Surgery remains the cornerstone of breast cancer treatment. Dr William Halstead, in the late nineteenth century, described what was considered optimal surgical treatment for breast cancer which remained the bench mark for more than a hundred years. Since that time, surgical management for breast cancer it has been refined by disciplined surgical studies and scientific trials. The cosmetic and functional damage has been minimised without compromising survival. Survival has increased from 40% five year survival in Halstead’s time to 87% five year survival at The Strathfield Breast Centre.
Evolution of Breast Cancer Surgery and the Concomitant Improvement in Survival
Cancer of the breast has been described for centuries; the recognition of the “bulging tumours of the breast” is recorded in the valuable Edwin Smith Papyrus of 1600 B.C. found at Thebes in Egypt in 1862 and translated by Breasted.1 Treatment was limited to two methods – either burn the lesion with fire, or remove it with a sharpened instrument.
Leonides, a Greek physician of the first century A.D. working in the great medical school at Alexandria, is believed to have been the first to carry out a surgical removal of the breast.2 His technique was to cut into normal breast tissue wide of the tumour. Leonides employed cautery to control bleeding, and to destroy residual tumour. He also advised that surgery was not indicated if the whole breast was hardened, or if the tumour was fixed to the chest wall. It is probable that Leonides was the first to recognise that breast cancers spread to the axilla. Nearly two millennia were to pass before any innovation would develop in the battle against breast cancer.
In 1654 Rembrandt painted a picture of his mistress entitled Bathsheba at her bath. Over 300 years later, an Italian physician vacationing in Amsterdam viewed the painting at the Rijksmuseum and noticed several characteristics of the left breast indicative of breast cancer. This observation inspired James S. Olsen to write “Breast cancer is an old disease. It transcends race, class, time, and space, a horror known to every culture in every age” in the opening chapter of his book Bathsheba’s breast: women, cancer & history.
In the late 1800’s Dr William Halsted had described the radical mastectomy that would be carried out for nearly 100 years and maybe for much longer.3 The procedure involved:
- Wide excision of the tumour and skin, covering the defects with grafts
- Routine removal of the pectoralis major muscle
- Routine axillary dissection
This was a destructive and disfiguring operation, carrying with it a high risk of post-operative disability such as lymphoedema. However survival rates improved to about 40% over five years.
As the nineteenth century was ending, two discoveries were made that had huge implications for the future management of breast cancer. The first was x-rays, which was to lead to mammography and radiotherapy. The second was the revelation that breast cancer was hormone dependent.
By the end of World War II the modalities, which would be used to treat breast cancer were all in existence. However, there were a wide variety of opinions, which produced confusion. Multiple papers appeared in the literature, which expressed the personal opinions of authors who used unconvincing small series of cases to support their hypotheses.
However, there were two papers, which appeared in 1948, which were ultimately to produce a revolution in breast cancer management, and would become accepted as the “gold standard” in the management of localised disease. The most important of these papers was from the Middlesex Hospital in London. David Patey described a modified technique of the standard radical mastectomy by preserving the pectoral muscles thereby avoiding a major component of the disfigurement.4 It was the forerunner of the modern trend towards conservative surgery. However, it did little to improve survival, which hovered around 50%.
In 1963 an article appeared in the British Medical Journal by Williams, Murley and Curwen.5 It was a retrospective study of cases treated by simple, radical and modified mastectomies with or without radiotherapy. Their conclusion reflected some of the feelings of the time: “The most impressive finding in this series is the remarkable similarity in survival rates following different methods of treatment.”
From here on there was a ground swell of opposition to radical surgery, which went hand in hand with increasing knowledge of the disease process. Bernard Fisher from the University of Pittsburgh asserted that breast cancer was a systemic disease and that it’s course was determined by a biological struggle between tumour and host, which in turn meant that management of the disease had to be re-evaluated. Referring to Halsted’s rationale for radical mastectomy, Fisher wrote in 1970 that, “…either the original surgical principles have become anachronistic or, if they are still valid, they were conceived originally for the wrong reasons.” 6
At the same time, the biomedical sciences were developing at an impressive rate allowing the dawn of a new era. The term “chemotherapy” had been coined in 1898, but it was not until the mid 50’s that adjuvant chemotherapy for breast cancer became widely accepted.
