The Emperor of All Maladies: A Biography of Cancer (13 page)

With the world around him erased and silenced by this routine and rhythm, Halsted now attacked breast cancer with relentless energy. At Volkmann’s clinic in Halle, Halsted had witnessed the German surgeon performing increasingly meticulous and aggressive surgeries to remove tumors from the breast. But Volkmann, Halsted knew, had run into a wall. Even though the surgeries had grown extensive and exhaustive, breast cancer had still relapsed, eventually recurring months or even years after the operation.

What caused this relapse? At St. Luke’s Hospital in London in the 1860s, the English surgeon Charles Moore had also noted these vexing local recurrences. Frustrated by repeated failures, Moore had begun to record the anatomy of each relapse, denoting the area of the original tumor, the precise margin of the surgery, and the site of cancer recurrence by drawing tiny black dots on a diagram of a breast—creating a sort of historical dartboard of cancer recurrence. And to Moore’s surprise, dot by dot, a pattern had emerged. The recurrences had accumulated precisely around the margins of the original surgery, as if minute remnants of cancer had been left behind by incomplete surgery and grown back. “
Mammary cancer requires
the careful extirpation of the entire organ,” Moore concluded. “Local recurrence of cancer after operations is due to the continuous growth of fragments of the principal tumor.”

Moore’s hypothesis had an obvious corollary. If breast cancer relapsed due to the inadequacy of the original surgical excisions, then even more breast tissue should be removed during the initial operation. Since the
margins
of extirpation were the problem, then why not extend the margins? Moore argued that surgeons, attempting to spare women the disfiguring (and often life-threatening) surgery were exercising “
mistaken kindness
”—letting cancer get the better of their knives. In Germany, Halsted had seen Volkmann remove not just the breast, but a thin, fanlike muscle spread out immediately under the breast called the pectoralis minor, in the hopes of cleaning out the minor fragments of leftover cancer.

Halsted took this line of reasoning to its next inevitable step. Volkmann may have run into a wall; Halsted would excavate his way past it. Instead of stripping away the thin pectoralis minor, which had little function, Halsted decided to dig even deeper into the breast cavity, cutting through the pectoralis
major
, the large, prominent muscle responsible for moving the shoulder and the hand. Halsted was not alone in this innovation:
Willy Meyer, a surgeon operating in New York, independently arrived at the same operation in the 1890s. Halsted called this procedure the “radical mastectomy,” using the word
radical
in the original Latin sense to mean “root”; he was uprooting cancer from its very source.

But Halsted, evidently scornful of “mistaken kindness,” did not stop his surgery at the pectoralis major. When cancer still recurred despite his radical mastectomy, he began to cut even farther into the chest. By 1898, Halsted’s mastectomy had taken what he called “an even more radical” turn. Now he began to slice through the collarbone, reaching for a small cluster of lymph nodes that lay just underneath it. “
We clean out or strip
the supraclavicular fossa with very few exceptions,” he announced at a surgical conference, reinforcing the notion that conservative, nonradical surgery left the breast somehow “unclean.”

At Hopkins, Halsted’s diligent students
now raced to outpace their master with their own scalpels. Joseph Bloodgood, one of Halsted’s first surgical residents, had started to cut farther into the neck to evacuate a chain of glands that lay above the collarbone. Harvey Cushing, another star apprentice, even “cleaned out the anterior mediastinum,” the deep lymph nodes buried inside the chest. “
It is likely
,” Halsted noted, “that we shall, in the near future, remove the mediastinal contents at some of our primary operations.” A macabre marathon was in progress. Halsted and his disciples would rather evacuate the entire contents of the body than be faced with cancer recurrences.
In Europe, one surgeon evacuated three ribs
and other parts of the rib cage and amputated a shoulder and a collarbone from a woman with breast cancer.

Halsted acknowledged the “physical penalty” of his operation; the mammoth mastectomies permanently disfigured the bodies of his patients. With the pectoralis major cut off, the shoulders caved inward as if in a perpetual shrug, making it impossible to move the arm forward or sideways. Removing the lymph nodes under the armpit often disrupted the flow of lymph, causing the arm to swell up with accumulated fluid like an elephant’s leg, a condition he vividly called “
surgical elephantiasis
.” Recuperation from surgery often took patients months, even years. Yet Halsted accepted all these consequences as if they were the inevitable war wounds in an all-out battle. “The patient was a young lady whom I was loath to disfigure,” he wrote with genuine concern, describing an operation extending all the way into the neck that he had performed in the 1890s. Something tender, almost paternal, appears in his surgical notes,
with outcomes scribbled alongside personal reminiscences. “Good use of arm. Chops wood with it . . . no swelling,” he wrote at the end of one case. “Married, Four Children,” he scribbled in the margins of another.

But did the Halsted mastectomy save lives? Did radical surgery
cure
breast cancer? Did the young woman that he was so “loath to disfigure” benefit from the surgery that had disfigured her?

Before answering those questions, it’s worthwhile understanding the milieu in which the radical mastectomy flourished. In the 1870s, when Halsted had left for Europe to learn from the great masters of the art, surgery was a discipline emerging from its adolescence. By 1898, it had transformed into a profession booming with self-confidence, a discipline so swooningly self-impressed with its technical abilities that great surgeons unabashedly imagined themselves as showmen. The operating room was called an operating theater, and surgery was an elaborate performance often watched by a tense, hushed audience of observers from an oculus above the theater. To watch Halsted operate, one observer wrote in 1898, was to watch the “
performance of an artist
close akin to the patient and minute labor of a Venetian or Florentine intaglio cutter or a master worker in mosaic.” Halsted welcomed the technical challenges of his operation, often conflating the most difficult cases with the most curable: “
I find myself inclined
to welcome largeness [of a tumor],” he wrote—challenging cancer to duel with his knife.

