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The surgical treatment of breast cancer
Maturitus, 9 (1987) 183-192 Elsevier Scientific Publishers Ireland Ltd.
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MAT 00423
The surgical treatment of breast cancer D.J. Marchant Department of Obstetrics and Gynecology and Department of Surgery, Tufts University School of Medicine, 171 Harrison Avenue, Boston, MA 02111, U.S.A. (Received 12 August 1986; accepted 11 May 1987) Controversy regarding the efficacy of surgical treatment of breast cancer has persisted since the earliest descriptions of this disease in the 6rst and second centuries AD. It has been acknowledged for many years that patients with untreated breast cancer survive for a surprisingly predictable period of 5 yr. Hence, in recommending extensive surgical procedures, the surgeon must recognixe the unique biology of breast cancer and the need for long-term follow-up. In spite of a voluminous body of literature concerning the treatment of breast cancer, the dissension and contention still continue. However, there is now increasing support for conservative treatment, including the less radical modified mastectomy, and in selected cases, wide local excision, axillary dissection and radiotherapy. As knowledge accumulates, it is clear that the treatment of breast cancer requires a multidisciplinary approach reflecting our understanding of the biology of this disease. (Key words: Cancer, Breast, Screening, Diagnosis, Surgery, Radiotherapy)
Background information There has been controversy regarding the efficacy of the surgical treatment of breast cancer ever since the earliest descriptions by Celsus and Galen in the first and second centuries AD. A recent article in ‘The Lancet’ is pessimistic in the extreme and indicates that even in this modern era of lesser surgical procedures and patient participation in treatment planning, there are those who believe that cancer of the breast is incurable, regardless of the treatment. The article states: “The evidence that breast cancer is incurable is overwhelming. The philosophy of breast cancer screening is based on wishful thinking that early cancer is curable cancer. Unable to admit ignorance and defeat, cancer propagandists have now turned to blaming the victims. They consume too much fat, they do not practise breast self-examination, they succumb to irrational fears and delay reporting the early symptoms. It would appear that no woman needs to die of breast cancer if she reads and heeds the leaflets of the cancer societies and has her breasts examined regularly. Adherence to these myths and avoidance of reality undermines the credibility of the medical profession with the public” [ 11.
Correspondence fo: D.J. Marchant, Department of Obstetrics and Gynecology and Department Surgery, Tufts University School of Medicine, 171 Harrison Avenue, Boston, MA, 02111, U.S.A. 0378-5122/87/$03.50 0 1987 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
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It has been realized for years that if breast cancer is not treated the survival period is a surprisingly predictable 5 yr. In one series, 20% of patients were still alive after 5 yr and 5% survived for 10 yr [2]. Thus, in discussing surgical treatment the surgeon must be aware of the natural history of breast cancer and the necessity for long-term (15-20 yr) follow-up in order to determine the efficacy of treatment. Surgical removal of the breast was described in the first and second century AD. In the early 19th century, local excision was the custom, but cures were infrequent. In 1867, C.H. Moore suggested that because of the pattern of spread and chest wall recurrence the entire breast should be removed, and by 1875 von Volkmann routinely removed the breast and the fascia pectoralis [3,4]. Halsted’s mastectomy was first mentioned in the surgical literature in 1891 and by 1894 he had performed 50 socalled complete mastectomies [5]. This ‘radical’ mastectomy, as the operation came to be known, was enthusiastically adopted in the United States and elsewhere. Unfortunately, the Halsted operation was reserved for relatively advanced cases and the early literature suggests that it did not result in an increase in either the cure rate or the survival period, although there was a dramatic reduction in chest wall recurrences. During the next several decades, the results of the radical mastectomy improved, principally because of the earlier diagnosis of breast cancer and the more selective use of this operation, particularly through the efforts of Haagensen, who identified the cases in which it promised a cure. Because the conventional radical mastectomy procedure did not take account of the fact that the internal mammary lymph node chain constitutes one of the primary routes of lymphatic drainage from the breasts, surgeons began to extend the classical operation to include a resection of the internal mammary nodes and even the chest wall. In 195 1, Urban and others in the United States popularized the extended radical mastectomy that removed the internal mammary chain and an overlying portion of the chest wall en bloc with the radical mastectomy specimen [6]. With the currently increasing acceptance that cancer of the breast is often a systemic disease - 50% or more of patients present with metastases - it is appropriate that previously held ideas regarding treatment be reassessed and placed in proper perspective. The realization that the majority of patients will not be cured with even the most extensive local treatment has resulted in a more conservative approach and the participation of the patient in treatment planning. Lesser surgical procedures including the ‘modified’ radical mastectomy and segmental resection combined with axillary dissection and radiotherapy have largely replaced the classic Halsted radical mastectomy. Diagnosis of breast cancer The diagnosis of breast cancer will be discussed in greater detail in other sections, but it is important at this stage to distinguish between the palage to distinguish between the palpable mass and the occult lesion. It is now well-established that breast cancer presents following a prolonged period of subclinical growth. Based on an average doubling time, a lesion 1 cm in size has probably gone through 30 doublings and has been present, at least in its subclinical form, for 6 or 7 yr. These lesions
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therefore have a significant opportunity to micrometastasize, which accounts for the failure to cure patients with even the most extensive local resections. Patients should therefore be encouraged to practice careful breast self-examination and physicians must be trained in the proper evaluation of the breast as part of the routine physical examination. The clinical description of any abnormality in the breast calls for the exercise of judgement. However, once a dominant mass has been described, a definitive diagnosis must be obtained. This, in the author’s opinion, means that with rare exceptions every dominant mass must be biopsied, using either the ‘skinny’ needle technique or excision biopsy. The obvious exception is the teenager with a fibroadenoma. It is important for the physician to understand that there are no typical changes suggesting breast cancer. Even the most benign appearing lesion may be an invasive intraductal cancer. Obviously, if we are to discover cancer before metastases occur, appropriate screening methods must be developed. At the present time, the best screening device is the mammogram and appropriate guidelines for screening have been published by the American Cancer Society and others [7j. Physicians