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The revolution in breast cancer surgery: Science or anecdotalism?

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Abstract

During the past 15 to 20 years, there have resulted revolutionary changes in the local/regional management of primary breast cancer. Why have those changes come about? Has science played a role or have they been entirely related to the experiences of a few who have “tampered with tradition” for some nebulous reason? This report traces the pathway of change from Halsted's time to the present and attempts to point out wherever possible the relation of these changes to science and/or to “anecdotalism.” It traces the origins of the Halstedian hypothesis of cancer management, the reasons for its perpetuation, and the clinical challenges to it which were really not challenges at all. A description of laboratory and clinical research in the 1960's which led to an alternative hypothesis is presented, as is a description of how clinical trials tested the alternative hypothesis. The results of those trials, recently reported, lend support to a concept of surgery for cancer which embodies biological principles rather than the mechanistic and anatomical principles of the past. A brief discussion is provided relative to how cancer surgery interrelates with other modalities and the article concludes with the author's concept of a surgical oncologist.

Résumé

Au cours des 15 à 20 dernières années le traitement local-régional du cancer du sein a subi un changement radical. Pourquoi ce changement s'est-il manifesté? La science a-t-elle joué un rôle ou bien est-ce le fait de quelques auteurs qui ont joué avec la tradition pour des raisons nébuleuses? Cet article trace le cheminement du changement depuis Halsted jusqu'à nos jours et souligne dans la mesure du possible ce qui revient à la science et à l'anecdote. Il retrace les bases de la conception thérapeutique originale de Halsted il définit les raisons de son maintien prolongé, il juge de la valeur des mises en question de cette conception. Une description de la recherche clinique et biologique au cours des années 1960 qui a conduit à une autre hypothèse est présentée ainsi qu'est relatée la manière dont les essais cliniques ont permis de juger cette nouvelle conception. Les résultats de ces essais rapportés récemment tendent à soutenir le fait que la chirurgie du cancer repose sur des principes biologiques plutôt que sur des concepts anatomiques et mécanistes. Une brève discussion qui concerne les inter-relations de la chirurgie oncologique et les autres méthodes thérapeutiques parachève cet article qui se termine par l'exposé des positions personnelles du chirurgien oncologiste qui en est l'auteur.

Resumen

En el curso de los últimos quince a veinte años os se han visto cambios revolucionarios en el manejo local-regional del cáncer primario de seno. iqCómo se han producido tales cambios? iqHan tenido que ver con la ciencia, o han sido solo el resultado de las experiencias de unos pocos que “se han entremetido con la tradición” por alguna razón no muy clara? Este informe revisa el camino del cambio desde los tiempos de Halsted hasta el presente y trata de señalar, en lo posible, la relación de los cambios con la ciencia y /o el “anecdotalismo”. El informe investiga los orígenes de la hipótesis Halstediana sobre manejo del cáncer, las razones para su perpetuación y las disputaciones clínicas que se le presentaron, los cuales al fin y al cabo no fueron verdaderas disputaciones. Se presenta una descripción de la investigación clínica y de laboratorio de los años os 1960's que dió lugar a una hipótesis alterna y se describe cómo varios estudios clínicos probaron la hipótesis alterna. Los resultados de estos estudios, recientemente informados, dan apoyo al concepto que establece que la cirugía del cáncer se fundamenta en principios biológicos más que en los principios mecanicistas y anatómicos que estuvieron en boga en el pasado. Se incluye una breve discusión relativa a cómo la cirugía de cáncer se interrelaciona con otras modalidades terapéuticas, y el artículo termina con el concepto del autor sobre qué es un cirujano oncológico. Dentro de este concepto, cualquier programa formativo en cirugía oncológica debe estar totalmente dirigido a lograr que algunos cirujanos puedan expandir su formación más allá de su orientación puramente metodológica, en tal forma que puedan convertirse en científicos capaces de introducir una perspectiva diferente al estudio del cáncer. El objetivo principal debe ser el de capturar el intelecto de aquellos cirujanos capaces de realizar una contribución a la oncología que se extienda más allá de los aspectos puramente técnicos de su disciplina. Mediante un programa de esta naturaleza los terapistas quirúrgicos podrán convertirse en oncólogos.

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  1. University of Pittsburgh, Pittsburgh, Pennsylvania, USA

    Bernard Fisher M.D.

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  1. Bernard Fisher M.D.
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Presented in part as the Heath Memorial Award Lecture, M.D. Anderson Hospital and Tumor Institute, November 3, 1982.

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Fisher, B. The revolution in breast cancer surgery: Science or anecdotalism?. World J. Surg. 9, 655–666 (1985). https://doi.org/10.1007/BF01655177

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