The MacNeil/Lehrer Report; 2191; Mastectomies

ROBERT MacNEIL: Good evening. If a woman develops breast cancer and her doctor recommends surgery, should that operation be a radical mastectomy or something simpler? That medical controversy, raging for years, was revived last week. The Harvard School of Public Health published a report questioning the need for many of the 25 million operations of all kinds performed in the United States each year: tonsillectomies, appendectomies, hysterectomies, for example. Many, the report said, were of questionable value and were contributing to the rising cost of health care.

One of the operations listed was radical mastectomy. The Harvard professors who wrote the report claimed that radical breast surgery was no more effective in terms of survival or recurrence than simple surgery. And they added, "It does, however, cost more in dollars for surgery and hospital stay and does induce more morbidity, more mutilation and more traumatic psychological adjustment, as well as carrying a greater risk of surgical death." Tonight we examine this ongoing argument: is radical mastectomy ever unnecessary surgery? Is less surgery, plus other forms of treatment, now as successful in treating breast cancer? Jim?

JIM LEHRER: Robin, it is not just an academic discussion for medical experts. Breast cancer is a grim personal reality for 90,000 women a year in this country, and a grim fear for the millions of others. So we`ve asked Mrs. Marvella Bayh to sit in with us tonight. Mrs. Bayh, wife of Senator Birch Bayh of Indiana, underwent surgery for breast cancer in 1971. Her case and those of Betty Ford and Happy Rockefeller three years ago focused attention on a subject that had not been publicly discussed before. Mrs. Ford and Mrs. Rockefeller both had radical mastectomies performed. This is the best-known and most common surgical technique. The entire breast, the underlying muscles in the chest wall, and the lymph nodes under the arm are removed. There is also a modified radical mastectomy, which leaves the muscles intact. That is the kind that Mrs. Bayh had. Other techniques are the simple mastectomy, with only the breast being removed; and the newest procedure, known as segmental mastectomy, or by laymen as lumpectomy: only the part of the breast where the tumor is found is actually removed. Robin?

MacNEIL: The argument that radical mastectomy may be unnecessary has gained support in recent years from a study conducted under the auspices of the National Cancer Institute, studied again in 1971 and is continuing. Three years ago preliminary findings were released which indicated that except for an occasional case the survival rate was no different after a radical mastectomy than with a simple one. Another report in that study is due shortly. The director of the study is Dr. Bernard Fisher, a breast cancer specialist and Professor of Surgery at the University of Pittsburgh, and he is with us this evening at the Public Television Station studios in Pittsburgh. Dr. Fisher, we don`t want to oversimplify this, but may I ask the simplest question first. Does your study tell you that radical mastectomy is unnecessary in most cases?

Dr. BERNARD FISHER: What our study tells us is that at the present time, which is now in the sixth year of the study -- the study having been begun in 1971 -- with an average time of follow up for some 1,700 patients of forty-nine months, and some patients are going as long as six years, that there is no difference at the present time in the statistics between those patients which had a radical mastectomy and those which had a lesser procedure.

MacNEIL: How do you support that conclusion other than statistically over that length of time? Could you elaborate on that a little bit, in other words?

FISHER: Well, one of the best ways to find out whether a hypo or not is to do what we call a clinical trial, and that means of a scientific study two different theses. And radical mastectomy was the accepted form of therapy for world over. Because of scientific reasons, not emotional or because of anything else, but because of change in science there became some suggestion that perhaps the lesser procedure would be just as efficacious. In 1971 a randomized clinical trial was begun, as I said, in which 1,700 women were randomized between radical mastectomy, the conventional form of therapy, versus simple -- or we call it total -- mastectomy, with and without radiation. And now, as I say, six years later, or an average time of almost five years, from a statistical point of view in terms of treatment failure, in terms of survival, there is at the present time -- and I continually reiterate that -- at the present time no evidence that there is a difference in the treatments.

MacNEIL: Do you as a specialist yourself believe cases in which the radical mastectomy, the traditional necessary?

