A Pathologist Views Diagnosis and Prognosis of Carcinoma of the Breast

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Abstract
The surgical pathologist studies submitted tissue specimens with two objectives. The first is correct diagnosis or description. In this Symposium, the diagnosis of mammary carcinoma will be taken for granted. The histologic diagnosis is straightforward in 95 per cent of the cases, and frozen-section diagnosis with practically perfect accuracy is commonplace in interested laboratories. We shall consider the infiltrating duct carcinoma, or scirrhous carcinoma, as the prototypetumor. Unless otherwise stated, the large series quoted usually group all histologic types under the collective term, carcinoma; only occasionally are special groups described. A second objective of the pathologist is to offer relevant prognostic information based on the biopsy and whatever material may be received subsequently. Significant prognostic data are available for mammary carcinoma, and these will be presented with the following constraints in mind: 1. Individual prognosis is impossible, especially in breast carcinoma. Long as well as short survival in the face of widely disseminated metastasis is well known. We offer only the more probable paths the disease will follow, hopefully to be contradicted occasionally in the grave cases. The term “survival” is preferred to “cure” ; even a happy ten-year follow-up may end in local or distant, fatal reappearance of disease. 2. Two factors combine to determine outlook: the state of the patient and the type of therapy. This paper will discuss therapy only rarely, and the series to be offered come from institutions performing conventional radical mastectomy, usually with postoperative radiation. There is no thicker statistical jungle than that confronting the student of breast-cancer therapy: he is beset on one side by various, often undescribed, clinical selection methods, and on the other by lack of operative details (especially concerning degree of axillary excision) and radiation factors. Only recently have we begun to see studies based on clinically comparable groups treated by different methods (2). Furthermore, clinical classifications will not be used in discussion of prognostic factors; this must not be construed as an opinion that they have no value; the pathologist simply does not see many of these factors in his material (2, 3). 3. A study of survival must naturally include causes of death operating independently of the tumor: the actuarial risk of any age group. Such a survey, representative of many large series, is shown in Figure 1. The serious losses consequent to axillary metastases are obvious, and the figures of this large, long-term series may be used as a representative group of the breast cancer problem (4). The five-year survival without metastasis is 75 per cent, falling to 30 per cent if metastases are present. After ten years, the curves roughly parallel the actuarial one. The patient's risk of dying then is no greater than that of her cohorts without breast cancer.

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