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Daniel Leff's Ronald Raven Travelling Fellowship 2013

A report on a combined surgical oncology and plastic surgical two-week observership at the MD Anderson Cancer Centre in Houston, Texas

I was privileged to receive one of the BASO Ronald Raven Travelling Fellowships awarded in 2013 and used the funding towards a combined surgical oncology and plastic surgical two-week observership at the MD Anderson Cancer Centre in Houston, Texas ("Oncoplastics" doesn't exist in the USA and my advice is it's probably best not to mention it!). 

MD Anderson is one of the world's premier cancer centres, treating nearly 120,000 patients and performing 66,000 surgeries hours per year.  MD Anderson is located within the Texas Medical Centre, which employs over 106,000 people (more than Apple and Google) of which 1 in 5 are employed in the health science field, making it the largest concentration of life science professionals anywhere in the world.  As soon as you arrive at MD Anderson you are struck by its sheer scale and enormity. The three primary buildings: "Main", "Faculty" and "Mays" are connected by vast sky bridges suspended over the freeways. Walking down these will certainly keep you fit but there is always the option of taking the golf buggy that transports patients and relatives (but only if there is room on the back!). The hospital has an aquarium, an art gallery and a 'park', and the sounds of the piano and flute can regularly be heard down the hallways (yes, you read all that correctly…just like any old UK NHS Trust!).

I was lucky to be supervised throughout my stay by Professor Henry Mark Kuerer who is as charming, bright and quick-witted as he is reserved and unassuming.  He made me feel part of the team immediately and was happy to be quizzed incessantly on his rationale for almost every decision he was making. The cases were complex in the extreme. Ductal carcinoma in situ treated by mastectomy with positive anterior and posterior margins… what would you do, he asked? (Nothing especially inspiring from me!). Prof Kuerer calmly gave the patients all the options from further skin excision to hormone therapy only and radiotherapy.  A patient with sporadic, node-positive, inflammatory breast cancer requested contralateral mastectomy. "Approximately 30-40% of patients request contralateral mastectomy here," Prof Kuerer informed me.  Quite staggering.  He advised her to treat the primary disease and delay decision-making regarding the contralateral breast.  A patient with history of mantle radiotherapy who is undergoing MRI surveillance has been found to have lobular carcinoma in situ and atypical ductal hyperplasia.  Prof Kuerer attends the patient with a clinician with a specialist interest in "Cancer Prevention" (… a branch of medicine I suspect yet to be established in the UK). The discussion includes the option for surgery but was also heavily focused on the benefits and side effects of Tamoxifen to reduce the risk of breast cancer in women at high risk.  Despite NICE guidance on the benefits of Tamoxifen, I had yet to experience a clinician offer Tamoxifen as a preventative strategy to women in the UK.  Finally, a patient arrives with a second episode of locally-recurrent disease having previously had breast conserving surgery and radiotherapy twice (…twice I thought…isn't that illegal!). It turns out she opted for a clinical trial of breast conserving surgery and partial breast radiotherapy when she recurred the first time. "Won't recommend that again," Prof Kuerer shrugs, and we go to lunch. 

I had the pleasure of observing Sarah DeSynder operate. 07.30am (…yes 07.30am sharp!) WHO-style checklist performed in the operating theatre with the whole team present and whilst the patient was still awake. (There are no anaesthetic rooms). Gave the patient the chance to tell them not to operate on the left breast (the consent clearly spelt out bilateral breast surgery!).  There was a lot of innovation to see. A patient was having radio-labelled seed guided excision of an area of ductal carcinoma in situ.  Seed localised surgery is actually more intuitive than I had appreciated, and it avoids many of the problems of needle localisation.  Abnormal axillary lymph nodes are clipped at diagnosis and radiolabelled seeds are subsequently placed to see the effects following neoadjuvant chemotherapy and to determine how often the clipped node is indeed the sentinel node. Smart study. Specimens were taken to the pathology department by Dr DeSnyder herself (pathology being co-located and just opposite theatres) and the chief breast pathologist showed me how they ink and cut the specimens. They also take specimen radiographs and use themto try to gauge the chances of margin positivity in real time. DeSnyder, the pathologist and the radiologist had a mini-MDT over one of the cases prompting her to take a further inferior margin.  How fabulous is that. I would typically have to wait 10 days to decide whether or not to re-operate for close or positive margins. 