FISHER: Well` they must be very few and far between. I think that most of us who are doing breast cancer surgery, based upon these statistics and others from throughout the world, have tended to see the need for radical as being almost extinct.

MacNEIL: From the woman`s point of view, does the simple mastectomy operation involve significantly less physical and emotional damage to the patient? In other words, if a woman could make a choice between the radical and the simple one, would there be a great difference to her?

FISHER: It must be emphasized that the so-called "simple" mastectomy, or total mastectomy, still removes the breast, so from that standpoint the patient loses her breast, the only difference being that she does not lose the muscles of her chest wall. And this does produce a significant decrease in morbidity in many, many cases.

MacNEIL: Are fewer radical mastectomies knowledge, in this country, perhaps partly as early conclusions?

FISHER: It`s very difficult to answer that question, and I don`t think that one can with any kind of assurance. One can only get impressions, and one gets the impression that there are more and more modified radical mastectomies being done.

MacNEIL: Thank you, sir. We`ll come back. On the other side of the issue is Dr. Cushman D. Haagensen, Professor Emeritus of Clinical Surgery at the College of Physicians and Surgeons of Columbia University. Dr. Haagensen has been a practicing surgeon for fifty two years, and has written numerous medical texts, including Diseases of the Breast. Dr. Haagensen, accepting that not all breast cancers are suitable for surgery, in those which are, what do you think of Dr. Fisher`s conclusions and those of the Harvard Public Health report?

Dr. C.D. HAAGENSEN: May I refer to the Public Health report from Harvard first? It was written by three non-experts in breast disease: Dr. Bunker, the Professor of Anesthesia; a cardiovascular surgeon and a statistician. None of these three gentlemen have a very close and intimate contact with the actual problems of treating breast carcinoma, so that I can expect that they`d be confused, as many of our young people are and some of our older people, about the rationale for radical mastectomy.

MacNEIL: What do you think of Dr. Fisher`s findings so far from the six years of his study?

HAAGENSEN: I don`t think Dr. Fisher`s studies meet the standards for comparison of different methods of treatment which we recognized long ago. First of all, patients who are entered into any kind of comparable study must be carefully classified as to the clinical extent of their disease. We now have such a plan. Breast carcinoma is a very slowly progressive disease, and we need to compare the early cases with the more advanced cases; otherwise, we`re having a race between a tortoise and a rabbit. We must compare for each different method of treatment the same clinical stage of advancement. Moreover, we must not compare for less than ten years. We know very well that five years is not long enough to form a valid opinion as to the usefulness of any method of treatment.

MacNEIL: So your point is that the findings haven`t had long enough yet to ...

HAAGENSEN: That`s one point. The other point I made a moment ago, namely, that Dr. Fisher`s patients are not classified according to any well-known, recognized clinical classification, so that we really don`t know the stage of advancement of his patients in terms of these classifications. There are two classifications which are widely used, an international one and our Columbia classification, which is simpler and easier to use.

MacNEIL: Right. Is radical mastectomy, in your view, always the safest form of surgery in the surgical treatment of breast cancer?

HAAGENSEN: Yes, and my reasons are very simple. I speak now as a pathologist. I know from long experience in pathology that the disease spreads from the breast through the lymphatic to the axilla -- to the nodes in the axilla. You don`t know quite how extensive the disease is in the breast; no one can tell. There are multiple foci of the disease in more than half the patients, so that it`s necessary to remove, really, all of the breast tissue. Secondly, we must remove the axillary nodes because they contain metastasis in approximately half the patients. Now, simple mastectomy does not attack these axillary nodes at all. It leaves them untreated, and I could very easily point out to you that in our radical mastectomy, for example, when the early stage "A" cases in our classification, when no nodes are involved, our ten-year survival rate was 76.6 percent. Of course, if we had known these nodes weren`t involved we needn`t have removed them, but there is no way of knowing. However, in this same early stage when one to three nodes contain metastasis, our ten-year survival rate achieved by a careful removal of all these nodes a seventy percent.

