Our milestones: A radical change that improved breast cancer surgery

In this post, we look at how a breast cancer clinical trial we helped fund in the 60s and 70s laid the foundations for improving surgery for women with early stage breast cancer. Its results allowed breast cancer surgeons to move away from ‘radical’ mastectomies towards kinder, less invasive surgeries.

Alex King, 52, is a volunteer on our London Cancer Awareness Roadshow. In 2009 she was diagnosed with early stage breast cancer after finding a pea-sized lump in her breast.

“When I was diagnosed I stayed positive and decided: ‘I’m going to fight this’. I got through it with amazing support from my son and daughter, my family and friends,” she says.

Alex’s treatment included surgery, chemotherapy and radiotherapy, which is given to kill any cancer cells left behind after surgery.

“My surgeon told me I was going to have a lumpectomy. He explained that during the surgery he would take just the tumour and a bit of healthy tissue from around it. The idea was to leave behind as much healthy breast tissue as possible, while at the same time removing the tumour.

“He described a lumpectomy as ‘breast-conserving surgery’, and I thought that sounded fantastic!”

Nowadays, lumpectomies are frequently used to treat women like Alex with early stage breast cancer.

But this wasn’t always the case.

Radical surgery, radical side effects

In the early 1900s the world was entering a new era. Women could compete in the Olympic Games, Einstein was proposing his theory of relativity, and King George V was ascending the throne in England.

But not everything was progressing.

Surgeons’ understanding of cancer at the time was limited, especially compared to what we know today.

This meant their approach to surgery as a treatment was to remove as much tissue as possible. They did this to try and get rid of all the cancer cells, in the hope that doing so would help more patients survive.

So for women diagnosed with breast cancer in the early 1900s, surgery took the form of a radical mastectomy, a type of surgery which lived up to its name.

Professor Arnie Purushotham, a breast cancer surgeon and senior clinical advisor at Cancer Research UK, explains: “These women were facing a severe operation. A radical mastectomy involved removing all of the breast tissue, the underlying muscles of the chest wall and lymph nodes from the armpit.”

After this difficult surgery, women experienced long recovery times and often, long-term side effects including swelling (lymphoedema) and difficulty moving their arms.

But the impact of the operation went far beyond just physical side effects.

This surgery was often very disfiguring for women, which caused many to experience psychological problems after the operation. These included poor body image, anxiety and depression as they tried to come to terms with the dramatic changes to their body.

So while these women were surviving breast cancer, it came at a high price.

Things had to change.

A changing focus

The mid-1900s were marked by the end of Second World War, with UK households facing rationing in the years that followed.

The desire to improve surgery was fuelled in part by a growing understanding of cancer and the biology of the disease.

But perhaps even more so, it was fuelled by the fact that doctors were seeing an increasing number of women who were reluctant – or completely refusing – to undergo radical mastectomies, because of the crippling physical side effects and emotional distress they caused.

To address these concerns, surgeons modified how they performed mastectomies, leaving behind the muscles of the chest wall.

Many surgeons were convinced this compromise was the best option. But many others disagreed.

“At the time, doctors were beginning to focus more on listening to patients, and were considering the psychological – not just physical – impact of radical and modified radical mastectomies,” says Purushotham.

To this end, some surgeons started to dial back surgery even further, performing what is now known as a lumpectomy.

“They were finding that women who had this less severe surgery often did better psychologically than those who had a more radical procedure,” says Purushotham.

But how did these women do physically? Did they still survive their cancer when they had a lumpectomy?

The answer was yes.

When surgeons studied the records of women who’d had radical mastectomies and compared them to those who had less severe surgery, there was very little difference between the groups in terms of how long patients lived after surgery.

This backed up the idea that a lumpectomy could be as good as a radical mastectomy as a treatment for breast cancer.

But because these findings had come from combining one off reports and medical records, many doctors and surgeons remained unconvinced.

