1. Medical Council Revokes Specialist Status of Breast Physicians 8 December 2006
2. BCAC Condemns Threat to Breast Physicians by Medical Council
   - Press Release 12 June 2006
3. Medical Council of New Zealand (MCNZ) Proposal to Revoke the Vocational Scope of Breast Medicine (September 2006)

Medical Council Revokes Specialist Status of Breast Physicians
December 8th

The strongly stated views of a wide range of patients, survivors and their representatives failed to sway the Medical Council from their earlier decision to revoke the specialist status of Breast Physicians in New Zealand. BCAC, the Breast Cancer Network, Breast Cancer Support, other breast cancer organisations and individuals made submissions to the Council in June seeking to reverse the decision and keep Breast Physicians working at the front line in multi-disciplinary clinics.

‘This is very disappointing,’ said BCAC Chair Libby Burgess, ‘and yet another blow for women with breast cancer in our country. Many of us have received care from a Breast Physician and can attest to their professional competency and thoroughness. The Council decision is very short-sighted and means we have lost valuable resources. I’d like to thank all those people who wrote in to the Medical Council, standing up for our Breast Physicians.’  

The Medical Council decided to revoke the specialist status because it felt the training and professional development of Breast Physicians was not up to standard. There are currently five doctors working as Breast Physicians in New Zealand and it is not known at this stage whether the Australasian Society of Breast Physicians will appeal the decision or review their processes to work towards compliance.

BCAC Condemns Threat to Breast Physicians by Medical Council

Breast Cancer Aotearoa Coalition (BCAC)
Media Release
Auckland, 12 June 2006
For Immediate Release

The Breast Cancer Aotearoa Coalition (BCAC) is concerned and dismayed over a decision by the New Zealand Medical Council (NZMC) to de-register the Australasian Society of Breast Physicians (ASBP). Last week, the shortening of waiting lists denied women the option of breast reconstruction in the public system. A pending strike by radiologists this week will delay treatment for many. A Hearing to review the Medical Council decision is scheduled for Tuesday June 13th and could bring even more bad news to New Zealand women with breast cancer if the de-registering is upheld.

‘Two upsetting announcements for women with breast cancer in one week is more than enough, ‘said BCAC Chair Libby Burgess. ‘We don’t need another.’

Ms Burgess said the de-registration of Breast Physicians would be yet another blow for breast cancer patients, adding that it would close the door on a positive career path into breast medicine for bright, young physicians, a loss that women with breast cancer can ill afford.

Breast Physicians are trained doctors who specialise in the growing area of breast medicine. These specialists can not only expedite a timely and accurate diagnosis of breast cancer but have a wide range of skills to offer women. They bring expertise, an extensive knowledge of women’s health issues and focus to the ‘multi-disciplinary team’, an approach internationally recognized as optimal for the treatment of breast cancer. They perform biopsies, follow-up on patients pre- and post-operatively, read mammograms, provide counseling, undertake research and do administration and management work.

‘They travel with the patient on her breast cancer journey,’ said Ms Burgess. ‘They are the glue that holds the multi-disciplinary team together, simplifying the process, helping the patient understand her diagnosis and make well-informed treatment decisions. 

‘BCAC members fortunate enough to have received care from New Zealand’s few Breast Physicians know first hand the value that these people bring to breast cancer treatment. The Medical Council will be failing the women of New Zealand and their families if it refuses to reaccredit the Australasian Society of Breast Physicians. New Zealand women will be deprived of valuable support at the breast cancer ‘front line’ where it is needed the most.’

Medical Council of New Zealand (MCNZ) Proposal to Revoke the Vocational Scope of Breast Medicine (September 2006)

The following document was sent by BCAC in response to the MCNZ proposal to de-register the Australasian Society of Breast Physicians (ASBP). The MCNZ proposal can be viewed at:
 http://www.mcnz.org.nz/portals/0/meded/consultation%20paper%20-%20breast%20medicine.pdf  

31 October 2006

Ms Megan Purves
Education Coordinator
Medical Council of New Zealand
 PO Box 11-649
Wellington

Re: Proposal to Revoke the Vocational Scope of Breast Medicine Consultation Paper, September 2006, Medical Council of New Zealand

Dear Ms Purves,

The Breast Cancer Aotearoa Coalition (BCAC) would like to express its continued dismay over the Medical Council’s decision (September 2005) that the Australasian Society of Breast Physicians (ASBP) not be granted reaccreditation. As a consumer group representing women with breast cancer in New Zealand, we believe this outcome will have an adverse effect on the diagnosis, treatment and care of women with this disease in our country. We strongly support the reaccreditation of the ASBP and urge you to reconsider your decision. 

