The Most Feared of Tumors

Of the hundreds of malignancies that afflict the human race, cancer of the female breast is perhaps the most widely feared. In the U.S. alone, 90,000 new cases will be diagnosed this year and 33,000 women will die of the disease. The American Cancer Society estimates that 1 woman out of every 15 will develop it. But although doctors still argue over the best ways of detecting and treating breast cancer, the statistics are not all unfavorable: of patients whose disease is detected as early as was Betty Ford's and who undergo such prompt surgery, as many as 75% to 90% are still well (no medical man will say "cured") ten years after their operation.

Unlike some malignancies that are triggered by the action of certain chemicals, notably lung and bladder cancers, breast cancer has no simple, identifiable cause. It is most common among women who have not borne or nursed children and a tendency to develop it appears to run in families. Breast cancer may strike before or after the menopause, but Dr. Arthur I. Holleb, chief medical officer of the A.C.S., believes that age as such is far less significant in the patient's prognosis than the stage at which the disease is diagnosed.

On this score, Betty Ford was a near-ideal patient. She was in otherwise good health and far from overweight. She had not taken any of the hypertension medications that have just been linked with increased risk of breast cancer (see MEDICINE). True, she had not detected the lump in her breast by self-examination, which might have prevented a delay of days or weeks. But when a lump was found in her routine checkup at Bethesda Naval Medical Center, she consented to immediate exploratory surgery, with the all-important proviso that if malignancy was detected, the doctors could remove the breast.

Her surgeon, Ohio-born Captain William J. Fouty, has specialized in female and pediatric surgery since he made Navy medicine his career. He has performed hundreds of mastectomies. After the anesthesiologist gave the go-ahead at 8:05 a.m., Fouty cut into the breast and within about ten minutes had removed the lump. It proved to be 2 cm. in circumference--no bigger than the tip of a man's little finger. A technician rushed the lump to the pathology department, where it was fast-frozen with liquid nitrogen. A thin slice was cut, which a pathologist examined under a microscope. Within five minutes the message was relayed to Fouty: malignant cells. In a 2 1/2-hour procedure, Fouty removed the entire right breast, its underlying pectoral muscle, and lymphoid tissue in the adjacent armpit. This tissue was also sent to pathology. Because it takes three or four days to process the lymphoid tissue for microscopic examination, it will not be known until later this week whether Betty Ford's cancer had already spread to some extent. If it had, her doctors may prescribe radiation, or medication, including hormones, alone or in combination with radiation.

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By happenstance, the leading U.S. authorities on breast-cancer detection and treatment are meeting at the National Cancer Institute, just across Rockville Pike from Betty Ford's suite at the Naval Medical Center. They are deep in debate over what operation should be performed in cases like Betty Ford's. One conservative school argues that only the lump need be removed (lumpectomy), or at most, the breast tissue surrounding it (simple mastectomy). Surgeon Fouty chose the course now approved by the great majority of U.S. breast surgeons: a radical mastectomy.

He stopped short of the supra-radical operation, in which lymph nodes under the breastbone are removed. These are less likely to be involved in situations similar to the First Lady's, in which the cancerous lump was on the outer, upper aspect of the breast, toward the arm. The argument over the best way to treat breast cancer cases like Betty Ford's is likely to continue long after she recuperates.

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