Experts stymied by

mysteries of breast cancer

Patricia Patterson

rustration sums up current medical opinion on breast cancer. “We’re F stymied by a lot of things,” Guy F Rob-

bins, MD, FACS, observed, moderating a panel discussion at the American College of Surgeons (ACS) meeting in October in Atlanta. Mortality rates havechanged little in the last 45 years despite the attention focused on the dis- ease and greater public awareness. Of all women diagnosed with breast cancer, from 45% to 80% are alive after ten years, depend- ing on the stage of the disease.

Physicians are learning that follow-up for three years, five years, or even ten years is not enough to pronounce a cure. Some now be- lieve patients have to be followed for 15 years before they can be declared free of disease.

“This is a chronic disease, and the sooner we learn it, the better off we’ll be,” said Dr Robbins, who is senior attending surgeon in the breast cancer service at Memorial Sloan- Kettering Cancer Center, New York City.

“No matter when we’re finding it, we’re treat- ing late disease,” Avram M Cooperman, MD, FACS agreed. Whether breast cancer is sys- temic from the beginning is controversial. “There’s probably some hormonal link be- cause the disease occurs in females, but we don’t know what it is, and that frustrates us.” He is from Columbia Presbyterian Medical Center, New York City. Of patients who have lesions less than 2 cm and no involved lymph nodes, 8 5 O / 0 are alive 10 to 15 years later, but in the other 15%, the disease advances rapidly.

“It’s the systemic disease that kills, but we still treat breast cancer like a local disease,” added F R C Johnstone, MD, FACS, who is on the faculty of medicine at the University of British Columbia, Vancouver.

The panel agreed they are seeing younger women with breast cancer, but it is unclear whetherthis is due to a higher incidence of the disease or earlier diagnosis. They also con- curred on the importance of lymph node in- volvement and earlier diagnosis in predicting how well a patient is likely to do.

Applying new discoveries in science and technology might help physicians get a better grip on earlier diagnosis, a Chicago physician believes. Louis Keith, MD, professor of obstet- rics and gynecology, Northwestern University Medical School, organized a symposium on early detection in Atlanta before the ACS meet-

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ing. The conference was sponsored by the Charles A Field Medical Foundation and the Society for the Study of Breast Diseases. Panelists discussed mammography, thermog- raphy, ultrasound, and improved application of an old technique called diaphanography.

About 80% to 90% of breast cancers are now discovered by women themselves, but only about half have annual breast exami- nations, and many probably do not examine themselves properly. The ACS panel esti- mated that only about one-fourth to one-third of women are doing breast self-examinations.

Of the imaging techniques, mammography is the most valuable for early detection, accord- ing to a Philadelphia radiologist. Speaking at thesymposium, Harold lsard, MD, said there is no longer need for concern about radiation exposure in these x-ray studies of the breast. Dosage is lower-0.3 to 0.4 rads compared to the 1 rad women were exposed to formerly. Dr lsard is clinical professor of radiology at Tem- ple University School of Medicine and chair- man emeritus of the Division of Radiology at Albert Einstein Medical Center, Philadelphia.

Over a 30-year period, annual mammog- rams would increase the risk of getting breast cancer from the usual 7% to 7.89%, using a dose of 0.46 absorbed rads, A Hamblin Letton, MD, FACS, estimated. A member of the ACS panel, he is on the staff of Georgia Baptist Medical Center, Atlanta, which has conducted a screening program. The National Cancer In- stitute figures that an individual woman screened once at age 35 with a 1 -rad exposure would have an increased lifetime risk of breast cancer of less than 1%.

So far, thermography hasn’t proved itself in early diagnosis. But at the symposium, Dr Keith suggested that physicians take another look at it because of recent improvements in technique and equipment. Thermography measures infrared heat patterns of body sur- faces. A French researcher reported that he found in a study that more than one-third of women with obviously abnormal thermograms developed cancers within five years. Also, rapidly growing tumors show up in a pattern on successive thermograms due to their in- creased metabolic heat production. This may mean these tumors, which have a less favor- able prognosis, could be detected earlier, said Michel Gautherie, head of research at the

French National Institute of Health and Medi- cal Research in Pans. Not definitive on its own, thermography may help highlight a group of patients who need further examination and follow-up. Thermograms are noninvasive and free of radiation, so they are considered harm- less.

A problem with mammography and ther- mography is that “they’re very poorly done in a lot of places,” commented Henry P Leis, Jr, MD, FACS, clinical professor of surgery and codirector of the Institute of Breast Diseases, New York Medical College, New York City. Dr lsard said one problem is that many mammo- grams are done on equipment not solely dedi- cated to that purpose.