During the 60’s the efficiency of radiotherapy delivery was improved dramatically, and confidence in its ability to “mop-up” tumour cells left behind following surgery grew.
During the early 70’s several significant trials proved that excision of the primary tumour, “lumpectomy”, followed by whole breast irradiation was as effective as total mastectomy for both local and ultimate disease control of most early-stage cases and was an obvious cosmetic improvement.
By this time the five-year survival rate had risen to about 70%. The cure rate also rose. Post-operative morbidity rates dropped which was in keeping with the trend towards conservative surgery.
The introduction of more sophisticated adjuvant chemotherapy and hormonal manipulation with the use of Tamoxifen in the mid seventies produced a further survival improvement of 10%, raising the five-year survival to 80%.
Continuing development of new age adjuvant therapies together with earlier diagnosis (aided by the Commonwealth Governments BreastScreen programme) has ensured continued improvement to the present where relative five-year survival for breast cancer in the Australian population has risen from 72% in the late 80’s to 89% in 2010. Relative survival is derived by comparing the survival of people diagnosed with breast cancer with that experienced by the general population. This is demonstrated in Figure 1.7
Figure 1: Relative survival percentages by period of diagnosis in the Australian female population, 1982-1987 to 2006-2010
It should be noted that this graph was calculated using the period method (Brenner & Gefeller 1996). This method calculates survival from a given follow-up or at-risk period. Survival estimates are based on the survival experience of people who were diagnosed before or during this period, and who were at risk of dying during this period. The period method is an alternative to the traditional cohort method, which focuses on a group of people diagnosed with cancer in a past time period, and follows these people over time.
Figure 2 shows survival data for The Strathfield Breast Centre’s patient population using the traditional Kaplan-Meirer curves. The improved survival is in part due to improved surgical technique, and in part due to better use of chemotherapy, hormone therapy, radiotherapy, and more recently, the new age monoclonal antibodies such as Herceptin (transtuzumab).
Figure 2: Survival percentages by period of diagnosis in The Strathfield Breast Centre’s population.
Women diagnosed with breast cancer today, have a much brighter future than those who faced the diagnosis generations or centuries ago. However, the story of breast cancer is incomplete – ultimately what we’d like to see is breast cancer becoming a preventable disease. We look forward to the news reader telling us “Today doctors at (some) medical institution announced that a (vaccine?) prepared from the (?prions) of breast cancer resulted in immediate and total disappearance of all signs of the disease. Further studies are planned to further explore this promising development.” When this happens, the story may be nearing completion.
Breasted JH, editor. The Edwin Smith Surgical Papyrus. Chicago, IL: The University of Chicago Press; 1930, Special Edition. 1984. The Classics of Surgery Library. Division of Gryphon Editions, Ltd. Birmingham (AB). Frontispiece.
De Moulin D. A short history of breast cancer. Boston: Martinus Nijhoff; 1983. p. 1–107.
Halsted WS. The results of operations for the cure of cancer of the breast performed at the Johns Hopkins Hospital from June 1889 to January 1894. Johns Hopkins Hospital Reports. Baltimore 1894–95;4:297–350.
Patey DH, Dyson WH. The prognosis of carcinoma of the breast in relation to the type of operation performed. Br J Cancer 1948;2:7-13
Williams IG, Murley RS, Curwen MP. Carcinoma of the female breast. Conservative and radical surgery. Br Med J 1953;2:787-96.
Fisher B. The surgical dilemma in the primary therapy of invasive breast cancer: a critical appraisal. Current problems in surgery. Chicago: Year Book Medical Publishers Inc.;1970.
Australian Institute of Health and Welfare & Cancer Australia 2012. Breast cancer in Australia: an overview. Cancer series no. 71. Cat. no. CAN 67. Canberra: AIHW.