June 3, 1994

5. Treating Breast Cancer

There is no test and never will be a test that can predict, for a chronic disease like cancer, that the patient will die of the disease on a certain date or will always be cured by treatment "X". The complexity of the tumor/host conflict preclude such accurate predictions. We are fortunate that our predictions work as well as they do.

Donald F. Gleason, 1992

If not treated, 75% of women with breast cancer will die within 5 years of diagnosis. Of the remaining 25%, most will die within the next 5 years. Do any untreated women with breast cancer survive for more than 10 years? I haven't been able to find much information on that score, and I have searched extensively.

In 1889, William Halstead originated the operation called "radical mastectomy," which involved removal of the cancerous breast, the chest muscles and the tissue and lymph nodes in the armpit. He also transformed surgery from a hurry-up procedure to the meticulous art that it is today. That life-saving operation became the standard treatment for breast cancer, regardless of the size of the cancer. Halstead's original work involved cancers which, by modern standards, would be considered large. Until the 1970s, a woman with a lump in her breast would have only two options: The life-saving option was that she would be anesthetized and a small piece of the lump would be removed, frozen and cut paper thin and immediately examined with a microscope by a pathologist. This was done in a room right next to the operating room and the pathologist stood by and waited for his specimen. If he decided that it was not cancer, the lump would be removed and the the woman would wake up with intact breasts. It was a happy event for her. If, on the other hand, he decided that it was cancer, she would wake up minus her breast and chest muscles. She would then face a convalescence that was often complicated by problems resulting from the surgery. It was very hard to find a competent surgeon who would do it any other way. The other option was to do nothing and, should it be cancer, to probably die of cancer within 10 years.

In the 1960s and '70s, statistical analysis of women treated by radical mastectomy or simply by removal of the breast (simple mastectomy) showed that women who had simple mastectomy were cured of their cancers as often as those getting radical mastectomy, and were spared many of the complications of the radical operation. In addition, more cancers were being detected while they were still small. In the 70s and 80s, the operation called modified radical mastectomy became the operation of choice, and by 1981 the Halstead radical mastectomy was rarely performed. The cure rate with a modified radical was as good as that obtained with radical mastectomy, with fewer complications. A modified radical is essentially the same as a radical mastectomy, except that the chest muscles are left alone. Its disadvantage is that there are more complications than with simple mastectomy, which had the same cure rate. Its advantage is that it allows a thorough examination of the lymph nodes. The presence of cancer in the nodes is the best indicator of whether the cancer is the kind that spreads readily, which indicates what the probability is of a complete cure. The number of lymph nodes with cancer in them is inversely proportional to the cure rate; the fewer positive nodes, the better the chances of a complete cure. Finding no positive nodes ups the the cure rate to better than 80%, and if the cancer is less than half an inch in diameter, the cure rate goes up to better than 90%.

There are now reliable data about cure rates for breast cancer from mastectomy (surgical removal of the breast). Half of all women who are treated with mastectomy will be completely cured by the operation alone. The odds go up to about 80% if the cancer hasn't spread beyond the breast. If the cancer has spread(metastasized) beyond the breast, the cure rate drops to about 30%. The presence of metastasis to the lymph nodes is not --repeat, is not-- a death sentence. Three out of ten women with metastasis to the lymph nodes will be completely cured by surgery alone. These odds may be improved with chemotherapy.

The most difficult thing for patients and therapists to accept is the fact that a small percentage of breast cancers will have spread beyond the breast and lymph nodes by the time that they are detected. These are usually incurable. Chemotherapy and radiation can give some women some extra years, but will rarely cure. About 20% or so of breast cancers don't metastasize readily and are curable by surgery even if the cancer is large when removed. The majority of cancers are curable if caught early and incurable if caught late. The problem is that it is impossible to tell which tumors will metastasize and which ones won't until they do it. So, the prudent thing for a woman to do is breast self examination and find that lump while it is still small. For women over age 50, mammography is a very useful adjunct.

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