must be aware of the liitations of mammography and should remember that X-ray study of the breast is a complementary procedure. If physical examination reveals findings that justify biopsy, this must be performed, even if the mammogram is negative. Aspiration and biopsy When a dominant mass is discovered on physical examination, the lesion may be cystic or solid, benign or malignant. An attempt should be made to aspirate the lesion with a fine-gauge needle. If the fluid is clear or cloudy and no residual mass is palpated immediately following the aspiration, follow-up examination after 1 mth with reassurance and monthly self-examination are recommended. If the mass remains immediately following aspiration, or if the fluid is bloody, the patient should have a mammogram and biopsy. If there is a residual mass on the first follow-up visit, mammography and biopsy are mandatory. If. the lesion is solid, excision biopsy is recommended, with the exceptions previously noted. Needle aspiration biopsy is a valuable and safe method for the diagnosis of breast cancer [8]. There are a variety of techniques available. The simplest is the use of a plastic syringe and a 23-25 gauge needle. The skin over the lesion is infiltrated with xylocaine, the needle is introduced, and several passes are made with suction applied to the syringe. In the ideal situation the pathologist is available and immediately places the recovered material on a slide. If a less than adequate sample has been obtained, further aspiration can be performed. If the aspirate is positive for cancer, the patient can be prepared for additional diagnostic studies and alternative treatment recommendations discussed. At the time of definitive treatment, adequate tissue must be obtained to confirm the diagnosis and to perform oestrogen and progesterone binding determinations. It should be emphasized that a negative aspiration does not rule out the possibility of cancer. Consultation with the radiologist is essential when an occult lesion is discovered on
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a screening mammogram. It must be determined with certainty that the lesion is in fact in the breast parenchyma. Occasional skin lesions may project into the breast as microcalcifications [9]. Moreover, some occult lesions appear benign and, depending on the experience of the radiologist, can safely be followed up with serial mammograms. Assuming that the lesion requires removal, a localization technique must be employed. We use a small needle with a ‘hook’, placed in the vicinity of the occult lesion [lo]. This is inserted by the radiologist under mammographic control. It is essential that the surgeon and the mammographer confer to determine the exact location of the lesion relative to the needle in the lateral and the craniocaudal views. The patient is then taken to the operating room and, usually under local anaesthesia, the specimen is removed together with the needle. Specimen radiography is performed and if the occult lesion is present, the wound is closed. The pathologist determines whether a rapid section diagnosis is feasible and if the margins are adequate, especially where wide local excision and radiotherapy are planned as definitive treatment. Outpatient biopsy under local anaesthesia is preferred for the palpable lesion. Available data suggest that postponement of definitive treatment for 1 or 2 wk does not adversely influence survival. However, it is essential for the surgery to be carefully performed, with minimal manipulation of breast tissue, sharp dissection, meticulous haemostatis and absolute asepsis. Infection or marked ecchymosis greatly interferes with definitive surgical treatment. Biopsy and delay of treatment can be justified only under ideal conditions. This means careful biopsy technique and immediate consultation with the therapeutic team responsible for definitive treatment. If the lesion is suspicious, at least 500 mg of tissue should be sent to the pathologist for oestrogen and progesterone receptor analysis. This will require a frozen section to determine whether the lesion is benign or malignant. It is therefore advisable that for all but the most obvious lesions, a frozen section be requested to ascertain whether oestrogen and progesterone binding determination should be performed. Since the majority of dominant lesions (80% in our series) are benign, it is essential that a cosmetic result be achieved. It is preferable to have the patient sitting prior to the biopsy in order to mark the skin in an appropriate skin fold or one of the lines of Langer. Skin lines in the supine position may not be cosmetic in the erect position. In order to decrease ecchymosis and to ensure maximum comfort, the use is recommended of a pressure dressing held in place with a large elastic bandage. This should be left in place for 24-48 h and then replaced with a small bandage until the sutures are removed. Treatment planning
We believe that the treatment of breast cancer requires a multidisciplinary approach. Each patient should obviously have her primary physician, but the treatment alternatives require in addition the expertise of not only the surgeon but also the radiotherapist and the medical oncologist. In order to accomplish this, a Breast Health Centre, staffed by surgeons, radiotherapists and medical oncologists was
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established some years ago. A key staff member in this clinic is the Nurse Coordinator, who takes care of liaison between the patient and the various medical disciplines. She coordinates the clinical appointments and arranges for appropriate follow-up appointments. She is also responsible for our education programme, dealing not only with our referring physicians but with the community at large. There are many medicolegal issues associated with the diagnosis and treatment of breast cancer, particularly the diagnosis. We have therefore established a protocol for the evaluation of patients with breast problems, as well as a detailed checklist to be certain that patients are informed of their diagnostic studies and their follow-up appointments. As a result of the increased use of the two-step procedure for the diagnosis and treatment of breast cancer, a number of patients are referred for a second opinion. Because of the legal implications, we are careful to evaluate all of the pertinent material, including the biopsy data and the treatment plan. We provide the referring physician with a detailed written consultation report. In most cases patients return to their physician for definitive treatment. Once a diagnosis of breast cancer has been established, a number of pre-operative studies should be carried out. Mammography is absolutely essential, even in the most obvious case. Synchronous cancer is present in 4-5% of patients and multicentric disease may be discovered in the involved breast. This may in fact preclude wide local excision and radiotherapy. All patients should have a chest X-ray, routine blood analyses and liver function tests. For invasive lesions, most surgeons recommend a bone scan and if there is any abnormality appropriate films of the involved area. Clinical staging using the TNM classification should be used, where T represents the tumour, N nodal involvement and M metastatic disease. Some surgeons use a staging similar to that for gynaecological tumours. In situ cancer is breast cancer that is non-invasive and has not spread below the limiting membrane of the ducts and glands of the breast. Stage I represents a cancer that is no larger than 2 cm and is confined to the breast. Stage II means that the cancer is between 2 and 5 cm in size, or is smaller but has