How do most newly diagnosed cancer patients select their doctors? They don’t.
They’re “referred,” almost always by their primary care physician.
Thus, with little other than the referral of a physician who they most likely see for no more than fifteen minutes once a year, the newly diagnosed cancer patient accepts without question which physician or physicians are to serve as guide and partner on the most important health journey of his or her life. Hell, I’ll even watch a movie trailer on-line before I commit to spending $30 and two hours dragging my family to the theater. To base such a crucial partnership, a partnership on which your survival literally depends, on the referral of a physician who likely knows little or nothing about you other than that you have cancer (and what you look like in your underwear) is insane. Is this how you pick your babysitters, and if so, how many children have you lost?
Finding Your Surgeon
Many of you will undergo surgery as part (or even all) of the treatment aimed at curing you. For most of you, surgery will be the initial treatment you receive. You need to understand this: the success of radiation therapy depends to a large extent on the equipment and a treatment protocol (set of instructions specific for treating your cancer), and the success of chemotherapy depends to a large extent on the pharmaceutical agents (chemotherapy drugs) and a treatment protocol; the success of surgical treatment depends almost entirely on a person: your surgeon.
Stated differently: pick a mediocre radiation oncologist or medical oncologist and odds are you’ll still receive acceptable treatment; pick the wrong surgeon and you may dramatically reduce your chance of beating your cancer. Radiation and chemotherapy depend heavily upon equipment, drugs, and standard guidelines. Surgery depends on a human being. If your surgeon does not have a clear understanding of how to operate on someone with your exact stage of your specific type of cancer, and/or if your surgeon does not have the technical experience and/or skills to perform the surgical procedure most likely to cure you, then what the hell are you doing letting this surgeon care for you? Thus, whether surgery is the initial or sole approach to curing you, or whether your surgery follows radiation and/or chemotherapy in your treatment plan, you’d better pick the right guy or gal to hold the scalpel.
So, how do you know who is the right surgeon for you?
There are a number of questions to which you should seek answers. Many can be answered simply by looking on the internet. Others you may have to ask of the surgeon’s staff via a phone call. Still others can only be answered by directly speaking with the surgeon. We’ll get to these questions in a second, but first, go back and read the title of this chapter. Go ahead…I’ll wait.
Back? Good. It’s all about you, Baby. That means if you are or were referred by your family doctor of forty years to a surgeon, but you don’t like the answers to the questions we’re about to discuss, it’s too damn bad. It will hurt your family doctor’s feelings if you pass on his referred surgeon? Too damn bad. For all you know, the referral is based on the fact that they’ve golfed together every third Saturday for years (no joke…many physician referrals are based on personal friendships, as most primary care physicians have no clue as to the surgeon’s true skills or knowledge). It will piss off the surgeon that you’re going to find someone else to perform your cancer operation? Too damn bad. Trust me (I’m a surgeon): the surgeon has an ego…he’ll/she’ll get over…within minutes…if not seconds.
So what makes a good surgeon?
A good surgeon is (1) interested and experienced in caring for cancer patients, (2) interested and experienced in specifically caring for cancer patients with your type of cancer, (3) interested and experienced in caring for cancer patients with your type of cancer and your specific stage of cancer. Now understand this: in many surgical fields, there are surgical “generalists” and surgical “specialists.” While this differentiation does not always help, it’s not a bad place to start. Generalist surgeons (such as general surgeons, gynecologists, head and neck surgeons, orthopedic surgeons, neurosurgeons, and urologists) complete college and medical school, then spend several (usually four to five) years as an intern (the first year) and then as a surgical resident before heading out to practice surgery. During this training, these future generalist surgeons are required to see, operate on, and care for a wide variety of cancer patients (under supervision). But there are several factors relating to where they train as residents which impact whether or not they were trained well enough to serve as your cancer surgeon. Surgical fellows have completed their generalist surgical training and chose out of interest to continue with more focused training in order to become surgical specialists. Those surgeons who complete a fellowship focused on specific types of cancer truly develop additional knowledge, skills, and expertise that can greatly benefit you. So what to do?
My suggestion is that if there is a fellowship-trained surgeon available to you (covered by your insurance and in a location which works for you and your family), start there.
