Monday, November 19, 2012

No quick cure for an ailing system

No quick cure for an ailing system

Dr. Peter Lennox and Dr. Sheina Macadam in Vancouver.

Photograph by: Thandi Fletcher , Postmedia News

The ancient Egyptians described it as a "coagulum of black bile" within the breast. In their papyrus writings, dating to 1600 BC, they surmised that getting rid of the excess bile - through surgery, special diets, purging or even attaching leeches to draw out the bad blood - could cure the disease.
In 1889, American surgeon William Halsted, a founder of renowned Baltimore teaching hospital Johns Hopkins, performed the first radical mastectomy on a breast-cancer patient. The disfiguring procedure, which removed the entire breast and pectoral muscle, prevailed as the standard treatment for most of the 20th century.
It wasn't until 1963, with the invention of the silicone gel breast implant, that modern reconstructive techniques emerged.
Over time, breast reconstruction has become less invasive and more refined. With the delicate surgical options that surgeons have at their disposal, women rarely need to live without breasts, if they so choose.
Yet only about one in 10 mastectomy patients in Canada ever undergo reconstruction.
The hurdles women face in getting the surgery are accepted by many as a fact of living in a country with a universal health-care system with its seemingly infinite list of patients and finite pool of resources.
In the last instalment of this series, Canadian plastic surgeons debate solutions for the problems that prevent many women from receiving an important final procedure in their breast cancer treatment.
Ottawa plastic surgeon Dr. Nicolas Guay is a strong proponent of women educating themselves about breast reconstruction to get the most out of the health-care system.
Amid the organized chaos of his office at the Ottawa Hospital's Civic campus are four years' worth of documents that make up the Canadian Collaboration on Breast Reconstruction. Guay launched the website last year as a resource for Canadian women seeking information on procedures.
"In the United States, they know how much they're paying on a monthly basis just to receive care and they shop for their options," he said.
But in this country, "patients tend to let themselves be guided by the normal pathway of consultation that their surgeon has," which can mean waiting years before they ever meet a plastic surgeon.
Through the website, women can search a database of Canadian plastic surgeons who offer breast reconstruction. They can narrow the search based on their criteria, be it shortest wait times, language, or type of breast reconstruction offered. When they have the name of a surgeon, they can call to book an appointment, then secure the appropriate referral paperwork from their family doctor or general surgeon.
"The surgeon finder is what's really innovative. Patients have the tools to select who is going to offer them the care instead of passively waiting for their usual pathway."
The impetus behind Guay's website is its collaborative aspect. More than 100 surgeons responded to his request for information, and are listed on the website. The same collaboration is what Guay believes is the solution to changing how the system approaches breast reconstruction.
"I didn't anticipate it being so important to be a spokesperson for my patients, but you do have to," he said. "If we approach our ministries of health with a collaborative decision, a majority decision on how this care should be given in Canada, we are going to have the ear of the public and have the ear of the politicians, and things will change."
Finding the time to advocate, however, is easier said than done.
"That's where I think sometimes we fail as surgeons, in finding innovative ways to approach the administration, to approach the Ministry of Health and tell them in a very diplomatic and polite way ... that we need more resources for this."
While many surgeons are quick to point to more funding as a solution, Winnipeg plastic surgeon Dr. Edward Buchel disagrees.
He said the onus should be on doctors to develop more efficient and cost-effective ways of performing reconstruction with existing resources. The alternative, he said, is leaving the decisions up to the politicians, which would invariably lead to worse care.
In Winnipeg, Buchel has improved efficiency from surgical and administrative standpoints.
"If you were a general surgeon, it might take you an hour and a half to do a mastectomy, and then you could do another case right after that," explained Buchel.
But if a plastic surgeon takes over to begin the reconstruction, which can take up to eight or 10 hours, "then your operating room is down ... and you're not making any money," he said.
Therefore, he introduced a system where plastic surgeons offer their operating room time for immediate breast-reconstruction cases.
"It's about making a very efficient use of the operating room," he said.
Buchel said he has also developed surgical techniques that have increased his operating pace by two or three times. That means he can see more patients, and reduce his backlog of delayed patients.
His increased efficiency impressed the regional health authority, which gave him more operating room time. "We guaranteed that the resources would be used to eliminate a wait-list for any reconstructive surgery."
Buchel has also worked to improve access to reconstruction for Manitoba women. His goal is to ensure all breast cancer patients know about reconstruction before they ever have a mastectomy.
After years of lobbying for change, Buchel said that today any woman diagnosed in Winnipeg is automatically informed of her options for reconstruction.
If a patient wants reconstruction, they see a plastic surgeon for a consultation before their mastectomy, said Buchel. If they are indifferent about reconstruction, they still see a plastic surgeon. Those who are certain they don't want reconstruction don't get a referral.
If the U.S. approach to raising awareness about breast reconstruction is any indicator, the real power to increase surgery rates in Canada lies in the hands of policy-makers.
Some states have passed laws to help bridge the information gap for women undergoing mastectomies.