But the immediate technical success of surgery was not a predictor of its long-term success, its ability to decrease the relapse of cancer. Halsted’s mastectomy may have been a Florentine mosaic worker’s operation, but if cancer was a chronic relapsing disease, then perhaps cutting it away, even with Halsted’s intaglio precision, was not enough. To determine whether Halsted had truly cured breast cancer, one needed to track not immediate survival, or even survival over five or ten months, but survival over five or ten
years
.

The procedure had to be put to a test by following patients longitudinally in time. So, in the mid-1890s, at the peak of his surgical career, Halsted began to collect long-term statistics to show that his operation was the superior choice. By then, the radical mastectomy was more than a decade old. Halsted had operated on enough women and extracted enough tumors to create what he called an entire “
cancer storehouse
” at
Hopkins.

Halsted would almost certainly have been right in his theory of radical surgery: that attacking even small cancers with aggressive local surgery was the best way to achieve a cure. But there was a deep conceptual error. Imagine a population in which breast cancer occurs at a fixed incidence, say 1 percent per year. The tumors, however, demonstrate a spectrum of behavior right from their inception. In some women, by the time the disease has been diagnosed the tumor has already spread beyond the breast: there is metastatic cancer in the bones, lungs, and liver. In other women, the cancer is confined to the breast, or to the breast and a few nodes; it is truly a local disease.

Position Halsted now, with his scalpel and sutures, in the middle of this population, ready to perform his radical mastectomy on any woman with breast cancer. Halsted’s ability to cure patients with breast cancer obviously depends on the sort of cancer—the stage of breast cancer—that he confronts. The woman with the metastatic cancer is not going to be cured by a radical mastectomy, no matter how aggressively and meticulously Halsted extirpates the tumor in her breast: her cancer is no longer a local problem. In contrast, the woman with the small, confined cancer
does
benefit from the operation—but for her, a far less aggressive procedure, a local mastectomy, would have done just as well. Halsted’s mastectomy is thus a peculiar misfit in both cases; it underestimates its target in the first case and overestimates it in the second. In both cases, women are forced to undergo indiscriminate, disfiguring, and morbid operations—too much, too early for the woman with local breast cancer, and too little, too late, for the woman with metastatic cancer.

On April 19, 1898
, Halsted attended the annual conference of the
American Surgical Association
in New Orleans. On the second day, before a hushed and eager audience of surgeons, he rose to the podium armed with figures and tables showcasing his highly anticipated data. At first glance, his observations were astounding: his mastectomy had outperformed every other surgeon’s operation in terms of local recurrence. At Baltimore, Halsted had slashed the rate of local recurrence to a bare few percent, a drastic improvement on Volkmann’s or Billroth’s numbers. Just as Halsted had promised, he had seemingly exterminated cancer at its root.

But if one looked closely, the roots had persisted. The evidence for a true cure of breast cancer was much more disappointing. Of the seventy-six patients with breast cancer treated with the “radical method,” only forty had survived for more than three years. Thirty-six, or nearly half the original number, had died within three years of the surgery—consumed by a disease supposedly “uprooted” from the body.

But Halsted and his students remained unfazed. Rather than address the real question raised by the data—did radical mastectomy truly extend lives?—they clutched to their theories even more adamantly.
A surgeon should “operate on the neck
in every case,” Halsted emphasized in New Orleans. Where others might have seen reason for caution, Halsted only saw opportunity: “I fail to see why the neck involvement in itself is more serious than the axillary [area]. The neck can be cleaned out as thoroughly as the axilla.”

In the summer of 1907, Halsted presented more data to the American Surgical Association in Washington, D.C. He divided his patients into three groups based on whether the cancer had spread before surgery to lymph nodes in the axilla or the neck. When he put up his survival tables, a pattern became apparent. Of the sixty patients with no cancer-afflicted nodes in the axilla or the neck, the substantial number of forty-five had been cured of breast cancer at five years. Of the forty patients
with
such nodes, only three had survived.

The ultimate survival from breast cancer, in short, had little to do with how extensively a surgeon operated on the breast; it depended on how extensively the cancer had spread before surgery. As George Crile, one of the most fervent critics of radical surgery, later put it, “
If the disease was so advanced
that one had to get rid of the muscles in order to get rid of the tumor, then it had already spread through the system”—making the whole operation moot.

But if Halsted came to the brink of this realization in 1907, he just as emphatically shied away from it. He relapsed to stale aphorisms. “
But even without the proof
which we offer, it is, I think, incumbent upon the surgeon to perform in many cases the supraclavicular operation,” he advised in one paper. By now the perpetually changing landscape of breast cancer was beginning to tire him out. Trials, tables, and charts had never been his forte; he was a surgeon, not a bookkeeper. “
It is especially true of mammary cancer
,” he wrote, “that the surgeon interested in furnishing the best statistics may in perfectly honorable ways provide them.” That
statement—almost vulgar by Halsted’s standards—exemplified his growing skepticism about putting his own operation to a test. He instinctively knew that he had come to the far edge of his understanding of this amorphous illness that was constantly slipping out of his reach.