Past Caring

Extreme measures: the history of breast cancer surgery

BMJ 2012; 344 doi: (Published 8 February 2012)
Cite this as: BMJ 2012;344:e834

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This is an extremely concise yet comprehensive and informative overview of the history of breast cancer surgery. As a clinical oncologist who trained in Edinburgh I was impressed that mention was made of simple mastectomy and radiotherapy as an alternative to radical mastectomy because that was the standard Edinburgh approach when I qualified in 1971 and had been so for decades and continued as such into the early 1980s.

Its proponent was Robert McWhirter who ran radiotherapy (and diagnostic radiology) in Edinburgh from the mid 1930s until he retired in 1971. Eventually his hypothesis - that surgeons had no right to invade the negative axilla and no need to venture into the positive axilla as radiotherapy to the peripheral lymphatics was sufficiently effective - was put to the test in the 1960s of an early randomised trial against radical mastectomy alone. However, he had previously persuaded his surgical colleagues in Edinburgh and the south east of Scotland to carry out only simple mastectomy (and many are the stories about he achieved that). This was, to say the least, controversial as the "gold standard" was as Halsted had described in the late 1890s and to do less was to risk death for the patient and professional criticism.

The Edinburgh experience was presented in a confrontational debate at the Royal Society of Medicine in 1948 when Sir Gordon Gordon-Taylor spoke eloquently and with flair for the radical operation. The debate was so popular that even Sir Geoffrey Keynes could not squeeze into the room. Robert McWhirter presented over a decade of unrandomised data. Sir Gordon, declaring himself unable to understand the "recondite mysteries" of radiotherapy espoused the approach of a surgeon known to have developed radical approaches to limb amputation for sarcoma - a sharp knife, a strong arm, a stout heart and the most radical clearance untrammeled, of course, by the mysterious radiation.

Sir Geoffrey had previously inflamed medical opinion by publishing eloquently on breast conservation surgery and radium irradiation carried out by him over the twenty years following World war I. The paper is a joy to read; he employed a lady "statistician"; he used a clinical staging system decades before the UICC; he compared his unit's results with all those of all the others in his London teaching hospital; and his patients did remarkably well and no worse than in the other units - but they retained their breasts something Sir Geoffery was determined to afford his patients so that they could avoid the terrors and mutilation of radical mastectomy. Sadly another world war intervened and radium was dispersed from the cities for safety in the likely event of mass bombing and breast conservation surgery was set back by almost another forty years.

Our history teaches us a great deal and I congratulate Wendy Moore as she has encapsulated a great deal in such a few words.

Competing interests: None declared

Alan Rodger, Retired clinical oncologist and medical director

Retired, 8 Clairmont Gardens, Glasgow, G3 7LW

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I congratulate the author on the overview of history of breast cancer and the extent to which doctors resulted in more harm than good. I'm afraid, however, that we have a long way to go. Many mastectomies are still performed on patients resulting in more harm than good.

The key is to select patients who will benefit from surgery. If there is metastatic disease, there is no benefit from local excision (except in some highly selected cases where it will result in better local control). Even in women with high risk disease (ie. palpable axillary nodal involvement) are not offered the best available staging investigations such as FDG or fluoro-oestradial PET/CT before the surgeon cuts. Many find out after the operation (or several years later) that they have metastatic disease.

The problem is further confounded by our limited ability to identify which breast cancers are indolent versus aggressive. The vast majority of breast cancers excised are well-differentiated oestrogen receptor positive tumours. Many women would die with the tumours rather than from their tumours, analogous to prostate cancer in men. Anti-hormonal therapy alone, especially in elderly patients or patients with comorbidities, is superior to surgery. Indeed surgery may even result in metastatic seeding in some patients. Patients remain uninformed with the benefits of surgery highlighted but the uncertainties hidden. The current practice may well be viewed as extreme in the years to come.

Competing interests: None declared

Harry Rogers, Internal Medicine Physician

Private Practice, Sydney, Australia

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