THE QUESTION OE THE CURABILITY OE CANCER OE THE BREAST. THE QUESTION OF THE CURABILITY OF CANCER OF THE BREAST. By J. COLLINS WARREN, M.D. OF BOSTON. Read at the Annual Meeting of the Massachusetts Medical Society, June 7, 1898. THE QUESTION OF THE CURABILITY OF CANCER OF THE BREAST. The great change which has been wrought by the exten- sion of the field of operation in cancer of the breast, and the improved technique of the operation introduced from time to time and more noticeably of recent years by Hal- sted, give renewed interest to statistics in this operation as they continue to accumulate. The contrast between the rare successes of former years and the present time I have already called attention to in a recent paper.* As the value of statistics is increased with the number of cases tabulated, it has seemed to me worth while to review the situation after an interval of two years and to endeavor to glean whatever there may be to throw light upon the great question : In how many cases may we hope eventually to save life on the lines on which surgeons are now working? The accompanying tables include seventy-two cases cover- ing an interval of fifteen years. It does not include all cases operated upon during that period, as the histories of many of the earlier cases could not be obtained, and many cases had to be thrown out, owing to imperfect pathological records. * Boston Medical and Surgical Journal, Nos. 12, 14, 1896. 4 QUESTION OF THE CURABILITY No. Date. Diag. Recue; Date. Alive and Well. Death, Date and Cause. 1 July, ’83 Colloid July, ’88, nodule, axilla removed May, ’95 2 June, ’84 Cancer 0 ’93 Jan.,’94, with apoplexy. 3 Dec., ’84 Scirrhus 0 April, ’97 4 Mar., ’85 Cancer (recur) Feb., ’94, in scar, re- moved Mar., ’98 5 July, ’85 Cancer O July,’91, with “sporadic cholera.” 6 Nov.,’86 Med. ca. March, ’89, local ? No answer. 7 Jan., ’87 Cancer April, ’87, local ? 8 Feb., ’87 Cancer May, ’88, removed, and again later. Oct., ’89, with recur. 9 Mar., ’87 Cancer 0 Mar., ’97 Mar., ’98 10 Oct., ’87 Med. ca. Local and general Aug., ’88, with recur. 11 Dec., ’87 Med. ca. Sterum and general Sept., ’90, with recur. 12 Jan., ’88 Med. ca. June, ’89, local Jan., ’90, with recur. 13 Feb., *88 Scirrhus April, ’88, local Aug., ’88, with recur. 14 Oct., ’88 Cancer 0 Mar., ’93 15 Oct., ’88 Scirrhus Not locally Aug., ’91, with recur. 16 Jan., *89 Med. ca. At autopsy Dec., ’92, with recur. 17 Jan., ’89 Med. ca. f Feb., *89, local, re- moved. | Feb., ’90, local, re- t moved ? No answer. 18 Jan., ’89 Cancer Nov., *89, local, re- moved Sept., ’91, with recur. 19 Feb., ’89 Cancer O Mar., ’98 20 Feb., ’89 Med. ca. General Sept., ’90, with recur. 21 April,’89 Med. ca. 5-6 mos., local July, ’90, with recur. 22 Aug., ’89 Scirrhus 3 mos., local Nov., ’89, with recur. 23 Nov., ’89 Cancer May, ’90, local, re- moved. • Oct., ’90, hopeless May, ’91, with recur. 24 Nov., ’89 ? After 2 yrs., local May, ’95, with recur. 25 Dec., ’89 Cancer Other breast after 9 mos., quack. Re- cur. scar. May, ’93, with recur. 26 Jan., ’90 Cancer Autumn, ’92, local. April, ’93, general Aug., ’93, with recur. 27 Jan., ’90 Cancer O Local Feb., ’91, with recur. (?) OF CANCER OF THE BREAST 5 No. Datr. Diag. Kecur; Date. Alive and Well. Death, Date and Cause. 28 Mar., ’90 Scirrhus Local Oct., ’90, with recur. 29 Nov., ’91 ? 0 Local (?) May, ’92. ? 30 Feb., ’92 Med. ca. Oct., ’92. 31 Oct., ’92 Med. ca. June, ’93, local May, ’94, with recur. 32 Nov.,’92 Cancer June, ’93, local June, ’94, with recur. 33 Nov., ’92 Cancer O Mar., ’98 34 Jan., ’93 Med. ca. Nov., ’94, local, re- moved Jan., ’98 35 Jan., ’93 Scirrhus Jan., ’95, local and general ? No answer. 36 Feb., ’93 Cancer 0 April, ’98 37 April,’93 Scirrhus 0 Mar., ’98 38 June, ’93 Scirrhus Local and general Mar., ’94, with recur. 39 June, ’93 Med. ca. Local and general Mar., ’94, with recur. 40 Sept.,’93 Scirrhus O June, ’98 41 Jan., ’94 Med. ca. July, ’94, local June, ’95, with recur 42 Jan., ’94 Scirrhus O Mar.,’98 43 Jan., ’94 Scirrhus Wound never healed July, ’94, with recur. 44 Feb., ’94 Med. ca. General July, ’97, with recur. 45 Feb., ’94 Scirrhus In spine Aug., ’95, with recur. 46 Feb., ’94 Med. ca. General June, ’94, with recur. 47 Feb., ’94 Med. ca. March, ’94 April, ’94, with recur 48 July, ’94 Med. ca. March, ’97, local re- moved May, ’98, local 49 Oct., ’94 Scirrhus Jan., ’96, local, re- moved Mar., ’96, with recur. 