Cancer’s most controversial surgery

By Molly McGuiness

Today, about 60 percent of women diagnosed with early-stage breast cancer choose to undergo lumpectomy surgery followed by radiation as their course of treatment.  
 
It’s a choice that was hard-won.  The most common procedure to treat invasive breast cancer in America was once the most controversial surgery in the medical community.

The new documentary film “Cancer: The Emperor of All Maladies,” a six-hour, three-part film series airing on PBS March 30, 31, and April 1, tells the story of cancer’s complicated past and the doctors who questioned convention in search of a cure.

Yahoo News Global Anchor Katie Couric sat down with Ken Burns, who produced the film, and Siddhartha Mukherjee, MD, who wrote the Pulitzer Prize-winning book it’s based on, to discuss how one doctor’s defiant hypothesis paved the way for how we treat breast cancer.

In the 1970s breast cancer was the second leading killer of American women. Nearly all patients who faced a diagnosis submitted to the same extreme therapy, the radical mastectomy.  

The procedure was pioneered by a surgeon named William Halsted at Johns Hopkins in 1882.  “Halstead had a kind of metaphor to think about it.  He thought that cancer was a stain.  And so it would spread like a stain. It would just sort of spread locally around your body, bigger and bigger and bigger,” says Mukherjee.   
“And so Halstead and his students decided, ‘Well, if that was the case, then the approach is, well, we should cut more.’ And cutting more has to equal curing more.  And so they began to launch what was then called a radical mastectomy, which became the superradical and the ultraradical mastectomy, where, in fact, it was like a manic operation in which you would remove not just the breast, but the tissue under the breast, the muscles that shrug your arm, the deep nodes under your armpit, the clavicle. It was like an evisceration.”  

For nearly a century, women underwent the surgery without question. And while more than a third of patients relapsed, few questioned the operation, until a surgeon from Pittsburgh named Bernard Fisher challenged Halstead’s theory.

Fisher suspected that stray cancer cells detached from the original tumor very early and migrated through the bloodstream or lymphatic system to other sites in the body. That meant that for those women whose breast cancer had already spread, the radical mastectomy would not be enough. For those whose cancer had remained localized, it was too much, and for those patients, Fisher proposed a much smaller operation called a lumpectomy, which removed the tumor but conserved the breast.

Fisher decided to test his theory in clinical trials and was immediately vilified by the medical community.  “It once again is this thing where you run up against tradition, “ Burns says. “You suggest something that’s counter to the momentum of the age of the received wisdom, and you’re a pariah.”

It took women advocating for women to change the establishment’s way of thinking. As women started to find out that there was an alternative out there, a movement took root, led by a science journalist named Rose Kushner who, at the age of 45, had been told she needed a radical mastectomy.  

“Rose Kushner said, ‘Wait a second, you’re butchering us … you’re mutilating us.  This cannot be.’  And so what you see is for the first time patients are beginning to enter into the discussion about their own care, their own fate.  And it’s women with breast cancer.  And that’s a huge turning point in the history of cancer,” says Burns.
 
Rallied by Kushner and others, breast cancer patients joined Fisher’s study. The trial comparing the radical mastectomy to the lumpectomy took a decade to complete, but in 1985, the results were released: It didn’t make a difference whether you amputated the whole breast or just took the tumor out of the breast. The survival rates were the same. Just over a century after the radical mastectomy was introduced, there was finally a new way. Although mastectomies remained common, Halstead’s radical surgery would become all but obsolete.

In the film, Susan Love, cancer surgeon and author, says, “What happens in medicine and in science is we come up with a story to explain our observations, and we get enamored of our story. And then we use that story to keep going on, and it propels the research, and it propels the kind of treatments you do, and it’s really only when you just can’t justify it anymore that we start to throw it out. “

It took 10 years, one persistent surgeon, and a lot of determined women fighting for their rights to turn the page, and the result was a new chapter in the treatment of breast cancer.