially "cured" of the first cancer. This in turn could potentially increase the longevity threat of a second/metachronous cancer though a renewed metastatic risk. Nonetheless, data on possible survival advantages of CPM have not yet matured to the point where it can be recommended as a medically "indicated" procedure.
Our breast cancer patients face an abundance of very legitimate fears related to the morbidity and mortality risks of the actual cancer as well as the adverse effects and toxicities of treatment for that cancer. Fortunately, we can assure them that for the majority of cases these treatments will be effective and their longevity will be protected. It is therefore understandable that the desire to avoid repeating this particular life experience may be strong. We have an obligation to explain the advantages and disadvantages, as well as the alternatives to CPM, with sensitivity and patience. We must also strive to make sure that our patients do not make premature decisions without understanding the consequences. Last, but certainly not least, we are ethically bound to offer only those treatments that we feel are medically reasonable and safe as well as oncologically sound. But we must also remember that the decision to pursue treatment and the choice between the options that we offer are ultimately rights that belong to the patient.
Dr. Newman in an ACS Fellow, professor of surgery, and director of the Breast Care Center and Multidisciplinary Breast Fellowship Program, University of Michigan Comprehensive Cancer Center, Ann Arbor.
