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Surgery for Breast Cancer (Part 4 of 8)

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Surgery for Breast Cancer (Part 4 of 8) BACKGROUND ON BREAST CANCER According to American Cancer Society esti- illary nodes large and fixed (unnatu- mates, about 108,000 cases of breast cancer rally held in place). Satellite skin were diagnosed in 1980, nearly all of which will nodules (attendant lesions on the sur- result in surgery. Approximately 35,000 deaths face of the skin). in the past year were due to the disease (1). Stage IV: Distant metastasis present (i.e., the Nearly 1 out of 12 women will develop breast disease has spread to distant parts or cancer at some point in their lives. The breast is organs of the body. ) the foremost site of cancer incidence and cause Normally, patients with stages I and II breast of death in American women. Despite new tech- cancer are considered “operable,” that is, there nology, the survival rates of women afflicted is merit in applying treatment techniques to try with the disease are not much improved over the and remove the malignancy or halt its spread. rates of 50 years ago. Although American Can- Often for patients at stage 111 and nearly always cer Society statistics indicate that when breast for patients at stage IV, the medical techniques cancer is discovered in a localized state, the 5- applied are done for palliation, because there is year survival rate is 85 percent, the general little likelihood of survival. prognosis is not very encouraging. Almost 50 percent of women with breast cancer eventually Discussion of breast cancer dates back to an- die of the disease (26,54), cient times. Hippocrates referred to it in his writing, although he believed that it, like all The extent or severity of breast cancer varies malignancies, from one case to the next. For the purposes of was incurable and better left alone. When afflicted women sought medical this case study, we will refer to the classifica- advice, their tumors were often already ulcer- tions of the Manchester staging system when ated and so implanted in the chest wall that a discussing the clinically recognizable symptoms of a cancer’s spread or extent of severity. That slow destruction of internal organs had already begun. In most cases, crude and painful treat- system consists of four “stages” (levels) as ment probably hastened the patient’s death. follows: During the Roman era, Celsus, a philosopher Stage I: Carcinoma (cancer) confined to 3 of science, advocated the application of caustic breast. No evidence of axillary, su- 4 5 agents to symptoms of early breast tumors. He praclavicular, or distant metastasis believed that once tumors reached a certain (transfers, or spreading, of disease turning point, they became malignant and no from one organ or part of the body to treatment could alleviate their damage. In the another). second century B. C., Galen began to propound Stage II: Carcinoma of breast with apparent b theories that cancer was due to a bodily ac- axillary node involvement. No evi- dence of supraclavicular or distant cumulation of black bile. He first noted the metastasis. crab-like appearance of some tumors, and called the disease “cancer” (16,39). Stage 111: Carcinoma of breast with ulceration, inflammatory changes, or edema Until the 19th century, breast cancers were (swelling due to fluids in the tissue) of treated by a variety of means, including bleed- greater than one third of breast. Ax- ing, purging, dieting, pressing the breast be- tween lead plates, applying salves and goat dung, and in a brutally crude manner amputat- 3 Involving the axilla (the area between the chest and the arm). ing the breast. With discovery of anesthesia in ‘Involving the area above I he clavicle (shoulder bone). ‘Involving distant parts or organs of the body. 1848, extended surgical operations became fea- 6The “axillary nodes” refer to the lymph nodes of the axilla, the sible. In 1867, the British surgeon Sir Charles area between the chest and the arm (including the armpit and sur- Moore published a paper rounding tissue). Lymph nodes are small masses of tissue that in the St. Bartholo- serve as sources of lymphocytes (a type of white blood cell) and as mew’s Hospital Report describing the tech- bodily defense mechanisms by removing toxins and bacteria. niques of radical mastectomy. Moore was the first physician to chronicle the had high mortality rates and low cure rates, procedure of radical mastectomy, but Dr. however, so Halsted returned to Moore’s tech- William Stewart Halsted of Johns Hopkins nique, employing the radical mastectomy as the University received credit for implementing it. routine treatment for breast cancer. In 1885, he At first, Halsted devised an ultraradical opera- published his first results in a study of 50 pa- tion in which the lymph nodes of the lower neck tients treated surgically (16,28,30). were removed as well as the breast, pectoral muscles, 7 and axillary nodes. This procedure