The Evolution Of Breast Cancer Treatment.
Words: Madeline King
The Edwin Smith Surgical Papyrus is the earliest recorded evidence we have of a reference to breast cancer. It was found in Egypt and written around 3000-2500BC. In these times treating the cancer seemed futile, which led many people to believe that breast cancer was a form of divine retribution. This encouraged women to keep the illness hidden. As it gained prominence leading medical practitioners, such as Hippocrates in 400BC, Greece recommended leaving women with later-stage tumours untreated, as any action taken seemed to shorten the lifespan of the patient.
In 200BC the Greek physician, Galen thought breast cancer was caused by too much black bile in the blood. As most of his patients were post-menopausal, he thought that bleeding was the solution to rid the body of black bile build up. Galen denounced the techniques of cauterising and ligatures that stopped blood flow, although in Alexandria a surgeon named Leonides had been progressively using these techniques for some time. Galen’s regressive teachings guided the medical profession for the next 1500 years, into the Middle Ages when faith healing and mystic remedies became common.
The Renaissance saw the foundation of the first organised medical schools and journals. In 1543, Andreas Versalius published a paper in Italy showing that many of Galen’s teachings were flawed. This allowed new ideas to emerge. In 1757, Henri LeDran wrote an article based on his theory that breast cancer had a local origin, or was based in one place, which caused people to think that surgery could provide a cure. Many surgeons were unsure about this as the results of these operations were poor. They often avoided the surgery until the later stages of the cancer, and by this time it was ineffective.
These surgeries were performed without anaesthetic or antiseptic, and the patient was tied down while the amputation was performed. They often involved impaling, burning and tying techniques to stop bleeding. As many patients died from infection afterwards, women sought different treatment options such as breast compression with metal plates, which remained popular into the 19th century.
This century saw the development and advancement of antiseptic and sterilisation techniques, which lead to the adoption of the surgical mask and sterile rubber gloves. This caused a great reduction in contamination. With the demonstration of anaesthetics by the dentist, William Morton in 1846, surgeons found they could concentrate on precision rather than speed, and surgery became more widely accepted.
This allowed William S. Halstead of Baltimore to develop the radical mastectomy, which removed the breast, lymph nodes in the armpit, and part of the chest wall muscle, leaving a big open wound that was later closed with a skin graft. Although more women still died from breast cancer than were cured, survival and local control rates were dramatically better compared with previous procedures. The radical mastectomy was used for the greater part of this century, especially in America. It was a disfiguring procedure, and encouraged women to keep their illness hidden.
In 1889, Stephen Paget realised that cancer cells could travel through the bloodstream to other parts of the body, but this was ignored. Critics declared that the cause of breast cancer was implicitly felt to be the fault of the female, whether its origins were in sin or in the concept of the ‘weaker sex’. The fact that it often occurred around menopause may have led many male surgeons to view it as a symptom of female deterioration.
At the turn of the century, George Beatson accidentally stumbled upon hormonal effects through experiments with ovary removal. Radiation therapy cured a cancer patient for the first time following to Marie and Pierre Curie’s discovery of radium. Blood groups were also discovered and transfusions finally became safe. The earliest differentiations between stages and types of breast cancers began in Germany, leading to a decline in radical surgery in Europe. In 1927, Geoffrey Keynes caused a stir in Britain by abandoning the radical mastectomy altogether. The writer Charlotte Perkins Gilman refused the procedure in 1932 and instead chose to commit suicide when her cancer became unbearable. As practitioners tried to move away from the radical mastectomy, more conservative approaches were sought and advances in hormone therapy occurred with the isolation of oestrogen in 1925 and testosterone a decade later.
