Friday, March 24, 2023

This week we begin a five-part series on Bernard (Bernie) Fisher, a clinician-scientist who has contributed more than anyone else to the way we clinically manage breast cancer until today. And since much of how we manage other solid tumors derives from the principles of how we manage breast cancer, it would be reasonable to say that Fisher has had a profound influence on the rest of solid tumor oncology as well.

Fisher was born in Pittsburgh in 1918 to Jewish Lithuanian immigrants (he died in 2019 at the age of 101), grew up in Squirrel Hill and spent his whole life there. He went to the University of Pittsburgh both for his undergraduate and medical school education, trained as a surgeon and then joined the school’s surgical faculty.

To appreciate his contributions, we must first review the status of breast cancer surgery at the time. The use of surgery for breast cancer is ancient, but its modern form harks back to the work of William Halsted. Halsted is an absolute legend in his own right. Born in New York City in 1852, he was an undergraduate at Yale before getting his MD degree from Columbia’s College of Physicians and Surgeons. He did an internship at Bellevue, then studied surgery in Europe for some years before returning to New York, where he practiced for several years. He is credited with doing one of the first cholecystectomy (gallbladder removal) operations in the U.S., performed on his own mother on his kitchen table at 2 a.m., from which she recovered uneventfully. He also did one of the first emergency blood transfusions ever, when he found his sister in shock from blood loss after childbirth, transfused his own blood into her, then operated on her and saved her life.

While a house officer at New York Hospital, he introduced the first ever use of the hospital chart as a means of tracking the patient’s vital signs—temperature, blood pressure, etc., a new innovation that became routine afterwards. Upon his return from Europe, he innovated the use of cocaine as a medication for anesthetic use. He became addicted to it and ultimately after several years had to be detoxed.

Around 1889, Johns Hopkins Hospital was opened in Baltimore as a new, innovative type of research medical school and teaching hospital. Halsted was one of the four doctors recruited to head one of its departments, as chief of surgery. (William Osler was appointed chief of medicine.) Among his other innovations at this time was the use of rubber gloves during surgery. He also started the concept of the first surgical residency training program.

OK, let us get back to breast cancer. Halsted performed the first radical mastectomy in the U.S. in 1882 while at Roosevelt Hospital in New York. The theory stemmed from the simple but logical idea that breast cancer spreads from its point of origin in the tumor in ever-widening circles. Thus, the more you cut out, the more likely you were to succeed in removing the cancer before tumor cells had reached the bloodstream or migrated to a point of no return. He developed this procedure further until it reached its apogee by 1898. This radical procedure involved resection of the breast along with the proximal axillary (armpit) lymph nodes up to the top. It also included removal of both pectoral (chest wall) muscles, including pectoralis major. The performance of this radical Halsted mastectomy did indeed reduce the breast cancer recurrence rate significantly and was thus deemed a major success, but was extremely disfiguring and disabling. Women had their chest wall removed down to the bare rib cage, and the degree of lymphedema (swelling) in the arm was extreme; without a pectoral muscle, they had difficulty moving their arms.

Nonetheless, this remained the standard of care for localized breast cancer into the 1970s. Indeed, some surgeons extended the logic of this procedure even further by extending the resection to include the supraclavicular lymph nodes or mediastinal nodes. Two concepts were included in the surgical oncologic approach. One was that the procedure needed to be an en bloc resection—all of the specimen removed as a single mass without cutting it. This remains until today as a credo in surgical oncology. The second was that there should not be a biopsy to invade through normal tissue and create a track through which malignant cells could be deposited by the needle. This led to the practice that women would be anesthetized not knowing whether they had cancer or not; they would be biopsied in the operating room and a pathology reading done while they were under and while the surgical team waited. If malignant, the procedure would then go forward and the woman would awake hours later with a radical mastectomy. My classmate Abe and I remember as medical students at Columbia operating with the late great Sven Kister, perhaps the best-known breast surgeon in NYC, a traditionalist and descendant of Halsted, who would perform these procedures in that way.

Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York.

This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.

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