Medicine: Urban’s Double Check

When a woman has had one breast removed for cancer, her risk of developing a malignancy in her remaining breast is only about 1% in each of the next ten years. The likelihood that she will have cancer simultaneously in both breasts is even less. Last week Margaretta (“Happy”) Rockefeller found that the law of averages had discriminated most cruelly against her: only five weeks after undergoing a radical mastectomy for cancer in the left breast, she had her right breast removed by less drastic surgery to eliminate a minuscule cancer that had been present but undetected at the time of her first operation.

At that, the wife of the Vice President-designate may well have been fortunate; early detection of her second cancerous growth greatly increased her chances for a long life. Discovery of the second malignancy would have been delayed—probably for many months—were it not for a technique developed by her surgeon, Dr. Jerome A. Urban, acting chief of the breast service at Manhattan’s Memorial Sloan-Kettering Cancer Center. Urban decided a dozen years ago that it might sometimes be wise during a mastectomy to take a sample of tissue (biopsy) from the corresponding position on the other breast and check that for the possibility of what doctors call bilateral disease. Over the years, Urban has followed this practice in about 80% of the approximately 1,200 mastectomies he has performed, withholding it only if the patient is infirm or too ill from advanced cancer or other disease.

When he removed Happy Rockefeller’s left breast, Urban cut out a thin wedge of tissue above her right nipple and sent this to the pathology laboratory, where part of it was immediately fast-frozen and sliced paper thin. The microscope gave no clear indication of cancer in this test, which was completed while the patient was still on the operating table. So Urban had no reason to cut farther. But the remainder of the tissue was fixed in paraffin for more detailed examination—a process that takes 24 hours or more. Next day, the more clearly stained paraffin sections revealed a group of cancerous cells about the size of two pinheads.

Then it was both too late and too early to remove the right breast—too late because the operation was over and too soon because the patient was in the early stages of convalescence and slightly anemic. Urban told Nelson Rockefeller the facts, and they agreed to withhold the word from Happy until she was well enough to undergo a second operation.

They broke the news to her two weeks ago, and with the stoicism that she has consistently displayed, she agreed to the date for last week’s operation.

Traditional Caution. The surgery was not a rerun radical mastectomy.

With the cancer apparently confined to so tiny a nodule, Urban needed to remove only the breast tissue itself, leaving intact the underlying muscle and adjacent tissue in the armpit. To be on the safe side, he sent lymph nodes from inside the breast for paraffin fixing and more microscopy, which proved negative as expected. Despite the surgeon’s traditional caution, Urban felt free to say, “We honestly believe Mrs. Rockefeller is cancer free now, and will be free.”

Some surgeons have been reluctant to follow Urban’s lead in routinely taking an opposite-breast biopsy; they note that if the biopsy reveals no need for further surgery, it leaves scar tissue that makes later diagnosis by mammography difficult, if not impossible. But Happy Rockefeller’s latest and widely publicized operation may well result in many more surgeons opting for Urban’s technique.