I observed one of the plastic surgeons, Dr Melissa Crosby, performing an implant exchange and a delayed latissimus dorsi flap reconstruction.  She was full of great advice.  She taught me her technique for dropping and re-anchoring the infra-mammary fold, explained the benefits of being able to sit the patients up repeatedly to check reconstructive symmetry, emphasised the value of on-table expandable sizers before determining the definitive implant, and explained the use of round implants to create…. in her words that "barbie-doll look"!  Oh, and always use "holy water" (….a term I later found out means saline and antibiotics mix) in the implant pocket. 

Another plastic surgeon, Dr Alderman, took time out to show images depicting some of the more extreme effects of radiotherapy delivered at MD Anderson. We discussed the impact of the regimens used on reconstruction. Patients in need of PMRT tend not to be offered an immediate free flap reconstruction at MD Anderson and they opt instead for the delayed-immediate technique. Then I observed Dr Mark Villa perform a therapeutic mammoplasty using a vertical scar inferior pedicle technique and used the opportunity to discuss and revise different skin patterns and pedicles with him. Finally, I was able to network with Professor Oliver Bogler, one of the leaders of the global academic programme (GAP), and had an opportunity to brainstorm ideas for collaboration and joint grant funding. 

However, of all the things I observed, it is the MD Anderson approach to clinical care and treatment of staff that most stands out. They really celebrate survivorship! (…how very American you may say!). If you survive cancer they make a very big deal of it, and in my view it should be and we could all learn from that. You can't walk down a hallway or enter a clinic without seeing a banner or a plaque that describes someone's struggle through adversity. They are fully focused on patient experience and there are several picturesque places throughout the hospital to take solace, learn and read (there are several learning centres specific for patients) or simply to talk to other cancer sufferers about their experiences.  The most remarkable centre for children, called "Kim's place" (named after Kim Perrot, a famous basketball player who contracted cancer) is filled with basket-ball hoops, pool tables, video-games, and a full sized cinema screen and it allows paediatric patients to taste a degree of normality.  From my experience, patients really appreciate all this effort and they are willing to travel thousands of miles across the USA to be treated at MD Anderson.  Staff are celebrated similarly. There are plaques celebrating divisional employee of the month on all the walls throughout the hospital.  I witnessed the new medical director address the entire theatre staff, and explain the culture of openness he wanted to foster: "If you have a problem with me… come to me and I will do the same for you. If someone comes to you and they have a problem with me, tell them to come to me.  If you and someone else have a problem with me …say let's go see him together!"... Inspirational stuff. 

My stay was made so much more enjoyable and productive for meeting two very special clinicians: Professor Alastair Thompson (the then Breast CSG chair) a breast surgeon oncologist who arrived at MD Anderson via Dundee, and his wife Stacey Moulder, a clinical oncologist. They explained the fundamentals of how MD Anderson functions (both good and bad), facilitated observation in theatre and outpatient clinics, took me along to combined MDTs, helped me find my around and were thoroughly generous with their time outside of work.  Houston isn't an especially top tourist destination I was told, but I was very thankful nevertheless to be pointed in the direction of RICE university district, the Minute Maid Baseball Stadium, and Hermann Park, all of which served up a treat.
I leave you with a mantra I saw typed on one of the Professor's doors at MD Anderson and that I am trying to take back into my clinical practice: "Treat the disease and you may win or lose. Treat the patient and you win, no matter the outcome".

Daniel Leff

Daniel Leff

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