Surgical Oncology of Breast Cancer

Halstedian paradigm: William Stewart Halsted (1852– 1922) postulated that breast cancer is a loco-regional disease and metastatic dissemination occurs by centrifugal and contiguous spread of the primary tumour with progressive involvement of adjacent tissue and the lymphatic system of the breast. 1 The operation of radical mastectomy aimed to remove en bloc the breast, pectoral musculature, and the axillary lymph nodes (up to level III). This operation is eponymously known as the Halsted mastectomy and was adopted as routine surgical practice for breast cancer patients in the first half of the 20th century. This procedure was undertaken for all operable tumours irrespective of clinical features and its rationale underpinned by the so-called Halstedian paradigm that maximal efforts at local control would prolong survival. Breast cancer was considered to originate as a localised disease with the belief that cure rates could be improved by a meticulous and comprehensive surgical approach with thorough resection of loco-regional tissues. Local recurrence was considered to be the cause of distant metastases, and the aim was to minimise rates of local relapse. Many patients treated with initial radical mastectomy developed local recurrence before they succumbed from distant metastatic disease. The operation of radical mastectomy dramatically reduced rates of local recurrence but had no impact on overall survival. Hence, this frequently mutilating operation did not yield any additional years of life for patients implying a problem with the existing paradigm.