Saving Breasts

Each year more than 100,000 American women are told that they have breast cancer. For nearly 9 out of 10 of them, the treatment is almost worse than the disease: mastectomy, or total removal of the breast and sometimes the underlying muscle too. Doctors have long argued over whether this disfiguring surgery is really necessary. Now the results of a long-awaited federal study suggest that for perhaps half of the patients, it is not.

The study, published in last week's New England Journal of Medicine, compared the results of mastectomy with a far less radical operation called lumpectomy, in which only the breast tumor and a small amount of surrounding tissue are removed. The research involved 1,843 patients, each of whom had a tumor that measured no more than 4 cm (or about 1 1/2 in.) in diameter. The participants agreed to be assigned randomly to three different treatment groups. About one- third underwent a mastectomy, one-third had a lumpectomy, and another third received radiation treatment in addition to a lumpectomy. The women in all three groups had their underarm lymph nodes removed and examined for signs of malignancy; if the nodes were cancerous, the patients were given chemotherapy following surgery.

Women in the study were monitored for an average of 39 months after surgery, but statistical methods were used to predict their survival after five years. , Results showed that there was no advantage to having the entire breast removed. In fact, the patients who fared the best were those who had a lumpectomy plus radiation. The five-year survival rate for such patients was 85%, as opposed to 76% for women in the mastectomy group. The radiation patients also had a reduced risk of breast-tumor recurrence: only 7.7% developed another tumor in the same breast, as opposed to 27.9% of those with a lumpectomy alone.

"I think we will see a swing away from mastectomies," predicted Dr. Bernard Fisher of the University of Pittsburgh School of Medicine, who headed the study, though he conceded that "old ways die hard." Indeed, many surgeons argue that until ten-year results are available, the case for lumpectomy will remain unproved.

Despite these reservations, the American Cancer Society hailed the study as an important step in "the revolution in breast-cancer treatment." But, emphasized Dr. Arthur Holleb, an A.C.S. vice president, since only small, early-stage tumors can be treated by lumpectomy, the need for early detection of breast lumps "is more important than ever."