Experience and practice in Canada

40-50 years ago our standard treatment was a Halstead type radical mastectomy.In the early 60’s Mr. Whirter, from Edinburgh, introduced simple mastectomyand radiation.In the late 60’s Sir Arthur Porritt, at St. Mary’s Hospital in London, carried outlumpectomy (breast conserving) and radiation.In Ontario, Canada, until the mid 80’s, our standard management was modifiedradical mastectomy.Lumpectomy and radiation then became an acceptable alternative forappropriate cases.At this time screening mammography was introduced in our province, Ontario,for all females aged 50 and over every 2 years.This increased our supply (number) of breast cancer patients. Initially, wewould carry out wire localized lumpectomy for diagnosis in these unpalpablelesions. For the first year or so, about 25% were cancer. Our management wasto offer auxiliary gland dissection and radiation - or mastectomy and glanddissection in positive cases.Although conservative surgery is offered, probably50% elect to have a mastectomy.In the last 5 years, sentinal node biopsy has become the standard initial glandmanagement in Ontario.In the last 2 years image guided biopsy has to some extent replaced guidedlumpectomy for diagnosis.In our hospital for unpalpable lesions our patients, on day of surgery, have totravel to a larger hospital 150kms. away and have an image guided wire insertedand radio-active material. They then return the 150kms. to us for surgery.For lumpectomy, we carry out a wide excision in order to avoid repeat surgeryas we do not have access to frozen section.Our sentinal node surgery is asstandard.When we carry out a mastectomy, this is a standard extended simplemastectomy through a fusiform incision from sternal border to mid axillaryline. Our flap dissection is carried out with a Harmonic Scalpel. If indicated, alimited LN dissection is carried out through the same incision. We no longerdissect high into the axilla i.e. beyond the lower border of the pectoris minor.We use 2 vacuum drains in all mastectomy wounds. And our patients stay inhospital, usually, 2 nights.All our cancer patients are referred to our regional cancer hospital, 150kms tothe east, where they are seen by radiation and medical oncologists.