THE BEST BREAST CANCER SURGEONS

CHOSEN BY FELLOW DOCTORS

WHAt are the hallmarks of a good doctor? technical expertise and skill, of course — but someone who understands you, someone you trust, is also vital.

Indeed, research shows that a good relationship with your doctor can actually improve the chances of a successful outcome. But how do you find a specialist who fits the bill?

that’s where this unique series of guides, running every day this week in the Mail, can help. We’ve identified the country’s top consultants — as judged by their peers. We’ve canvassed the views of more than 260 consultants across seven specialties from around the country and asked them this very simple, but key, question: If your own nearest and dearest were to need treatment in your field, to whom would you refer them — and why?

the consultants who earned the most votes from their peers are the ones who made it into our guides — though patients should bear in mind that this is not a scientific study.

And, of course, there are many superb and highly skilled specialists all over the country who didn’t make it on to our list, but who spend every day of their working lives transforming patients’ lives.

to help you make informed decisions about your care, we’ve also talked to experts about the latest thinking on treatment. today, we focus on breast reconstructive surgery.

WHY IMPLANTS ARE MORE COMMON

Just at the point when a woman can be at her most vulnerable, dealing with a breast cancer diagnosis, she is likely to be confronted by further bewildering choices on a matter to which she’s probably never given much thought: Would she like breast reconstruction?

some women may consider this a distraction; others see it as a step to aiding their self-confidence and recovery.

under National Institute for Health and Care Excellence (NICE) guidelines, all breast cancer patients should be offered the full range of breast reconstruction procedures.

Broadly speaking, these fall into two main categories: implant-based reconstruction, or using the woman’s own surplus tissue, known as flaps, harvested from areas such as the abdomen, inner thigh or the back, to rebuild the breast.

Reconstruction can be carried out at the same time as the cancer surgery, or it can be delayed until all other treatment, such as chemotherapy and radiotherapy, is completed.

Although all options should be on the table for each woman, in practice it’s far less clear-cut.

Most good surgeons will want to take the woman’s preferences into account, but a number of factors will influence which reconstruction option is best. the stage of cancer, the woman’s size and shape, where in the breast the lump is located and whether radiotherapy is necessary — this can scar and shrink tissues and interfere with blood supply to the breast, making reconstruction more difficult — these are all key factors in determining which type of reconstruction will produce the best cosmetic result, and whether it can be done immediately.

A woman with a smaller lump in the lower part of a medium to large, pendulous breast may be a good candidate for therapeutic mammoplasty — where the lump is removed with a cancer-free margin of tissue around it (i.e., a lumpectomy), allowing the surgeon to reshape the remaining tissue into a smaller breast.

In a slim and smaller-breasted woman, breast conservation can be more of a challenge.

‘In a small breast, removing even a 1cm lump can leave a big defect,’ says simon smith, a breast surgeon at Broomfield Hospital in Chelmsford. ‘so then you have to think about whether you can move a bit of tissue from elsewhere to fill this, or consider whether that patient might be better with a mastectomy, then an implant reconstruction.’

In fact, 70 per cent of patients electing to have breast reconstruction end up with an implant. It is probably the simplest, most straightforward route and ‘it can get a lovely result’, according to stephen McCulley, a breast surgeon at Nottingham City Hospital.

However, it is unlikely to age as well as a flap reconstruction, and if radiotherapy is needed, this may shrink the skin and harden the implant, in which case further surgery may be needed.

With own- tissue breast reconstruction, the DIEP flap — where tissue and its blood supply is taken from the abdomen — is the gold-standard treatment. It is ideal for women with surplus fat around the abdomen, providing a soft, natural-feeling breast without any muscle-loss.

the key benefits of such microsurgical procedures — and only plastic surgeons are able to undertake these — is that they can provide a natural-looking and feeling breast which will gain and lose weight with the woman.

But there are drawbacks — these are lengthy, complex operations and if some muscle has to be taken to boost blood supply in the breast, it can weaken areas where the tissue was mined.

Breast surgeons are the first port of call in the referral process. they diagnose suspicious lumps, carry out all necessary cancer surgery and also orchestrate chemotherapy and radiotherapy when it’s needed.

Breast reconstruction is done by breast surgeons and plastic surgeons, sometimes called oncoplastic breast surgeons.

Oncoplastics is effectively a hybrid of oncology (cancer care) and some types of plastic surgery; oncoplastic breast surgeons are experts in clearing cancer and can undertake implant recon-structions and breast conserva-tion surgery, with the aim of creating the sort of cosmetic result the patient can live with.

However, it’s worth noting that the term ‘oncoplastic’ commonly tagged on to the title ‘ breast surgeon’ does not necessarily signify any further qualification

— many breast surgeons who have adopted the term have had no formal training in oncoplastics, although the majority may well have done courses or visited hospitals to learn from experienced surgeons and have become very good in the process.

