A recent history of breast cancer treatments

When William Stewart Halsted (1852-1922) published his results in 1894, he established the first standardized treatment for breast cancer: the radical mastectomy. Guided by the belief that cancer spread centrifugally from the breast outward, Halsted removed the breast, pectoral muscles and axillary lymph nodes in a single en bloc operation. In a world without imaging, radiotherapy or systemic therapies, local eradication became synonymous with cure. Halsted’s operation, backed by his authority at Johns Hopkins, shaped surgical thinking for more than half a century.

But the cost was devastating. Radical mastectomy produced disfigurement, chronic pain, lymphedema and permanent functional damage. Patients lived with their illness carved into their bodies, a trauma that medicine did not yet have the language to acknowledge, let alone treat. The procedure reflected an era of paternalism in which the surgeon’s role was to act, not to listen, and survival was considered separately from identity, intimacy and self-perception. The woman disappeared behind the disease. Still, with no alternative strategies available at the time, Halsted’s approach was celebrated as rigorous, scientific and life-saving.

Bernard Fisher and the systemic disease paradigm

By the mid-twentieth century, cracks appeared in the Halstedian dogma. Metastatic relapse occurred even after “perfect” surgery, and pathological studies revealed early dissemination beyond the breast. Bernard Fisher (1918-2019) transformed these observations into a revolutionary hypothesis: breast cancer is a systemic disease from its inception, not merely a local process. If true, more radical surgery could never prevent recurrence, and escalation was not the answer.

Fisher’s work through the National Surgical Adjuvant Breast and Bowel Project (NSABP) reshaped both oncology and clinical science. His randomized trials (a groundbreaking concept for surgery at the time) demonstrated that radical mastectomy offered no survival advantage over breast-conserving approaches. In doing so, Fisher not only changed breast cancer treatment but accelerated the rise of Evidence-Based Medicine, replacing hierarchy with data and shifting the question from “How much can we remove?” to “What truly improves survival?”.

This conceptual shift re-centered breast cancer management on systemic control: endocrine therapy, chemotherapy and, later, targeted drugs. For the first time, surgery became one element of an integrated strategy, not a solitary weapon.

Psychological impact of breast cancer treatments

While the scientific paradigm evolved, another truth emerged: breast cancer is not only a biological event, but a psychological, relational and existential one. Mastectomy alters body image, identity and sexuality. Clinical studies show high rates of distress related to scars, asymmetry and changes in self-perception, with consequences on confidence, relationships and intimate life. Women frequently describe a sense of violated femininity, a disconnection from their own bodies and fear of rejection, even in stable partnerships.

Chemotherapy adds its own burden. Alopecia, repeatedly identified in psycho-oncology literature as one of the most traumatic treatment effects, functions as a public marker of illness. Unlike internal toxicities, hair loss is visible, stripping away privacy, control and normalcy. Its psychological impact correlates with anxiety, depressive symptoms and social withdrawal, sometimes more than the physical side-effects themselves.

Modern care has begun to address this dimension: oncoplastic techniques, immediate reconstruction, scalp-cooling systems, sexual-health counseling and structured psycho-oncological support now form part of comprehensive treatment. The lesson is undeniable: treating breast cancer means treating the person, and ignoring the psyche leads to incomplete care.

Veronesi and the rise of breast-conserving surgery

If Fisher dismantled radical surgery, Umberto Veronesi (1925-2016) built the future. In the 1970s, Veronesi challenged the entrenched belief that “more” surgery meant “better” outcomes. His landmark Milan trials introduced quadrantectomy with radiotherapy, demonstrating, years before most surgeons were ready to accept it, that conserving the breast did not compromise survival. When long-term results, later published in The New England Journal of Medicine, confirmed that breast-conserving surgery offered equivalent survival to radical mastectomy, a historical pivot became irreversible.

But Veronesi’s revolution was not simply technical: it was anthropological. He openly stated that mutilation was a failure of medicine, not a necessity, and that the aim of therapy must be to “save a woman, not just remove a tumor.” For the first time, oncologic effectiveness and bodily integrity were recognized as co-priorities, not mutually exclusive goals. The breast was reframed as part of identity, sexuality and self-image, and not merely as an organ to sacrifice in the name of survival. This shift redefined success: no longer measured only in recurrence curves, but also in the preservation of dignity.

Moreover, Veronesi’s model paved the way for true multimodality. Radiotherapy was no longer an adjunct but an integral partner in local control. Oncoplastic surgery later expanded this philosophy, merging oncologic safety with aesthetic and psychological well-being. Shared decision-making and quality-of-life endpoints entered clinical research and guidelines, influencing international protocols for decades to come. In essence, Veronesi did not just change an operation: he changed the meaning of cure, anchoring modern breast cancer care in a balance between science and humanity.