We welcome the opportunity to respond to the above mentioned Consultation Paper and the following is our response to the question: How will you or members of your organisation be affected if breast medicine is not recognized as a vocational scope of practice in future?  I write on behalf of our members   – the majority breast cancer survivors – with whom I have consulted in preparation of this response. I have detailed our response under six topics we believe have direct relevance to the care of our women with breast cancer, all areas where women would be seriously disadvantaged if the vocational scope of breast medicine was no longer recognised by the MCNZ. 

• Cancer is the leading cause of death in New Zealand for women aged 25-74 years.  Breast cancer is the most common cause of cancer death in women (Statistics New Zealand, 2005).
• 2500 New Zealand women are diagnosed with breast cancer each year (Ministry of Health, 2002).
• Over 700 NZ women are predicted to die as a result of breast cancer in 2006 (Ministry of Health, 2002).
• Despite having a lower risk profile for breast cancer, Māori women have a 21% higher incidence of the disease than non-Māori women (Robson et al. 2005), and this is particularly evident in the under 40 age group (McCredie et al., 1999).
• Māori women are 68% more likely to die from breast cancer than non-Māori (Robson et al. 2005). .
• Clearly, this disease impacts on many New Zealand families. 

The Breast Physician
A Breast Physician is defined as: ‘…a medical practitioner who, following a period of training, works in the clinical practice of breast disease diagnosis, adopting a holistic approach to investigation and management. The breast physician may do... clinical examination, interpretation of imaging, sonographic examination, counseling, interventional procedures, and administration if a dedicated breast unit. The breast physician works as a member of a multi-disciplinary team (and) … has to develop extensive knowledge over all the specialities involved in the investigation of breast disease in order to coordinate appropriate care and follow up of patients.’
 (ASBP Competency Standards and Training Program for Breast Physicians, Version 6, January 2006)

This unique specialty provides valuable, much needed focus on a disease that claims the lives of over 600 New Zealand women every year.  BCAC is surprised and disappointed that the Medical Council has seen fit to reject the application for reaccreditation of Breast Physicians as there is clearly a need for greater support and resource allocation in this area.  Loss of this specialty would serve only to reduce the options and provision of critical services to New Zealand women faced with a breast cancer diagnosis.  Without the formal recognition of Breast Physicians through Medical Council accreditation, talented young medical professionals are less likely to be attracted to this area of medicine, and this would have a long-term detrimental effect on the quality of care provided to breast cancer patients.

1. Breast Physicians are an integral part of the multi-disciplinary team approach to managing the diagnosis, treatment and care of breast cancer patients
Patients with breast cancer have a better outcome when they are treated by clinicians who have a large breast cancer caseload (Sainsbury, Haward, Rider et al., 1995, Lancet, 345: 1265-70).  The Royal Australasian College of Surgeons’ Guidelines for the Surgical Treatment of Breast Cancer (March 1998) state: ‘Breast cancer is a complex disease requiring collaboration of a number of health disciplines for its diagnosis, treatment and follow up. Multi-disciplinary management can be best achieved by the development of a multispecialist clinic.’  ‘A patient-centred approach to care’ is recognised as an essential element in the model of multi-disciplinary care (Brennan et al., 2005. Fifth Scientific Meeting Australasian Society for Breast Disease, 22-24 Sept. 2005, abstract, p. 88). 

A multi-disciplinary approach is widely recognised as optimal for the treatment of breast cancer (e.g., J Michael Dixon, RCF Leonard 1996. BMJ 312:145-8), offering the best outcomes for breast cancer patients. In fact, changes in the focus of breast cancer treatments have demanded such an approach. Modern techniques have created a need for specialists (surgeons, pathologists, radiologists and so on) to communicate well and many now work in such teams of which Breast Physicians are a key component. It is an approach that forms the cornerstone of Australia’s breast cancer treatment (where outcomes for women with breast cancer are 28% better than they are for women in New Zealand, Skegg et al. 2002) and is also lauded in New Zealand’s Cancer Control Action Plan 2005-2010 (Goal 3: Ensure effective diagnosis and treatment of cancer to reduce morbidity and mortality; Objective 1: Provide optimal treatment for those with cancer; Objective 2: Develop defined standards for diagnosis, treatment and care for those with cancer; p47). Indeed it is very likely that the multi-disciplinary team approach will be a recommendation of the guidelines for breast cancer, soon to be developed by the New Zealand Guidelines Group (NZGG) under contract to the Ministry of Health (contract signed October 2006). Revoking the vocational scope of breast medicine now would be a backward step which could then necessitate a costly reinstatement in the near future.