Plastic and reconstructive surgeons are qualified to carry out the most complex microsurgical breast reconstructions, but not to remove the cancer, for example with a lumpectomy or mastectomy (although some now do extensive further training for this, too).

In large breast units, oncoplastic breast surgeons work with the plastic surgeons as a team; breast surgeons in smaller hospitals, which are unlikely to have an on-site plastic surgeon, may well refer patients suitable for flap reconstructions to larger regional units providing such services.

‘This in itself is a quality indicator, the sign of a hospital wanting to provide the full spectrum of reconstructions for their patients,’ says Mr McCulley.

So what are the hallmarks of the best breast and plastic surgeons? ‘Cancer clearance is absolutely the numberone priority,’ says Jo Skillman, a plastic and reconstructive surgeon at University Hospital in Coventry.

‘It has to be safe — but it is a fine balance. We have to take enough tissue, but not overdo it. If we don’t take enough, we can compromise cancer clearance. If we take too much, we compromise the aesthetic result.’

To identify the country’s very best consultants in breast reconstruction, we canvassed the views of around 40 breast and plastic surgeons themselves. Here, we reveal their choices, with a selection of personal comments about why they chose them.

RECONSTRUCTIVE SURGEONS RATED BY THEIR PEERS PAUL HARRIS

The Royal Marsden Hospital in London

WHAT THEY SAY ABOUT HIM: ‘An unbelievable surgeon with brilliant results who has great rapport with his patients,’ says one of his peers. According to another: ‘His breasts always look amazing and never fail. You really cannot tell the reconstructed breast from the other. He can make a DIEP flap [where tissue from the abdomen is used to rebuild the breast] work well in virtually anyone. He is also very good at taking his patients’ views on board.’

PRIVATE: The Royal Marsden Hospital (private care), The London Clinic, Parkside Hospital in Wimbledon.

FIONA MacNEILL

The Royal Marsden Hospital in London

WHAT THEY SAY ABOUT HER: ‘Incredibly experienced, technically gifted and with an international reputation. She is also kind, really caring, is a good diagnostician and she looks after her patients very well,’ says a fellow surgeon. ‘Will give a very sensible opinion on how best to manage difficult cases and her patients can feel reassured that the best decisions for their treatment are being made.’

PRIVATE: The Royal Marsden Hospital (private care), The London Breast Clinic.

VENKAT RAMAKRISHNAN

Broomfield Hospital in Chelmsford WHAT THEY SAY ABOUT

HIM: ‘ Technically brilliant, a lovely man and generally regarded as one of the best in the country for the DIEP flap reconstruction. He is also an innovator who has pushed the boundaries, streamlining the service at his hospital for flap reconstructions so that it is almost a production line — this means more patients benefit from the service than would otherwise be the case.’

PRIVATE: Nuffield Health Brentwood Hospital in Essex, Spire Wellesley Hospital in Southend- on- Sea, BMI Southend Hospital, Springfield Hospital in Chelmsford.

DOUGLAS MACMILLAN

Nottingham City Hospital WHAT THEY SAY ABOUT

HIM: ‘ Technically a very good breast surgeon who is very thorough and who does lots of implant reconstructions,’ according to one of his peers. ‘He thinks hard about providing the best aesthetic outcome and takes an active interest in the academic side of breast reconstruction — a sign of someone in the forefront of the field, interested in honing his skills.’

PRIVATE: BMI The Park Hospital in Nottingham.

GERALD GUI

The Royal Marsden Hospital in London WHAT THEY SAY ABOUT

HIM: ‘ Very creative with a great reputation and a very big, fairly international practice,’ says a contemporary. ‘ He is an experienced cancer surgeon who publishes widely [a sign of someone at the forefront in his field], pays great attention to detail and achieves excellent results with low complication rates, particularly with implants.’

PRIVATE: The Royal Marsden Hospital (private care), The London Clinic.

STEPHEN McCULLEY

Nottingham City Hospital WHAT THEY SAY ABOUT

HIM: ‘ Technically skilled and dualtrained in oncoplastics so he can both clear the cancer and offer the full spectrum of breast reconstructions. He has a very good aesthetic eye and has a sound understanding of how he can best restore the breast,’ according to one.

‘Very confident, an excellent communicator and also caring of his patients,’ says another.

PRIVATE: The Redcliffe Rooms, Woodthorpe Hospital, BMI The Park Hospital, all in Nottingham.

RICHARD SUTTON

Royal United Hospital in Bath WHAT THEY SAY ABOUT

HIM: ‘ Technically a great surgeon who gets very good results and who handles the tissues beautifully to minimise any possible damage,’ comments one fellow surgeon. ‘He is also a gentleman, a genuinely kind and

sensitive man who cares about his patients,’ was another comment. PRIVATE: Circle Bath Hospital, BMI Bath Clinic

STUART JAMES

The Royal Marsden Hospital in London WHAT THEY SAY ABOUT HIM: ‘ Tremendous, technically brilliant and really understands aesthetics — for a man, he really gets it,’ says one of his peers. ‘He is also a very good communicator and is one of the few plastic surgeons who understands that the person sitting in front of him has a serious illness and that tackling this is all about team effort and is not only a matter of breast enhancement. ‘Caring, but not touchy-feely.’

