The management of early breast cancer is showing a growing tendency to move away from radical surgery back towards conservative surgery and systemic adjuvant therapy. This paper and the one that follows review the data that underly this trend and consider the clinical and biological principles that are presently used to make a decision regarding the optimal primary treatment for breast cancer. The conclusion is reached that conservatism is based on a false understanding of the disease and on false conclusions drawn from premature analysis of data from clinical trials.
Optimal management can be determined by appropriate preparative investigation. Breast cancer patients can be divided into three groups: early cases, with a good prognosis, late, incurable cases and an intermediate group. Radical therapy by surgery or surgery combined with radiotherapy gives better results than a conservative approach in the early and intermediate groups. The intermediate group should be seen as having a poor, but not necessarily hopeless prognosis. These cases may benefit particularly from adjuvant chemotherapy, but this should not be used as an excuse to deny the patient adequate local measures, which alone (at present) offer hope of cure. The problem posed by the third group should be seen as one of optimal palliation.
Adjuvant systemic therapy raises hope of improving results, but no patient with breast cancer has yet been cured by chemotherapy or the application of immunological principles. Future improvements are most likely to derive from optimal use of each modality, and not at the expense of the most effective method at present available–radical surgery. The many remaining questions regarding management can best be answered by careful, controlled clinical studies, and every effort should be made to include patients with a poor prognosis in appropriate clinical trials.