Radical mastectomy now outdated
CMAJ 1997;156:1379
See response from: I. Olivotto, et al
The articles "Patterns of initial management of node-negative breast cancer in two Canadian provinces" (CMAJ 1997;156:25-35 [abstract / résumé]), by Dr. Vivek Goel and associates, and "A surgical subculture: the use of mastectomy to treat breast cancer" (CMAJ 1997;156:43-5 [abstract / résumé]), by Dr. Adalei Starreveld, make fascinating reading. Not only is it remarkable that the patterns of practice differ so much between Ontario and British Columbia, but one is left wondering why outdated radical mastectomy procedures are still being performed in such large numbers, especially in older women and women in rural areas in BC. Is this largely a function of how recently the surgeon has been trained and his or her academic affiliation, or a more general reluctance to keep up-to-date with current scientific evidence?
It has been evident for at least 10 years that breast-conserving surgery, followed by timely radiation therapy, is equivalent to mastectomy in terms of outcome. Adjuvant chemotherapy with such agents as tamoxifen should be part of the program, to lower the rate of recurrence.
In BC an additional factor is the shortage of radiation machines. Although such therapeutic equipment is available in Vancouver and Victoria, the existing machines in Victoria are inadequate to deal with the demand, and proposals to upgrade and expand equipment have recently been shelved by the Ministry of Health. It appears that funds are available for the questionable screening mammography of asymptomatic women 40 to 49 years of age, but not for timely radiation therapy for all of the women with breast cancer who could benefit from it.
The larger question remains: What are the best ways to incorporate recommendations based on new scientific knowledge into medical practice?
Timothy Johnstone, MB, BS
Victoria, BC
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