The surgeon's role in primary breast cancer

Summary

During the 1960s, it was suggested that, at least in clinical stage I disease, simple mastectomy or even wide excision, plus radiotherapy to the breast and gland fields resulted in the same distant recurrence rate and survival as the orthodox radical operation. It was thought that local control of the disease was not important in terms of ultimate prognosis and it was felt that minimal surgery incurred no penalty. It was forecast that breast cancer would soon be treated by radiotherapy alone, possibly even without removal of the tumour.

Four developments have materially affected the situation.

• 1. It has been shown that assays of hormone receptors should be carried out on all primary tumours.

• 2. In clinical stage II disease, it has been demonstrated that restricted surgery results in a penalty in terms of distant recurrence and survival.

• 3. It is now realised that the number of involved axillary lymph nodes must be known to evaluate future prognosis.

• 4. Adjuvant chemo or endocrine therapy have proved to be effective in treating patients with heavy axillary node involvement.

These developments mean that the effective treatment of early breast cancer must entail removal of the tumour, achieve local control of disease and include axillary node dissection. Currently, only the modified radical mastectomy effectively equates with these three aims. Nevertheless, it is possible that tumour excision, irradiation to the tumour bed and breast, and axillary node dissection would achieve the same object whilst conserving the breast.