spread to the axillary lymph nodes. Pathological staging is effected after examination of the operative specimen. As mentioned earlier, a two-step diagnostic and therapeutic programme is recommended for most patients. Biopsy is performed on an outpatient basis by aspiration needle biopsy or open biopsy. If cancer is present, as determined by frozen section, oestrogen and progesterone binding studies are performed. Alternative treatment plans are then discussed, with the patient and her family. There is no evidence that a delay of l-2 weeks between the diagnosis and definitive treatment affects the prognosis. In some states, the law obliges the physician to discuss alternative treatments with the patients [ 111. In California, this must be entered in the patient’s record [ 121. The two-step procedure has resulted in an increase in second opinions. This does not affect prognosis and is reassuring to the patient and her family. Obviously, however, shopping around for a treatment that suits the patient, i.e. the seeking of second, third and fourth opinions, is to be discouraged. A number of treatment protocols are available and these should be appropriately discussed with the patient and her
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family. Whenever possible, we attempt to place patients on protocol in an effort to determine the long-term efficacy of the treatment employed. Surgical treatment A number of factors influence the choice of definitive surgical treatment for breast cancer. Important considerations include the size and histology of the lesion, the skill and experience of the multidisciplinary team and the wishes of the patient. Beginning in 1979, a number of consensus development conferences on the treatment of primary breast cancer have been held [ 131.The basic question asked has been which treatments provide the best chance for the disease-free survival of early breast cancer patients. These conferences have dealt specifically with the controversy as to whether conservative surgery, including dissection of the axillary lymph nodes, followed by irradiation of the breast, is as effective as the modified or radical mastectomy. It is fair to say that dissension and contention continue, although during the past 6 yr there has been increasing support for conservative surgery combined with radiotherapy as a primary treatment for women with early breast cancer. Since 1979 a number of reports have been published relating to both retrospective studies and prospective, randomized clinical trials, the latest of which concluded that segmental mastectomy followed by breast irradiation in all patients, and adjuvant chemotherapy in women with positive nodes, is appropriate therapy for stage I and II breast cancers less than 4 cm in size, provided that the margins of the resected specimens are free of tumours [ 141. While the concept of conservative surgery has gained favour there has been.controversy concerning the technical details of the surgery and radiotherapy to be employed. First of all, there must be agreement on the terms to be used [ 151. Conservative surgery means a wide local excision with resection of the tumour and l-2 cm of adjacent breast tissue, designed to provide clear margins of resection. Quadrantectomy means the resection of the tumour with the involved quadrant of the breast, including the overlying skin. The terms ‘lumpectomy’ and ‘segmental mastectomy’ are imprecise and their use is discouraged. Axillary dissection means the dissection of the axillary contents from the tail of the breast to the latissimus dorsi and the axillary vein superiorly and the lateral border of the pectoralis minor medially. The use of the term ‘axillary sampling’ is again discouraged because it is not a precise statement of the extent of the surgical procedure. The use of conservative surgery and radiotherapy requires four important criteria, to be considered: (1) (2) (3) (4)
patient selection; the surgery for the primary tumour; radiotherapy for the primary tumour; and the surgery for the axilla.
The principal advantage of conservative treatment is cosmetic.
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Certainly, there are no data to indicate that the conservative approach provides improved survival in comparison with the radical or modified radical mastectomy. Thus, the major criterion for patient selection is the ability to resect the primary tumour adequately without causing a cosmetic deformity. Patients who are poor candidates for breast-conserving treatment include those with widely separated primary tumours in the same breast, patients whose mammograms reveal diffuse disease in many quadrants, and those with large tumours and relatively small breasts. Patients with central lesions involving the nipple-areolar complex can be successfully treated by resection of the nipple-areolar complex with careful attention to the final cosmetic result. Reconstruction of the nipple has been accomplished following radiotherapy. Other factors to be considered include patient’s age and the size of the breast. It has been known for patients in their middle 70s to request conservative treatment for cosmetic reasons and for younger patients to request not only modified radical mastectomy but also simple mastectomy on the opposite breast as well in order to avoid future concern about recurrence of the cancer in the treated breast and the development of a new cancer in the opposite breast. Where appropriate, treatment alternatives are accordingly offered to all patients, regardless of their age. Adequate surgical resection implies grossly clear margins. The surgeon must mark the specimen appropriately for orientation by the pathologist. It is important to determine the distance between the tumour and the closest margin of resection. Tissue should be removed for oestrogen and progesterone receptor studies without disturbing the evaluation of the respected margins. Microscopic involvement is best determined at the time of the evaluation of the permanent sections. It is generally agreed that if the microscopic margins are positive after a wide excision, further excision should be performed. This can be accomplished at the time of the axillary dissection. Since the principal goal in conservative surgery is the final cosmetic result, it is preferable to mark incisions with the patient in the sitting or standing position. Frequently, a skin fold can be observed in the axilla that will disguise the incision and provide for unrestricted motion of the arm. The lines of Langer may not follow a circumareolar pattern when the patient is in the sitting or standing position and the location of the breast incision therefore depends on the best cosmetic line. Most of our patients are admitted following surgery and remain in the hospital for 48 h. If meticulous axillary dissection is performed and there is adequate haemastasis drainage is not employed. With careful closure of the surgical wound in the breast and adequate compression following the surgery, wound drains are not required either. The sutures are removed after 5 days and radiotherapy is started within a week to 10 days following the surgery. It is generally agreed that the breast should be treated with 180-200 rads/day up to a total dose of 4500-5000 rads. Doses over 5000 rads result in fibrosis and retraction, giving an unacceptable cosmetic result. For patients treated with a wide local excision and in whom microscopic evaluation reveals close margins of resection, ‘boost’ therapy is recommended. There remains some controversy regarding the technique to be used for this supplemental radiation, but whatever the technique employed, the cosmetic result should not be impaired.
