NTIL A LITTLE OVER 30 YEARS AGO, CANCER U of the breast appeared to pose few conceptual difficulties for the average clinical ob- server. Here was a superficially placed and easily observed malignant lesion that was believed to move in orderly progression from a microscopic change in mammary tissue, through a phase of clinically palpable tumor, and eventually a sojourn of varying duration in the axillary lymph nodes before invading the bloodstream. Caught by the surgeon before it shunned the temporary hospitality of the lymph nodes, and correctly treated, the disease could be eradicated and the patient cured.
Furthermore, the choice of treatment offered n o real dilemma. Since the turn of the century, radical mastectomy had been an established procedure; indeed it was the perfect operation for cancer.
T h e change that has taken place in the last 3 decades is surely remarkable, therefore. It was heralded by growing disquiet about the poor overall survival rates, and, in particular, by our failure to cure some patients with disease apparently confined to the breast, and many with easily removable nodes in the axilla. A fresh look at its natural history and behavior was, therefore, imperative, more especially since a new weapon had become available in the shape of radiotherapy.
T h e new look at the disease-and its management-has continued unabated until now. I t has inspired millions of written and spoken words, some of them significant; and stimulated millions of man hours, some of them useful, on the part of pathologists, clinicians, and statisticians. It has engendered controversy, vituperation, contumely-and even vilification. Today, the cynic can point to the confusion that has arisen; and, in both North America and the United Kingdom, the number of women dying of breast cancer has been remarkably constant over the years. In fact,