The history of breast cancer surgery is a tale of woe and intrigue. It is a story of strong personalities and procedures that were based more on beliefs than on science. Old ideas die hard. It took years before breast cancer surgeons were willing to give up on long-established practices. Now, a new study suggests that lymph node removal for stage I or II breast cancer patients may not be beneficial. This will no doubt lead to controversy, just like the research that preceded it.
The History of Radical Mastectomy:
Dr. William Halsted, one of the founders of Johns Hopkins Hospital, was a charismatic surgeon who dramatically changed the course of breast cancer treatment. He was the first U.S. surgeon to perform a radical mastectomy (in 1882). This became known as the Halsted procedure or the Halsted mastectomy. It involved the complete removal of all breast tissue along with muscles and fascia under the breast. Surgeons literally cut to the bone.
In his landmark article in the Annals of Surgery (Nov.,1894), Dr. Halsted described in great detail the radical nature of his surgical technique. He reported that of the first 50 cases he treated his success rate (no local or “regionary” recurrence) was 73 percent. He went on to state:
“In 43 of the 46 cases (93 percent) there has been no true local recurrence. Twenty-four are living and 10 are dead. In other words, there has, as I have said, been local recurrence in only three cases (6 percent). These statistics are so remarkably good that we are encouraged to hope for a much brighter, if not a very bright, future for operations for cancer of the breast.”
The Dismal Breast Cancer Prognosis Pre-Halsted:
According to Dr. Halsted, before lymph-node removal and radical mastectomy, breast cancer patients had a very poor prognosis:
“Every one knows how dreadful the results were before the cleaning out of the axilla [armpit] became recognized as an essential part of the operation. Most of us have heard our teachers in surgery admit that they have never once cured a case of cancer of the breast.”
Because Dr. Halsted was so respected amongst his peers and because his reported success rate was so much better than anything else at the time, the radical mastectomy became the accepted treatment for breast cancer for many decades.
The Dark Side of Radical Mastectomy:
There were problems, however. Because so much of the chest wall and armpit tissue were removed, wound healing was challenging. There was also a great deal of pain, and it often became permanent. Arm movement could be restricted and something called lymphedema was problematic.
When lymph nodes in the armpit are removed there can be swelling, pressure, pain and limited motion. Fluid accumulation in the arm, hand, fingers and chest occur because of damage to the lymph system.
The War Over Radical Mastectomy:
For more than 60 years, most American physicians believed that the Halsted procedure was the only appropriate way to treat breast cancer. They believed that by removing as much of the chest wall as possible along with lymph nodes they could eliminate the cancer and save lives.
But in the 1960s there was a challenge to the radical mastectomy approach to breast cancer. Dr. Bernard Fisher offered a new view of breast cancer. He proposed that it could be a systemic disease. If pockets of cancerous tissue had already migrated from the breast, radical surgery would not make a difference. He proposed a randomized clinical trial to test his hypothesis.
In 1971 patients were recruited from 34 different institutions. Eventually over 1,000 breast cancer patients were assigned to receive either a radical mastectomy, a “simple” mastectomy without lymph node removal or a simple mastectomy with follow-up radiation therapy to the lymph node area.
The results were announced on September 30, 1974, and a lot of surgeons were shocked. There was no difference in survival between the three groups. The trial “challenged and reversed 6 decades of breast cancer treatment lore” (JAMA, Sept. 12, 2017). Not surprisingly, a lot of surgeons (and other health professionals) reacted badly to this news.
Backlash Over Data:
In an article published in the journal Cancer (August, 1975), Dr. Fisher acknowledged the furor this study produced.
“Certain surgeons, radiation therapists, medical oncologists, and others, who, for the most part, had never heard the report or seen the data, related the findings to their own specialty, and to their own experiences and convictions, and took it upon themselves to deprecate them vociferously in the public forum…Those well-worn and battle-weary protagonists and antagonists of this or that surgical procedure girded their loins for another round of combat!”
Dr. Fisher was a surgeon-scientist. He valued data over beliefs. But many of his colleagues were outraged at the report. In 1977, he noted that:
“…positive axillary lymph nodes are not the predecessor of distant tumor spread but are a manifestation of disseminated disease” (Cancer, June, 1977).
Nevertheless, lymph node removal has remained a key component of breast cancer treatment to this day.
Lymph Node Removal 2017:
For decades, breast cancer surgeons believed that removing all lymph nodes from the armpit area was essential for reducing the risk of recurrent breast cancer. This was certainly Dr. Halsted’s belief over 100 years ago. But exactly how effective is this practice?
A study designed to answer that question surprised many oncologists and surgeons. After more than six years of follow-up, there was no difference in mortality between stage I and II breast cancer patients who had full lymph node removal and those who did not.
“When first proposed, this study was considered risky, if not reckless–leaving behind known cancer violated long-held, surgical principles of always removing cancer when it is known to be present…
“With a median follow-up of 9.3 years, the 10-year overall survival rate was 86.3% for the 446 women who only had sentinel node dissection and was 83.6% for the 445 women who had an axillary node dissection, which is a difference that was not statistically significant…
“What has been learned from more than a century of breast cancer surgery? Medicine has vastly improved because of greater rigor applied to evidence generation in terms of clinical trial design and statistical examination of clinical research…
“Less can be more in clinical medicine, meaning that providing fewer diagnostic tests or treatments may be just as good for patients as when very aggressive interventions are pursued…”
Change is Challenging:
It was hard for breast cancer surgeons to cut back on the Halsted procedure. The radical mastectomy was ingrained in their culture of medicine and their understanding of cancer. It is likely that some surgeons will also have trouble abandoning lymph node removal for stage I and II breast cancer. Be prepared for vigorous debate on this topic in the coming years.
Our understanding of cancer in general and breast cancer in particular has evolved greatly over the last 100 years. Many oncologists are starting to agree with Dr. Bernard Fisher that cancer is often a systemic disease. That is why immunotherapy is gaining such a foothold.
To learn more about breast cancer diagnosis and treatment you may want to listen to two radio interviews we did with renowned breast cancer surgeon and researcher, Susan Love, MD.
In the following interview Dr. Love discusses DCIS (ductal carcinoma in situ) and breast cancer treatment.
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