If the patient requires adjuvant chemotherapy because of positive nodes, this treatment must be integrated with the radiotherapy. However, there is also a lack of agreement regarding the merits of concomitant as against sequential chemotherapy and radiotherapy [ 151. It has been our practice to initiate three cycles of chemotherapy, complete the radiotherapy and then proceed with three additional cycles of chemotherapy to finish the adjuvant treatment. While the conservative approach appeals to many patients, statistics clearly indicate that most patients are in fact treated with the modified radical mastectomy. The Patient Care and Research Committee of the American College of Surgeons Commission on Cancer reported in their 1982 audit that 55% of patients treated in 1976 had undergone a modified radical mastectomy and 28% had had a Halsted radical operation [ 161. Comparable figures from the 1978 survey revealed that nearly 50% of women treated in 1972 had had a Halsted mastectomy and only 28% had a modified radical mastectomy [ 161. Currently, it is estimated that at least 80% of patients undergoing radical surgery for breast cancer have the modified operation. In this operation the entire breast is removed without sacrificing the pectoralis major or minor muscles; axillary dissection similar to that used for the conservative operation completes the procedure. The Halsted radical mastectomy is recommended only for those patients with lesions involving the pectoral fascia or muscle. The conservative and radical approaches each have advantages and disadvantages. Obviously, the main advantage of the conservative approach is the preservation of the breast, but the price to be paid is the extended radiation treatment and the real concern felt by some patients that future symptoms in the retained breast are associated with tumour recurrence. With the more radical approach, treatment is accomplished within a few days and cancer obviously cannot recur in the breast. Many of the patients elect to undergo reconstructive procedures at a later date and some surgeons now perform the reconstruction at the time of the modified radical mastectomy. In our own Breast Health Centre each new patient is seen by the therapeutic team, including the surgeon, radiotherapist and medical oncologist. Based on the size of the lesion, its location and the mammographic findings, a consensus is reached by the team and a recommendation made to the patient by the primary physician. We have found that about half of our patients request mastectomy with the possibility of later reconstruction, and about half opt for the conservative approach with wide local excision, axillary dissection and radiotherapy. Properly performed, both approaches result in similar overall survival rates approximately 60% for Stage I and II lesions, with a local recurrence rate of 8%. Postoperative management Our patients are seen in the immediate post-operative period by the ‘Reach to Recovery’ team. The patients are matched for similar procedures, i.e. either modified radical mastectomy or the conservative approach. The patients are also seen by the physical therapist and many return to our voluntary counselling sessions. The
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patients continue to be followed up at the Breast Health Centre every 3 mth during the first year and every 4 mth during the second and third years. Yearly mammograms are obtained and, if indicated, repeat bone scans and other studies are performed to detect metastatic disease. Quality of life is of paramount concern and patients are encouraged to discuss reconstructive procedure and psychosexual concerns. Although we are committed to the team approach in the treatment of breast cancer, each patient retains her own primary physician (in our case the surgeon who initially sees the patient) and she is encouraged to contact either this physician with any concerns, or the Nurse Coordinator, who will then refer her to the appropriate physician for further discussion. The future The use of conservative surgery and radiotherapy as primary treatment for patients with early breast cancer will increase. It will be necessary for more centres to adopt the multidisciplinary approach to ensure that this type of treatment is provided safely. A number of surgeons are now experimenting with the CO2 laser. The surgical laser vaporizes tissue and creates a dry, sterile field that minimizes blood loss. It is too early to assess fully the potential value of this technique. It is clear, however, that breast cancer surgery has moved away from the radical approach to a more conservative position, reflecting our better understanding of the biology of the disease. References 1 Skrabanek P. False premises and false promises of breast cancer screening. The Lancet 1985; 316320. 2 Bloom HJG, Richardson WW, Harries EJ. Natural history of untreated breast cancer (18051933). Comparison of untreated and treated cases according to a histological grade of malignancy. Br Med J 1962; ii: 213-221. 3 Moore CH. On the influence of inadequate operations on the theory of cancer. R Med Chir Sot (London) 1867; 1: 245. 4 Von Volkmann R. Beitrage zur Chirgurie. Leipzig, Breitkotf und Hartel, 1875. 5 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 Rep. 1894-95; 4: 297. 6 Urban JA, Marjani MA. Significance of internal mammary lymph node metastases in breast cancer. Am J Roentgenol. Radium Ther Nucl Med 1971: 111: 130. 7 Council on Scientific Affairs. Early detection of breast cancer. J Am Med Assoc 1984; 252: 30063011. 8 Vorher RH. Breast aspiration biopsy: clinical opinion. Am J Obstet Gynecol 1984; 148: 127-133. 9 Homer MJ, Marchant DJ, Smith TJ. The geographic cluster of breast microcalcifications - Is it really intramammary? Surg Gynecol Obstet 1985; 161: 532-534. 10 Homer MJ. Non-palpable breast lesion localization using a curved-end retractable wire. Radiology 1985; 157: 259-260. 11 Chapter 214 General Laws of the Commonwealth of Massachusetts. An act providing certain rights to patients and residents in hospitals, clinics and certain other facilities, Section H, 1979. 12 Health and Safety Code, Section 1704.5, State of California breast cancer informed consent law (SB 1893), 1981. 13 Special report on treatment of primary breast cancer. N Engl J Med 1979; 301: 340.
192 14 Fisher B et al: Five-year results of a randomized clinical trial comparing total mastectomy tal mastectomy with or without radiation in the treatment of breast cancer. N Engl 312: 665-681. 15 Special report on limited surgery and radiotherapy for early breast cancer. N Engl 313: 1365-1368. 16 Wilson RE. Progress in breast cancer treatment, today and tomorrow. Am Co1 Surg Bull
and segmenJ Med 1985; J Med 1985; 1983; 68: 2-6.