The two approaches needed testing head to head. Clinical trials were needed.There was a lack of solid, scientific evidence to show a lumpectomy was as good as its more radical counterpart.

Testing times – the Guy’s Hospital trial

In 1961, at Guy’s Hospital in London, an important clinical trial was underway to help finally answer the question and which surgical approach was best.

Funded by Cancer Research Campaign (one of the forbearers of Cancer Research UK), the trial focused on women with early stage breast cancer.

It followed two groups – one had a radical mastectomy, the other a lumpectomy. Both groups received radiotherapy.

These trials finally put the radical mastectomy story to bed once and for all.

Professor Arnie Purushotham

In total, 370 women aged 50 and over took part in the trial and were randomly assigned to one of the surgeries.

The trial ran for 10 years, and the women were followed up with check-ups to see if there was any difference in survival between the groups.

They were also given questionnaires on a regular basis to assess and compare their quality of life following treatment.

The trial proved that for women with early stage breast cancer, the same positive survival outcome could be achieved with a lumpectomy as with the more severe, radical mastectomy.

But where lumpectomies shone was in reduced side-effects that women experienced along with better emotional and psychological wellbeing.

“There was a pressing need for this trial to be carried out, to make sure women with early stage breast cancer were getting the best treatment,” says Purushotham.

“The results marked a paradigm shift in how the medical community in the UK and globally saw lumpectomies – they were game changing. Women with early stage breast cancer could now choose to have a lumpectomy as part of their treatment.”

This small trial laid the foundations for further clinical trials comparing radical mastectomies and lumpectomies.

Encouragingly, its results were backed up by larger studies in the US and Europe that ran from the early ‘70s to the late ‘80s. These trials followed patients for 20 years and confirmed the findings of the UK trial.

As Purushotham recalls: “These trials finally put the radical mastectomy story to bed once and for all and showed that it’s not necessarily the best or only way to treat women with early stage breast cancer.”

Lumpectomy – small surgery, big impact

In 1990, based on the findings of these trials, including the one we helped fund, the National Institute of Health in the US released a statement.

I chose to have a lumpectomy because that’s what felt right for me.

Alex King

It recommended that lumpectomies followed by radiotherapy should be used “instead of mastectomies to treat early breast cancer, whenever possible”.

The UK soon followed suit, and lumpectomies became the recommended procedure for some women with early stage breast cancer, who met certain other criteria. This change offers many women a breast-conserving surgical option, without affecting their survival.

Patient choice is also now a major factor in selecting which of these treatments is best.

Some women feel a mastectomy is the best option for them, whereas others would rather have a lumpectomy.

“Nowadays, it is very much patient-led. I was always asked: ‘How do you feel about this? Are you happy for us to do this?” says Alex.

“I chose to have a lumpectomy because that’s what felt right for me.

“I’m super happy with how my body looks after my lumpectomy. I took part in the World Cancer Day 2016 naked photoshoot to show women that you can still be womanly even though you’ve had part of your breast removed – that was my motivation. The photos are lovely and tasteful, and when I look at them I just feel so empowered!”

It’s important to note that for some women, a mastectomy is still the best option. It depends on the person and their cancer. Every patient needs to discuss what’s best for them with their doctor so they can make an informed choice.

Looking to the future

Today, more people survive breast cancer than ever before. And research and improvements in surgery have been a big part of this.

But there’s still more we can do to help more women survive the disease. That’s why we continue to fund research into all aspects of the disease including how to prevent it, diagnose it earlier and improving treatments so they are tailored to each patient’s disease.

As Purushotham looks to the future, he highlights this last point: “As we continue to improve surgery, radiotherapy, drugs and combination treatments, we’re starting to offer patients treatment that’s more targeted to them and the specific faults in the tumour.”

And for Alex, having that option to do what was right for her made all the difference.

“My scar is amazing. I’m proud of my breasts as they are now and I feel that I have a lot to be thankful for!”

Fiona