Radical Surgery

Often the less there is to justify a traditional custom the harder it is to get rid of it.

Mark Twain

The word radical has many meanings (radix means root in Latin). One of the meanings is "treatment directed to the cause" or "going to the root of a process." It also conveys the impression in cancer surgery of the cancer being a growth with many roots, and radical surgery removes those roots. The word has undergone much the same evolution in medicine as it has in politics; so while the word radical originally referred to "getting at the root" of the tumor, it now often refers to extreme surgery in which large amounts of normal tissue are removed along with the tumor; the opposite of conservative. The theoretical basis for radical surgery is that if you remove both the primary tumor and the seeds of metastasis in the adjacent lymph nodes, there should be a better chance of curing the disease.

The most frequently used radical operation is radical mastectomy: the removal of the breast and a large amount of adjacent tissue including the largest chest muscle and the lymph nodes in the arm pit (axillary lymph nodes). This eighty-year old operation is the treatment of choice for "curable" breast cancer, regardless of the type, location or stage of invasion.

Some surgeons question whether the removal of so much "healthy tissue" is necessary to cure a cancer. There are more complications following radical mastectomy than following the simpler operations, and still more complications if radiation is used with it. How much depends on the ability of the surgeon and whether the surgery is used with radiation therapy. There is little question that the less radical the surgery, the fewer the complications that are generated by the surgery itself. if a simpler procedure worked equally well, it should be the method of choice.

Since we have little real understanding of what makes tumors grow and spread, it is necessary to evaluate treatment empirically. To do this, it is necessary to eliminate as much bias as possible from experiments. We know that no two surgeons are equally skillful, and that everyone has his own particular bias. One surgeon may believe that radical mastectomy is the only treatment, and another may believe that simple mastectomy, or simple tumor removal, will have the same results. These attitudes will not only affect the outcome of the surgery, but the emotional state of the patient. It is very easy to "prove" a theory by selecting the proper cases for each operation. Valid experiments use a group of surgeons; each one performing all of the different operations, except that the surgeon is told, by means of some predetermined system, which operation he is to perform. The results can then be analyzed by using statistical methods applicable to such "randomized" and "prospective" experiments.

In 1959 S. S. Smith and A. C. Meyer reported the survival rates of 448 patients with breast cancer that were treated by either simple or radical mastectomy in Rockford, Illinois. Their data were later analyzed in 1961 by Michael Shimkin and his coworkers. Shimkin, who is both a physician and a statistician, dealt with the fact that the two sets of data would have to be comparable. If, for example, on]y the less severe appearing cases are subject to the simpler operation, then the data would be biased in favor of the simpler operation. They analyzed the cases by the clinical stage of the disease and found that roughly the same types of tumors were found in the groups treated with the radical operations as with the simple ones. In analyzing these data, there was no evidence found that radical mastectomy resulted in better patient survival than simple mastectomy; if anything, it was the other way around. These authors concluded, conservatively, that a truly objective evaluation could now be attempted without jeopardizing the lives of any of the patients. George Crile (1964) performed a reIatively uncontrolled experiment at the Cleveland Clinic. He operated on his patients with a simple mastectomy, and compared the results with those of his colleagues who used the radical procedure. He found that a larger percentage of patients treated with simple mastectomy survived longer. Following the studies of R. Mcwhirter (1964), D. Brinkley and J. L. Haybittle (1966) performed a well-controlled prospective experiment on the treatment of moderately advanced (Stage II) cancer of the breast. They compared, as did McWhirter, radical mastectomy with irradiation with simple mastectomy plus x-irradiation. The five-year survival was 65% with a simple mastectomy plus irradiation, against 52% with a radical. There was no question in the minds of the authors about the superiority of the simpler operation (used witb irradiation). The results were so unequivocal that they discontinued the experiment and inaugurated the simpler operation as their treatment of choice "for humanitarian reasons." When I evaluated their data using an actuarial method that indicates mortality rates, it is evident that these differences are not due solely to early mortality, but are due to actually divergent death rates. In other words, the patients do better throughout the whole time period studied, with the most favorable results appearing five and six years following treatment. Despite these studies, no large objective study was undertaken in this country.

In 1970 (Fisher et al., 1970) a report was published of an analysis of the effect of radiotherapy following radical mastectomy in the treatment of breast cancer. This was a prospective study in which a valid statistical analysis could be performed and valid conclusions could be reached. Fisher and his co workers found that the use of radiation after radical mastectomy did not improve survival. In other words, in terms of survival, radiation was of no value (it also produces complications).

