The appropriate breast cancer paradigm.

Perhaps no other disease or its treatment has evoked such strong feelings as has breast cancer. The reasons for this are to be found both in our culture in general and in medicine in particular. The breast, in certain contexts, is the symbol of motherhood, nourishment, and security while in others it rep resents beauty and femininity. There are equally compelling medical connotations which have made supporters of certain therapeutic alternatives act like religious zealots. Breast cancer has a long natural history; thus, early results may provide a misleading assessment of long-term outcome. Strongly held beliefs as well as the need for long-term follow-up have provided the ingredients for aminated debate concerning the disease and its treatment. In the middle of the 19th century, women with breast cancer typically presented to their physicians with locally advanced disease, not simply with a lump in the breast. These women sought attention for ulcerated lesions of the breast or for painful axillary involvement by the disease. There was no effective local therapy or any useful systemic anticancer treatment available at that time. Attempts at surgical extirpation generally resulted in a prompt return of the disease locally. The futility of therapy only reinforced the nihilistic attitude of the population regard ing the advisability of prompt treatment for suspicious breast masses. The introduction of the radical mastectomy by Willy Meyer (1) and W. S. Halsted (2) at the end of the 19th century not only was an important therapeutic advance but also provided the first important medical paradigm for this disease. The use of radical mastectomy was based on a model of cancer spread that was centrifugal. A tumor started locally, infiltrated via the lymphatics in a direct and contiguous fashion to the regional lymph nodes, and then spread distantly. In its most doctrinaire presentation, espoused by Halsted, this model explained even distant métastasesby contiguous extension. This notion of the disease provided a rational basis for a radical operation designed to resect widely the tumor and contiguous tissues, including the regional lymph nodes. Thus, the primary appeal of radical mastectomy was that it was based on an important theory of disease spread. Secondly, the newly developed method coin cided with the rapid improvement in surgical and anesthetic techniques, which was required if the operation were to be performed properly. This became the paradigm for much of cancer surgery and en bloc dissections became important in the treatment of a variety of other cancers. To disagree with the radical mastectomy, therefore, was to threaten the philosophi cal underpinning of all radical surgery. It is in this context that one must consider what happened when McWhirter suggested that if postoperative radiation were to be used, the radical mastectomy might be replaced by simple mastectomy, thereby avoiding the morbidity associated with the radical operation (3). While this technique was based on the