I patients with operable breast cancer, is it wise to perform prophylactic castration as an adjunct to mastectomy or is it wiser to perform therapeutic castration at a later date, if needed, for the treatment of metastasesP This is, indeed, the physician's dilemma! Is the wisdom of prophylactic castration an irrationally held truth or is it more likely to be a carefully reasoned error. As long as the practice of medicine continues to be, as Osler said, "a science of uncertainty and an art of probability," then the appropriate treatment for the appropriate patient must tremble in the balance of our clinical judgment.
What are the scientific facts and what are the current guidelines for determining the best total treatment policy for premenopausal patients with operable breast cancer? In young women with this monstrously destructive disease is the future too important to be left to tomorrow?
Ovarian hormones are known to have a profound effect upon certain hormone-sensitive tumors of the breast. T h e remarkable response of some breast cancers to therapeutic castration is impressive evidence in support of this concept. A young woman of 35 with extensive bone metastases secondary to a large and inoperable breast cancer was surgically castrated. She has had at this time a striking 4-year remission of her widespread disease following oophorectomy as the one and only form of systemic treatment. This gratifying palliative effect is probably the result of a reduction in estrogenic activity below an unknown but highly critical level.
Confirmation of the importance of this change in the endocrine milieu on breast cancer is to be found in the recent report of Feinleib4 of Harvard. In this very convincing cohort study of the occurrence of breast cancer in 6,908 women undergoing an artificial