Some surgeons are now doing what is known as a "modified radical mastectomy." The operation spares the pectoralis muscle and at the same time involves the removal of most of the axillary lymph nodes. At the present time, the available evidence indicates that this procedure may be as effective as the removal of the breast, the pectoral muscles, and the lymph nodes. The data are by no means conclusive.

You may question why I present the work of a few groups of doctors weighed against the prevailing "mass of medical opinion." It is simple: these groups have cited evidence. The "mass of medical opinion" is just that; "opinion." The only studies that are relevant are those which objectively compare two procedures.

Radical mastectomy is so firmly entrenched that most surgeons would feel that they were doing a patient an injustice to perform anything but that particu]ar operation. There is no question that it works, and that cancer has been cured by it; but so does the simpler operation.

There are some cases of breast cancer in which no treatment will work and the outcome will be fatal regardless of treatment (there is no way of identifying these). Of the remaining (potentially curable) ones, there may be a few in which the removal of tumors and lymph nodes might be more effective than simple removal of the breast. In the majority of treatable cases, the simple removal of the breast may be just as effective.

In the mouse, we know that if we take a tumor out of one part of the breast, another may crop up in another part. The same may be true of the human breast. If this is so, then the removal of the entire breast --indeed the removal of both breasts--may very well be prophylactic. I find this argument very hard to buy, because it is analogous to saying that the best prophylaxis against automobile accidents is suicide. If it could be shown that the odds of the woman developing an untreatable breast cancer following the surgical removal of ,a treatable one was very high, removal of both breasts might make sense, but there is little good evidence available at the present time. The available data indicate that the odds are in the neighborhood of one in forty. This could be considered a high risk in a young woman, but a low one in an old woman.

There has not, to date, been an objective test of simple tumor removal (lumpectomy), although it has been tried and reported as effective. It is not likely that there will be a decent trial until the question of radical versus simple mastectomy is unequivocally settled. At the present time, a woman with breast cancer is likely to lose her breast regardless of the size of the tumor or the type of cancer.

The radical operation currently in use was originated by Halsted in 1889 and has been gospel ever since. It does little good to point out that the available evidence shows no advantage of radical surgery over simple mastectomy. Radical mastectomy is the treatment of choice in the same way as bleeding was the treatment of choice for a wide variety of ills several century ago; and the same way as sweating was prescribed for fevers, gargling for sore throats, and tincture of iodine for almost everything else, forty years ago. It is the usual course of the history of medicine and science that a few individuals are far ahead of their colleagues, and that it takes at least twenty years for the rest to catch up.

Offhand, one would believe that the advent of a better treatment would be greeted by the medical profession with open arms. This is basically true about brand-new treatments such as the artificial kidney, kidney transplant, skin transplant, antibiotics, and so on. There are, however, a few innovations which the medical profession finds difficult to accept. They are the ones that require the admission of a certain amount of culpability. For a physician, who has devoted his entire life to helping people, to have to admit to himself that a treatment that he has been using has either maimed or killed some of his patients is the most difficult thing that he can possibly do. When it was discovered that radiation caused both mutation in the germ cells and leukemia, an attempt was made to persuade radiologists to protect those parts of their patients that do not have to be irradiated. A lead apron over the gonads was encouraged and as complete a lead shielding of infants as was possible. Dentists x-raying teeth could, by placing a lead apron on the laps of their patients, protect the gonads from irradiation. Some physicians and dentists finally did this in response to public pressure, saying that "If we do not do this for the patients, they will not want x-ray." Some did it in a sincere effort to protect their patients. Why this resistance? Because, in order to protect their patients, it required the admission that what they had been doing before was wrong and possibly injurious. For a physician or dentist to admit to himself that he might perhaps have caused the development of an abnormal or leukemic child is anathema. It is psychologically easier not to admit it, and to continue doing the same thing, than to admit to a lack of knowledge and change. Before it is possible to alter a fixed opinion, it is first essential to admit to the possibility that the opinion might be wrong. For a surgeon to admit to himself that a procedure which he was taught was the best possible treatment for cancer might conceivably involve the unnecessary mutilation of a patient takes a kind of courage that few people are capable of.
This indictment of the current treatment of breast cancer Is all the more poignant because of one very important intangible. We have no way of knowing how many women with early breast cancer might have visited the doctors sooner had they not been afraid of losing their breast as a consequence. It is possible that, even if a simple removal of the tumor were not quite as medically effective as the removal of the entire breast, more lives might ultimately be saved by the use of the simpler operation because women would have the tumors removed earlier.