He commented that ultrasound can distin- guish between malignant and cystic lesions in the breast. It is not useful as a screening tool yet, although that is being studied. In diaphanography, a special light is shown through the breast, and a photograph is taken using infrared-sensitive film. The breast is a translucent orange. Cysts show up paler and lighter, fibrous growths are dark red patterns, and cancers are dark brown.

Mass screening programs of women seem to be finding more cancers earlier. In a five- year National Cancer Institute program in Philadelphia, 42% of the cancers found were at the earliest stage-less than 1 cm in diame- ter with no axillary lymph node metastases. Almost 75% had no lymph node involvement. Perhaps most significant, almost half of these lesions were found by mammography, not by palpation. Moreover, screeners found more cancers than they expected-a little more than 10 per 10,000 women. The study used mam- mography, thermography, and clinical exami- nation on a group of 18,000 women between the ages of 45 and 65. Reporting results at an ACS press conference was Gordon F Schwartz, MD, professor of surgery at Jeffer- son Medical College, Philadelphia.

The main message from the panel and sym- posium was that no single diagnostic test is best and all are complementary. The conclu- sion was the same for surgery: The operation must be selected according to the individual patient and her disease. But surgeons agreed that cure of the disease has to be the primary goal.

Dr Leis said the modified radical mastec-

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tomy has replaced the classic Halsted radical mastectomy as the favored procedure for pa- tients with Stage l and Stage 2 cancers. In Stage 1 disease, no axillary lymph nodes are involved, whereas in Stage 2, axillary nodes are involved, but they are less than 2.5 cm in diameter and not fixed to overlying skin or deeper structures of the axilla.

The Halsted procedure was extensive and disfiguring, taking the pectoralis major muscle and involving a thorough dissection of the axil- lary nodes. Lymph nbde dissection is still im- portant in the modified operation, but more muscle is left. This provides for more arm movement and makes breast reconstruction easier.

Others are advocating lesser procedures, removing only the cancer and varying amounts of the breast tissue. Follow-up reports of treatment failures for these patients vary con- siderably, Dr Leis commented. He cautioned that large studies with long-term follow-up are needed before any conclusions are drawn.

One of the problems with choosing a surgi- cal procedure is that experts disagree on the importance of lymph node involvement. Also, the significance of multicentricity-cancer oc- curring in a different quadrant of the breast from the primary tumor-is still not under- stood. That is an argument against the lesser operations. In addition, some believ’e that breast cancer is a systemic disease from the beginning, even before a lump can be clinically detected. If that is the case, they reason, it makes little difference how extensive the mas- tectomy is, for in many patients the cancer will already have spread.

To test the significance of multicentricity and the results of lesser procedures, the National Cancer Institute is sponsoring a new phase of the National Surgical Adjuvant Breast Project. Patients are divided into three groups and treated by total mastectomy with axillary dis- section of the lymph nodes, segmental mas- tectomy with axillary dissection, or segmental mastectomy with axillary dissection followed by irradiation of the breast. The study began in 1976, so no definitive data are available yet.

In the meantime, Dr Johnstone from British Columbia reported a disturbing trend in statis- tics from the British Isles. He said that a higher mortality rate is being reported in England and Wales compared to the US and Canada. The

main difference between the two areas, he believes, is that 80% of American patients still have radical surgery, whereas the majority in England and Wales have lesser procedures.

“While radical surgery benefits only those patients whose disease has spread to axillary nodes,” he said, “there is no practical and certain method of distinguishing these patients from those whose cancers have not spread, and no proven therapy exists for treating the disease once it has spread.” He continues to advocate the radical mastectomy.

Nurse-midwife program receives federal aid The University of Pennsylvania School of Nursing’s recently established nurse-midwifery master’s program has been awarded a Nurse Practitioner Training Grant by the U S Department of Health and Human Services. The $1 23,269 grant is for the 1980-1 981 academic year, but will be reviewed for renewal until 1983.

The master’s program accepted its first students last fall. It is the only graduate program in Pennsylvania for nurse-midwives, as well as the first basic preparation in nurse-midwifery. Students in the program must be registered nurses with at least one year of nursing experience. Graduates of the four-semester course earn a Master of Science in Nursing. Certified nurse-midwives care for essentially healthy women before, during, and after childbirth and provide gynecological care and family planning.

Joyce Beebe Thompson, CNM, is the director of the educational program in nurse-midwifery at the School of Nursing in Philadelphia. She is also a partner in the nurse-midwifery practice associated with the high-risk obstetrical group practice at the Hospital of the University of Pennsylvania. The hospital will serve as the chief clinical site for the program. Thompson comes from Columbia University, New York City, where she directed the graduate program in nurse-midwifery from 1974 until 1979.

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