woman getting a mammogram, overdiagnosis, breast cancer survivors, hormone replacement therapy

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.

A new study of the 10-year overall survival rate found no difference in survival between the two groups of women (JAMA, Sept. 12, 2017). An editorial in JAMA that accompanied the study noted that:

“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.

Extended Interview with Dr. Love 

In the following interview Dr. Love discusses DCIS (ductal carcinoma in situ) and breast cancer treatment.

How to Reduce Your Risk from Breast or Prostate Cancer

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  1. Janice
    NC
    Reply

    My OB-Gyn said “you have a lump and I will schedule a mamogram and tell them exactly where to look.” since I had washed the inside of a rental and painted it, I felt maybe the lump was due to over exertion and with RA lumps come and go. After resting the site, using a tea as a poltice that cures beast cancer, I did schedule a mamogram which was negative. When they examine a man’s parts to this extreme I might consider another mamogram. Otherwise, no thank you

  2. Joyce
    Texas
    Reply

    I agree that surgeons do not consider quality of life after treatment. I had a successful mastectomy at my own insistence for estrogen receptive Stage II breast cancer in 1999. This was followed by 5 years of Tamoxifen & two years of Femera. I was used to an active lifestyle & was able to return to full time teaching within three weeks!

    However, I got lymphedema less than a month after my surgery which has restricted my quality of life because of its limitations. About a year ago, I got lymphedema in my chest area which comes with even more restrictions. It appears that I have it also in my right arm now due to an IV that was moved while in place in ER some 17 years later!

    I particapated in a study in 1999 at MD Anderson that showed an injected dye could be use to locate sentinel node biopsies to accurately determine if cancer cells had spread. Why is this guideline not being followed in 2017?

    While I am thankful to have Survivor as a label, I wonder if my current blood cancers are a result of my cancer treatment in 1999. I know my daily struggle with lymphedema is a direct result.

  3. C C
    Greensboro
    Reply

    I was diagnosed with Stage 1 breast cancer in 2012. My surgeon discussed the lumpectomy and removal of lymph nodes with me. His plan was to remove the tumor and the lymph node closest to the cancer and send both to pathology immediately. If the node was negative, no additional lymph nodes were removed. If it was positive, then the next one was removed and sent to pathology and so on until the next node was negative. Fortunately, the first node was negative. I had radiation, no chemo, and Arimidex for 5 years. So far so good, no lymphedema . The incision sites are still slowly changing as they heal over the years and continue to improve. I am very fortunate to have caught the cancer so early during my regular screening mammogram. It is important to discuss all aspects of the surgery with the surgeon and oncologist.

  4. Laurel
    Georgia
    Reply

    It seems like, again, that for too many doctors, quality of life after treatment is unimportant to them. They look at death as a failure and do all they can to prevent it. However, if that death prevention comes with a low quality of life, then death becomes a relief. I see this in doctors who dismiss the side effects of prescriptions also. Thank you for this study. I hope to never need the information, but if I do, this gives me (and my family) the statistics to support a less radical, better quality of life, treatment.

  5. Mick
    Reply

    Today, there are so many variations of treatment, but 3 years ago, my treatment was to undergo a by-lateral mastectomy (my choice) with the affected breast having the first lymph node removed as a precaution. It tested negative which was an assurance that my cancer had not spread.

    I did not have to undergo the dreaded chemotherapy and radiation. My cancer was detected during a yearly mammo and the two spots were in the very early stages. Had my cancer been more advanced, my treatment might have been entirely different. There really is no one way.

  6. Ken
    central Illinois
    Reply

    This article doesn’t mention radiation treatment. I have not read the JAMA article but suspect that the women in both groups did have radiation to the axillary lymph nodes. Radiation completely destroys lymph nodes, thus removing them without the disfiguration of surgery. Radiation causes other problems such as muscle rigidity and soreness and fatigue. But it certainly does an effective job of killing cancer tissue – and is an option that was not available when Halsted did his surgery at Johns Hopkins.

  7. Kay
    Charlotte NC
    Reply

    I had Stage IIB breast cancer 20 years ago in 1997. I was in treatment almost the entire year, first with Taxotere (experimental at the time), then a modified radical mastectomy, then a combination of Adriamycin/Cytoxin, then 36 radiation treatments. At the time of the mastectomy the surgeon removed most of the lymph nodes (I think 13 or 16) under my arm. They were negative according to the pathology report, but I think the surgeon doubted that report. My cancer was treated before they started doing sentinel node biopsy to determine if the cancer was present in the lymph nodes. The mastectomy was also done after the four Taxotere treatments, which may have knocked out any cancer that was in the nodes before.
    I know cancer treatment has advanced greatly in the last 20 years, but my thought is that I would rather be overtreated and still be alive than undertreated and be dead. I had two children at home when I was diagnosed and would have done anything to live to raise them. I accomplished that goal because I had an aggressive oncologist who was determined to beat this disease if he could, and I will be forever grateful to him.

  8. Yvonne
    South Africa
    Reply

    15 years ago I was diagnosed with breast cancer. Following a lumpectomy and minor treatment I was clear. However I did not experience the same 9 years before that when I had to receive treatment for cancer of the uterus. Mayor surgery and extensive treatment was the order of the day then.
    My personal feeling is remove the least and treat symptomatically. Immunotherapy is definitely the way to go
    Just incidentally, in my family we die due to cancer.

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