50 Nov., ’94 Med. ca. Aug., ’95, local, re- moved Oct., ’96, hopeless ? 51 Dec., ’94 Scirrhus ? May, ’95 ? 52 Jan., ’95 Scirrhus O Mar., ’98 53 Jan., ’95 Cancer 0 Mar., ’98 54 Mar., ’95 Scirrhus 0 Mar., ’98 55 April,’95 Med. ca. Feb., ’96, local, operated (?) April, ’97, with recur. 56 Aug.,’95 Med. ca. June, ’96, local, operated. July, ’97, inoperable 6 QUESTION OF THE CURABILITY No. Date. Diag. Recur; Date. Alive and Well. Death, Date and Cause. 57 Sept., ’95 Scirrhus 0 Mar., ’98 58 Oct., ’95 Scirrhus O Mar., ’98 59 Nov., ’95 Med. ca. Immediate.Operated ? Jan., ’96, with recur. 60 Dec., ’95 Med. ca. ? Nov., ’96 9 61 Jan., ’96 Med. ca. May, ’96, local Mar., ’97, with recur. 62 Jan., ’96 Med. ca. 0 Mar., ’98 63 June, ’96 Scirrhus O Mar., ’98 64 Oct., ’96 Med. ca. 0 Oct., ’97 65 Oct., ’96 Cancer ? Dec., ’97, with recur. 66 Dec., ’96 Med. ca. ? June, ’97, “suddenly.” 67 Jan., ’97 Med. ca. Jan., ’98, local, re- moved Feb., ’98 68 June, ’97 Med. ca. O Jan., ’98 69 Nov., ’97 Med. ca. May, ’98, stenum and humerus 70 Dec., ’97 Cancer ? 71 Jan., ’98 Carcinoma 0 Jan., ’98, pulmonary embolism. 5th day. 72 Feb., ’98 Med. ca. O* April,’98 Of the 72 cases there are 26 known to be alive at the present time, and 38 known to have died. Of the latter there were, however, two cases in which death occurred of other diseases than cancer, and that too long after the dan- ger limit had been passed. In other words, nearly half of the cases are known to be living to-day, or to have died of other disease than cancer. Of the 26 living cases there are 3 who now have recur- rence of the disease, and 4 who have had a recurrence but remain well at the present time. The following table shows in a general way the locality of the relapse: * 0 in recurrence column signifies “ none.” OF CANCER OF THE BREAST. 7 Recurrences. Humerus Local. General. Doubtful. and Totals. Sternum. Dead, 25 7 3 35 Alive, 1 1 1 3 Unreported, 4 4 8 Alive and well, 4 4 Totals, 34 8 7 1 50 The above table shows the great importance of a careful study of the proper limits of the field of operation, for we find that in the 50 cases in which recurrence took place there were 34 local recurrences and only 8 in which the field of operation remained in a healthy condition. Such statistics emphasize the importance of strict atten- tion to the rules now laid down, viz. : the removal of a large margin of the cutaneous covering of the breast, a careful reflection of the edges of the wound, and removal of the subcutaneous fat for a considerable distance around the mammary gland, the removal of the pectoral muscles, and a minute and painstaking dissection around the sheath of the axillary vessels. In only one of the successful cases was there a dissection of the supraclavicular glands. I have, however, four times operated upon the neck of a patient for infected glands, in which case the original operation field has remained healthy for four years. I feel confident that had the supraclavicu- lar region been explored at that time a small gland would; have been discovered, and a permanent cure would have; been secured. It is my custom at the present time to explore the pos-- terior cervical triangle in all cases, and although in the- majority I fail to find disease, this addition to the operation) does not appear to add to its danger or to the amount of shock. 8 QUESTION OF THE CURABILITY In regard to the situation of the growth we find that in 25 cases no statement is made as to the locality. This leaves 47 cases. In 13 of these the disease was found in the upper and outer quadrant, in the upper and inner quad- rant in 6 cases; in the central region in 6 cases; in the upper hemisphere in 5 ; in the lower and outer quadrant in 5 ; in the outer hemisphere in 3 ; in the inner hemisphere in 1. These figures show that the disease is most frequently found in the upper and outer quadrant than in any other quadrant, in the upper hemisphere more frequently than in the lower hemisphere, and in the outer hemisphere than in the inner hemisphere. In two cases the disease originated on the anterior axillary fold and I have named this in a class by itself as " Cancer of the anterior axillary border,” the disease apparently be- ginning as in Paget’s disease in the skin, and subsequently involving the breast. The periods during which recurrences are observed are also of value, and they are given in the subjoined table. In nine cases