The Laws of Medicine by Siddhartha Mukherjee Read Free Book Online Page B

also the most dangerous. Few stories involving the mix of hope and illusion in medicine are more tragic, or more long-drawn, than that of the radical mastectomy.
    By the early 1900s, during the brisk efflorescence of modern surgery, surgeons had devised meticulous operations to remove malignant tumors from the breast. Many women with cancer were cured by these surgical “extirpations”—yet, despite surgery, some women still relapsed with metastasis all over their bodies. This postsurgical relapse preoccupied great surgical minds. In Baltimore, the furiously productive surgeon William Halsted argued that malignant tissue left behind during the original surgery caused this relapse. He described breast-cancer surgery as an “unclean operation.” Scattered scraps of tumor left behind by the surgeon, he argued, were the reason for the metastatic spread.
    Halsted’s hypothesis was logically coherent—but incorrect. For most women with breast cancer, the real reason for postsurgical relapse was not the local outgrowth of remnant scraps of malignant tissue. Rather, the cancer had migrated out of the breast long before surgery. Cancer cells, contrary to Halsted’s expectations, did not circle in orderly metastatic parabolas around the original tumor; their spread through the body wasmore capricious and unpredictable. But Halsted was haunted by the “unclean operation.” To test his theory of the local spread of cancer, he amputated not just the breast, but a vast mass of underlying tissue, including the muscles that move the arm and the shoulders and the deep lymph nodes in the chest, all in an effort to “cleanse” the site of the operation.
    Halsted called the procedure a radical mastectomy, using the word radical in its original meaning from the Latin word for “root”; his aggressive mastectomy was meant to pull cancer out by its roots from the body. In time, though, the word itself would metastasize in meaning and transform into one of the most inscrutable sources of bias. Halsted’s students—and women with breast cancer—came to think of the word radical in its second meaning: “brazen, innovative, bold.” What surgeon or woman, faced with a lethal, relapsing disease, would choose the non radical mastectomy? Untested and uncontested, a theory became a law: no surgeon was willing to run a trial for a surgical operation that he knew would work. Halsted’s proposition ossified into surgical doctrine. Cutting more had to translate into curing more.
    Yet women relapsed—not occasionally, either, but in large numbers. In the 1940s, a small band of insurgent surgeons—most prominently Geoffrey Keynes in London—tried to challenge the core logic of the radical mastectomy, but to little avail. In 1980, nearly eight decades after Halsted’s first operation, a randomized trial comparing radical mastectomy with a more conservative surgery was formally launched. (Bernie Fisher, the surgeon leading the trial, wrote, “In God we trust. All othersmust bring data.”) Even that trial barely limped to its conclusion. Captivated by the logic and bravura of radical surgery, American surgeons were so reluctant to put the procedure to test that enrollment in the control arm faltered. Surgeons from Canada and other nations had to be persuaded to help complete the study.
    The results were strikingly negative. Women with the radical procedure suffered a host of debilitating complications, but received no benefits: their chance of relapsing with metastatic disease was identical to that of women treated with more conservative surgery, coupled with local radiation. Breast cancer patients had been ground in the crucible of radical surgery for no real reason. The result was so destabilizing to the field that the trial was revisited in the 1990s, and again in 2000; more than two decades later, there was still no difference in outcome. It is hard to measure