Breast cancer remains a challenging diagnosis, transforming many aspects of patients’ lives beyond physical health.
By Dr David Lim, General and Breast Surgeon, Mt Lawley
Breast cancer was mentioned in the first known surgical text, known as the Edwin Smith Papyrus (named after the American that acquired it in 1862). This Egyptian document dated circa 1600 BCE described 48 cases of various pathologies and how to deal with them in a practical and rational way.
Case 39 in this text described a swelling in the breast as: “the disease was cool to touch, bulging and spread all over the breast”. This was deemed incurable.
Hippocrates, a forerunner in separating medicine from religion, coined the term ‘karkinos’ which eventually led to ‘carcinoma’.
He also misguidedly propagated the humoral theory that diseases arose from an imbalance of four ‘humors’ within the body (blood, phlegm, black bile and yellow bile). Cancer was thought to be an excess of black bile.
Galen, another figure of equal fame in antiquity, also supported humoral theory. In surgical treatment of the disease, he discouraged cautery to remove excess black bile through bleeding.
Horrific surgical practices were utilised over the years by surgeons in futile efforts to treat breast cancer, with instruments devised to extirpate the breast in a rapid and efficient manner, of utmost importance in the era before anaesthesia.
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The 19th century witnessed the birth of anaesthesia (Seishu Hanoaka in 1804 and William Morton in 1846). Joseph Lister in the 1860s pioneered antiseptic surgery, applying the research of Louis Pasteur.
Countless advancements and brave innovations were made in surgery. Many individuals made contributions that were no less significant than those mentioned here.
Despite this optimism, mortality of breast cancer remained high and the prognosis from breast cancer was grim.
“Most of us have heard our teachers in surgery admit that they have never cured a case of cancer of the breast,” – William Halsted.
Escalation of surgery
William Halsted is considered the father of modern surgery and is one of the founders of the Johns Hopkins medical school.
His contributions include the “Tenets of Halsted” to be used in surgery – this includes gentle handling of tissues, meticulous haemostasis, preservation of blood supply, strict aseptic technique, minimum tension on tissues, accurate tissue apposition and obliteration of dead space. All the above are still principles adhered to.
He published his landmark paper in 1894 on the outcomes of 50 patients with breast cancer that he treated with a radical mastectomy. This operation excised the entire breast, regional lymphatics and pectoralis muscles. Although mutilating and morbid, Halsted’s paper reported significantly improved recurrence rates compared to contemporaries.
For many who had surgery alone, long-term cancer-free survival remained elusive, but radical mastectomy became the gold standard for many decades, disseminated by Halsted’s disciples near and far.
Key messages
- Breast cancer surgery has evolved over centuries.
- Today there are many surgical options.
- Treatments continue to be refined and improved.
Refinement of technique
The development of chemotherapy, radiotherapy, breast imaging, gene testing, screening, hormone therapy, targeted therapies and breast awareness drastically changed the face of breast cancer outcomes in the latter half of the 20th century.
During this time, surgeons revisited their practices. Large RCTs demonstrated equivalent survival rates with lumpectomy and radiotherapy. Although not suitable for every patient, breast conservation became possible without compromising cancer treatment outcomes.
Donald Morton, in 1992, developed a technique for sentinel node biopsy in melanoma treatment. This was evaluated in breast cancer, eventually replacing axillary clearance in staging the axilla in clinically node-negative patients.
Current landscape and the future
Breast cancer surgery and the development of oncoplasty as a subspecialist craft group was born in the 21st century.
Today, there is a huge array of oncoplastic techniques that facilitate breast conservation. Where not possible, reconstruction with implants or autologous techniques are available for suitable patients that desire it.
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Neoadjuvant systemic treatment (NAST), including recent breakthroughs in targeted and immunotherapies, has further allowed refinement of surgical options. Downstaging of the primary tumour facilitates breast conservation.
In some settings, positive lymph nodes may no longer mandate axillary clearance after NAST, as other methods, such as targeted axillary dissection (TAD), can be used to evaluate treatment response in the axilla.
Today, within a multidisciplinary team, surgery remains indispensable in breast cancer treatment. However, patients would tell you that it is only part of an arduous and intrepid journey.
It is impossible to overstate the vital role played by breast nurses, support and advocacy groups, physiotherapists, social workers, psychologists, occupational therapists, genetic counsellors, community nurses and, of course, family and friends.
We are a far cry from the bygone days of desperate and mutilating surgery, but there is no doubt that breast cancer surgery will continue to achieve more for our patients as it evolves in its role and techniques.
Author competing interests – nil
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