Given that New Zealand struggles with shortages of radiologists and other specialist physicians, there is particular value in the breast physician whose skills and training cover the range of disciplines found within a multi-disciplinary team.  Without this broader specialty, New Zealand’s limited medical resources will continue to provide a barrier to the establishment of additional multi-disciplinary teams with the necessary breadth of skills to function effectively.  Breast Physicians embody an efficient means of providing many of the required specialist areas of knowledge needed to provide optimal care.
           
BCAC believes that the provision of this optimal care for women with breast cancer, now and in the future, will be adversely impacted if the multi-disciplinary team approach to management of their disease is compromised by the removal of Breast Physicians. Patients experience extra benefit from Breast Physicians, through their more ‘holistic’ approach to care, as discussed in the next section of this response. Breast Physicians are much valued within existing practices for their professional expertise and this input can only be advantageous for other practices throughout New Zealand. De-registration will deprive  patients and teams currently employing Breast Physicians of a valuable resource, will limit the options available to patients of  such teams and would inhibit the future growth of multi-disciplinary teams.

The ASBP requires its members to work within a multi-disciplinary team. BCAC applauds this requirement while the MCNZ regards this as grounds for de-registration because such a practice ‘…is sustainable only in large centres’. Such an approach condemns women throughout New Zealand to less than optimal care and therefore less than optimal outcomes. Our relatively poor survival statistics (Skegg et al. 2002) demonstrate that women need more specialist clinics across the country, adequately staffed by qualified professionals including Breast Physicians.

2. Multi-disciplinary teams outside Auckland could benefit from the employment of Breast Physicians and offer improved treatment to patients as a result
While the MCNZ has rightly pointed out that the New Zealand branch of the ASBP exists only in Auckland at present, to use this fact as another reason to de-register the ASBP is short-sighted at best. Major centres outside of Auckland where multi-disciplinary teams exist could benefit from the addition of Breast Physicians to their practices if the vocation was encouraged and more young professionals were drawn to it. To de-register now would effectively eliminate opportunities for those wishing to pursue a vocation within the field of breast medicine.

Council also states that ‘The ASBP did not produce robust evidence of improved outcomes in treatment of patients when a Breast Physician was involved.’  BCAC questions whether sufficient data is yet available to establish this, given the relatively small number of Breast Physicians and the fact that there is presently no systematic nationwide collection of breast cancer data in New Zealand.  The exception to this is the Auckland Breast Cancer Register, which has collected data since 2000.  If an area of specialty requires such robust, long-term survival data before its existence can be justified, then it is hard to envisage how the Council could approve the emergence of any new specialty areas. 

 Establishing ‘robust evidence of improved outcomes’, when there are no comparative data from other regions lacking Breast Physicians, will be difficult indeed.  We presume also that the Council is concerned only with survival statistics when referring to ‘outcomes’.  BCAC challenges this.  Breast cancer does not kill patients immediately.  The demand for long-term survival figures to support reaccreditation of Breast Physicians seems a cynical move, and an argument all too often used to maintain the status quo in cancer treatment in New Zealand.  Ironically, the longer breast cancer patients live, the longer the wait for this ‘robust evidence’ to support improvements in their care.  For a woman facing breast cancer, the quality of treatment she receives and the psychological outcome can be greatly improved by the addition of a Breast Physician to her medical team, regardless of the final outcome in terms of her continued survival.  Many members of BCAC can attest to this from personal experience.

3. The knowledge of the Breast Physician overlaps other medical disciplines and this benefits patients
Council states that the inability of the ASBP to show a body of knowledge specific to the vocational scope of breast medicine and that the knowledge provided overlaps into other medical disciplines is also grounds for de-registration. BCAC sees this overlapping as a distinct advantage for breast cancer patients under the care of a multi-disciplinary team.

