Halsted's radical mastectomy

William Stewart Halsted, the first chief of surgery at the Johns Hopkins Hospital, held that a surgeon operating for breast cancer should answer for the whole region the disease spread through: the main growth, the armpit, the pectoral muscles and the area above the collarbone. He set out his results in November 1894 in the journal Annals of Surgery, covering operations at Johns Hopkins from June 1889 to January 1894.

In what he called the complete method, the surgeon removed the breast, cleared the contents of the armpit and the region below the collarbone, usually cleared the region above it as well, and took at least part of the pectoralis major muscle. Every one of the 50 patients treated this way had cancer in some or all of the axillary glands, and 27 had been judged hopeless or unfavorable at operation. Halsted could trace only three local recurrences, 6 percent, and he wrote that the figures encouraged hope for a brighter future.

The radical mastectomy remained the standard surgical treatment for breast cancer until the late twentieth century. Its costs fell on the patients. Letters to Halsted kept in the Johns Hopkins archives describe restricted arm movement, a swollen arm now recognized as lymphedema, pain and fear of recurrence, and Halsted himself acknowledged arm swelling after the operation.

Surgeons first tried still larger operations, the extended and super-radical mastectomies, which brought little benefit. The trend then reversed, toward the modified radical mastectomy, which spares the chest muscles, and later breast-conserving surgery.

Randomized trials settled the question. The National Surgical Adjuvant Breast and Bowel Project began its B-04 trial in 1971, assigning 1,665 women to radical mastectomy or to total mastectomy with or without radiation; at 25 years Bernard Fisher and colleagues found no significant difference in survival. Its B-06 trial, begun in 1976, found no survival difference between total mastectomy and lumpectomy in 1,851 women, and lumpectomy followed by radiation became accepted treatment when the tumor margins were clear.