Unlike gall bladder surgery, about which there is no controversy, different postulates underlie the rationale for mastectomy and lumpectomy. Until the 1960s, breast cancer was conceived as a methodical march from a central encampment outward like a company of soldiers filing from a barracks to outlying regions via two terrains: along mountainous muscles and through marshes of lymph. Now, it is indisputably held that cancerous cells travel to distant sites (metastasize) via the bloodstream. It is also indisputable that, in a majority of women, this happens years before a tumor is or can be detected. By the time detection has occurred, either by palpation or mammography, the tumor has been germinating for approximately 10 years.

The Achilles heel is that, whereas cancer originates in the breast, it has the potential to spread. The word "cancer" derives from the Latin meaning "crab-like" because it claws and crawls into other tissue. Women do not perish from the local problem, but from the systemic one--and whether or not they do, and when, is dependent on the biological properties of the tumor: how fast and aggressively it multiplies, scatters, and infiltrates. It is now believed that individual body ecology is also a factor--the relationship between the seeds of the disease and the body--soil in which they are planted. Some think that within this tumor--host relationship, immunity is as significant as the virulence of the malignancy. To know whether the tumor has shed cells that have migrated to other parts of the body is only possible in retrospect--after there is evidence of malignant breast tissue growing in the bone, liver, lungs, or brain. No satisfactory method exists for detecting micrometastases or the trajectory of single cells that travel through the blood and lymph--some finding a home and colonizing. Even less mechanistic theories have been proposed, suggesting that genetic factors (inherited or mutagenic) cause normal cells to transform and become malignant, a process that is wholly out of reach of the surgeon's scalpel.

It is all the more baffling fully aware of these data, Sally's doctor assured her by saying, "We got it all." What he meant was, "I hope that you have no cells maturing in a distant site, but there is no way for me to know that. What I know is that the 1.5-cm tumor that was in your breast is no longer there, and that this would be the case whether we'd done a mastectomy or lumpectomy. The reason I did a mastectomy is to prevent local recurrence, even though I'm aware that local recurrence itself has no impact on survival and that women who have lumpectomy live just as long as those who have mastectomy. Survival depends on the systemic picture." If the horse bolted before the stable door was shut, no repair of the barn or its latch will be of consequence. Similarly, no use will come of removing more and more breast, or the chest wall, or nearby lymph tissue, if the malignant cells have taken up residence in the femur, liver, or lungs.

By now it's well known: it is not necessary for a woman to lose her breast in an effort to save her life. Yet the majority of physicians still subscribe to the belief that mastectomy is the "gold standard," even though they are fully cognizant of equivalent outcomes for the less invasive lumpectomy. Despite the National Cancer Institute's (NCI) declaration in 1990 that lumpectomy followed by radiation is the preferred therapy (note 1), only 26% of diagnosed women today receive the breast-conserving lumpectomy. Most doctors advise in favor of mastectomies, and most women have them, demonstrating that data alone are not powerful enough to spur change--in medical or social practice.