MacNEIL: I see. How do you evaluate, in the simplest terms, in terms of survival rate the most common alternative to radical surgery, and that is the simple breast surgery? Simple, or total, as Dr. Fisher just described it -- in other words, the removal of the breast but not of the muscles underneath it?

HAAGENSEN: Or the lymph nodes. I have a series of cases to provide a comparison. I`ve tried to compare the end results at ten years of these different types of operations with our own results, and I have a series of cases treated by simple mastectomy alone from Detroit by Dr. Miller; the ten-year survival rate was forty-four percent, and ours with radical mastectomy is seventy percent.

MacNEIL: Thank you. We`ll stop it there and go back to Dr. Fisher for his reaction to that. It seemed to me that Dr. Haagensen was making two critical points, Dr. Fisher: one, that you didn`t classify your patients in this study; and that not enough time had gone by to effectively evaluate the survival rate.

FISHER: Yes, well, that`s rather interesting, because the classification that we have been using is a pretty close approximation of Dr. Haagensen`s own classification. That classification was begun by us in the first clinical trial that we ever did in 1958, and we used the Haagensen classification. Since that time there have been some slight modifications, but essentially it`s the same. So I think we can wash that out without any more discussion.

In terms of the time not being sufficient, those purists would suggest that perhaps we should wait ten, some of them even say twenty, some say thirty, and you know, where do you stop? Most of us are probably not going to live long enough to see that eventual final conclusion. I would only like to emphasize that based upon all of our studies and others the vast majority of treatment failure rates -- treatment failures in patients with breast cancer -- occur within the first two and a half to five years following surgery ... up to two and a half, then last but still a progressive number of failures until five years. The failure rate between the fifth and the tenth year is really very small indeed. Now, everything in medicine is probabilities and statistics, or most everything, and what we find is that if one goes for five years and the results are the same, then every six months thereafter or every few months that the results remain the same the odds become astronomically greater that we will see very significant changes with the passage of more time. There is always the possibility; but as I say, the probability becomes very much less.

MacNEIL: Dr. Haagensen?

HAAGENSEN: A good example of the difference in ten-year survival between five and ten years is illustrated by data concerning radiation used alone as a method of treating breast carcinoma. Bacless, the great master of modern radiotherapy, had a sixty percent five-year survival rate, but at ten years it was thirty percent.

MacNEIL: Thank you. Jim?

LEHRER: Yes, now to the reactions and the questions of someone personally involved in this controversy, and that`s Mrs. Marvella Bayh, wife of Senator Bayh. She had a modified radical mastectomy in 1971 and has been involved in the American Cancer Society efforts to combat breast cancer ever since. Mrs. Bayh, first, what is your reaction to this debate thus far?

MARVELLA BAYH: Well, I think it`s extremely confusing to a layman to hear two distinguished doctors like this at such swords` points on the subject. It almost makes you wonder what`s a woman to do. When you go, you obviously put your trust in your physician because I wouldn`t want to tell him what type of surgery to do on me any more than I`d want to tell the dentist how to fill my tooth. So it is a bit confusing to the average woman.

LEHRER: Let me ask you, from a patient`s point of view, what is the difference -- psychological or physical or whatever -- between these various procedures, do you think?

BAYH: There is a difference. I meet women who`ve had the radical mastectomy, the old Halstead radical, who can`t, for example, wear dresses like I`m wearing tonight with the arm showing; they suffer from a swollen arm. Sometimes they can`t wear the V-neck dress because of the extensive surgery. So I`m grateful that my physician decided to do the modified radical. It doesn`t sound like much difference, but there is a big difference to the woman because most of your muscles over the chest wall are left, which makes it much easier to dress the way you want to dress and to get a good prosthesis that handles the problem successfully. I also feel, though, that I`m very grateful that my doctor took my lymph nodes, because that determines the type of follow-up therapy and procedure that you have.

