Breast Cancer

A consensus that less is more

Some 90 years ago a Baltimore surgeon, Dr. William Halsted, devised the operation that soon became the standard treatment in the U.S. for breast cancer, a disease that now strikes 106,000 women and claims 34,000 lives a year. It is the radical mastectomy, which involves cutting away not only the breast but also the lymph nodes in the armpit, and underlying chest muscles. Yet with more breast cancer being detected at earlier stages, the trend has been away from disfiguring if often lifesaving "radicals." Still, 25,000 women a year undergo these operations, largely at their physicians' behest.

Last week at a conference sponsored by the National Institutes of Health in Bethesda, Md., leading doctors and researchers, including surgeons, made the strongest public plea yet for a reversal of this surgical practice. After a nine-hour debate, they concluded what an increasing number of studies have been showing: that if breast cancer is discovered when tumors are still small (even if nearby lymph nodes are also cancerous), radicals may no longer be the preferred treatment. For such cases, although not necessarily in more advanced ones, the NIH "consensus" panel endorsed the so-called total mastectomy, with removal of some lymph nodes. This procedure, the panelists said, would not lessen chances of survival and offers several advantages.

In a total mastectomy, unlike the radical, the chest muscles are left intact. The benefits: the operation produces less discomfort and disfigurement, and the scar is lower on the chest, giving the women more options in clothing. Also, it enhances the possibility of breast reconstruction.

Largely at the urging of a lay member, Rose Kushner, herself a breast cancer victim, the panel also recommended another reform. At present, most suspected breast cancer patients sign a paper upon admission to hospitals giving the surgeon blanket authority to undertake whatever treatment is deemed necessary, even if the initial intention is to do only a biopsy--taking a tissue sample from the breast to see if any cells are cancerous. To their great distress, many women have found upon awakening that the surgeon has taken a breast as well as the sample. Kushner persuaded the largely male panel to endorse a two-step approach: a biopsy first, followed by an interval--sometimes as long as a month--before the next treatment, thus giving the patient and physicians time to reflect what, if any, surgery is best. Said Kushner, who had insisted on this two-step procedure in her own case: "We should be awake to make the decision." -

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