Last month, we concentrated on the dangers and inaccuracies of the various screening facilities to detect breast cancer. With this issue, we offer evidence that most doctors still overtreat early breast cancer, cutting out more than they need to or overloading the patient with drugs or radiation.Despite a variety of surgical techniques, a host of back up therapies and many confident headlines about breast cancer breakthroughs, the astonishing truth is that surgical treatment of breast cancer hasn't advanced one single step in the past century. Edward F Scanlon, MD of the Northwestern University Medical School summarizes the prevailing view: "...over a period of 100 years, breast cancer treatment has evolved from no treatment to radical treatment and back again to more conservative management, without having affected mortality." (The Journal of the American Medical Association, 4 September 1991.)

The standard procedure for breast cancer this century has been the radical mastectomy, a mutilating operation which involves removing the breast, much of the skin, the chest wall and the lymph nodes, developed by Dr William Halsted a hundred years ago.

Shortly after the Second World War, a study at three hospitals in Illinois showed little difference in five and 10 year survival rates between radical mastectomies, simple mastectomies, or simple removal of tumour. In 1969, The Lancet (29 November) reviewed 8,000 cases and again found no difference in survival between any of the procedures. Nevertheless, the Halsted procedure maintained its grip on the average surgical mind well into the 1970s and 1980s, when in some areas it was replaced by a modified radical, which removed tissue and breast, but left the chest wall, or a simple mastectomy, which only removed the breast itself.

Like the earlier studies, numerous trials in the Eighties have shown that mastectomy provides no benefit in terms of cancer recurrence or survival over breast conserving surgery (BCS) such as simple lumpectomy (removal of the tumour itself) or quadrantectomy (removal of a portion of the breast). In one, by the National Surgical Adjuvant Breast and Bowel Project in Pennsylvania of nearly 2000 women over nine years, there was no significant difference in survival without the cancer spreading to other parts of the body between those who had undergone lumpectomy, lumpectomy plus irradiation or total mastectomy.

As a result of these comparative studies, the American National Institutes of Health in 1990 recommended that surgeons opt for breast conservation surgery over mastectomy for the majority of women with stage I or stage II breast cancer. By this they mean cancer less than 4 cm in diameter limited to the primary site (ie, single breast) without involvement of the chest muscle or overlying skin. In the past, doctors felt that cancer found in the axillary lymph nodes was evidence of metastasis (spread), and grounds for radical mastectomy. With the NIH's announcement, the involvement of the lymph nodes (so long as it is on the same side as the tumour) is now considered immaterial.

Regardless of the NIH's decision, most doctors don't offer BCS to the majority of women with early breast cancer. A Seattle study published in the Journal of American Medical Association (25 December, 1991) examined cancer registry information between 1983 and 1989. In total, less than a third of women with stage I or II disease were offered BCS, even though three quarters of all women diagnosed with breast cancer fall into the early stage category. Furthermore, that proportion declined after 1985.