Major problems in clinical surgery最新文献

Cancer of the male breast is infrequent but not rare. In contrast to women, men are generally older at its onset and present with more advanced cancers. In comparable circumstances, they are probably equally curable with radical surgery. The tumor is sensitive to irradiation and often responds to endocrine ablations, making the latter exceptionally useful for palliation of systemic metastases. Hormones and chemotherapy can also be beneficial.

Screening is a more complicated issue than has been indicated in this chapter. Long-term followup is essential to exclude misleading initial impressions, and survival predictions must stand this test. The problem of interval cancers must be acknowledged, and methods of developing more cost-effective systems that might provide even broader coverage of the population at risk have to be considered. Suffice it to say that mass screening for breast cancer can be accomplished. Large numbers of American women are sufficiently concerned about this disease to participate, as evidenced by the success of the National Cancer Institute/American Cancer Society Breast Cancer Detection Demonstration Projects. It has been demonstrated that breast cancers so small that they would previously be considered a pathological curiosity are detected with surprising frequency. The ultimate effect on survival time by this screening can of course only be determined after passage of time, but there is every reason to believe that it represents one of the really great advances in detection-diagnosis in recent history. The chief detection modality is mammography, and it is to be expected that technological advances in this area will permit images of even greater reliability and resolution at a level of radiation exposure that will be acceptable to everyone. The definitive role of thermography in detection of breast disease has yet to be fully determined. The maximal scientific benefit and the true impact of the screening demonstration projects will be realized only after long-term followup of the 280,000 participants.

Among premenopausal women approximately 7 per cent of newly diagnosed breast cancers are accompanied by pregnancy, with most patients being in the fourth decade of life. The prognosis of these patients, and of those whose cancers are diagnosed soon after pregnancy, is generally less favorable than that of nonpregnant females, but if age and stage of disease are comparable, pregnancy per se has little influence upon prognosis. Mastectomy is as effective for pregnant patients as for others and the chance of spontaneous abortion is small. Therapeutic abortion does not improve the chances for cure of patients with clinically localized cancer. Effective endocrine therapy or chemotherapy for advanced or disseminated breast cancer does require therapeutic abortion, and an early pregnancy is best terminated without delay. For pregnancies near term the decision depends greatly upon the desire of the patient for a child. Unless therapeutic needs are urgent, intervention can often be delayed temporarily without significant deterioration of the patient. Pregnancies subsequent to a mastectomy have little bearing upon continued well-being, and as long as the patient is clinically free of cancer no therapeutic benefit can be expected from interrupting them. A decision for future pregnancies should be individualized with due regard for the risk of recurrence and the desirability of completing one's family while still reasonably young. Progress with the treatment of breast cancer depends in part upon the appreciation that cancers do occur during pregnancy and lactation, that they are best diagnosed early and that they are curable. Pregnancy should neither deter a prompt diagnosis nor delay definitive treatment.