Of course, the fellowship training had to emphasize cancer surgery (it does you no good to see a gynecologic surgeon whose fellowship and expertise are in the area of fertility, or a urologist whose fellowship was focused on kidney transplantation). Find a surgical specialist whose fellowship training focused only on or heavily on caring for patients with your type of cancer. Here’s a general guide regarding surgical specialists for several types of cancer:
- For colon or a rectal cancer, meet with a Colon & Rectal Surgeon. We (I’m one of these guys) specialize in the care of patients who own these two related but in many ways unique large bowel cancers. If there is no fellowship-trained Colon & Rectal Surgeon available (and be careful, as many general surgeons advertise themselves as Colon & Rectal Surgeons but have not completed fellowship-training, so find out via the internet or by asking the surgeon), you will be in good hands if you find a general surgeon with significant experience and interest in colon or rectal cancer care. One note of warning: rectal cancer is very different than colon cancer and, in my opinion, should only be treated by a fellowship-trained Colon & Rectal Surgeon unless impossible for you to find or have covered by your insurer (and don’t give up on the latter without a fight); failure to do so may mean that your rectal cancer is not staged correctly, treatment is not provided in the correct order (some patients benefit from radiation and chemotherapy prior to surgery), and surgery may unnecessarily leave you with a permanent “colostomy” (when the end of the large intestine drains through the wall of your abdomen into a bag.
- For pancreatic, hepatic (liver), or biliary (the tubes draining the liver) cancer, meet with either a fellowship-trained Surgical Oncologist or a fellowship-trained Hepatobiliary Surgeon. If meeting with the former, make certain that he/she is experienced and interested in the care of patients with your type of cancer (ask this, because Surgical Oncologists often focus only briefly on a number of types of cancer during fellowship training, and even after fellowship, some still have limited experience with these complicated cancers). If you still cannot find the right surgical specialist, head to an academic medical center (a hospital with a medical school, also referred to as a “teaching hospital”) and seek out a general surgeon with significant experience and interest in your type of cancer. All major surgical teaching hospitals (that is, those teaching hospitals that train surgery residents) have one or more surgeons who are passionate about the care of pancreatic/hepatic/biliary cancers. Again, do your research (for these types of cancer, search the websites of the academic medical centers nearest you; you will likely find one or more surgeons whose profiles clearly state their interest in these cancers).
- For lung cancer, meet with a Thoracic (chest) Surgeon. Now, this can be tricky, as most Thoracic Surgeons are actually trained as Cardiothoracic Surgeons; that is, their fellowship training included heart surgery as well as lung surgery (and the focus on heart surgery is often much greater than the focus on lung cancer). There are only a few pure (no heart) Thoracic Surgery fellowships that train surgeons who are truly passionate about lung cancer (as well as cancer of the esophagus). That doesn’t mean that a Cardiothoracic Surgeon is not experienced or interested in treating lung cancer; however, many if not most of these surgeons are most passionate about heart surgery. Thus, if no thoracic-only-fellowship-trained Thoracic Surgeon is available to you, find a Cardiothoracic Surgeon with experience and interest in treating lung cancer. (There is no place for a general surgeon in the surgical care of a lung cancer patient.)
- For esophageal cancer, see the previous bullet on lung cancer, as Thoracic (chest) Surgeons are the most experienced and interested in the care of diseases of this thoracic organ as well. As with lung cancer, if no thoracic-only-fellowship-trained Thoracic Surgeon is available to you, find a Cardiothoracic Surgeon with experience and interest in treating esophageal cancer. (Unlike the case with lung cancer, there are a limited number of general surgeons who are experienced and interested in esophageal cancer. That said, this would be my very last choice, and such a general surgeon would have to be practicing at a teaching hospital to provide the required post-operative care.)
- For cancer of the ovary, uterus, or cervix, seek out a Gynecologic Oncologist (these are general Obstetrician/Gynecologists who receive additional fellowship training focused on gynecologic cancers). This is critical, as the vast majority of general Obstetrician/Gynecologists have very limited training and expertise in the surgical care of gynecologic cancers (in fact, many general Obstetrician/Gynecologists refer most or all of their gynecologic cancer patients to Gynecologic Oncologists.) Only if no Gynecologic Oncologist is available (and you should be willing to drive a bit, if necessary) should you seek care from a general Obstetrician/Gynecologist. If this is your situation, do your homework to make certain that this generalist has significant experience and interest in your cancer type and stage.
