guest editorial: the case against delayed operation for breast cancer

GUEST EDITORIAL A recent editorial extolled the virtues of delayed operation for breast

The Case Against cancerandmaintainedthat delaybeDelayed Operation tweenbiopsyanddefinitivetreatment

of breast cancer carried no added riskfor Breast Cancer for the patient.' There is no convincing

evidence to support this viewpoint.Although several authors have con

cluded that such delay does not causeany demonstrable harm, their data arebased upon patients with small primarytumors, relatively localized disease andminimal nodal involvement.2―

When patients with disease of similar extent in the breast and regionalnodes are compared, the salvage ratedecreases as the time interval betweenbiopsy and definitive surgery is prolonged. We found that patients treatedby biopsy and immediate extended radical mastectomy had approximately a20 percent greater five-year salvagerate, clinically free of disease, thanthose with disease of similar extenttreated by the same operation following a delay of two weeks or more afterbiopsy. When disease was limited to thebreast and nodes were clear, there wasno significant difference in the salvagerate of each group. However, when axillary and/or internal mammary nodescontained metastases, the five-year salvage rate of patients treated by immediate surgery was roughly twice asgreat as that of similar patients operated upon two weeks or more following biopsy. Similar observations havebeen made by others.4'5

Aspiration biopsy should not be usedas an outpatient procedure to rule outthe presence of breast cancer. It is significant only when it is positive. A negative aspiration biopsy does not ruleout the presence of breast cancer—thetumor may be benign or a malignanttumor may have been missed by theneedle—immediate local excision of themass with frozen section examinationis indicated. Aspiration biopsy as anoutpatient procedure should be re

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served to document the presence ofcancer in patients with advanced inoperable breast cancer. Ideally, aspirationbiopsy should be used for the diagnosisof breast cancer as an inpatient procedure when the lesion is clinically apparent and when definitive therapy canbe instituted immediately.

There is a great tendency to limit theextent of excisional biopsy when it isperformed under local anesthesia. Minimal breast cancers can easily be missedby this method. This is particularlytrue of in situ noninfiltrating cancerswhich usually can be found only afterthorough pathological examination ofgenerous excisional biopsies.

There is no convincing evidence thatdelayed operation does not penalize thepatient with breast cancer. The risks ofoutpatient biopsy and delayed operation outweigh its convenience. Biopsy,frozen section and immediate mastectomy still represent the best routine fortreatment of primary breast cancer.

M.D.

Attending Surgeon, Breast ServiceMemorial Hospital for Cancer and

Allied DiseasesClinicalAssociateProfessorofSurgery

CornellUniversityMedicalCollegeNew York, New York

References

1. Earle, A. S.: Delayed operation for breast carcinoma. Surg. Gynec. Obstet. 131: 291, 1970.2 Jackson, P. P., and Pitt8, H. H: Biop8y with

delayed radical mastectomy for carcinoma of thebrea8t. Amer. J. Surg. 98: 184.189. 1959.3. Pierce, E. H.. et a!.: Biopsy of the breast followed by delayed radical mastectomy. Surg. Gynec.Obstet. 103: 559-564. 1956.4. Nohrman, B. A.: Cancer of the breast: clinicalstudy of 1042 cases treated at Radiumhemmet,1936-1941. Acta radiol. (supp. 77) 1-98, 1949.5. Sayago. C., and Sirebrenik. D.: Surgical biopsyas a disseminating factor in breast cancer. ActaUnio Internat. Contra Cancrum 15: 1161-1164.1958.

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