Chapter 5: Breast Surgery

Introduction

While breast cancer has been recognized as a disease process since the Egyptians described it in 3000 BC,¹ treatment is generally thought to have originated with Dr. William Halsted. In 1894 with his publication “The Results of Operations for the Cure of Cancer of the Breast,”² radical mastectomy (removal of the breast, muscle, and lymph nodes) was introduced as the mainstay of treatment for breast cancer. Halsted wrote, “I was led to adopt this procedure because, on microscopical examination, I repeatedly found when I had not expected it that the fascia was already carcinomatous, whereas the muscle was certainly not involved.” He then went on to say, “There are undoubtedly many surgeons still in active practice who have never cured a cancer of the breast.”

Fortunately, with improved understanding of the biology of cancer, specifically the hormonal aspect of breast cancer, along with the advent of mammography, treatment has evolved significantly since Halsted’s initial description of the morbid and disfiguring radical mastectomy. Breast cancer has paved the way in cancer research and treatment, and the majority of patients today can be cured. Advances in chemotherapy and radiation therapy have allowed for more limited surgery, creating the modern systemic, multidisciplinary approaches.

The first major change in therapy came in 1971 with initiation of the National Surgical Adjuvant Breast and Bowel Project (NSABP) B04 Trial, which established total mastectomy (removal of only the breast) as equally effective for early breast cancer with the benefit of lower morbidity than radical mastectomy.³ This led to the NSABP B06 trial for invasive cancer and the NSABP B17 trial for DCIS, which demonstrated that lumpectomy plus radiation, today’s breast conservation therapy (BCT), is equivalent to more radical surgery.^4,5 Breast surgery continued to scale down with the NSABP B32 trial establishing the role of the sentinel lymph node biopsy⁶ and the Z0011 trial eliminating need for axillary node dissection in women with early-stage breast cancer and one or two positive nodes.⁷

Advancements were also achieved in the area of systemic therapy. The NSABP B18 trial established the role of neoadjuvant therapy in breast cancer treatment,⁸ while the NSABP P1 and NSABP P2 trials introduced the use of hormonal therapy, namely, tamoxifen and raloxifene.^9,10 Additional trials have led to improvements in chemotherapy and use of more targeted agents. Breast cancer therapy today would be unrecognizable to Dr. Halsted, and research continues to look for ways to provide individualized targeted treatment while minimizing morbidity and improving outcomes.

Breast cancer therapy has benefited from large, multinational trials with extended follow-up, made possible in large part by the NSABP consortium. Many of the trials described in this chapter began in the 1970s, and interval follow-up has now been published in several manuscripts. We present the long-term results when they are available, as 25-year data can build on, and ...