- For prostate cancer (which rarely needs surgery), bladder cancer, or renal (kidney) cancer, you should see a Urologist. You should not be overly concerned if you find no fellowship-trained urologist whose fellowship focused on cancer (very uncommon), because many general urologists have significant experience in the surgical treatment of these cancers. That said, many Urologists focus on benign conditions, like prostatic hypertrophy (enlarged prostate), erectile dysfunction, and urinary incontinence (involuntary urine loss). Again, find the Urologist who not only has experience but also clearly has real interest in your type and stage of cancer.
The approach to surgeon selection is the same for cancers not mentioned on this list: if there is a surgeon who has completed not only general surgical training but also additional fellowship training with some or complete focus on your type of cancer, that surgeon’s office is a good first place to visit. If not, thoroughly research the generalist surgeons available to you: look on the surgeon’s internet site, as physicians routinely present their areas of professional expertise and interest. Don’t be shy about calling the surgeon’s office and speaking with the surgeon’s nurse (remember, it’s all about you, Baby, so who cares about a little embarrassment when you’re trying to get cured), asking about the surgeon’s experience regarding your type and stage of cancer. And if the previous steps lead you to the generalist surgeon’s office for an introductory meeting, own your cancer, step up, and ask specifically about that surgeon’s experience (training, number of patients routinely cared for, outcomes, complications) in treating cancer patients with your type of cancer and your stage of cancer. Don’t be shy, don’t feel embarrassed or guilty, and don’t be afraid to ask questions and seek answers. It’s all about you, Baby.
Even the most intelligent, rationale person
can lose perspective when threatened with cancer.
And it's understandable.
Fear can powerfully influence rationale thought. Fear of side-effects. Fear of dying. So when it comes to cancer therapies, who wouldn't want a better "alternative?" One that promises no nausea or vomiting. One that promises you'll keep your hair. One that guarantees a cure. It sounds too good to be true!
Here's the scoop. There are, in my experience, two broad categories of cancer treatments other than those offered by Western medicine: "alternative therapies" and "supplemental therapies." I suggest The Four Rules to allow you to simply differentiate between alternative treatments (which I strongly oppose) and supplemental treatments (which, while I may not always endorse, I do not oppose).
The Four Rules
- The "therapy" is not recommended as a replacement for any or all of the treatments recommended by your cancer physicians;
- The "therapy" does not reduce or in any way negatively impact the effectiveness (or have the potential to do so, according to your cancer physicians) of any or all of the treatments recommended by your cancer physicians;
- The "therapy" does not delay your receiving any or all of the treatments recommended by your cancer physicians;
- The "therapy" does not significantly drain your wallet.
The first three rules allow you to differentiate between "alternative" and "supplemental" cancer therapies. If the therapy under consideration violates any one or more of these first three rules, it's an alternative therapy, and regardless of the promises, the testimonials of the miraculously cured patients sharing their amazing, joyful stories on the website, walk away. If not one of the first three rules is violated, the therapy is likely supplemental. That doesn't mean you should jump at it; it only means that proceeding with caution (meaning a great deal of skepticism) is acceptable.
And regardless of the other rules, never, ever violate Rule Four, as to do so may place a great burden not only on you, but on your loved ones.
Trustworthy Cancer Resources & Contact Information
City of Hope Cancer Center (Duarte, California)
Cleveland Clinic (Cleveland, Ohio)
Clinical Trials Registry & Results Database (A service of the U.S. National Institutes of Health)
Dana-Farber Cancer Institute (Boston, Massachusetts)
Duke Cancer Institute (Durham, North Carolina)
Johns Hopkins (The Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland)
LIVESTRONG Foundation (Founded by cancer survivor Lance Armstrong, this group provides support to patients, raises funds for research, and serves as a forum and voice for cancer patients)
Massachusetts General Hospital Cancer Center (Boston, Massachusetts)
Mayo Clinic Cancer Center (The main Mayo Clinic is in Rochester, Minnesota, but Mayo Clinics are also in Phoenix and Scottsdale, Arizona and in Jacksonville, Florida)
MD Anderson Cancer Center (Houston, Texas)
Memorial Sloan-Kettering Cancer Center (New York, New York)
Moffitt Cancer Center (Tampa, Florida)
National Cancer Institute
St. Jude Children's Research Hospital (The first and only National Cancer Institute-designated Comprehensive Cancer Center that is devoted solely to children. Memphis, Tennessee)
Stanford Cancer Institute (Palo Alto, California)
Stand Up 2 Cancer (A terrific national organization which provides support to patients, raises funds for research, and serves as a forum and voice for cancer patients)