With the addition of the Breast Physician, the patient can have a direct report from an expert with a comprehensive overview of all the disciplines involved, someone who has attended each meeting in person and can explain how decisions about options for her care were reached.  This is a tremendous support for the patient, providing her with a sense that she has a ‘direct line’ to the team, someone on her side who has expert knowledge and can present her concerns to the other specialists with sufficient technical credibility to be heard well.  With a Breast Physician on her team, the patient has a tangible sense that there is someone else seeing the whole picture of her case, understanding her emotional concerns, interacting with all the other doctors, and synthesising all the relevant information.

Breast Physicians perform biopsies, follow-up on patients pre- and post-operatively, read mammograms, conduct ultrasound examinations, provide counseling, undertake research and do administration and management work.  They are well and comprehensively trained, knowledgeable in a range of women’s health issues and dedicated to their area of specialty. In short, Breast Physicians bring an extraordinary amount of expertise, skill and focus to a multi-disciplinary team and have much to offer patients.

Those of us who have experienced breast cancer with the specialist treatment, guidance and support of the Breast Physician can attest to this.  The breadth of experience and knowledge of the Breast Physician, combined with the ability to effectively communicate with the patient, are invaluable skills. In particular, the ability of a trained specialist to translate the complex medical information being provided by surgeon and oncologist into understandable and manageable knowledge enables the patient to progress through the highly stressful journey that is breast cancer with greater confidence.  This enables the patient to face difficult, unpalatable decisions with a degree of composure and clarity, and thus facilitates optimal engagement in well-informed decision-making.

As previously mentioned, the breadth of knowledge and expertise embodied in the Breast Physician efficiently provides specialist input across a range of disciplines, making the optimal multi-disciplinary approach more feasible in New Zealand’s environment of limited medical resources.

4. Breast Physicians can help alleviate a nationwide shortage of radiologists
There is a nationwide shortage of radiologists and few are trained specifically in breast radiology (Baker et al. 2005, NZMJ 118 No 1221). The adverse impact of this on the care of women with breast cancer has been extensively publicized and documented. This shortage will continue to affect women well into the future.

It is now established that radiologists who specialise in reading mammograms are better able to detect the heterogeneous population of malignant breast lesions that indicate breast cancer.  For example, the United States Mammography Quality Standards Act 1992 requires that interpreting physicians maintain ongoing experience, defined as 960 examinations per 24 months (Finder, 2004. Implementation of the MSQA, presentation available at: www.iom.edu/Object.File/Master/20/809/Finder.ppt#256, 1, Implementation of the Mammography Quality Standards Act (MQSA)).

The BreastScreen Aotearoa programme is falling short of its screening targets (only 48% of eligible women are being screened despite a 70% target. Source: Percentage derived by BCAC from data contained in Independent Monitoring Reports Jan – June 2005 and July – Dec 2005, www.healthywomen.org.nz) and this is partly due to a lack of resources to fulfill the programme’s expectations. Key screening staff are in short supply. Breast Physicians are desperately needed within the breast screening programme. They can be easily and less expensively trained to undertake the role of radiologists in breast cancer detection, while providing a broader skills, experience and knowledge of breast cancer in addition to a well-developed ability to communicate with patients.

It is widely accepted that a woman’s chances of an early diagnosis are far better if her radiology work is analysed by a professional who specializes in breast medicine e.g. a Breast Physician working within a multi-disciplinary team. One member of the BCAC Steering Group can personally attest to her misdiagnosis by a radiologist working within a radiology clinic, one who did not specialise in mammography. It was only by referring herself to a specialist breast clinic, where her mammogram was read by a Breast Physician, that she was eventually diagnosed. Similar stories are often brought to the attention of BCAC. The potential for misdiagnosis would be increased if breast specialty resources were reduced or unavailable. Especially given the nationwide shortage of radiologists, it seems short sighted by Council to consider removing breast physicians who are well qualified to read x-rays, conduct ultrasounds and to make accurate diagnoses.

5. Can other doctors in other areas of the country do the work of the Breast Physician?
The field of breast medicine encompasses a wide range of breast conditions of which breast cancer is only one. A Breast Physician is clearly better trained and qualified to diagnose a condition than the often overworked GP, a group whose numbers are dwindling in parts of New Zealand. BCAC has received too many stories where women have not been diagnosed expeditiously with serious consequences for the patient. New Zealand-wide accessibility of Breast Physicians working within multi-disciplinary teams and within the BreastScreen Aotearoa programme would greatly improve our breast cancer detection rates. Because of a heightened awareness of the disease, more and more women are being referred for further diagnostic work for breast symptoms, a trend that will continue, and our system must accommodate this demand. Eliminating a valuable resource such as the Breast Physicians, medical professionals who are fully capable of diagnosing a range of breast conditions, will only exacerbate serious work force issues already apparent within this area.

