It was in 1882, when Dr. John Halstead removed the entire breast, the chest muscles and the glands below the arm. After his landmark paper on breast cancer, the Radical Mastectomy- also called as the Halstead’s Mastectomy became the surgery which was the hallmark of breast cancer.
It left a large disfiguring scar on the chest and the survivors, if they did not die of cancer, had a terrible life. Their arms used to swell- what the doctors call as lymphedema. Many times such hands couldn’t be used. They used to get repeated infections in the swollen hand, and an angry red welt could almost always be seen.

If the lady survived the cancer, what remained was a miserable life. Then a young, energetic surgeon came along and he said- wait a minute, is this all really necessary?

His name was David Patey, and he advocated removing a smaller muscle along with the breast and axillary nodes. His technique spared the large muscle called Pectoralis Major, thereby preserving major functions. The 1969 paper in Annals of Surgery is a fascinating read. It showed that despite removing less amount than what Halstead advocated, the patients didn’t do worse.

So, was more actually better?
Most surgeons are lazy, and I think they like to do the absolute minimum that is required. But seriously, future generations of surgeons focused more on doing less surgery. So much so, that the modern surgeries of breast cancer resemble nothing to what Halstead propagated as the cure for cancer. Though his contribution remains vital to the treatment of breast cancer.

Today, the most common surgery performed is called MRM-modified radical mastectomy. It entails removing the breast and some skin, along with some nodes in the axilla. Usually there is a thin linear scar. The fancy name for that is aesthetic flat closure. The other most common surgery is called a wide local excision- the cancer is removed with some amount of healthy tissue thus preserving the breast. If required, something called as oncoplastic breast surgery could be done, which entails maintaining an aesthetic appearance of the breast, while taking the cancer out.

Removing less doesn’t mean that you are compromising patient outcomes. Breast conservation
is more easily accepted, leaving less physical and psychological trauma. The results of removing the entire breast vs results of doing a wide local excision, scientifically are the same. Both can lead to a cure.

Since Halstead’s time, taking the cancer out with some margins has been the sine quo non of breast cancer surgery. Margins and the ways may change, but this principle remains unchanged. And that is the most critical point in the treatment. No amount of chemotherapy, radiation or any other treatment can work properly, if some cancer has been left behind.

We should thank Dr. William Halstead for establishing this principle.