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MAT 00423
The surgical treatment of breast cancer D.J. Marchant Department of Obstetrics and Gynecology and Department of Surgery, Tufts University School of Medicine, 171 Harrison Avenue, Boston, MA 02111, U.S.A. (Received 12 August 1986; accepted 11 May 1987) Controversy regarding the efficacy of surgical treatment of breast cancer has persisted since the earliest descriptions of this disease in the 6rst and second centuries AD. It has been acknowledged for many years that patients with untreated breast cancer survive for a surprisingly predictable period of 5 yr. Hence, in recommending extensive surgical procedures, the surgeon must recognixe the unique biology of breast cancer and the need for long-term follow-up. In spite of a voluminous body of literature concerning the treatment of breast cancer, the dissension and contention still continue. However, there is now increasing support for conservative treatment, including the less radical modified mastectomy, and in selected cases, wide local excision, axillary dissection and radiotherapy. As knowledge accumulates, it is clear that the treatment of breast cancer requires a multidisciplinary approach reflecting our understanding of the biology of this disease. (Key words: Cancer, Breast, Screening, Diagnosis, Surgery, Radiotherapy)
Background information There has been controversy regarding the efficacy of the surgical treatment of breast cancer ever since the earliest descriptions by Celsus and Galen in the first and second centuries AD. A recent article in ‘The Lancet’ is pessimistic in the extreme and indicates that even in this modern era of lesser surgical procedures and patient participation in treatment planning, there are those who believe that cancer of the breast is incurable, regardless of the treatment. The article states: “The evidence that breast cancer is incurable is overwhelming. The philosophy of breast cancer screening is based on wishful thinking that early cancer is curable cancer. Unable to admit ignorance and defeat, cancer propagandists have now turned to blaming the victims. They consume too much fat, they do not practise breast self-examination, they succumb to irrational fears and delay reporting the early symptoms. It would appear that no woman needs to die of breast cancer if she reads and heeds the leaflets of the cancer societies and has her breasts examined regularly. Adherence to these myths and avoidance of reality undermines the credibility of the medical profession with the public” [ 11.
Correspondence fo: D.J. Marchant, Department of Obstetrics and Gynecology and Department Surgery, Tufts University School of Medicine, 171 Harrison Avenue, Boston, MA, 02111, U.S.A. 0378-5122/87/$03.50 0 1987 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
of
184
It has been realized for years that if breast cancer is not treated the survival period is a surprisingly predictable 5 yr. In one series, 20% of patients were still alive after 5 yr and 5% survived for 10 yr [2]. Thus, in discussing surgical treatment the surgeon must be aware of the natural history of breast cancer and the necessity for long-term (15-20 yr) follow-up in order to determine the efficacy of treatment. Surgical removal of the breast was described in the first and second century AD. In the early 19th century, local excision was the custom, but cures were infrequent. In 1867, C.H. Moore suggested that because of the pattern of spread and chest wall recurrence the entire breast should be removed, and by 1875 von Volkmann routinely removed the breast and the fascia pectoralis [3,4]. Halsted’s mastectomy was first mentioned in the surgical literature in 1891 and by 1894 he had performed 50 socalled complete mastectomies [5]. This ‘radical’ mastectomy, as the operation came to be known, was enthusiastically adopted in the United States and elsewhere. Unfortunately, the Halsted operation was reserved for relatively advanced cases and the early literature suggests that it did not result in an increase in either the cure rate or the survival period, although there was a dramatic reduction in chest wall recurrences. During the next several decades, the results of the radical mastectomy improved, principally because of the earlier diagnosis of breast cancer and the more selective use of this operation, particularly through the efforts of Haagensen, who identified the cases in which it promised a cure. Because the conventional radical mastectomy procedure did not take account of the fact that the internal mammary lymph node chain constitutes one of the primary routes of lymphatic drainage from the breasts, surgeons began to extend the classical operation to include a resection of the internal mammary nodes and even the chest wall. In 195 1, Urban and others in the United States popularized the extended radical mastectomy that removed the internal mammary chain and an overlying portion of the chest wall en bloc with the radical mastectomy specimen [6]. With the currently increasing acceptance that cancer of the breast is often a systemic disease - 50% or more of patients present with metastases - it is appropriate that previously held ideas regarding treatment be reassessed and placed in proper perspective. The realization that the majority of patients will not be cured with even the most extensive local treatment has resulted in a more conservative approach and the participation of the patient in treatment planning. Lesser surgical procedures including the ‘modified’ radical mastectomy and segmental resection combined with axillary dissection and radiotherapy have largely replaced the classic Halsted radical mastectomy. Diagnosis of breast cancer The diagnosis of breast cancer will be discussed in greater detail in other sections, but it is important at this stage to distinguish between the palage to distinguish between the palpable mass and the occult lesion. It is now well-established that breast cancer presents following a prolonged period of subclinical growth. Based on an average doubling time, a lesion 1 cm in size has probably gone through 30 doublings and has been present, at least in its subclinical form, for 6 or 7 yr. These lesions
185
therefore have a significant opportunity to micrometastasize, which accounts for the failure to cure patients with even the most extensive local resections. Patients should therefore be encouraged to practice careful breast self-examination and physicians must be trained in the proper evaluation of the breast as part of the routine physical examination. The clinical description of any abnormality in the breast calls for the exercise of judgement. However, once a dominant mass has been described, a definitive diagnosis must be obtained. This, in the author’s opinion, means that with rare exceptions every dominant mass must be biopsied, using either the ‘skinny’ needle technique or excision biopsy. The obvious exception is the teenager with a fibroadenoma. It is important for the physician to understand that there are no typical changes suggesting breast cancer. Even the most benign appearing lesion may be an invasive intraductal cancer. Obviously, if we are to discover cancer before metastases occur, appropriate screening methods must be developed. At the present time, the best screening device is the mammogram and appropriate guidelines for screening have been published by the American Cancer Society and others [7j. Physicians must be aware of the liitations of mammography and should remember that X-ray study of the breast is a complementary procedure. If physical examination reveals findings