William Stewart Halsted and the Radical Mastectomy - "Hope for a Much Brighter Future?"

William Stewart Halsted as born into a prominent family in New York City on September 23, 1852. He graduated from Yale in 1874, where he was reported to have below average academic achievements, but in his senior year discovered an interest in medicine. He graduated from Columbia University College of Physicians and Surgeons in 1877. Soon after graduation from medical school, Halsted went to Europe to study under several prominent physicians, as there were no formal residency training programs in the United states at this time.

Halsted returned to New York in 1880, where he operated at several hospitals and took on many roles. He became known as an extremely bold surgeon and charismatic leader. He pioneered many techniques, including one of the first cholecystectomies (on his on mother) and blood transfusions (transfusing his own blood into his own sister). He is credited with many advances in surgical technique, including the development of various types of forcepts, sutres, ligatures, advances in aseptic technique, anesthesia, precise anatomical dissection, hemostasis, wound closure, and minimization of tissue damage.

In 1892, Halsted, along with the other members of the “Big Four” - William Osler (”the father of modern medicine”), Howard Kelley (gynecologist), and William Welsh (pathologist) - was instrumental in the founding of Johns Hopkins Medical School and was appointed its first professor of surgery. At Hopkins, Halsted started the first surgical residency training program in the United States, incorporating pedagogical principles he had observed in Europe.

Halsted performed the the first radical mastectomy for breast cancer in the United States in 1882 at Roosevelt Hospital in New York. The Halsted operation removed the breast, infraclavicular and supraclavular lymph nodes, axillary contents and pectoralis muscles in an en-bloc ressection. The basis for this operation has become known as the “Halsted Hypothesis,” which states that operable or early stage breast cancer is essentially a loco-regional disease and that extensive local surgery will offer the patient the best chance of cure.

According to Halsted, tumors spread in an orderly predefined and predictable manner based on mechanical considerations to regional lymph nodes and surrounding tissue via lymphatics and direct extension before distant metastases occur. Lymph nodes may briefly serve as filters or barriers to further spread. Local and regional disease foci are then the instigators of distant spread.

Halsted first published his findings regarding “ the results of operations for the cure of cancer of the breast performed at the Johns Hopkins Hospital from June 1889 to January 1894” in the Annals of Surgery. His series consisted of 50 cases and showed a five year rate of local recurrence of just 6%. These results were outstanding, considering that, “the prognosis was considered hopeless or unfavorable in 27 of the 50 cases” and in each of the 50 cases, some or all of the axillary nodes were positive and many cases had positive intraclavicular and supraclavicular nodes as well.

Halsted’s series showed a vast improvement in terms of loco-regional recurrence rates from similar series published by his European counterparts, which Halsted said “was a fair exposition of their best work that has been done in treatment of cancers of the breast.” Loco-regional recurrence rates among the European surgeons ranged from 58-85%. One of the main reasons Halsted offered for his superior results is that the European surgeons did not routinely include a complete axillary dissection in their procedures, whereas Halsted did, supporting his view of the superiority of more extensive surgery and the role of positive lymph nodes in propagating future recurrences.

Halsted further opines:” Everyone knows how dreadful the results were before the cleaning out of the axilla became recognized as an essential part of the operation. Most of us have heard our teachers in surgery admit that they have never cured a case of cancer of the breast.” Regarding his own results, he states, “These statistics are so remarkably good that we are encouraged to hope for a much brighter, if not a very bright, future for operations for cancer of the breast.”  

These results offered a a major step forward at the time, particularly when viewed in light of the advanced stage of presentation in most of the cases and lack of any of the systemic therapies we rely upon today. Halsted is a much maligned figure today for what is perceived as the excursiveness of his operation. Needless to say, however, his operation saved the lives of countless patients and was the standard treatment for breast cancer for almost 100 years, well into the 1970’s.

References:  

1. Wikipedia: William Stewart Halsted

2. Fisher B, Anderson SJ: The breast cancer alternative hypothesis: is there evidence to justify replacing it? J Clin Oncol 28:366-374, 2010

3. Roberts CS: H. L. Mencken and the four doctors: Osler, Halsted, Welch, and Kelly. Proc Bayl Univ Med Cent 23(4): 377–388, 2010  

4. The Results of Operations for the Cure of Cancer of the Breast Performed at the Johns Hopkins Hospital from June, 1889, to January, 1894. Ann Surg 20(5): 497–555, 1894