Cancer of the Breast: The Surgeon's Dilemma
SUDDENLY, after 50 years of complacent acceptance of radical mastectomy, the surgical world is plunged in doubt. On the one hand, Urban and Baker1 and Wangensteen2 advocate extension of the radical operation to include resection of the internal mammary nodes; on the other, there is mounting evidence that simple mastectomy gives better results than the conventional radical operations.3
Since even in the most skillful hands the conventional radical mastectomy may cause disfigurement and dysfunction, it is important to determine whether it is really necessary to employ it routinely. To date there is no proof that the results of radical mastectomy are better than those of simple. Pathologists may theorize on the rationale of eradicating cancer by extended surgery,4 but in the final analysis it is the survival of patients that counts. So little is known about the ways of cancers and the complex relationships of tumors to their hosts that theoretical considerations based on the traditional concept of the spread of cancers are of little value.
In the traditional concept of the spread of cancer, the tumor is at first localized, later spreads to the regional lymph nodes, and finally throughout the body. According to this concept the most extensive operation performed at the earliest possible moment should give the best chance of cure.
In opposition to this concept is the theory that Gatch5 has long held and that MacDonald6 has named biologic predeterminism. In this concept, the course of the disease is thought to depend chiefly upon the biologic. . .