This month, I’m continuing to resurrect memories from the 19th National Conference on Breast Cancer, held in 1981 (Never heard of this conference?…check out last month’s blog — March 2019). This interdisciplinary breast cancer meeting began its run in 1962, long before San Antonio (1977), but never made it to today’s line-up. Best I can tell, it switched from annual meetings to biennial, then later merged with other American College of Radiology activities. Nevertheless, I was there 38 years ago, completely ignorant of everything being presented.
Surgical approaches were all over the map. Recall that the NSABP B-06 had not yet reported their results in 1981, so lumpectomy was not a “given” by any stretch. Mastectomy still ruled. However, the Italians were there, talking about QUART (quadrantectomy, axillary dissection and radiation therapy) in the Milan I trial, a shocking concept for those of us who only had one tool in the box – mastectomy. I don’t recall if Veronesi was the presenter or not (I wouldn’t have known Umberto from Adam anyway), but at a minimum, a member of his team showed how a surgeon could conserve the breast with relative ease (preferably, with the lesion in the UOQ, given that the approach was still en bloc resection of tumor with nodes, if possible).
Veronesi et al would beat the NSABP to the punch by publishing their initial results for Milan I in the NEJM three months after I heard their presentation in 1981 – in brief, claiming survival equivalency. I suppose Bernie Fisher was forever galled that he was not “first,” given that he had originated the groundwork for conservation, had tested the underlying principles (e.g., “common vascular channel theory”) in the lab using rat models, and had carefully prepared a scientific approach to proving his “Alternative Theory” using prospective, randomized clinical trials that had already injured Halstedians with the B-04 trial – whew! – all of his efforts beginning in the 1950s. In contrast, Veronesi had been in the extended radical camp shortly before he decided to switch to QUART, a concept still grounded in Halstedian principles. As I would understand many years later, it was the closest thing to industrial sabotage in the world of breast cancer at the time (comparable to Christiaan Barnard slipping in that first heart transplant wherein the patient lived 18 days, while Norman Shumway at Stanford spent a career in preparation for a safe and successful “first” transplant, only to end up in second place).
Although the conference sponsors did not include a single surgical society, some of the big names were there, mostly defending the modified radical mastectomy as a replacement for the Halsted radical. But there were also proponents of “ultra-radical” or “extended radical” or “super-radical mastectomies” where it was believed that Halsted was correct about the biology of breast cancer, but he simply didn’t take it far enough. Those pesky internal mammary nodes needed en bloc chest wall resection, and darned if that clavicle doesn’t get in the way when trying to remove those supraclavicular nodes.
A French plastic surgeon wearing a white suit and a dashing persona, confidently explained that breast cancer was a bilateral disease, and the only procedure that was ever appropriate was bilateral mastectomy, along with bilateral reconstruction. The premise of his argument was that microscopic cancers could be identified with regularity on the opposite side. Few at that time considered that pathology findings might not correlate exactly with the emergence of clinical disease. Having seen this issue argued (in several organ systems) during my surgical pathology fellowship at UCLA (1977-78), I was not tricked. Still, it was a thought-provoking presentation, squelched to a degree by marginal cosmesis with the reconstructions of the day.
Last month, I mentioned the Rube Goldberg apparatus that filled a room, all for the purpose of bilateral screening ultrasound, with the patient lying face down and her breasts submerged in a pool of gel. It would be more than 30 years before this concept of “whole breast” ultrasound made it into the clinic. Nevertheless, I saw the pre-pre-prototype. Breast imaging was HUGE at this conference. Mammography was considered a brand new test, barely proven, so it should be no surprise that competing forms of imaging were discussed at great length.
For instance, thermography and its various iterations was a popular topic, even though the technology had been condemned already by the American College of Radiology. The huge BCDDP was still in progress, testing the feasibility of mass population screening, initially with both mammography and thermography. But results had been so poor with thermography that it had been deleted from the BCDDP before completion of the study. Yet, here we were, 3 years after thermograms had been kicked out of the BCDDP, and all sorts of heat-seeking missiles were being proposed.
