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WHEN I was a surgical resident in the early 1950s, I knew exactly what to do for a patient with primary operable breast cancer. She needed a classical Halsted radical mastectomy with meticulous dissection of the entire axillary contents.
Therefore, I was surprised to read an article1 by 2 British statisticians in the journal Surgery, Gynecology and Obstetrics. Drs Park and Lees discussed the results of breast cancer operations at great length. Indicative of the many differences in medicine between 1951 and 2000, their paper was 33 pages long. They finished this lengthy review with the conclusion that surgical intervention did little to alter the natural history of the disease.
The surgical community in the United States paid little attention to Park and Lees, and the enthusiasm for radical mastectomy continued. In the late 1950s there was even some consideration given to the addition of internal mammary node dissection for a primary lesion in the medial portion of the breast.
In the early 1960s, an experienced, internationally known breast surgeon advocated a time-consuming dissection, attempting to make certain that every bit of loose areolar tissue was dissected from the axillary vein. There is a story, perhaps apochryphal, that a visiting surgeon, after observing this prolonged procedure, remarked, "I never before saw a breast cancer metastasize on the operating table." At the same time, I was part of a traveling surgical group that was visiting a famous surgical department. There I witnessed an axillary dissection that was incomplete by traditional standards. No effort was made during the operation to clear the axillary vein completely. The operation was described as a radical mastectomy, and their reported 5-year survival figures were comparable with other reports in the literature.
As surgeons continued to evaluate the results of treatment for breast carcinoma, periodic reports questioned the importance of traditional radical mastectomy. A meeting was convened in Washington, DC, to discuss the problem, and the group proposed the first multicenter study of treatment. In this study, women with breast cancer were randomized intraoperatively to 1 of 3 treatment groups: (1) total (simple) mastectomy, (2) total mastectomy with postoperative radiation therapy, and (3) radical mastectomy. I represented the University of Rochester, Rochester, NY, at this meeting. During the conference, one of the national leaders in breast cancer surgery refused to participate because he knew that partial mastectomy was the appropriate initial therapy. Another equally well-known surgeon refused to enroll patients because he knew that radical mastectomy was the only possible choice.
Through the years, I cared for a number of women with breast carcinoma. There were a few excellent results—one of my patients is alive and well 40 years after her first and 30 years after her second radical mastectomy for infiltrating ductal carcinoma. However, too many patients with apparently favorable tumors later developed metastatic disease.
One patient in particular demonstrated to me the vagaries of this disease. This patient was a personal friend. When I first saw her, she was a healthy woman in her 50s who was referred to me because of very suspicious mammographic findings in her left breast. I was pleasantly surprised when the tissue I removed demonstrated benign mammary dysplasia.
Both she and her internist requested that I participate in her further care. Five years later I was reviewing her most recent mammograms with the radiologist. The radiologist, noting a minimal change in the lower outer quadrant of the opposite breast, said, "I don't think that this is significant. Let's repeat the study in 3 months to check the area."
When I talked to the patient, I reported to her the radiologist's suggestion, but I recommended that it would be more prudent to localize and remove the lesion. The patient agreed, and I removed a 7 × 7-mm block of tissue. This occurred early in the days of needle localization, and when I took the specimen to the laboratory, the surgical pathologist on call sneered, "What did you remove that for?"
Several days later the pathology report reached me: "Benign mammary dysplasia." However, when I looked at the single slide, I was concerned by what I saw, so I took the slide to the chief of surgical pathology, who had not reviewed this case. After looking at the slide, he said, "I'm not sure about this. I'll get some more slides made." The further cuts from this small bit of tissue demonstrated infiltrating ductal carcinoma.
The next day, I discussed the situation with the patient. I told her that if there was ever a place for lumpectomy in the management of breast cancer, this was probably it. However, I said that I was not comfortable with this approach, and I recommended either a wider local resection followed by radiation therapy or a modified radical mastectomy. Since the patient was a friend of my wife, she asked me what advice I would offer if she were the patient. I assured her that my advice would be exactly the same.
The patient decided to have a radical mastectomy done. When the specimen was studied, there was no residual cancer in the breast, but 2 of the axillary lymph nodes contained metastatic carcinoma. Fortunately, after a full course of chemotherapy, she is living and well, without recurrence 15 years later.
A mammographic lesion that a skilled mammographer wished to reevaluate in 3 months, an excisional biopsy specimen that was unimpressive grossly and initially interpreted officially as benign disease, a mastectomy specimen with 2 involved axillary lymph nodes, a patient living and well 15 years later after a course of chemotherapy—do these events represent a triumph of careful follow-up and appropriate therapy? Or do they represent the natural history of this disease in this particular patient? I still wonder.
Morton JH. Some Thoughts on Breast Cancer. Arch Surg. 2001;136(3):357–358. doi:10.1001/archsurg.136.3.357
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