Paradigm Shift From Halstedian Radical Mastectomy to Personalized Medicine

Abstract

The paradigm shift in breast cancer biology has changed the management of breast cancer from radical mastectomy to precision medicine. In the late 19 th century, William Steward Halsted thought that breast cancer was a local-regional disease, and he proposed radical mastectomy, which became the standard surgical treatment of breast cancer for nearly 100 years (1). Halsted succeeded in decreasing the locoregional recurrence rate to 6% at 5 years in contrast to his European counterparts, whose local recurrence rates ranged from 50 to 80% (2). Despite the decrease in local recurrence rate, radical mastectomy did not improve survival rate in comparison to lesser surgical procedures. Bernard Fisher's alternative paradigm championed an emergence of breast cancer as a systemic disease in 1970s (3-4). He considered that breast cancer was a systemic disease at the outset as a consequence of cells entering lymphatics, but also into the blood via communications. According to this hypothesis, systemic treatment became a substantial part of breast cancer management, and multidisciplinary approaches were required for a more effective treatment. Prospective randomized clinical studies of the 1970s and 1980s (NSABP B04, NSABP B06, MILAN I study, etc.) supported Fisher's hypothesis -variations in the extent of local therapy such as simple mastectomy, quadrantectomy or wide tumour excision plus whole-breast radiation therapy yielded no significant differences in survival outcomes (5-7). Both Halstedian and Fisherian Hypotheses recommended one treatment protocol (radical mastectomy or systemic treatment±radiation therapy) to all patients with breast cancer (one size fits all). Since these two old hypotheses did not separate low-risk patients from highrisk patients, overtreatment was a major problem for patients with low-risk breast cancer. Today, we accept the intermediate paradigm that is combination of Halstedian and Fisherian hypotheses. Rising breast cancer awareness and mammographic screening have increased early-stage breast cancer and ductal carcinoma in situ rates. Almost half of these patients have good prognostic factors and do not require systemic treatment and/or radiation therapy. Patients diagnosed via screening mammography have better prognostic factors than symptomatic breast cancer patients. Systemic treatment and radiation therapy have very harmful side effects despite of their life saving benefits (8). They are also expensive and impose an economic burden on the health care system (9). Paradigm Shift From Halstedian Radical Mastectomy to Personalized MedicineVahit Özmen Department of General Surgery, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey J Breast Health 2017; 13: 50-53 DOI: 10.5152/tjbh.2017.312017 ABSTRACT Breast cancer management changed from radical mastectomy to precision medicine in a period longer than a century. The aims of these changes were to refrain from overdiagnoses and overtreatments as well as their harmful side effects and extra costs. Breast cancer is a heterogen...

Avoidance and Period-Shortening of Neoadjuvant Chemotherapy Against Triple-Negative Breast Cancer in Stages I and II: Importance of Ki-67 Labeling Index and the Recognition of Apocrine-Type Lesions

“…Both Halstedian and Fisherian hypotheses recommend certain treatment protocol to all patients with breast cancer. Along with “the spectrum theory” as reviewed by Özmen, 87 we should separate low-risk patients from high-risk patients to avoid overtreatment for low-risk patients. It is likely that certain percentage of low-risk patients accompanying good prognostic factors do not require systemic and/or radiation therapy.…”

OLFM4, LY6D and S100A7 as potent markers for distant metastasis in estrogen receptor‐positive breast carcinoma

“…Molecular features of distant metastasis remain largely unknown, and it is still impossible to accurately predict it in breast cancer. Breast cancer is considered a systemic disease at the onset as a consequence of cells entering lymphatics or veins, and it is suggested that distant metastasis is not a random event, but is, at least in a part, determined by characteristics of breast carcinoma cells at the primary site. Therefore, in this study, we first examined the gene expression profile of ER‐positive stage IV breast carcinoma tissues based on microarray analysis, and newly identified OLFM4 , LY6D and S100A7 as genes closely linked to distant metastasis.…”

Paradigm shift in the local treatment of breast cancer: mastectomy to breast conservation surgery

“…Halsted proposed that breast cancer spread from the breast to the pectoralis muscle then to regional lymph nodes and then finally to distant sites (1). Based on this very plausible theory, clinicians adopted an aggressive surgical approach to achieve local control.…”

“…One hundred years ago, during the Halstedian era, women with breast cancer were treated with surgery alone, radical mastectomy and axillary clearance regardless of the stage at presentation (1). From this 'one size fits all' approach, we have progressed to tailored and personalized management, taking into consideration individual patient and tumour factors.…”