Q: Tell us about an unexpected experience with an associate.
She was 80, post lumpectomy, referred for radiotherapy. She was among a wave of patients avoiding mastectomy in the wake of the NSABP B-06 report providing lumpectomy and whole-breast radiotherapy equal to masectomy.
I was in my secon year out of residency, new to solo practice.
She held a prescription from the senior surgeon upstairs. It was written like a medication order: "Please give 5000 R to the lumpectomy area alone." I suppressed my astonishment at this attempt to subvert my training and generously ignored the outdated unit of dose. The patient and I discussed whole-breast treatment, the current standard of care, and scheduled simulation.
“The surgeon has long since retired, and now partial-breast irradiation has emerged as a viable treatment alternative.” — Bruce W. Hershatter
While colleagues later told me they would have treated without discussing it with the surgeon, I felt the need to be transparent and to educate the surgeon on the current standard of care. So I took the elevator to the surgical offices. The surgeon was the same age as my dad, gruff, and barely listened to the data supporting my approach before saying, "Right or wrong, this is the way I want it done. But if you must have it your way, go ahead."
The patient began treatment and in the third week had whole breast desquamation. She was miserable and convinced this toxicity resulted from my disagreement with her surgeon. After two weeks off and lots of Silvadene, she was ready to resume. This time, I boosted the lumpectomy site alone, carrying the dose to — you guessed it — 5,000 R (now 50 Gy).
Failure distant from the lumpectomy site in an untreated breast would have been a hard suit to defend in that era. The surgeon has long since retired, and now partial-breast irradiation has emerged as a viable treatment alternative. I never did get the chance to ask him how he knew.
Bruce W. Hershatter, MD, FACR, Associate Professor of Radiation Oncology at Emory University, Atlanta