From endocrine therapy to targeted treatments

While surgery evolved toward conservation, systemic therapy ushered in a new biological era. Tamoxifen revolutionized hormone-receptor–positive disease, proving that blocking endocrine pathways could extend survival and prevent recurrence. In the late 1990s, trastuzumab transformed HER2-positive breast cancer from one of the most aggressive subtypes into one of oncology’s greatest success stories.

The trajectory has since accelerated. Precision oncology now guides treatment decisions based on molecular signatures rather than anatomy alone. Antibody-drug conjugates (ADCs) represent the newest evolution, delivering cytotoxic agents directly to cancer cells while sparing healthy tissue. ADCs such as trastuzumab deruxtecan have expanded the therapeutic landscape even for HER2-low disease a category once considered orphan of targeted options.

Breast cancer has thus become a blueprint for the integration of local and systemic therapy: surgery for local control, radiotherapy for consolidation, and drugs designed to silence the biological drivers of disease. The question is no longer “How much should we remove?” but rather “Which pathway must we block to restore control?”.

Toward a humane and precise future

Modern breast cancer care stands on the shoulders of this history. Screening is moving toward risk-adapted strategies rather than uniform schedules. Surgery is increasingly conservative and reconstructive. Systemic therapy is tailored to tumor biology. Psycho-oncology is integral to care, not ornamental. The trajectory from Halsted to targeted therapy reveals a unifying lesson: the science advanced when medicine learned to humanize the body it aimed to save.

The future pushes this arc further, toward precision medicine grounded in empathy. Genomics, immunotherapy and next-generation ADCs will continue to refine survival outcomes, but the true measure of progress will be the ability to deliver cures that preserve identity, dignity and wholeness. Breast cancer no longer demands the sacrifice of the body to save life. The next frontier is ensuring that every woman emerges not only alive, but intact in mind, body and self.

Halsted WS. I. The Results of Operations for the Cure of Cancer of the Breast Performed at the Johns Hopkins Hospital from June, 1889, to January, 1894. Ann Surg. 1894 Nov;20(5):497-555. doi: 10.1097/00000658-189407000-00075. PMID: 17860107; PMCID: PMC1493925.
Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, Jeong JH, Wolmark N. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002 Oct 17;347(16):1233-41. doi: 10.1056/NEJMoa022152. PMID: 12393820.
Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, Aguilar M, Marubini E. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002 Oct 17;347(16):1227-32. doi: 10.1056/NEJMoa020989. PMID: 12393819.
DeVita VT Jr, Rosenberg SA. Two hundred years of cancer research. N Engl J Med. 2012 Jun 7;366(23):2207-14. doi: 10.1056/NEJMra1204479. Epub 2012 May 30. PMID: 22646510; PMCID: PMC6293471.
Slamon DJ, Leyland-Jones B, Shak S, Fuchs H, Paton V, Bajamonde A, Fleming T, Eiermann W, Wolter J, Pegram M, Baselga J, Norton L. Use of chemotherapy plus a monoclonal antibody against HER2 for metastatic breast cancer that overexpresses HER2. N Engl J Med. 2001 Mar 15;344(11):783-92. doi: 10.1056/NEJM200103153441101. PMID: 11248153.
Modi S, Jacot W, Yamashita T, Sohn J, Vidal M, Tokunaga E, Tsurutani J, Ueno NT, Prat A, Chae YS, Lee KS, Niikura N, Park YH, Xu B, Wang X, Gil-Gil M, Li W, Pierga JY, Im SA, Moore HCF, Rugo HS, Yerushalmi R, Zagouri F, Gombos A, Kim SB, Liu Q, Luo T, Saura C, Schmid P, Sun T, Gambhire D, Yung L, Wang Y, Singh J, Vitazka P, Meinhardt G, Harbeck N, Cameron DA; DESTINY-Breast04 Trial Investigators. Trastuzumab Deruxtecan in Previously Treated HER2-Low Advanced Breast Cancer. N Engl J Med. 2022 Jul 7;387(1):9-20. doi: 10.1056/NEJMoa2203690. Epub 2022 Jun 5. PMID: 35665782; PMCID: PMC10561652.
Kocan S, Aktug C, Gursoy A. "Who am I?" A qualitative meta-synthesis of Chemotherapy-induced alopecia and body image perception in breast cancer patients. Support Care Cancer. 2023 Mar 28;31(4):237. doi: 10.1007/s00520-023-07704-8. PMID: 36973593.
Ye M, Du K, Zhou J, Zhou Q, Shou M, Hu B, Jiang P, Dong N, He L, Liang S, Yu C, Zhang J, Ding Z, Liu Z. A meta-analysis of the efficacy of cognitive behavior therapy on quality of life and psychological health of breast cancer survivors and patients. Psychooncology. 2018 Jul;27(7):1695-1703. doi: 10.1002/pon.4687. Epub 2018 Mar 26. PMID: 29500842.