BCAC has heard from many women who report that while their medical professionals deliver excellent care, they often lack empathy and understanding of the emotional and psychological issues. Each specialist has their own area of expertise and sometimes all a woman needs is to speak with a medical professional who has the skill and time to pull all the information together, organise it and discuss it in an empathetic way to enable the patient to understand.

As part of their certification, Breast Physicians are required to counsel 200 women (logged formally) and to attend a recognised counseling course.
     
Breast Physicians offer a unique blend of skills. They can help a woman see the entire picture, review her care as a process and understand the changes that are happening within her body and mind as a whole. Such support cannot be measured and ‘robust evidence’ of its efficacy cannot easily be provided. However there is statistically sound data suggesting that women who receive counseling and support have a better quality of life and better survival outcomes than those who do not (Spiegel et al, 1989 Lancet 2:888-891).

There are 10-14 Breast Physicians working in New Zealand currently. BCAC believes this should increase to at least 25-30 and be targeted to where the need is greatest. The field of breast medicine originally evolved to fulfill a health need that was not being met and now that need has increased substantially. The MCNZ proposal to deregister Breast Physicians will only broaden the gap between need and provision of services to breast cancer patients.

6. Women with breast cancer will benefit now and in the future if competent medical professionals are attracted to and supported in the area of breast health
Breast cancer registrations have been steadily increasing in New Zealand over the past 30 years. This disease is the leading cause of cancer death in New Zealand women. The trend is expected to escalate over the next decade as our population ages. More women will be diagnosed with breast cancer and these women deserve and will expect best practice care delivered by competent professionals.

Early diagnosis of breast cancer results in a greater likelihood of a curative outcome. Delays in diagnosis and treatment can have devastating consequences as early disease may avoidably be allowed to progress to an advanced stage. Breast Physicians dedicated to this area of medicine can expedite a timely diagnosis and can then, given the breadth of their training, support women through the treatment and follow-up process. This serves both clinical and emotional needs for the women helping with their understanding and assimilation of information, thus improving their ability to make appropriate decisions regarding treatment options. This type of care allows a woman to feel she has some control over the situation and results in a greater trust in the medical professionals involved and a better acceptance of the overall process and outcome.

The ability to provide internationally recognised levels of care to women with breast disease in New Zealand is already limited by a lack of professional resources. Although numbering only 10-14 in New Zealand, Breast Physicians are an indispensable resource, offering excellence in breast care by providing a unique combination of diagnostic and medical skills coupled with a systemic, holistic approach to breast health, including psychological support.

BCAC believes the Council’s decision on breast medicine is short-sighted, given the continuing rise in the incidence of this disease in New Zealand, and reduces the likelihood of optimum outcomes for women with breast disease.
  
Conclusion
We hope the Council will take into account the views of those who are most affected by this decision, namely the many thousands of breast cancer patients of New Zealand whom BCAC represents. We hope that Council will see breast medicine as an innovation that if supported would allow the expansion of multi-disciplinary teams despite regional shortages of other specialists. If their vocational scope is revoked, Breast Physicians would revert to registration in a general scope of practice. Such a move would reduce career opportunities and leave talented young graduates to pursue more financially rewarding specialty areas.

2500 women are diagnosed with breast cancer in our country every year. 1 in 10 women will be affected by breast cancer in their lifetime – some specialists are now saying the rate could be closer to 1 in 8. As long as breast cancer claims over 600 lives every year, two women per day, it is irresponsible to remove resources from the breast cancer front line. Our Breast Physicians provide a valuable resource that BCAC believes must be encouraged, supported and offered opportunities, rather than threatened with de-registration. Every one of the 2500 women diagnosed every year in New Zealand deserves the best care possible, now and in the future. It would clearly be a mistake to remove this resource which currently serves women so well, a resource that will be much needed in the future by a health system that is already struggling to maintain an optimal standard of care.

BCAC requests that the MCNZ grant re-accreditation to the vocational scope of breast medicine and encourage the development of this specialty field.

Please do not deprive New Zealand women and their families of this much needed, valued and well-respected resource. 

Libby Burgess
Chair, Breast Cancer Aotearoa Coalition (BCAC)