Reflections on careers in breast care

Miss Fiona MacNeill is a Consultant Oncoplastic Breast Surgeon at the London Breast Clinic and the Royal Marsden, former Breast Tutor at the Royal College of Surgeons of England, and the first female President of the ABS.

Ms Sarah Downey is a Consultant Oncoplastic breast surgeon at James Paget University Hospital, Honorary Senior Lecturer at the University of East Anglia and ABS Vice President.

Miss Buket Ertansel is an MD Research Fellow at St George’s Hospital London, Trainee General Surgical Registrar, South London Deanery and Treasurer of the Mammary Fold.

What is your experience in breast care?

Fiona: Breast surgery did not exist as a speciality during my general surgery training, so I was appointed as a consultant general surgeon doing emergency on-call. Local GPs referred mainly woman with breast and lower GI/anal problems to the novel female surgeon. ‘Embracing the opportunity’, we developed specialist breast clinics and a breast multidisciplinary team based on the Nottingham model and following NHSBSP standards.   

Using the breast training gained with Mr Rob Carpenter and by attending the early oncoplastic breast surgery courses established by Mr Dick Rainsbury, Mr Gus McGrouther and Mr Chris Khoo, we slowly developed an oncoplastic service. This required collaboration with the plastic surgery team at St Andrews plastic centre in Chelmsford. I clearly remember the first bilateral reduction mammoplasty for bilateral breast cancer Mr Niri Naranjan and I performed in 1998. It seemed an obvious solution and encouraged us to expand the regional oncoplastic practice and set up joint educational courses.  

Mr Hugh Bishop is a memorable mentor. He gave me the confidence, opportunity and senior backing to try and establish breast surgery as a speciality as well as incorporate more specialist breast surgery into higher general surgery training and the FRCS exam. At this point in time, breast surgeons were often regarded as failed general surgeons.

Sarah: I have been very fortunate to have had an immensely rewarding career and to have enjoyed the majority of its phases. I do not come from a medical family, and they were surprised at my choice. My father can still not stand to think of me holding a knife! My mother was proud but recognised the impact such an involved career had on other aspects of my life. My great appreciation is that I had the choice. Every career has compromises outside of work but I am grateful that I was able to choose which compromises I did or did not make. Ensuring the next generation has those choices is a really important driver for me.

Buket: During my time as a core trainee, I was introduced to breast surgery and was struck by the surgeon’s central role within the multidisciplinary team, leading patient care. It was during my higher surgical training in general surgery where my longstanding interest in surgical oncology deepened and when I discovered my passion for breast oncoplastic surgery. Working in a specialist breast unit has provided invaluable insight into the intricate dynamics of a closely knit MDT. I have had the pleasure of working with our specialist care nurses, oncologists and radiologists on a daily basis. Additionally, becoming involved in the Mammary Fold, the trainee division of the ABS, has broadened my understanding on practice within the UK.

What inspired you to work in this field?

Fiona: Honestly? The most likely explanation for pursuing a career in surgery is because Dad told me not to be ridiculous and teachers and medical school interviewers insisted it was not possible (remember this was late1970s). This was puzzling – why did being a woman mean you could not be a surgeon?  My brain and hands seemed to work as well as anyone else’s and Mum (an ex Highland & Islands flying nurse then theatre sister at the Southern General in Glasgow) seemed to think it was perfectly achievable…

Having a clear goal of becoming a surgeon was what allowed me to survive six years of medical school.  As a non-science student, we did a preliminary year called 1st MB to get us up to speed in human biology, organic chemistry and medical physics. Fellow students were mainly mature postgrads who had worked as lawyers, journalists, nurses, and most had arts degree backgrounds. Their dedication and drive have remained an inspiration ever since; showing a callow 18-year-old that very hard work and some sacrifice was required to get where you wanted to be.

Sarah: I did a research project related to mammography as an undergraduate and my first surgical job was for Prof Roger Blamey. He was an inspirational individual. I still remember so many important lessons learnt early on from him. When I asked his advice about surgical exams, he took time and made coffee to talk me through the steps. He valued all of those working with him, whether they were male or female made no difference at all. I have met a series of similarly inspiring male surgeons through my career. I have the great fortune to have worked with Prof Jerome Pereira for 20 years and he continues to inspire me with his enthusiasm for making a difference to patients with breast cancer.

Buket: The relationship between patient and breast surgeon felt truly unique, the breast surgeon’s role is a vital one, that not only involves treating a patient’s surgical pathology but also providing essential emotional support during a challenging time. Breast surgery, in particular, is a rapidly evolving specialty with advancements such as systemic therapies, surgical de-escalation, and personalised reconstructive treatment options, making it an exciting and dynamic field to be a part of. I have been extremely fortunate to have many inspirational seniors (many women and men) who have shown me how they carefully balance technical expertise, oncological precision, and compassionate patient care.

What are you most proud of achieving in your career so far?

Fiona: Without doubt my fellows. You all know who you are, but the first was Mr Richard Sutton who arrived dauntingly well-versed and trained. These keen, smart new oncoplastic trainees were hard work – always asking annoying questions, constantly challenging what I said or did, but they stimulated me to learn and grow as a consultant and constantly improve my practice, for which I am forever grateful.