toralis major and pectorals minor are the key ones in terms of this 7The pectoral muscles are the muscles of the chest. The pec- discussion. RADICAL MASTECTOMY AS THE STANDARD TREATMENT For 80 years, the radical mastectomy re- One New York surgeon who has strictly ad- mained the “treatment of choice” for surgeons hered to this practice is Dr. Guy Robbins. Rob- working with breast cancer. In 1970, 80 percent bins, who bases his rationale on the many cases of all women in the United States diagnosed as he has seen in which the nodes under the pec- having breast cancer received a radical mastec- toral muscles have been cancerous, is one of tomy. This surgery involves removal of the those who is convinced that the only way to en- breast along with the muscles of the chest wall sure removal of all local and regional cancer is (the pectorals major and the pectorals minor). to perform a radical mastectomy. In addition, the axillary chain of lymph nodes is Halsted’s second principle involves operative dissected and removed. technique (28): Radical mastectomy is a debilitating opera- The suspected tissues should be removed in tion with frequent postoperative complications one piece (meaning the muscles and breast) and side effects. It leaves an extensive scar that 1) lest they would become infected by the divi- extends over the patient’s shoulder. Halsted ad- sion of tissues invaded by the disease, or of lym- vised removing the fat under the flap of skin left phatic vessels containing cancer cells, and 2) to close the wound, leaving the chest itself because shreds or pieces of cancerous tissue covered by a sheet of skin stretched tightly over might readily be overlooked in a piecemeal extir- the ribs. The removal of this fat creates a notice- pation. able depression in the chest that is difficult or This principle further implies that radical impossible to conceal. Skin grafts often are nec- mastectomy is the only way to ensure the exci- essary to adequately cover the exposed rib cage sion of all possible cancer cells. In addition, the (16). immediacy that this principle connotes prob- Two principles of surgery for cancer of the ably fostered the mode of operating that can be breast that were advocated by Halsted have re- characterized as: Perform biopsy with the pa- mained deeply ensconced in the minds of many tient under anesthesia; if malignancy is found, surgeons to this day. The first principle is the perform an immediate radical mastectomy with removal of the pectoral muscles. Halsted wrote the patient under the same anesthesia. (28): The prospect of going into surgery and awakening without a breast has caused untold About eight years ago (1882), I began not only to typically clean out the axilla in all cases of anxiety to many women. In recent years, some cancer of the breast but also to excise in almost surgeons have been performing a two-step pro- every case the pectorals major muscle, or at cedure: 1 ) incisional or excisional biopsy under least a generous piece of it, and to give the tumor local or general anesthesia, and 2) further sur- on all sides an exceedingly wide berth. gery, if required, several days later. They do 8 ● Background Paper #2: Case Studies of Medical Technologies this working within the logical model that can- cerous and possibly precancerous tissue as cer cells will not spread appreciably in the short possible. time before further surgery and that a respite of The patient mix today is very different from several days before surgery gives the patient that of a century ago, and alternative treatments with cancer time to cope with the diagnosis. are available. With the present emphasis on At the time Halsted was practicing medicine, bodily self-awareness and routine physical ex- early detection techniques and routine self- aminations, tumors are frequently much smaller examination were nonexistent. The average case when detected than were the tumors reported by of breast cancer was usually characterized by a Halsted. A question now common among sur- tumor so large that it often filled the entire geons is whether a radical procedure is nec- breast or was fixed to the chest. Ulcerating essary to cure the less extensive cancer. Despite malignant lesions were common and extensive mounting evidence in favor of the lesser pro- axillary node involvement almost inevitable. cedures, many surgeons still perform radical For a surgeon confronted with these symptoms, mastectomies as routine breast cancer surgery. the logical course was to remove as much can- RADICAL MASTECTOMY RECONSIDERED Considerable research on the efficacy of the cording to Drs. Leslie Wise and Oliver Cope, radical mastectomy has been conducted over the however, the radical mastectomy does not meet last several decades. As stated above, until only these criteria because the procedure does not in- a few years ago, it was the nearly automatic volve removal of the supraclavicular and in- treatment of choice for breast cancer.
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