it was not possible to learn the date of recur- rence, but of the other 41 cases 37 occurred during the first 3 years ; of the remaining 4 cases 2 recurrences are found between 3 and 4 years, and 2 between 5 and 9 years. One of these exceptionally late recurrences was a colloid cancer in which an axillary gland evidently had been overlooked. In the case in which a nodule was removed from the pecto- ral region nine years after the original operation, it seems reasonable to assume that a new infection had taken place in a para-mammary gland. The existence of these glands is now well recognized by anatomists, and the fact shows the importance of including all such adjacent gland tissue in the field of operation. This table also shows how rare are the recurrences after three years. OF CANCER OF THE BREAST. 9 It seems to me highly probable that many cases, re- ported as unusually late recurrences, are cases which have not been carefully examined. The patient’s word has been taken when suddenly a generalization of the disease reveals the true condition. Every case should receive a thorough examination by a competent surgeon at the end of three years. If under these circumstances the report is favorable, there is probably not more than one chance in a hundred that the disease will ever show itself again. Recurrences : Before i yr. 1 yr. 2 yrs. 3 yrs. 4 yrs. 5 to 9 yrs. ? ■ Totals General 2 2 2 2 8 Local 11 11 5 3 2 2 34 Doubtful 7 7 Humerus and Sternum 1 1 Totals 14 11 7 5 2 2 9 50 Taking the three years’ limit as the gauge of success, we find there are seventeen such cases. Two of these are dead ; one dying, ten years after the operation, of apoplexy, and one dying of sporadic cholera six years after the operation. Three of these have had recurrences, one in the axilla and two in the pectoral region. These nodules were removed, and the patients are now alive and well, one of them three years, one four years and one ten years after the last opera- tion. Of the remaining twelve the operation was per- formed in three cases over three years ago; in four cases over four years ago ; in two cases over five years ago ; in one, over nine years ago; in one, eleven years ago ; and in one case over twelve years ago. An analysis of the diagnosis in these seventeen cases shows that nine were reported to be cases of " cancer,” six reported as cases of "scirrhus,” one medullary cancer and one colloid cancer. With one exception only the cures consist of the milder forms of cancer if we assume that the term " cancer ” indi- cates a condition midway between scirrhus and medullary. QUESTION OF THE CURABILITY It is somewhat discouraging to find that only one case of genuine medullary cancer has been rescued from the lot. In this case there was a recurrence in the pectoral region two years later which was successfully removed, the patient since remaining well for over three years. The clinical history of the case bore out therefore the original diagnosis and showed it to be correct. The percentage of cures, or those which have passed the three years’ limit, in fifty-five cases, is 30.9%. In estimating these results it should be remembered that these operations extend over a period of fifteen years, and that the earlier operations do not compare with the later ones in thoroughness. They do, however, cover that period in which the axilla was dissected in all cases, but of the earlier operations not much more can be said than this. If now we begin with January 1st, 1893, and take in all those cases which come up to the three years’ limit, that is up to April, 1895, or just three years ago, we find twenty-two cases with eight cures or a percentage of cures of 36.3%. A large number of these cases include those of hospital patients, many of them of malignant types, and patients who have delayed calling attention to their disease. If now we take the cases in private practice only, during this same period we find they are twelve in number with six deaths, one re- currence, and five cures, or 41.6%. On the other hand, taking all the cases in private practice during fifteen years we find the percentage 34.7 %. Comparing these figures with those given in statistics, collected by Dowd,* we find 199 cases, with 71 cures, or 39.6%. This percentage seems remarkably high for so large a series, but it includes Rotters’ series with 50%, including only fifteen cases, and Cheyne’s with 57%, including only thirty-three cases. * Annals of Surgery, March, 1898. 