Friday, 20 December 2013

Lessons from history #9: mastectomy

In the early days of surgery, surgeons tried to out do each other in their ability to perform bigger operations, and mastectomy was no exception. For breast cancer, excising the tumour seemed like logical treatment, at least for local control. It also seemed logical that if some excision was good, more excision was better. So simple tumour excision soon gave way to simple mastectomy, which gave way to total mastectomy, which gave way to radical mastectomy, which gave way to things like the ‘extended’ radical mastectomy and the ‘supra-radical’ mastectomy (which included excising the chest wall, amongst other things). Yet, all of this effort was done without properly evaluating the effectiveness – it was all based on what seemed like a good idea.

The high recurrence rate after early attempts to cure breast cancer by local resection led to the hypothesis that the cancer spread through the local tissues. Therefore, the more that was removed, the less likely it was to recur, and the standard treatment became removal of the whole breast (mastectomy). In 1894, Halstead from Johns Hopkins announced the radical mastectomy, an operation that involved not only removal of the breast, but of the muscles over the front of the chest and the lymph nodes in the axilla (armpit).

In 1927, the extended radical mastectomy was developed by Handley and in 1949 Wangensteen proposed the supraradical mastectomy. In the 1950s, Urban proposed an extended radical mastectomy that involved, among other things, the en bloc resection of the chest wall.

None of the techniques showed an obvious change in the recurrence rate or mortality rate, although none were ever tested directly against each other in a clinical trial.

Always looking for a new angle, and probably exhausted from all the extended supra-radical mastectomies, surgeons eventually started trying less invasive surgery, and in the 1970s, mastectomy was tested against lumpectomy (just removing the tumour) for some types of breast cancer. There were some large randomised trials comparing different types of mastectomy (radical, standard and lumpectomy) with and without the addition of radiotherapy. Interestingly, none of the studies showed any difference in long term survival between any of the groups. Radiotherapy lowered the rate of local recurrence, but didn’t influence overall survival either. In fact, nothing influenced overall survival. (20 year follow up for the two big studies are here and here).

The bottom line

The story of the radical (not to mention extended supra-radical) mastectomy is a case-study in medical hubris, overtreatment, flawed assumptions and lack of scientific discipline. These days, patients with breast cancer usually have a lumpectomy, and mastectomy is reserved for recurrences or large, invasive tumours. But it appears that even then, surgery may only affect the local disease, not distant disease, and not mortality. This history forces us to question whether surgery for breast cancer increases longevity at all – a question I hope to address in a future post.

4 comments:

  1. "a question I hope to address in a future post"
    Really looking forward to this future post. What is the reaction of your colleagues to your suspicion that surgery doesn't increase longevity?

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    1. Thanks. I spoke to a very senior breast surgeon (now retired) a few years back who has seen it all. He agrees that surgery is mainly for local control. I have written the post and will publish it in the next few weeks.

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  2. I too look forward to your forthcoming post. My grandmother underwent radical double in the seventies and my elderly neighbour (85) has recently had a mastectomy and she was advised it the best course 'just in case'. Do you have a view to pre-emptive surgery based on family history?

    Btw / thanks for such an interesting blog

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    1. Thanks. You have touched on a topic that I have looked at but deliberately avoided in the post above: prophylactic mastectomy, like Angelina Joie had. There is some evidence that in people with high risk of breast cancer, their risk is lowered with bilateral prophylactic mastectomy. It certainly makes sense: if you have very little breast tissue (like a man, for example) then your risk of breast cancer is lower. There are no controlled trials so there may be some overestimation of the benefit, and the benefit is usually measured in breast cancer incidence, not mortality, and these are two very different things.
      I deliberately avoided that topic because it is different - I was only interested in whether mastectomy was helpful for someone who has breast cancer. The post above gives a historical perspective, the next one asks the big question: does surgery for established breast cancer affect your chance of dying early?

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