One of the most important things to consider in deciding which treatment to have for cancer is, What are the consequences of making a wrong decision? In the case of breast cancer, treating the cancer by removing the lump (lumpectomy) will spare the breast, and may or may not cure. If the wrong decision is made (the cancer would have been cured by removing the breast but not by removing the lump), the tumor will spread resulting in death. The equation consists of possible cure and keeping the breast against possible not-cure and death. Our information at this time is that more cures will be obtained by removal of the breast. If, therefore, living is the only (or major) consideration for you, then the only reasonable procedure is to have the breast removed. if you would rather accept an added risk of dying than losing a breast, then lumpectomy is your choice. Decisions about removal of both breasts, or prophylactic surgery such as the removal of the colon in chronic ulcerative colitis, should consider the probability of making a wrong decision and its consequences.

What if a surgeon wants to do an operation on you that you do not wish to have done; what are your choices? The canons of medical ethics state that a physician cannot give a patient a treatment the patient doesn't want. In other words, the patient can always say "No." Faced with this refusal, your physician can try to persuade you of the wisdom of his position; a very reasonable thing to do. He may consider things from your point of view and propose some other reasonable alternatives; or, he can say "I will not treat this condition the way you would like; you will have to go to someone else." All of these alternatives are reasonable, and allow the patient a reasonably free choice. With the exception of abortion, and some sterilization operations, one can almost always find a physician who will administer the treatment that you consider reasonable. You must, however, be careful, because there are some physicians who will do anything for a buck. Often this is coupled with incompetence.

Signs of reasonableness are appearing among surgeons which may well have been non-existent twenty or thirty years ago. I know a surgeon who believes that radical mastectomy is still the best treatment for breast cancer. When someone comes to him and says, "Doctor, do what you think best," this is the treatment that he administers. If, however, after carefully discussing the problem with his patient and presenting his own point of view, the woman in question wants a simpler operation, he is willing to go along with it; and he does a very competent job.

I posed a hypothetical question to another surgeon: "What would you do if a woman comes to you with a tumor of the breast that was less than one inch in size, and she stated unequivocally that she did not, under any circumstances, want her breast removed?" He said that this offered him a reasonable alternative. He would prefer the usual operating room procedure of taking a frozen section (this is a piece of tissue that is taken at the operating table and examined quickly by a pathologist), followed, if it was malignant, by a radical mastectomy. If, however, the woman refused to have her breast removed, then he said that he would remove the lump using a local anesthetic, and would send the specimen to a pathologist for examination. Should the tumor prove to be benign, that would be the end of it. On the other hand, if the pathologist declared it to be of the malignant variety, he would try to persuade the woman of the wisdom of having a radical mastectomy. I told him that I was under the impression that this was not the way that it was generally done, and he replied that this was the way in which he, and the colleagues in his institution, trained surgeons. In other words, the treatment that a woman receives for breast cancer can, in a large measure, be determined by her attitude at the time that she visits a surgeon. If she is adamant about not having her breast removed, it would take a very unreasonable man to refuse her the simplest possible operation. Most patients are unwilling to make life and death decisions (or what they envision to be life and death decisions) for themselves, and prefer to have them made by others. I know that I don't feel this way, and I'm sure there must be a reader or two who thinks in much the same way that I do. I also know that my attitude would be quite different if I had small children, from what it would be if my children were all grown. I might be more willing to take a chance if there were no small children depending on me.
Flexibility is laudable, but unfortunately, it is not too common. I know an excellent surgeon who has this flexible attitude about every conceivable operation, except breast cancer.

With most forms of cancer, it is deadly to delay making a decision. Nevertheless, no matter what decision you make, you are the one who has to live with it. Get the best information that you can, weigh it against your own sense of values, and decide. The only option that you should not allow yourself is the option of doing nothing. When a woman is past the childbearing age, and someone recommends that she have her uterus removed because it is cancerous, it is usually not as great a decision to make because she is weighing her life against the loss of an organ for which she has no further use. In a woman who intends to have children, this is a much more difficult decision to make; and with regard to losing a breast it may be more difficult. At the present time there are no conclusive answers. As with all human decisions there is no way of achieving anything approaching certainty.

We know that the probability of a cure is related to the size of the tumor when it is taken out. The larger the tumor is, the less the chance of the surgical cure. The chances of a cure drop about 10% for each increase of 1cm. (3/8 of an inch) in tumor diameter. In view of this, you are probably better off having a lumpectomy while the tumor is less than an inch in diameter than you are having a radical mastectomy when the tumor is 2 inches or more in diameter. If the fear of losing your breast causes you to delay seeing a doctor and having surgery, find yourself a doctor who will remove the lump while it is still small and will spare your breasts --and good luck.

If you find yourself impaled on the horns of a dilemma and can't decide between radical mastectomy, simple mastectomy, or lumpectomy, DO NOT DELAY --HAVE THE LUMP REMOVED IMMEDIATELY and make the other decisions afterward.

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