Rebuke for Radical Mastectomies

Studies support limited surgery, chemotherapy for breast cancer

For almost a century, the cornerstone of treatment for breast cancer was the Halsted radical mastectomy. In this physically and often emotionally scarring operation, the breast, underlying chest muscles and lymph nodes in the armpit are removed. In the past decade, however, most doctors have recommended less drastic surgery, particularly for women whose cancer is detected early. Now a major study confirms that women with very small tumors are just as well off with limited operations that spare most of the breast tissue.

The study, conducted between 1973 and 1980 by Dr. Umberto Veronesi and colleagues at Italy's National Cancer Institute, involved 701 women with tumors less than three-quarters of an inch in diameter. About half underwent radical mastectomies; the rest had "quadrantectomies," losing only the quarter of the breast with the tumor, plus lymph nodes in the armpit. The partial mastectomy patients received radiation therapy following the operation; since 1976 drug therapy has been given to women in both groups whose cancer had spread to the lymph nodes. The results, reported in the New England Journal of Medicine, showed no difference between the two groups in either recurrence of disease or survival. In women with early breast cancer, an estimated 5% to 10% of the 110,000 new cases diagnosed last year in the U.S., "radical mastectomy appears to involve unnecessary mutilation," say the researchers. For women with more advanced cancers, most doctors recommend removing the breast but leaving the chest muscles intact.

The Journal also contained an encouraging report about the effectiveness of chemotherapy after mastectomies. A study of 1,863 women whose cancer had spread beyond the breast revealed that recurrence rates dropped when a chemical called tamoxifen supplemented an established two-drug regimen known as PF (L-phenylalanine mustard and 5-fluorouracil). The effects were most striking in postmenopausal women, a group that in the past did not seem to benefit from chemotherapy. Says the study chairman, Dr. Bernard Fisher of the University of Pittsburgh: "In women over 50 years old with multiple lymph node involvement, 45% will have a reoccurrence of disease within two years if there is no postoperative treatment. With PF we were able to cut that down to 30%. When we added tamoxifen, it went down to 5%." Tamoxifen is an anti-estrogen and appears to work best in women with tumors that are dependent on the hormone. About 70% of postmenopausal women fall into this category, according to Fisher.

The British Medical Journal, meanwhile, carried two reports indicating that oral contraceptives do not increase the risk of developing breast cancer. In one study 23,000 women using birth control pills were compared with an equal number who had never used the contraceptive.

No difference was found in the incidence of breast cancer. The other study involved 17,032 women who used either the Pill or an intrauterine device or diaphragm. Again no link was shown between breast cancer and oral contraceptives. But researchers are cautious.

Breast cancer may take a long time to develop, they note, and oral contraceptives have been in widespread use only since the mid-1960s.

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