that justify biopsy, this must be performed, even if the mammogram is negative. Aspiration and biopsy When a dominant mass is discovered on physical examination, the lesion may be cystic or solid, benign or malignant. An attempt should be made to aspirate the lesion with a fine-gauge needle. If the fluid is clear or cloudy and no residual mass is palpated immediately following the aspiration, follow-up examination after 1 mth with reassurance and monthly self-examination are recommended. If the mass remains immediately following aspiration, or if the fluid is bloody, the patient should have a mammogram and biopsy. If there is a residual mass on the first follow-up visit, mammography and biopsy are mandatory. If. the lesion is solid, excision biopsy is recommended, with the exceptions previously noted. Needle aspiration biopsy is a valuable and safe method for the diagnosis of breast cancer [8]. There are a variety of techniques available. The simplest is the use of a plastic syringe and a 23-25 gauge needle. The skin over the lesion is infiltrated with xylocaine, the needle is introduced, and several passes are made with suction applied to the syringe. In the ideal situation the pathologist is available and immediately places the recovered material on a slide. If a less than adequate sample has been obtained, further aspiration can be performed. If the aspirate is positive for cancer, the patient can be prepared for additional diagnostic studies and alternative treatment recommendations discussed. At the time of definitive treatment, adequate tissue must be obtained to confirm the diagnosis and to perform oestrogen and progesterone binding determinations. It should be emphasized that a negative aspiration does not rule out the possibility of cancer. Consultation with the radiologist is essential when an occult lesion is discovered on
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a screening mammogram. It must be determined with certainty that the lesion is in fact in the breast parenchyma. Occasional skin lesions may project into the breast as microcalcifications [9]. Moreover, some occult lesions appear benign and, depending on the experience of the radiologist, can safely be followed up with serial mammograms. Assuming that the lesion requires removal, a localization technique must be employed. We use a small needle with a ‘hook’, placed in the vicinity of the occult lesion [lo]. This is inserted by the radiologist under mammographic control. It is essential that the surgeon and the mammographer confer to determine the exact location of the lesion relative to the needle in the lateral and the craniocaudal views. The patient is then taken to the operating room and, usually under local anaesthesia, the specimen is removed together with the needle. Specimen radiography is performed and if the occult lesion is present, the wound is closed. The pathologist determines whether a rapid section diagnosis is feasible and if the margins are adequate, especially where wide local excision and radiotherapy are planned as definitive treatment. Outpatient biopsy under local anaesthesia is preferred for the palpable lesion. Available data suggest that postponement of definitive treatment for 1 or 2 wk does not adversely influence survival. However, it is essential for the surgery to be carefully performed, with minimal manipulation of breast tissue, sharp dissection, meticulous haemostatis and absolute asepsis. Infection or marked ecchymosis greatly interferes with definitive surgical treatment. Biopsy and delay of treatment can be justified only under ideal conditions. This means careful biopsy technique and immediate consultation with the therapeutic team responsible for definitive treatment. If the lesion is suspicious, at least 500 mg of tissue should be sent to the pathologist for oestrogen and progesterone receptor analysis. This will require a frozen section to determine whether the lesion is benign or malignant. It is therefore advisable that for all but the most obvious lesions, a frozen section be requested to ascertain whether oestrogen and progesterone binding determination should be performed. Since the majority of dominant lesions (80% in our series) are benign, it is essential that a cosmetic result be achieved. It is preferable to have the patient sitting prior to the biopsy in order to mark the skin in an appropriate skin fold or one of the lines of Langer. Skin lines in the supine position may not be cosmetic in the erect position. In order to decrease ecchymosis and to ensure maximum comfort, the use is recommended of a pressure dressing held in place with a large elastic bandage. This should be left in place for 24-48 h and then replaced with a small bandage until the sutures are removed. Treatment planning
We believe that the treatment of breast cancer requires a multidisciplinary approach. Each patient should obviously have her primary physician, but the treatment alternatives require in addition the expertise of not only the surgeon but also the radiotherapist and the medical oncologist. In order to accomplish this, a Breast Health Centre, staffed by surgeons, radiotherapists and medical oncologists was
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established some years ago. A key staff member in this clinic is the Nurse Coordinator, who takes care of liaison between the patient and the various medical disciplines. She coordinates the clinical appointments and arranges for appropriate follow-up appointments. She is also responsible for our education programme, dealing not only with our referring physicians but with the community at large. There are many medicolegal issues associated with the diagnosis and treatment of breast cancer, particularly the diagnosis. We have therefore established a protocol for the evaluation of patients with breast problems, as well as a detailed checklist to be certain that patients are informed of their diagnostic studies and their follow-up appointments. As a result of the increased use of the two-step procedure for the diagnosis and treatment of breast cancer, a number of patients are referred for a second opinion. Because of the legal implications, we are careful to evaluate all of the pertinent material, including the biopsy data and the treatment plan. We provide the referring physician with a detailed written consultation report. In most cases patients return to their physician for definitive treatment. Once a diagnosis of breast cancer has been established, a number of pre-operative studies should be carried out. Mammography is absolutely essential, even in the most obvious case. Synchronous cancer is present in 4-5% of patients and multicentric disease may be discovered in the involved breast. This may in fact preclude wide local excision and radiotherapy. All patients should have a chest X-ray, routine blood analyses and liver function tests. For invasive lesions, most surgeons recommend a bone scan and if there is any abnormality appropriate films of the involved area. Clinical staging using the TNM classification should be used, where T represents the tumour, N nodal involvement and M metastatic disease. Some surgeons use a staging similar to that for gynaecological tumours. In situ cancer is breast cancer that is non-invasive and has not spread below the limiting membrane of the ducts and glands of the breast. Stage I represents a cancer that is no larger than 2 cm and is confined to the breast. Stage II means that the cancer is between 2 and 5 cm in size, or is smaller but has spread to the axillary lymph nodes. Pathological staging is effected after examination of the operative specimen. As mentioned earlier, a two-step diagnostic and therapeutic programme is recommended for most patients. Biopsy is performed on an outpatient basis by aspiration needle biopsy or open biopsy. If cancer is present, as determined by frozen section, oestrogen and progesterone binding studies are performed. Alternative treatment plans are then discussed, with the patient and her family. There is no evidence that a delay of l-2 weeks between the diagnosis and definitive treatment affects the prognosis. In some states, the law obliges the physician to discuss alternative treatments with the patients [ 111. In California, this must be entered in the patient’s record [ 121. The two-step procedure has resulted in an increase in second opinions. This does not affect prognosis and is reassuring to the patient and her family. Obviously, however, shopping around for a treatment that suits the patient, i.e. the seeking of second, third and fourth opinions, is to be discouraged. A number of treatment protocols are available and these should be appropriately discussed with the patient and her
