A realistic appraisal of the case for conservative operation for breast cancer

Advocates of limited surgical procedures, who hold that standard radical mastectomy is an archaic and obsolete procedure, are prone to depict surgeons who differ from this view as wedded to an inflexible dogma, unrelenting in their insistence that any and all patients with breast cancer should be treated by standard radical mastectomy. If there are any such, they are rare indeed. The fundamental position is that the scope of the primary operative procedure should be correlated with the extent of the clinical pathologic setting of disease in each individual patient with the aim of removing all disease present while interfering least with appearance and function. Two factors of paramount importance which limit the choice of treatment are the very high incidence of multicentric foci of cancer in the breast and the fact that even in the favorable category of Stage A by the Columbia Classification, 30% of patients will have involvement of the axillary lymph nodes. On the other hand, when carcinomas are identified by calcifications alone in the absence of palpable tumor and of demonstrable X ray mass, nearly 100% have normal axillary nodes. For this group and for nonivasive intraductal carcinoma any procedure more extensive than total mastectomy would be difficult to justify. For occult carcinomas with demonstrable X ray mass, and for some small low grade type tumors with limited potential for node invasion, the modified radical operation is the operation of choice. Standard radical mastectomy is obligatory for all Stage 2 lesions and for a large percentage of Stage 1 tumors, excepting only small superficially situated tumors, especially when the factors of age or concomitant serious medical disease are considerations. For these the modified radical operation is acceptable, although the Patey procedure is to be preferred to the more limited version of the modified radical.