Becoming a Breast Tutor at the Royal College of Surgeons of England in 2006 was a pivotal moment in my education and training year career.  Helping to set up the first breast and oncoplastic skills courses with Mr Marcus Galea and Mr Adrian Ball was a busy and exciting time. It has been deeply rewarding over the last 30 years to see general surgery trainees develop into properly trained skilled specialist oncoplastic surgeons, in turn inspiring and training the next generation to develop better skills and innovative. 

The natural extension of becoming so involved in training was to become a member of the European group of surgeons who set up of the first specialist breast exam (FEBS) which Prof Lynd Wyld now leads.

As major responsibility of being a Breast Tutor was to facilitate and roll out the UK SLNB training with Prof Mansel and Mark Kissin. To be part of something that fundamentally changed breast surgery practice which saved thousands of women unnecessary axillary clearances was a tremendous privilege. Axillary surgery has never been without its controversies and challenges, but for me, SLNB and its clear evidence base was the inspiration to consider how we could do more to de-escalate breast cancer surgery.

Sarah: The joy of having reached this stage in my career is that I have so many fabulous female colleagues. ABS was the first professional meeting I attended where the women outnumbered the men and included so many nursing colleagues. I am so looking forward to my role as President of ABS as I am following in the footsteps of my favourite mentors, both male and female and know I have such a great supportive membership and team of Trustees to work alongside.

Buket: I am delighted that I have been able to undertake my higher surgical training in such a vibrant, ethnically and culturally diverse area such as London and help patients of all backgrounds. A highlight of my career has been the opportunity to pursue my MD in the vital field of breast-conserving surgery, focusing on optimising outcomes for women and contributing to advancements in this research field. 

What has been the biggest challenge you’ve faced?

Fiona: A major challenge was trying to be true to who I was as a person and maintain empathy and humanity within an often-brutalising training system with minimal sleep and heavy workloads. But these pressures were experienced by all surgery trainees, some managed better than others and this did not seem to correlate with biological sex.

Buket: Balancing motherhood, a partnership and career development in the later stages of training has come with its fair share of obstacles and challenges. However, being a mother brings me immense joy, and has greatly enriched both my personal and professional life. 

In your experience, are there any obstacles that women in healthcare commonly encounter in their careers?

Fiona: The biggest barrier to success is usually ourselves. Having enough self-belief and confidence to follow a career pathway that is not well mapped out by others who ‘look-like-me’.  In my day patients, hospital staff, trainers etc found it difficult to know how to treat or speak to a woman surgeon. These feelings and experiences will be recognisable to many of you for similar or different reasons.  

We now understand the importance of supporting diversity, role-models and mentoring but during surgery training in the 1980-90s there were very few female trainees and even fewer female consultants. Being a female role model was a tremendous responsibility and at times an irksome burden – I never forget being ‘rolled out’ at all the RCS charity and marketing meetings and conferences as the first female tutor!  There was no-one ahead of me to watch and emulate. Breaking glass ceilings can give you a headache…

There were some amusing incidents along the way: a very senior and august trainer told me it was impossible having me on the team as he could not swear at a ‘lady’ SHO. We came to an agreement: SHO first and a lady only occasionally, so he could swear as much as he liked if it made him feel better – it certainly made me work harder!

The occasion when asked by a (female) interviewer if I would like time to consult my husband before accepting a higher surgery training post outside central London.  An operating table observation: ‘women like you are responsible for society’s problems because you bring up latch key (delinquent) children!’ My response is not printable. But these anecdotes are historical and of course attitudes have changed considerably. 

Women do face unique challenges in pursuing a career in a demanding speciality such as breast surgery. Even in 2025, woman are often the main home makers and caregivers to their own family as well as ageing relatives. Part-time training is only a part-solution and we need to be more innovative in how we support women balancing their home life and career.

Sarah: My mothers’ generation had the career choices of secretarial work, teaching or nursing. When I was appointed a general surgical registrar, I was still a minority (two female registrars out of 57). I found this daunting when going to my early surgical meetings and seeing my male colleagues en masse but when actually doing my clinical work, I really found there was no discrimination. Patients and colleagues alike are simply interested in whether you have the required clinical knowledge and skills and whether you are a team player.

Buket: Healthcare has made significant progress in promoting inclusivity and mentorship for women, and breast surgery is a standout specialty with strong female leadership in both clinical care and research. However, further development is still needed to ensure women have a greater presence in executive leadership roles, enabling equitable career progression. Many women juggle demanding clinical roles alongside family responsibilities, and factors such as maternity leave and childcare can present challenges that impact career advancement.

How do you think we can best support the next generation of female healthcare professionals?

Fiona: By providing a supportive, stimulating and inspiring learning environment for all trainees.

Sarah: We have seen so many steps forward in breast cancer care over the past 30 years with huge improvements in both quantity and quality of life beyond the diagnosis. But there is so much more we can do. It is the best team sport I have ever come across.

Buket: Inclusivity is a crucial focus, and having strong role models within training environments is essential. Supporting less than full time work, whether for family, personal interests, or alternative professional development, is vital in creating a more accommodating workplace. I believe this approach will help attract a diverse group of women with varied skills and interests, ultimately enriching our field of breast care with a broader range of perspectives.