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family. Whenever possible, we attempt to place patients on protocol in an effort to determine the long-term efficacy of the treatment employed. Surgical treatment A number of factors influence the choice of definitive surgical treatment for breast cancer. Important considerations include the size and histology of the lesion, the skill and experience of the multidisciplinary team and the wishes of the patient. Beginning in 1979, a number of consensus development conferences on the treatment of primary breast cancer have been held [ 131.The basic question asked has been which treatments provide the best chance for the disease-free survival of early breast cancer patients. These conferences have dealt specifically with the controversy as to whether conservative surgery, including dissection of the axillary lymph nodes, followed by irradiation of the breast, is as effective as the modified or radical mastectomy. It is fair to say that dissension and contention continue, although during the past 6 yr there has been increasing support for conservative surgery combined with radiotherapy as a primary treatment for women with early breast cancer. Since 1979 a number of reports have been published relating to both retrospective studies and prospective, randomized clinical trials, the latest of which concluded that segmental mastectomy followed by breast irradiation in all patients, and adjuvant chemotherapy in women with positive nodes, is appropriate therapy for stage I and II breast cancers less than 4 cm in size, provided that the margins of the resected specimens are free of tumours [ 141. While the concept of conservative surgery has gained favour there has been.controversy concerning the technical details of the surgery and radiotherapy to be employed. First of all, there must be agreement on the terms to be used [ 151. Conservative surgery means a wide local excision with resection of the tumour and l-2 cm of adjacent breast tissue, designed to provide clear margins of resection. Quadrantectomy means the resection of the tumour with the involved quadrant of the breast, including the overlying skin. The terms ‘lumpectomy’ and ‘segmental mastectomy’ are imprecise and their use is discouraged. Axillary dissection means the dissection of the axillary contents from the tail of the breast to the latissimus dorsi and the axillary vein superiorly and the lateral border of the pectoralis minor medially. The use of the term ‘axillary sampling’ is again discouraged because it is not a precise statement of the extent of the surgical procedure. The use of conservative surgery and radiotherapy requires four important criteria, to be considered: (1) (2) (3) (4)
patient selection; the surgery for the primary tumour; radiotherapy for the primary tumour; and the surgery for the axilla.
The principal advantage of conservative treatment is cosmetic.
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Certainly, there are no data to indicate that the conservative approach provides improved survival in comparison with the radical or modified radical mastectomy. Thus, the major criterion for patient selection is the ability to resect the primary tumour adequately without causing a cosmetic deformity. Patients who are poor candidates for breast-conserving treatment include those with widely separated primary tumours in the same breast, patients whose mammograms reveal diffuse disease in many quadrants, and those with large tumours and relatively small breasts. Patients with central lesions involving the nipple-areolar complex can be successfully treated by resection of the nipple-areolar complex with careful attention to the final cosmetic result. Reconstruction of the nipple has been accomplished following radiotherapy. Other factors to be considered include patient’s age and the size of the breast. It has been known for patients in their middle 70s to request conservative treatment for cosmetic reasons and for younger patients to request not only modified radical mastectomy but also simple mastectomy on the opposite breast as well in order to avoid future concern about recurrence of the cancer in the treated breast and the development of a new cancer in the opposite breast. Where appropriate, treatment alternatives are accordingly offered to all patients, regardless of their age. Adequate surgical resection implies grossly clear margins. The surgeon must mark the specimen appropriately for orientation by the pathologist. It is important to determine the distance between the tumour and the closest margin of resection. Tissue should be removed for oestrogen and progesterone receptor studies without disturbing the evaluation of the respected margins. Microscopic involvement is best determined at the time of the evaluation of the permanent sections. It is generally agreed that if the microscopic margins are positive after a wide excision, further excision should be performed. This can be accomplished at the time of the axillary dissection. Since the principal goal in conservative surgery is the final cosmetic result, it is preferable to mark incisions with the patient in the sitting or standing position. Frequently, a skin fold can be observed in the axilla that will disguise the incision and provide for unrestricted motion of the arm. The lines of Langer may not follow a circumareolar pattern when the patient is in the sitting or standing position and the location of the breast incision therefore depends on the best cosmetic line. Most of our patients are admitted following surgery and remain in the hospital for 48 h. If meticulous axillary dissection is performed and there is adequate haemastasis drainage is not employed. With careful closure of the surgical wound in the breast and adequate compression following the surgery, wound drains are not required either. The sutures are removed after 5 days and radiotherapy is started within a week to 10 days following the surgery. It is generally agreed that the breast should be treated with 180-200 rads/day up to a total dose of 4500-5000 rads. Doses over 5000 rads result in fibrosis and retraction, giving an unacceptable cosmetic result. For patients treated with a wide local excision and in whom microscopic evaluation reveals close margins of resection, ‘boost’ therapy is recommended. There remains some controversy regarding the technique to be used for this supplemental radiation, but whatever the technique employed, the cosmetic result should not be impaired.