LEHRER: To make sure we understand, now, the removal of the lymph nodes is the modified radical.

BAYH: Right. The simple does not take the lymph nodes.

LEHRER: Or the arm muscles -- the chest muscles.

BAYH: Right, so the difference is that the muscle is left with the modified radical, but those lymph nodes are taken. And I understand -- I`m just a layman speaking -- but I understand that in about thirty percent of the time when doctors say, "I am sure we surrounded it, let`s not take the lymph nodes; I`m sure the lymph nodes are clear and clean," that in about thirty percent of the time when they go ahead and take them the doctor is found to be wrong, that there is involvement with the lymph nodes.

LEHRER: We`ll ask the doctors about that in a moment.

BAYH: At that point, I want to live, and I`m willing to pay a big price to live. I obviously don`t want to be disfigured any more than necessary, but if there`s a gamble to be taken I`d rather err in doing a little too much than not enough, because I want to live not only five years but I want to live a long time.

LEHRER: Sure. Well, when you had your surgery six years ago were you aware of these many options? Did the doctor lay out the options to you or did he say, "Look, there are other options and this is what I recommend," or how did that work?

BAYH: I think your question to me shows how far we`ve come in the last six years, because we hadn`t discussed it openly six years ago. I think I`m a reasonably well-read woman, but there had been no articles in the women`s magazines, there had been nothing on television; I didn`t know the difference between the different degrees of surgery, but if I had known I don`t feel I would have wanted to have tied my surgeon`s hands. Because, number one, he doesn`t know exactly what he`s going to find when he gets in there, and I have to have faith and trust in that surgeon and know that he or she is interested in my good health, in my survival and that they will do everything that they feel needs to be done to save my life. But I also trust that they won`t do anything that will make me have a swollen arm for the rest of my life unless that`s absolutely necessary.

LEHRER: Let`s bring Dr. Haagensen and Dr. Fisher in. I`d like to start by asking you, Dr. Haagensen, when you deal with a patient do you lay out the options and let the patient decide, or do you say, "Look, this is what I think ought to be done"?

HAAGENSEN:I never play God with a patient; I answer all their questions as best I can and as patiently and as long and they`re interested.

LEHRER: What does that mean, sir? You usually recommend radical mastectomy, though, right?

HAAGENSEN: Yes. I don`t know any operation that`s as safe. And if I may make a comment -- if Mrs. Bayh will forgive me -- in the radical mastectomy we do the incision goes straight up over the strapline of the bra and you can wear a sleeveless dress in the summertime and we do not have swollen arms following our operation.

BAYH:I think that`s terrific. I do meet many women, however, throughout the country that do.

HAAGENSEN: Yes, I`m sure.

BAYH: And as I travel for the American Cancer Society this is one thing I`ve learned, is that the procedures in the different parts of the country vary a great deal, and women are a little confused by that also.

LEHRER: Dr. Fisher, what is your reaction to Mrs. Bayh`s general comment that when in doubt, go the whole way?

FISHER: I don`t want to confuse the issue, but it`s very important that we emphasize one point here. Nobody -- and I`ve spoken to this, I have written about this -- is recommending a simple mastectomy alone to day. One is recommending that the glands in the axilla, in the armpit, be taken out, whether one does a modified radical or a so-called modified total, or modified simple -- they`re the same operation. Really it depends on the viewpoint of the radicalism or the conservatism who does the operation. But the reason for taking out these glands today is different than it was a few years back. The glands are taken out, as Mrs. Bayh said -- and it is our own work from the NSAPB, the group that has carried out these studies, we`ve been the ones who preached about the one-to-three and the four-plus nodes and so on, and we know that the best way to know what`s going on in that patient is to take out the glands and have them examined histologically. So I don`t want it left unsaid that I am recommending a simple mastectomy alone. I`m recommending that the glands be taken out no matter what the procedure is; even if a segmental mastectomy is done, the glands should be taken out, because now we are in the situation where we are using more and more systemic therapy for patients with breast cancer...