PRIVATE: The Royal Marsden Hospital (private care), Spire Gatwick Park, 108 Harley Street, The Chelsea Outpatient Centre, all in London.

ALSO HIGHLY THOUGHT OF: SIMON WOOD

Charing Cross Hospital in London WHAT THEY SAY ABOUT

HIM: ‘Huge experience on a very broad spectrum of breast reconstructions, including lots of difficult cases with women with advanced disease.

‘He is a quiet, self-effacing man who publishes and presents widely [a sign he’s at the forefront of this field] and is very approachable, down-to-earth and genuine, with lots of common sense.’

PRIVATE: Parkside Hospital, The London Clinic, Imperial Private Healthcare, all in London.

IAIN BROWN

Royal Cornwall Hospital in Truro WHAT THEY SAY ABOUT

HIM: ‘He gives a lot of thought to what reconstruction will work best for each patient and has great technique — he tries hard to avoid implants and will try to conserve the breast if at all possible,’ according to one. ‘A lovely man and a great communicator as he takes his patients through this process, when they’re at their most vulnerable.’

PRIVATE: Duchy Hospital in Truro.

STEVEN THRUSH

Worcestershire Royal Hospital WHAT THEY SAY

ABOUT HIM: ‘One of the newer generation of consultants, he is totally dedicated to breast surgery,’ says a surgeon who nominated him. ‘He is very caring and very sound oncologically — in other words, cancer clearance is, as it should be, the top priority, but he also has a very good aesthetic eye.

‘He wants to restore the most naturallooking breast, unlike some oncoplastic breast surgeons who might be too ready with an implant.’

PRIVATE: Spire South Bank Hospital in Worcester, BMI The Droitwich Spa Hospital in Worcestershire.

P. G. ROY

John Radcliffe Hospital in Oxford WHAT THEY SAY ABOUT

HER: According to one surgeon: ‘She’s young, engaging, technically outstanding and with huge energy. She also has a good aesthetic eye and has developed a technique for partial breast reconstruction — i.e., lumpectomy and sculpting the remaining tissue, taking tissue from elsewhere, to achieve excellent results.’

Another says: ‘She does wonderful work with the LICAP flap [suitable for women with breast cancer in the outer part of the breast — here, skin and fat are taken from under the arm to rebuild the breast].’

PRIVATE: Oxford Breast Clinic, Nuffield Health The Manor Hospital in Oxford.

PROFESSOR ANDREW BAILDAM

Manchester and London WHAT THEY SAY ABOUT

HIM: ‘In a sense, he’s the godfather of oncoplastics,’ says one simply. ‘He helped set up a UK training fellowship scheme for breast oncoplastics in 2002 and he has artist’s hands — it is a pleasure to watch him operate.’

‘He completely understands the 3D aspects of the breast and he gets amazing results,’ comments another. ‘He is a really good oncosurgeon and has a wonderful aesthetic sense.’

PRIVATE: (Works privately only) BMI The Alexandra Hospital in Cheshire; King Edward VII Hospital, The Harley Street Clinic, The Wilmslow Hospital, all in London.

JOHN MURPHY

University Hospital South Manchester WHAT THEY SAY

ABOUT HIM: ‘A relatively new appointee, he is a breath of fresh air with lots of new ideas. He tries hard to avoid mastectomy if at all possible.

‘He has led the way with implantbased reconstructions as opposed to own-tissue reconstructions. He is also very personable.’

PRIVATE: Spire Manchester Hospital, BMI The Alexandra Hospital in Cheshire.

ANNE TANSLEY

Royal Liverpool and Broadgreen University Hospitals WHAT THEY SAY

ABOUT HER: ‘A very good surgeon, a lovely person and a next-generation Fiona MacNeill,’ says one, referring to a leading figure in this field (see far left). ‘She has been a key figure in driving up the quality of breast surgery and devotes a lot of time to running training courses for the next generation in oncoplastics.

‘She has also been a key figure in bringing oncoplastic surgeons and plastic surgeons together which benefits all patients.’

PRIVATE: Spire Liverpool Hospital, Spire Murrayfield Hospital in Wirral.

SIMON SMITH

Broomfield Hospital in Chelmsford WHAT THEY SAY

ABOUT HIM: ‘ A lovely man, who is technically very skilled and who really understands the importance of the most careful tissue handling in getting the best results — there is huge skill in removing the breast well and this is what he will do, leaving what we call a good skin envelope,’ says one of those who nominated him.

‘If this is done well, plastic surgeons can do an amazing reconstruction. He also gets beautiful results with therapeutic mammoplasty [where the cancerous lump is removed and the remaining tissue is reshaped into a smaller breast].’

PRIVATE: Springfield Hospital, The Chelmsford, both in Chelmsford.