If the patient requires adjuvant chemotherapy because of positive nodes, this treatment must be integrated with the radiotherapy. However, there is also a lack of agreement regarding the merits of concomitant as against sequential chemotherapy and radiotherapy [ 151. It has been our practice to initiate three cycles of chemotherapy, complete the radiotherapy and then proceed with three additional cycles of chemotherapy to finish the adjuvant treatment. While the conservative approach appeals to many patients, statistics clearly indicate that most patients are in fact treated with the modified radical mastectomy. The Patient Care and Research Committee of the American College of Surgeons Commission on Cancer reported in their 1982 audit that 55% of patients treated in 1976 had undergone a modified radical mastectomy and 28% had had a Halsted radical operation [ 161. Comparable figures from the 1978 survey revealed that nearly 50% of women treated in 1972 had had a Halsted mastectomy and only 28% had a modified radical mastectomy [ 161. Currently, it is estimated that at least 80% of patients undergoing radical surgery for breast cancer have the modified operation. In this operation the entire breast is removed without sacrificing the pectoralis major or minor muscles; axillary dissection similar to that used for the conservative operation completes the procedure. The Halsted radical mastectomy is recommended only for those patients with lesions involving the pectoral fascia or muscle. The conservative and radical approaches each have advantages and disadvantages. Obviously, the main advantage of the conservative approach is the preservation of the breast, but the price to be paid is the extended radiation treatment and the real concern felt by some patients that future symptoms in the retained breast are associated with tumour recurrence. With the more radical approach, treatment is accomplished within a few days and cancer obviously cannot recur in the breast. Many of the patients elect to undergo reconstructive procedures at a later date and some surgeons now perform the reconstruction at the time of the modified radical mastectomy. In our own Breast Health Centre each new patient is seen by the therapeutic team, including the surgeon, radiotherapist and medical oncologist. Based on the size of the lesion, its location and the mammographic findings, a consensus is reached by the team and a recommendation made to the patient by the primary physician. We have found that about half of our patients request mastectomy with the possibility of later reconstruction, and about half opt for the conservative approach with wide local excision, axillary dissection and radiotherapy. Properly performed, both approaches result in similar overall survival rates approximately 60% for Stage I and II lesions, with a local recurrence rate of 8%. Postoperative management Our patients are seen in the immediate post-operative period by the ‘Reach to Recovery’ team. The patients are matched for similar procedures, i.e. either modified radical mastectomy or the conservative approach. The patients are also seen by the physical therapist and many return to our voluntary counselling sessions. The
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patients continue to be followed up at the Breast Health Centre every 3 mth during the first year and every 4 mth during the second and third years. Yearly mammograms are obtained and, if indicated, repeat bone scans and other studies are performed to detect metastatic disease. Quality of life is of paramount concern and patients are encouraged to discuss reconstructive procedure and psychosexual concerns. Although we are committed to the team approach in the treatment of breast cancer, each patient retains her own primary physician (in our case the surgeon who initially sees the patient) and she is encouraged to contact either this physician with any concerns, or the Nurse Coordinator, who will then refer her to the appropriate physician for further discussion. The future The use of conservative surgery and radiotherapy as primary treatment for patients with early breast cancer will increase. It will be necessary for more centres to adopt the multidisciplinary approach to ensure that this type of treatment is provided safely. A number of surgeons are now experimenting with the CO2 laser. The surgical laser vaporizes tissue and creates a dry, sterile field that minimizes blood loss. It is too early to assess fully the potential value of this technique. It is clear, however, that breast cancer surgery has moved away from the radical approach to a more conservative position, reflecting our better understanding of the biology of the disease. References 1 Skrabanek P. False premises and false promises of breast cancer screening. The Lancet 1985; 316320. 2 Bloom HJG, Richardson WW, Harries EJ. Natural history of untreated breast cancer (18051933). Comparison of untreated and treated cases according to a histological grade of malignancy. Br Med J 1962; ii: 213-221. 3 Moore CH. On the influence of inadequate operations on the theory of cancer. R Med Chir Sot (London) 1867; 1: 245. 4 Von Volkmann R. Beitrage zur Chirgurie. Leipzig, Breitkotf und Hartel, 1875. 5 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 Rep. 1894-95; 4: 297. 6 Urban JA, Marjani MA. Significance of internal mammary lymph node metastases in breast cancer. Am J Roentgenol. Radium Ther Nucl Med 1971: 111: 130. 7 Council on Scientific Affairs. Early detection of breast cancer. J Am Med Assoc 1984; 252: 30063011. 8 Vorher RH. Breast aspiration biopsy: clinical opinion. Am J Obstet Gynecol 1984; 148: 127-133. 9 Homer MJ, Marchant DJ, Smith TJ. The geographic cluster of breast microcalcifications - Is it really intramammary? Surg Gynecol Obstet 1985; 161: 532-534. 10 Homer MJ. Non-palpable breast lesion localization using a curved-end retractable wire. Radiology 1985; 157: 259-260. 11 Chapter 214 General Laws of the Commonwealth of Massachusetts. An act providing certain rights to patients and residents in hospitals, clinics and certain other facilities, Section H, 1979. 12 Health and Safety Code, Section 1704.5, State of California breast cancer informed consent law (SB 1893), 1981. 13 Special report on treatment of primary breast cancer. N Engl J Med 1979; 301: 340.
192 14 Fisher B et al: Five-year results of a randomized clinical trial comparing total mastectomy tal mastectomy with or without radiation in the treatment of breast cancer. N Engl 312: 665-681. 15 Special report on limited surgery and radiotherapy for early breast cancer. N Engl 313: 1365-1368. 16 Wilson RE. Progress in breast cancer treatment, today and tomorrow. Am Co1 Surg Bull
and segmenJ Med 1985; J Med 1985; 1983; 68: 2-6.