Levin (Med. Record, Jan. 27, 1917, p. 175) has recently made some startling statements in regard to the recurrence of carcinoma after breast operations. While granting that early cases without lymphatic involvement yielded good results, he states that these represented at the utmost only 25 per cent of the cases operated on: 75 per cent were advanced cases with involvement of the skin and lymph glands. Of these barely 25 per cent could be cured by radical operation, and in 52 per cent of the advanced cases operated on metastases appeared in distant organs without local recurrences. The longer the period after the operation the greater was the number of recurrences.
He quoted Heurtaux, a French surgeon, who had followed up 284 cases which he himself had operated on during the previous 20 years. H. stated that four years after operation 43 per cent remained free of the disease, eight years after only 16 per cent, and 20 years after only 2.5 remained free from the disease. There were a great many cases of carcinoma of the breast reported in which the patient died from metastasis in different organs without local recurrence 10, 15, and 20 years after the operation. The late metastases most frequently took place in the skeleton, which was due to the fact that skeletal lesions might continue a long time without causing clinical symptoms.
Dr. Levin confirmed the skeletal involvement by roentgenograms of ten cases of carcinoma of the breast observed during the last two years, in which it was found that the metastases must have been present at the time of operation.
Dr. Willy Meyer in the discussion said that physicians had long been too prone to consider carcinoma a local disease, and when he found signs of metastatic infection he never felt that he could expect anything from an operation.
We can only state with Hartwell and others that every especially favorable series of cancer cases, and this applies particularly to the breast, should be subject to close scrutiny. Why did this or that operator get marvelous results and an equally efficient man get very poor ones?
There are also many factors to be considered. How many cases were of the senile or scirrhous type? How many of the tumors removed were proved microscopically to be cancer? If one operates radically on every tumor or swelling in the breast, however small, the end results will, of course, be more favorable; for undoubtedly many innocent lesions, chronic mastitis, adenoma, cystic tumors, etc., are often removed unnecessarily. The question also arises as to what was the after care, and what steps were taken to prevent recurrence? In view of the statement of Hildebrand, just quoted, that 35 per cent is the maximum possibility for permanent cure, and considering the terrible pain and miserable death one so constantly sees in recurrences, it really becomes a question as to the advisability of surgical interference.
The opinion has been expressed more than once by those who have watched the disease, that if left alone, with ordinary medical care, the entire average of 100 cases would be better, as to length of life and suffering, than if submitted to operation. I shall hope to show you in a later lecture that a greater proportion of breast tumors, diagnosed as cancer by competent surgeons, have recovered completely for years, under proper dietary and medical care than the percentage yielded by operative procedure.
There is a wealth of statistics regarding operations for cancer of the cervix uteri. Despite the figures obtained by radical operators like Wertheim, the vast majority of those surgeons who practise either vaginal or abdominal hysterectomy have obtained far inferior results to those of Byrne, with his cautery, which is still in use. Wertheim once reported the astonishing figure of 61 per cent of 5–year recoveries. In a later report, however, Wertheim stated that only about one half of the cases that come to him are operable, and of these about one half are cured by operation, that is, about 25 per cent of all cases. But experience shows that if these cases could be followed up there would be very many late recurrences. The claims of Wertheim and others must be offset, however, by the high operative mortality reported by many; as the cases must have been incipient in order to be operable, it is possible that Byrne with his cautery could have done nearly as well, and Byrne never lost a patient. But Klein of Munich, by circular letters compiled many statistics, and concluded that the percentage of cure was but 4.5 per cent, and Klein himself obtained only 3.6 per cent. Reinecke asserted that only 10 per cent of cases of cancer of the cervix can be cured.
Fredrick (Trans. Gynæcol. Soc., 1905, p. 136) collected the records of 500 hysterectomies for cancer of the cervix performed by prominent colleagues and himself. Of this entire material there had been but 13 five-year cures. In discussion Henrotin stated that he had practically given up abdominal hysterectomy. Currier stated that surgery was a failure as a cure for cancer.
At an earlier session of the Society, 1900, in a discussion of Pryor’s paper, Van de Warker asserted that surgery had done nothing for cancer; Lapthorne Smith said that many women did better if left alone. J. Byrne stated that hysterectomy for cancer was a crime. Engleman thought that cancers left alone may insure a longer survival than those treated surgically.