Chapter 5: Breast Anesthesia

“In God we trust, all others must have data”

-Dr. Bernard Fisher


Breast cancer was first considered a curable surgical disease. In 1882 William Halsted, the Surgeon-in-Chief at the newly founded Johns Hopkins Hospital, performed the first radical mastectomy. In this operation the surgeon removed the breast tissue, axillary lymph nodes, and underlying muscle tissue. In subsequent decades other surgeons removed additional anatomical structures like ribs, the clavicle, part of the sternum, internal mammary lymph nodes, and the latissimus dorsi muscle. The word radical means “root” in Latin. Halsted thought by taking more tissue he was treating the “root” of the disease. He believed in the Centrifugal Theory of Cancer: cancer spreads locally like a pinwheel from its origin, therefore resecting more tissue means more cures. However, data showed more extreme surgeries did not cure more breast cancer, but they did horribly disfigure women, leaving them with permanent disability and painful complications

The Radical Mastectomy

In 1924 Dr. Geoffrey Keynes, a young physician in London, took a different approach. He was consulted for a ulcerating malignant lump in breast of a 47 year old thin, frail woman. He was concerned she would not survive the radical mastectomy. Instead he tried a more conservative approach: he buried 50mg of radium in her breast. Over the subsequent months the mass became smaller, softer, and less fixed to the underlying breast tissue. Keynes thought this smaller tumor could be resected without taking the breast or underlying tissue. Over the next 3 years he showed his cancer recurrence rates were at least comparable to the radical mastectomy. When he presented his data, Halstedian surgeons mockingly called his smaller surgical procedure a “lumpectomy”.

Dr. Keynes was largely forgotten until 1953 when Dr. George Crile of the Cleveland Clinic learned about him while on sabbatical in London. He reproduced Keynes’ results over 6 years in the United States. Surgeons began to seriously question Halsted’s Centrifugal Theory of Cancer. By the late 1960s the culture of medicine was also changing- society now demanded accountability for physician decision-making. In 1967 Dr. Bernard Fisher became chair of the National Surgical Adjuvant Breast and Bowel Project, a consortium of universities working together to design large scale clinical trials for breast cancer. Their first study’s results were made public in 1981: it showed breast cancer recurrence over 10 years was identical for radiation + lumpectomy and radical mastectomy. Turns our Dr. Geoffrey Keynes was correct.

The next 40 years of breast cancer research focused on treating breast cancer without harming women. In 1991 Dr. Armando Giuliano showed sentinel lymph node biopsy was just as effective as axillary dissection. That means women could have a single lymph node removed in a smaller surgery instead of a surgical exploration. This resulted in fewer complications, less pain, and reduced risk lymphatic arm swelling. I had the honor and privilege of working with him in the operating room several times in my residency. His kindness, engagement, and enthusiasm betray his age. Myself and my colleagues agree he is the only surgeon with the charisma to convince women a sentinel lymph node biopsy was just as good as an axillary dissection.

Breast Biopsy and axillary dissection

Today breast cancer treatment is a multidisciplinary discussion between the patient,medical oncologists, surgical oncologists, radiation oncologists, and laboratory scientists. Biological research into the cellular basis of cancer has transformed breast cancer treatment. Now we can individualize chemoradiation regimens and immunotherapy to precisely target breast cancer subtypes. The American Cancer Society recently reported breast cancer mortality has decreased 39% between 1989 and 2015.1

Anesthesiology also plays a role in breast cancer treatment. Anesthesia for breast surgery focuses on treating pain and preventing nausea.

As more breast cancer patients survive they will require medical care. Chronic pain is a significant problem in this patient population, affecting up to 80% of survivors. Risk factors for chronic pain after breast cancer surgery are obesity, young age, previous radiation, preoperative anxiety/depression, high pre and post-operative pain scores, and axillary dissection. Controlling perioperative pain may play a significant role in the quality of life of these patients after they survive cancer.

Young women are very susceptible to post-operative nausea and vomiting (PONV) from opioids and anesthetic gas. I find preemptive pain management utilizing a multimodal analgesic technique allows me to use less, if not no, opioids. I give an extra anti-emetic medication before surgery, then choose anesthetics that decrease PONV. During surgery I utilize ketamine for analgesia. Ketamine, given prior to incision in spine surgery, may decrease the incidence of chronic pain up to a year after spine surgery. Emerging evidence suggests it can prevent the transition from acute pain to chronic pain by inhibiting specialized neurons in the spinal cord and/or brain. Research is ongoing to fully understand who is most likely to benefit from its unique pharmacology.

After surgery is over I extubate patients deep in stage III of anesthesia then allow them to slowly emerge without choking on their breathing tube. Furthermore the use of regional anesthesia, which is using numbing medication like lidocaine to numb nerves, may further decrease the chronic pain experienced by breast cancer survivors.3 In the future anesthesiologists will likely play a significant role in prevention of chronic pain in breast cancer survivors.


Footnotes:

  1. My brief history of breast cancer is derived from pages 193-226 of Siddhartha Mukherjee’s book “The Emperor of All Maladies: A Biography of Cancer” published in 2010. I also summarized the advancements in breast cancer articulated by Drs. Stefano Zurrida and Umberto Veronesi in their 2014 article: “Milestones in Breast Cancer Treatment”. The American Cancer Society statistic was retrieved on July 4, 2020. It can be found here: https://www.cancer.org/latest-news/report-breast-cancer-death-rates-down-39-percent-since-1989.html
  2. I synthesized knowledge from my colleagues and my own literature search. My risk factors were derived from “Predictors of Persistent Pain After Breast Cancer Surgery: A Systematic Review and Meta-Analysis of Observational Studies” By Li Wang, MD; Et al. One article I found relating to breast surgery was: “Chronic Pain Following Cosmetic Breast Surgery: A Comprehensive Review” By: Ivan Urits, Md; Et al. Although breast cancer surgery is different from cosmetic breast surgery techniques might transfer between the two fields.
  3. Paravertebral blocks may become more prominent in the future of breast surgery. One article I found was “Thoracic Paravertebral Block Reduced the Incidence of Chronic Postoperative Pain for More than 1 Year After Breast Cancer Surgery” By: Hiroki Shimizu, MD; Et al

Published by Nabil

Nabil Othman, MD is an anesthesiology resident physician at Cedars Sinai Medical Center in Los Angeles, CA. As a Michigan native he advocates calling carbonated, sugary beverages "pop". When he is not an indentured servant in the hospital he enjoys CrossFit, telling everyone he meets about CrossFit, and attempting dangerous hikes in Hawaii with his college roommates.

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