There is a definite trend in surgery today towards questioning many operative procedures which long have been considered standard technique. These operations are being challenged by some surgeons as being too radical, and by other surgeons as not being radical enough. The value of surgical therapy can be measured only in terms of how successful it is in accomplishing its purpose. In the recent past, the value of radical surgery for breast carcinoma has been challenged by many thoughtful and qualified surgeons. In their hands, the results achieved with methods such as simple mastectomy or radiotherapy have been as good as those achieved with radical mastectomy. Radical mastectomy, as originally described by Halsted, was a logical procedure. The purpose was to remove, as much as possible, all tissue that might contain cancer cells. However, not long afterwards Halsted himself recognized the inadequacy of the operation and attempted to extend the original procedure in order to eradicate more cancer-bearing areas. The lack of a more complete knowledge of the dissemination of breast cancer was a great handicap. Consequently, as the postoperative morbidity and deformities increased the salvage rate decreased. Despite the increase in our knowledge of the dissemination of this disease, some surgeons have recently attempted to extend the scope of operation even further. They excise the internal mammary chain of nodes, and in some cases extend the procedure to the supraclavicular area. On the other hand, some surgeons have refined their criteria of operability by performing biopsies of the internal mammary and apical axillary nodes in selected cases; if these nodes are involved, the patient is not subjected to a futile radical mastectomy, but receives radiotherapy. The underlying reason for the failure of radical surgery to cure these patients is the unpredictability of dissemination of the disease by way of the lymphatics and blood stream. The microscopic growing edge of the carcinoma is not recognizable clinically, and the surgeon cannot determine in each case how far the circle of fascial permeation extends. Careful study of the lymphatics of the breast shows that complete eradication by the surgical approach is almost impossible except in very early cases; but such patients constitute only a small percentage of those who apply for treatment. In these early cases, if the disease is limited to the breast, the radical procedure is unnecessary. We are all agreed that early cases can be cured; what we need to learn is the best method of treatment. At present no method can be guaranteed to cure. However, in properly selected cases, the simpler procedures (followed by adequate radiation therapy, if indicated) have definite merit and are associated with a survival rate comparable to, if not better than, that associated with radical mastectomy. Moreover there is less postoperative morbidity. Halsted, in reporting to the American Medical Association on his experience with 210 radical operations began his presentation with a wise observation: “It is especially true of mammary cancer that the surgeon interested in furnishing the best statistics may in perfectly honorable ways provide them.” Statistical methods can be overstrained in evaluations of the surgical approach to any disease. Each cancer and each host is a complex variable. In individual cases it is impossible to tell with accuracy how important a specific therapeutic maneuver may be as a factor in survival or in detection of the regional persistence of disease. Results following the simpler procedures compare well with those following the more radical operations. In fact some surveys indicate that the survival rate after simple mastectomy may be even higher than that after radical mastectomy. Among the alleged attributes of the well respected surgeon, integrity is essential. Technical competence to carry out the surgical procedure to its completion with gentleness and dexterity is of the greatest importance. Of comparable importance is good surgical judgment—“the moment of Truth.” This describes a crucial moment when the surgeon has to decide on what he believes is the best procedure for his patient. The surgeon has a very serious moral obligation to his patient at that moment in making the correct decision. Has the disease progressed to the point where any surgical procedure is futile? Is the disease at a particular stage in which unnecessary mutilation and surgical exercise will be of no benefit to the patient? This is a moment when one has to delve deep into his conscience and rationalize carefully, deliberately and honestly. Only then will it become a moment of insight into the great difference between what we profess and what we may do. The physician must take personal responsibility, at least in private conscience, for what happens to other human beings.
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Open Access
Jul 1, 1994
Robert L Whalen + 7
