When I was first training to become a surgeon in the 1970’s, it was widely understood that once breast cancer escaped the breast where it had started, it had the potential to cause your death.
At that time, we would do a breast biopsy in the operating room. We would immediately examine the tissue to look for cancer cells. If we found them, we would do a radical mastectomy. It wasn’t until a patient woke up from the anesthesia that she learned she had breast cancer and would no longer have one of her breasts.
While I was getting my training a large study was taking place in Italy, led by the oncologist Umberto Veronesi. His study randomly assigned women diagnosed with breast cancer to have either a quadrantectomy (surgery to remove about one quarter of the breast tissue) and radiation or a radical mastectomy. Much to everyone’s surprise, survival rates were the same in both groups. It was the first indication that cancer cells could get out of the breast early on. This has been confirmed by research using liquid biopsies (blood tests) that have found DNA from cancer cells in the blood of women newly diagnosed with breast cancer. In other words, finding the cancer “early” does not assure that it has not spread nor does more aggressive surgery.
This understanding has led to an increased interest in neoadjuvant treatment, which is the use of chemotherapy or hormone therapy before the surgery. (Traditionally, systemic therapy has been given after surgery. This is called adjuvant treatment.) There are three key advantages to giving treatment before surgery. First, you get a chance to see if the tumor responds to the treatment. If it does, it gets smaller. Secondly, you are focused on the most important cancer cells, those that have long ago escaped from the tumor. Thirdly, if the tumor shrinks, less tissue needs to be removed from the breast.
Knowing that cancer cells leave the breast early, also gives us the opportunity to think about new ways to treat the tumor in the breast, like low-level laser therapy, radiofrequency ablation, and cryotherapy. Studies have suggested that these techniques, which leave dead cancer cells in the breast, may have an immunotherapy effect, with the dead cells training the immune cells to kill other cells that are similar to them.
We have come a long way scientifically and clinically since the days of the radical mastectomy. Yet, it’s been hard to move past the false notion that more surgery is always better. As a result, far more women than necessary are treated with a single our double mastectomy because they think that this more “aggressive” surgery will help them survive longer. I think we owe it to all the women who long ago agreed to enter a clinical trial that compared radical mastectomy to a quadrantectomy or a lumpectomy followed by radiation to help women newly diagnosed with breast cancer understand that when it comes to surgery, more is not better, and that, rather, they want to be sure they are getting the systemic treatment that will do the best job of slowing or stopping the growth of the cancer cells that have already left the breast.