The most bizarre, I recall, was a bra with built-in heat sensors that changed color like a mood ring when the breast heated up focally, identifying a problem and narrowing it to one quadrant. There was precious little data to support its use, even in that era when it might be said that data was optional. And when an audience member attacked the speaker as being outrageously premature at best, unethical at worst (my words, but you get the picture…she was angry at the speaker for his deplorable science), the inventor finally stormed off the stage with his bra, stating: “Well, it doesn’t matter what you say, these things will be available in stores next month, and we’ve already planned a huge marketing campaign.” Catcalls followed. (We might have been in the dark ages, but the absence of light was remarkably colorful.)
You may or may not be aware that this concept of a “mood ring” bra never went away (Google “thermography bra”). Just last month, a patient of mine asked me to look at a device that was being proposed to her company (she was in charge of employee health) as a disc to be placed inside a bra, with several strips of plastic radiating from the center, another “mood ring” approach. It was the exact concept I’d seen presented at the Hotel Del nearly 40 years ago. It is noteworthy that the FDA recently had to yell “Stop” to the thermography powerbrokers who, having failed to convince the medical community, were planting their devices in spas and resorts. In a way, it’s a shame. It’s always possible that the technology will evolve into something useful, but the bias against thermography is so powerful now due to its sneaky attempts at introduction that I don’t think a valid approach would ever get a fair shake (nor would it likely add anything to the multi-modality approaches already available).
By far, the most vivid memory I have from the Hotel Del Coronado in 1981 is that of a female audience member standing up in the middle of the crowd to interrupt a speaker, and chewing him out to the point that he could barely continue. Never saw it before. Never seen it since. She made the anti-mood-ring-bra protestor seem like a wimp. Here’s how it went down:
Oddly enough, in these prehistoric days of breast cancer management, at the dawn of the revolution, male presenters (which were the overwhelming majority) would sometimes begin their talks with 35mm slides showing “artsy” breast photos. I don’t know…maybe they still do at plastic surgery meetings. But the practice has dwindled away over the years, as men became gradually sensitized to the fact that breast adulation walks a tightrope over the pit of junior high jokes. But it was so common back then that it was nearly the norm — the introductory slide would show marble breasts from a nude sculpture (at best) or a sexy actress in a low-cut top (at worst). But what I witnessed at the Hotel Del was the worst of the worst.
An older physician (who clearly had no time to contemplate anachronisms) opened his presentation with a cartoon review of breast shapes and sizes, each with a specific tag. Imagine a window-paned backdrop, containing perhaps 16 frames, each with a different breast shape, and each with its own moniker. If he had only zipped through the slide quickly, he might have made it to safety, but instead, he chose to read the “funny” names one by one.
About 3 or 4 breasts into the frivolity, a woman rose above the sea of bodies and began yelling at the speaker. I couldn’t understand her at first, as the caveman kept the hilarity going for a moment until she could be ignored no longer. After the room turned deadly silent, this was what rang out: “I can’t believe that we’re sitting here trying to defeat a disease that is killing thousands and thousands of women every year, and you’re up there like a school boy making a mockery of women and their breasts, turning our deaths into a X#!X! joke.” She followed this with a litany of insulting adjectives. I almost felt sorry for the poor guy, blindsided by 1981, completely oblivious that the 20th century had arrived and that women were making a most unusual claim – that they should be treated respectfully and as equals to men. The poor old soul just hung his head, apologized and tried to continue. (I don’t even remember his topic.)
One thing for sure – after that, I never made a joke about breasts, either through slide presentations or conversations. Not even a casual or slang reference. I never used a work of art to open a talk, and I certainly never used a busty actress. I didn’t even try to slip by, like some were doing, with various double-mound formations that occur in nature. Once, a medical oncologist gave me a slide he’d taken in Europe, a road sign with no words, just a drawing that warned motorists about two bumps in the road that were coming up soon – I never used the slide. In short, that woman at the Hotel Del nearly 40 years ago, whoever she was, scared the bejesus out of me.
Next month – Before the Hotel Del – Part 3
Early Breast Cancer 