Hickey R C, Gallager H S, Dodd G D, Samuels B I, Paulus D D, Moore D L
Adv Surg. 1976;10:287-312.
Radical mastectomy as originally conceived at the turn of the century consisted of complete removal of the breast tissue, the overlying skin, the pectoral muscles, the intervening lymphatics and the axillary lymph nodes. The aim was logical but initially the results were poor. Only 41% of the 76 patients in Halsted's original series were without disease at the end of 3 years. The principal reason for this was the advanced stage of disease in the patients selected for treatment. By contrast, Gilbertsen, using clinical examination alone, surveyed women 45 years of age or older and found that of 32 patients with breast cancers detected by the screening procedure, 24 had no axillary lymph node involvement. The absolute 5-year survival rate of this group was 96%, which approaches the anticipated survival of comparable women free of breast cancer. Those with positive lymph nodes had an absolute survival rate of 75% at 5 years. Further, of 13 patients observed for 10 years, the survival rate for those without node involvement was 90% and for patients with node involvement was 33%. Patients treated at the Barnes Hospital in St. Louis between 1912 and 1933 were contrasted with similarly treated patients at the Barnes Hospital and the Ellis Fischel Cancer Hospital from 1940 to 1955. A poorer survival rate in the earlier series was related primarily to the greater frequency of advanced and larger tumors. That a significant reduction in breast cancer mortality can be achieved is becoming increasingly apparent. Among survey-detected breast cancers in the study conducted by the Health Insurance Plan of Greater New York, the 6-year mortality was half of that of controls. This reduction is even more impressive when one considers that among these patients were many with full invasive, mass-forming carcinomas at the time of initial screening. A recent report by Wanebo, Huvos and Urban discusses the treatment of prognostically favorable forms of breast cancer by modified radical mastectomy. It is possible to select from among their patients those who fit the definition of minimal breast cancer. In this group the 5-year survival rate was 97% and the 10-year survival rate was 95%. Only 1 patient died of breast cancer in 10 years. In another reported group of 65 patients with intraductal carcinoma only, there were no deaths due to breast cancer in 10 years. Should the NCI-ACS demonstration projects show, as now seems probable, that community screening programs can be effective in early breast cnacer detection, it is to be anticipated that widespread public demand for screening facilities will follow. This may present insurmountable logistic and economic problems. The total number of radiologists in the United States is not sufficient to screen annually the total population of women over age 40, or even over age 50. There is great need for the development of criteria for the ready identification of that segment of the population in which most of the cancers would be found...
根治性乳房切除术最初是在世纪之交提出的，包括彻底切除乳房组织、覆盖的皮肤、胸肌、其间的淋巴管和腋窝淋巴结。其目的是合理的，但最初效果不佳。在霍尔斯特德最初的系列研究中，76例患者中只有41%在3年末无疾病。主要原因是所选治疗患者的疾病分期较晚。相比之下，吉尔伯森仅通过临床检查，对45岁及以上的女性进行了调查，发现在通过筛查程序检测出的32例乳腺癌患者中，24例没有腋窝淋巴结受累。该组的绝对5年生存率为96%，接近无乳腺癌的可比女性的预期生存率。有阳性淋巴结的患者5年绝对生存率为75%。此外，在观察10年的13例患者中，无淋巴结受累患者的生存率为90%，有淋巴结受累患者的生存率为33%。将1912年至1933年在圣路易斯巴恩斯医院接受治疗的患者与1940年至1955年在巴恩斯医院和埃利斯·菲舍尔癌症医院接受类似治疗的患者进行了对比。早期系列中较差的生存率主要与晚期和较大肿瘤的发生率较高有关。乳腺癌死亡率能显著降低这一点越来越明显。在大纽约健康保险计划进行的研究中，筛查发现的乳腺癌患者中，6年死亡率是对照组的一半。当考虑到这些患者中有许多在初次筛查时患有完全浸润性、形成肿块的癌时，这种降低就更令人印象深刻了。瓦内博、胡沃斯和厄本最近的一份报告讨论了改良根治性乳房切除术对预后良好的乳腺癌形式的治疗。从他们的患者中可以选出符合微小乳腺癌定义的患者。在这组患者中，5年生存率为97%，10年生存率为95%。10年中只有1例患者死于乳腺癌。在另一组报告的仅患有导管内癌的65例患者中，10年中没有因乳腺癌死亡的病例。如果美国国立癌症研究所-美国癌症协会的示范项目如现在看来很可能的那样表明社区筛查项目在早期乳腺癌检测中是有效的，预计随后公众对筛查设施的广泛需求将会出现。这可能会带来无法克服的后勤和经济问题。美国放射科医生的总数不足以每年对40岁以上甚至50岁以上的女性总人口进行筛查。非常需要制定标准，以便迅速识别出能发现大多数癌症的那部分人群……