LEHRER: Systemic therapy -- what do you mean, sir, by that?

FISHER: Chemotherapy, hormonal therapy and so on as an adjuvant to surgery. Now, this is not a totally proven modality, but more and more evidence is accumulating to be very optimistic about it. This is given to patients who are at high risk of having a treatment failure, and those are people who have positive nodes in the armpit. That is why the nodes should be taken out. So I would clear that point up: simple mastectomy, our study showing that simple is equivalent to radical from a biological point of view, is an extremely important milestone. From a practical point of view in terms of patient care, as I said, the glands should be taken out no matter what the procedure.

BAYH: May I ask Dr. Fisher a question?

LEHRER: Yes.

BAYH: Then, Dr. Fisher, I`m a little confused. What is the difference, then, between your definition of a simple mastectomy and the modified radical mastectomy? I thought that the only difference between those two was the removal of the lymph glands with the modified radical, and now you`re saying with the simple you`re taking them, too.

FISHER: It`s the same thing, except that the radical mastectomies as a concession to being less radical calls it a modified radical mastectomy. The surgeon who is more concerned about doing less extensive surgery, as a concession calls it a modified total. It`s the same thing.

BAYH: Fine. Thank you.

LEHRER: You mean it`s the exact same operation, Doctor, with different labels, depending on who the doctor is?

FISHER: It`s different from a philosophic point of view. Dr. Haagensen`s clean-out of the axilla, taking all of the glands out of the axilla, was for the express purpose of removing every last cancer cell. The reason for taking the glands out from the armpit with a simple mastectomy is for staging purposes. You follow that?

LEHRER: No, sir, I don`t. Staging purposes...

FISHER: Meaning to determine whether the glands are involved or not so that one might think about giving chemotherapy.

LEHRER: Dr. Haagensen, you shook your head, sir. For what reason?

HAAGENSEN: Yes, I shook my head. You can`t, I believe, solve this problem - - this terribly difficult problem -- of trying to cure breast carcinoma by making all sorts of compromises with surgery. No operation is good enough, no operation is thorough enough to suit me. We do the best we can, and still we don`t succeed as often as we wish. We spend about five or five and a half hours doing our operation. We don`t penalize the patient much more with it, but we do a much more thorough removal. We get an average of thirty nodes out of the axilla, and in the average hospital they get six or eight, or something like that. And our chances with this kind of surgery of getting every cell out are a great deal better, and the fact that we have succeeded in doing this is illustrated by the point I made a moment ago, that in our patients with one to three nodes involved, in which we did a careful axillary dissection, we still had a seventy percent ten-year survival rate. This is surely a reason for doing a careful, complete, thorough operation in this terribly dangerous disease.

BAYH: I`d like to ask Dr. Haagensen a question. Why is it, then, that some women have the swollen arm and the heavy arm problem and others do not if it isn`t caused by the Halstead radical?

HAAGENSEN: It`s a question of surgical technique. You can get a swollen arm after a simple mastectomy perfectly well. But with modern surgery, carefully, meticulously done, there`s no need of having a swollen arm.

LEHRER: A final comment from Dr. Fisher.

FISHER: Yes, I would just like to say that our studies are being carried out by between thirty-five and forty of the leading medical schools and cancer centers in the United States, they`re being done by hundreds of surgeons with radiation therapists, pathologists, and so on. The results that we get we feel are most representative of the kinds of results that are being gotten throughout the country today.

LEHRER: All right, Doctor. Robin?

MacNEIL: Thank you very much, Dr. Fisher in Pittsburgh, for joining us tonight. Thank you, Mrs. Bayh, and good night, Jim. Thank you, Dr. Haagensen. That`s all for tonight. Jim Lehrer and I will be back tomorrow night, and other news permitting, we`ll be looking at prospects for peace now in the Middle East through the eyes of Crown Prince Hassan of Jordan. I`m Robert MacNeil. Good night.