More Surgery Options Tied to Changing Medical Views

Women facing breast cancer surgery today have many more options than in past years, largely because of changing medical thinking about the amount of tissue that needs to be removed.

Surgery is the most common form of treatment, but over the past dozen years the type of surgery selected by most surgeons has steadily become less radical and less disfiguring.

Today, instead of removing the entire breast, the lymph nodes and the surrounding muscles, a popular strategy until the 1970s, surgeons and patients now can choose among four less drastic operations.

Extent of Cancer Critical

Which one they select depends to a large extent on how far the cancer has advanced and how convinced the surgeon is that the chosen operation would remove all of the cancerous cells.

According to the American Cancer Society, no single way of treating breast cancer can be recommended for all of the estimated 130,000 new cases that will occur in the United States this year. The modified radical mastectomy that surgeons at Bethesda Naval Medical Center say they may perform today on First Lady Nancy Reagan is the most common breast cancer surgery now performed.

In 1974, both Betty Ford, wife of President Gerald R. Ford, and Happy Rockefeller, wife of Vice President Nelson A. Rockefeller, received modified radicals for breast cancer. Three years later, Rose Elizabeth Bird, then chief justice of California, underwent the same procedure.

Since the early 1900s, women with breast cancer almost always had the so-called Halsted radical mastectomy. But by the 1970s, sufficient medical evidence had accumulated to show that the operation was unnecessarily drastic for a great majority of those women.

Modified Mastectomies

As a result, a less severe surgery--the modified radical mastectomy--came into wide use. Because it does not involve removing underlying muscle, according to experts, a deep depression in the chest is avoided and the woman has a much better range of arm motion afterward.

Although at least three other less drastic operations also have come into use in the last 15 to 20 years, considerable controversy remains over how much tissue needs to be removed to ensure that all of the cancer cells in the breast have been eliminated.

One of the operations is called the simple mastectomy, which leaves both the muscle and the lymph nodes intact. Another, called subcutaneous mastectomy, removes the breast tissue but retains the nipple and the skin. Experts, according to the American Cancer Society, recommend subcutaneous mastectomy only as a preventive measure for women who are at very high risk of developing breast cancer--not for those with cancer.

The so-called lumpectomy operation, in which only the cancer and nearby breast tissue are removed, preserves most of the breast and the underlying tissues. This procedure can be done in half an hour and requires no hospitalization unless the surgeon wants to remove several of the lymph nodes to make sure that the cancer has not spread there.

Developed in Finland

The lumpectomy was developed in Finland about the same time that the modified radical operation was being studied in England.

By the 1970s both operations were in use in this country, but the modified radical was used far more widely.

Whether any of the five types of operations should be followed by radiation or chemotherapy depends on many individual considerations, such as whether the cancer had already spread to the lymph nodes and whether a patient is pre- or post-menopausal.

A nationwide study in 1976 found that women who underwent lumpectomies, followed by radiation and chemotherapy if the cancer had spread to the lymph nodes, had better five-year survival rates than those who had simple mastectomies alone. A National Cancer Institute panel now recommends chemotherapy only for women who have not reached menopause.

Longevity Studied

Another national study compared radical mastectomy, simple mastectomy plus radiation of the lymph nodes and simple mastectomy without any radiation. The 10-year results, reported in 1985, showed that patients who received radical surgery lived no longer than those who had the simple mastectomy. Irradiating the nodes also failed to improve survival.