In New York, for example, cancer surgeons are legally bound to discuss breast reconstruction options with patients prior to their mastectomy, even if they have to refer the patient elsewhere for surgery.
Immediate reconstruction at the same time as mastectomy has also increased in the U.S., in part due to a recommendation by the Commission on Cancer of the American College of Surgeons in 2001 to incorporate the practice in the treatment of early-stage breast cancer.
Dr. Steven Morris, a plastic and reconstructive surgeon in Halifax, believes the onus is on Canadian governments to address the problem here as well, not doctors.
"Although we'd like to, we don't have the control of the different pieces of it to fix it. We're just kind of like the guys on the treadmill working."
To accommodate increasing demands for breast reconstruction, Morris said the "the allocation of resources needs to change."
With an aging baby boomer population, Morris is bracing for the "crunch" on health-care funding.
The problem is compounded by patients becoming better informed through the Internet about cutting-edge medical procedures, which also tend to be more expensive, he said.
A common barrier for mastectomy patients is difficulty navigating the health-care system. Seeking a second opinion on reconstruction from a plastic surgeon isn't easy when there is a significant wait time for a consultation.
Dr. Stefan Hofer, chief of plastic surgery at Toronto General Hospital and head of the University Health Network's Breast Restoration Program, said the solution to lengthy wait lists could be a telephone helpline.
In the Netherlands, where Hofer is originally from, if a person is facing a lengthy wait for an operation, they can call a helpline for assistance in finding a surgeon who can perform the procedure sooner.
"So the agency would actually call the office of the doctor ... and they would place people who had excessive wait times," he explained.
A helpline could also prevent Canadian women from seeking surgery in the U.S. when they face excessive wait times in this country, said Hofer.
There are many surgeons in Canada with the skills to perform breast reconstruction who have shorter wait times compared to some highly sought-after surgeons in busy metropolitan areas, he said.
Dr. Blair Mehling, a plastic surgeon in Edmonton, said he finds it mind-boggling just how much breast cancer survivors are willing to put up with in their quest for reconstructive surgery.
"It blows me away the length of time that women will wait just to see me for a consult and then for the surgery," said Mehling, adding that he has had delayed reconstruction patients wait as long as five years for him to operate. "It's not that they're happy about it, but we're very accepting of the flaws in the system."
He said the problem highlights a need for a shift in health-care policy.
In Alberta, he said, trauma cases - patients needing surgical care of physical injuries - appear to take precedence over cancer cases, which sees breast-cancer patients consistently being pushed to the back burner.
"Right now in Alberta, the wait time target to have a patient in for immediate breast reconstruction is three weeks," said Mehling. "Trauma cases are supposed to be in the operating room within a week of us seeing the consult."
In Edmonton, the main problem is a lack of plastic surgeons who offer breast reconstruction, said Mehling. Of those who do, many are expected to work several on-call emergency room shifts per week, which take up a lot of time that could be spent performing reconstructions, he said.
While the "knee-jerk response" would be to hire more plastic surgeons who do breast reconstruction, Mehling said, "you could equally make the argument that we could solve the problem by getting more plastic surgeons that do trauma."
While they are aware health-care funding is tight, plastic surgeons Dr. Peter Lennox and Dr. Sheina Macadam are adamant that more operating room funding is necessary to deal with the heavy breast-reconstruction patient load in Vancouver.
Both said they are struggling to work through a backlog of delayed reconstruction patients who are waiting two to three years for surgery.
"There's a whole bunch of variables in there," he said. "One is getting another surgeon, but you also need the resources to support it, so that's the hard part."
But in a universal health-care system, Lennox said he realizes requesting more resources is not always possible.
Vancouver plastic surgeon Dr. Nancy Van Laeken said she wouldn't be opposed to a two-tier health-care system to better handle the volume of breast reconstruction patients.
Van Laeken has privileges at the Cambie Surgical Centre, a private hospital catering mostly to patients with third-party medical insurance. Although patients can pay for some procedures, breast reconstruction is not offered at this point, she said.
"I'm not sure if this is politically correct for me to say, but it would be nice to know that if that patient wanted to have that surgery done in Canada, that they could call up one of us," Van Laeken said. "There are many aspects of the reconstructive piece that would be considered cosmetic, so it would be more accepting to go ahead and do that here because it is not a purely functional issue."
While he is not opposed to the idea of a two-tiered health-care system in Canada, Winnipeg's Buchel said he strongly disagrees with women paying for reconstruction when they have lost their breasts to cancer.
He reasoned that breast reconstruction is no different than many other "covered" procedures, from cardiac bypass to hip replacement surgery.
"Most of the stuff we do, it's all for quality of life," said Buchel. "You know, you're 65 or 70 years of age, and we're spending $10,000 to $15,000 on these people on new hips for them. Very little of that is survival. That's giving them a quality of life."
Buchel is not opposed to a European-style two-tier system, "where there is a safety net, but everyone has the option of having their own private insurance." But does he ever want to see cancer patients paying out of pocket for their cancer treatment?
"No. Never."

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