11 OF CANCER OF THE BREAST. It is possible that some surgeons include those cases only in which an operation gives a chance for cure, selecting those in which they have advised a radical operation with the distinct view to a permanent cure. In my own series those cases only have been omitted where the entire growth could not be removed, such operations being clearly only palliative. It is evident that high percentages can be obtained only when cases are selected with some care, but present ex- perience with the new operation hardly justifies one as yet in deciding what are the limits of the curable class. Until then many incurable cases will undoubtedly be subjected to operation. It seems at least a more humane policy to sacrifice our statistics for the sake of saving occasionally a desperate case. On the other hand, it is to be hoped that wider experi- ence will enable us to spare many a patient the ordeal of a useless operation. It should be said here, however, that even in palliative operations life is prolonged and suffer- ing often spared to a remarkable degree. In regard to causation. In eight cases only is trauma given as a probable cause of the disease. In four cases there was a history of abscess, and in two cases a history of mastitis. The question of the involvement of the axillary and supraclavicular glands is one of great practical interest. The record mentions glands felt in the axilla in fifty-four cases only. My impression is that in one or two cases only has a careful search by the pathologist failed to unearth in- fected glands in this region. In five cases supraclavicular glands are mentioned. Three of these cases are dead, one is alive, and in one the result is unknown. In only fifteen cases is there a record of a retraction of the nipple. In my opinion this is a most unreliable symp- tom. 12 QUESTION OF TIIE CURABILITY One often sees an inversion of the nipple which is quite a different condition, and one quite frequently associated with anatomical peculiarities. It has no pathological sig- nificance. There may be extensive disease of the breast without a sign of retraction of the nipple. This retraction is caused by the involvement of the ducts and their cicatricial con- traction. The dimpling of the skin over the nodule is of greater significance, and is in marked contrast to the protrusion of the growth, in the case of a benign tumor or cyst, above the surface when the patient is in the recum- bent posture. One of the first questions asked a patient with a nodule in the breast usually is : " How long has it existed ?” The average period in sixty-eight cases was 10.1 months. It is interesting to note that in sixteen cures the average period was 11.6 months, whereas in thirty-eight failures the average period was 9.4 months. In private practice the general average was somewhat better, being only 7.8 months. Here again we find eleven successful cases, giving an average of 8 months; and seventeen failures, giving only 7.6 months as the average time. The inference to be drawn from this is, that the longer duration of time during which the disease existed previous to the operation in the successful cases clearly shows a milder form of the disease. In one case I have succeeded in operating within three weeks from the time the tumor was known not to exist. In this case a minute infected gland was found in the axilla. The patient was cured by the operation. In summing up the results obtained from these data I think we may be justified in saying that a surgical operation can save, as a rule, those cases coming under the head of "scir- rhus,” and even of "cancer” ; that in the case of " medullary cancer ” an earlier interference may claim a fair propor- OF CANCER OF THE BREAST. 13 tion. Before, however, the percentages of success are to be permanently placed so high that we may hope to save over one half of our cases, the professional public must be edu- cated up to that point that they will send their patients early, and not wait until the case has become hopeless before they advise their patient to consult a specialist. More difficult still will it be to instruct patients them- selves to realize the importance of not neglecting any lump .in the breast, and also to overcome that strange propen- sity in the cancerous to conceal their disease.