In 1930, a fluoroscope was used to perform a detailed mammography, allowing for the early detection of small cancers. The American Cancer Society sponsored the Women’s Field Army in 1936 to raise public awareness of breast cancer. This occurred through women’s magazines, which began publishing the personal accounts of women with cancer. These were written to encourage women to seek medical help, struggling to allay the perception that breast cancer sufferers somehow became less feminine, while implicitly telling women to submit themselves to male medical authority. A 1947 study showed that breast cancer was a leading cause of death in American women, and state-funded films about breast self-examination were released. The introduction of a breast screening trial showed a 30% drop in mortality in results first published
In 1946, a team of American pharmacologists began experimenting with chemotherapy by injecting a compound similar to mustard gas into a cancer patient, which reduced the size of the tumours. Over the next two decades significant advances were made in this field, including the development of cyclophosphamide and the discovery of 5-fluorouracil, agents still used in treatment today. Tamoxifen was also found to block oestrogen receptors, starving some breast cancer cells of the oestrogen they needed to grow. Emil Frei and Emil Freireich advanced chemotherapy in 1965 by using combinations of drugs to attack cancer cells.
In 1957, Bernard Fisher set up the NSABP (the National Surgical Adjuvant Breast and Bowel Project), a research organisation to study breast cancer treatments. The movement for conservative surgery had gathered steam, and in the 1970’s this group went on to do one of the first two randomised trials comparing breast conserving surgery and radiotherapy with mastectomy. In doing so they disproved many of the 19th century arguments for the radical mastectomy. At this point American surgeons were performing twice as many radical procedures as the British, and in other parts of Europe the operation had all but died out.
In 1967 silicone breast implants were introduced to cancer patients and the psychological effects of radical surgery began to be questioned by the medical profession. The cosmetic developments and screening programmes initiated in the 1970s meant that the visibly grotesque tumours of the past became rare, encouraging the acceptance and discussion of breast cancer in the
In 1972, Shirley Temple went public with her diagnosis, followed by Betty Ford and Happy Rockefeller in 1974. Ford’s treatment was widely covered in the media, including diagrams of the mastectomy that openly showed the breast. Rose Kushner published an activist account of her traumatic male-dominated experiences with breast cancer. At the time doctors would take a biopsy while the patient was unconscious, and if it showed that she had breast cancer they would immediately perform surgery. In 1979, Kushner pushed for a two-step process to allow the patient to wake up, become informed and make her own decision
At this point the Italian Umberto Veronesi discovered that removing a quarter of the breast was just as effective as a mastectomy in many areas when combined with radiotherapy. He called the operation a quadrantectomy. In 1979, the modified radical mastectomy gained credence as surgeons realised that the radical mastectomy had reached its limits without improvements in mortality rates. Bernard Fisher also found that adjuvant or post-operative chemotherapy could improve survival rates. This was a major step in understanding breast cancer as a systemic disease requiring systemic therapy as well as local surgery.
Big advances were also made in research. Formestane was discovered in 1982, which inhibited the production of oestrogen and worked on women who were resistant to tamoxifen. The HER2 family of proteins was discovered, and later linked to breast cancer progression. Goserelin was found to suppress ovarian function in 1987, to help premenopausal women with breast cancer. An anti-cancer protein called p53 was found to suppress tumours and contribute to preventing DNA mutation in 1989.
Professional interest in the field of psycho-oncology arose, emphasising the importance of a patient’s happiness as well as her medical progress. Common responses to breast cancer diagnosis were psychologically categorised, and a link was found between feelings of helplessness and depression and a poor outcome. A study in 1989 suggested that group sessions helped improve survival.
The BRCA1 and BRCA2 genes were discovered in the mid-90s. Mutations in these were predicted to have as much as an 85% lifetime chance of leading to breast cancer. In 1999, American spending on cancer research reached US$700 million as new drugs were discovered and trialled across the world. Trials also commenced to compare tamoxifen to drugs called aromatase inhibitors.
In 2002, the World Health Organisation confirmed that screening women aged between 50-69 reduces breast cancer mortality by 35%, saving one in every 500 screened lives. BreastScreen Aotearoa estimates that for every 1,000 women in this age group screened every two years for 20 years, seven deaths from breast cancer will be prevented.
The success of campaigns for early detection mean mortality rates today are decreasing and the social dialogue around breast cancer has moved from the hidden dark ages into a public forum of acceptance. Sociological studies now look into the female experience of breast cancer, and clinical trials continue to search for new and better treatment options. The introduction of chemotherapy has allowed treatment to evolve from surgery alone to developments in oestrogen blocking drugs, immunotherapies and beyond.