Two landmark studies confirm what a small group of maverick surgeons proposed nearly 40 years ago: Women need not lose a breast to survive early-stage breast cancer.
After 20 years of research, the studies -- published in the Oct. 17 issue of The New England Journal of Medicine -- show that removing just the tumor offers women an equal chance of survival compared with removing the entire breast and many surrounding tissues.
"It's a footprint in history," says Bernard Fisher, MD, director of the National Surgical Adjuvant Breast and Bowel Project. "The studies [unequivocally] show that more is not better, that the mutilation surgery performed in the past can be put at rest, that it is now part of medical history," he tells WebMD. Fisher is the lead researcher of one of the NEJM studies.
Developed in 1902, the radical mastectomy was the treatment of choice for breast cancer for more than 80 years. It involved "removing a good portion of the torso -- until you could see ribs, all the way up into the armpit," Otis Brawley, MD, associate director of the Winship Cancer Institute at Emory University School of Medicine in Atlanta, tells WebMD.
In the 1970s, "a few very forward-thinking, smart, and somewhat brave surgeons started advocating and doing studies to show that simple mastectomy (removal of only the breast itself) was equal to a radical mastectomy," says Brawley. "These surgeons were criticized openly back in the 1940s, '50s, '60s -- called malpractitioners -- for even suggesting that this finding might be true. People would not have an open mind toward the possibility."
Today, the most common form of mastectomy -- "modified radical mastectomy" -- involves removal of the breast, the lymph nodes under the arm, the lining over the chest muscles, and occasionally part of the chest wall muscles.
Fisher was one of the maverick surgeons who first suggested that total mastectomy was putting women through needless suffering. So was Umberto Veronesi, MD, researcher with the European Institute of Oncology in Milan, Italy; he is the lead researcher of the second study in the NEJM.
In 1973, Veronesi's group began a study of 701 women receiving either lumpectomy plus radiation therapy or radical mastectomy. In the 20-year follow-up reported this week, Veronesi finds that the overall survival rate in the two groups was virtually identical.
In 1980, Fisher began enrolling 1,800 women in what became a 20-year study. It produced similar results: Total mastectomy offers no advantage over either lumpectomy or lumpectomy plus radiation therapy.
The studies show the benefits to the patient, but they also add critical information about the biology of cancer, Fisher tells WebMD. "These studies demonstrate that surgery was not going to be ultimate answer," he says. "They show that so much can be done systemically, treating the patient with chemotherapy, before and after surgery."
In fact, for the past 15 years, lumpectomy has been an accepted alternative. There are laws in some 30 states stating that a physician must inform a woman that she is eligible for either procedure, says Brawley.
Yet despite all the scientific data, "which is unequaled in the literature on the local treatment of cancer, many women today are not offered the option of breast-conserving therapy," writes Monica Morrow, MD, in an editorial accompanying both studies. She is a researcher with the Northwestern University School of Medicine in Chicago.
Morrow and colleagues found that only 43% of women with early-stage breast cancers were being treated with the breast-conserving approach, she writes. Lumpectomy is still "viewed as a less-aggressive therapy appropriate for only for women with a good prognosis," she writes.
"It is time to declare the case against breast-conserving therapy closed and focus our efforts on new strategies for the prevention and cure of breast cancer," Morrow says.
Says Brawley, "I'm happy, thrilled, that these two authors are able to say, 'I told you so.'"