Two Centuries of Medical Treatment & Teaching

In the late 1800s, women with breast cancer had little reason for hope unless they had access to a teaching hospital such as New Haven Hospital. Practicing surgeons, who were also training the next generation of physicians at Yale, kept up with the latest treatments including the then-new radical mastectomies.

Yale-educated William Halsted was credited with the first such complex surgery in 1882. More modern cancer therapies—radiation, chemotherapy, hormonal therapy, and immunotherapy drugs— were still many, many years in the future, meaning the only treatment was the disfiguring radical mastectomy that included the removal of the cancerous tumor, nearby muscle and tissue, and lymph nodes.

By many accounts, Dr. Halsted was untroubled by the effects of the surgery when weighed against its potential to prolong life.

“After all, the hospital, the operating room and the wards should be laboratories,” Dr. Halsted said in 1904, giving the annual address in medicine at Yale. “…and we know from experience that where this conception prevails not only are the cause of higher education and medical science best served, but also the welfare of the patient is best promoted.”

By then a renowned surgeon at Johns Hopkins and a founder of its medical education program, Dr. Halsted also addressed the critical importance of the establishment, decades earlier, of a hospital in New Haven and the creation of the institution that would become the Yale School of Medicine. It was the birth of one of the first academic medical centers in the nation.

Treating, Teaching & Testing Theories

Now, 120 years later, that academic medical hub has grown in expertise, size, and reputation. And the Center for Breast Cancer in New Haven is a nationally-known program, offering breakthrough treatments to hundreds of patients annually.

“We are able to cure the vast majority of individuals with breast cancer but there is still much work to be done,” said Dr. Eric Winer, an expert in breast cancer, and director of Yale Cancer Center and president and physician-in-chief of Smilow Cancer Hospital at Yale New Haven Health.

“Cure” is not a term used casually by those who treat cancer. It is a hard-earned outcome that results from decades of dogged research, dedicated clinicians, and a commitment to care and cure in all hospitals.

New Haven Hospital’s specialized breast cancer surgeons were among the first to perform breast-preserving lumpectomies, instead of mastectomies, and its clinicians and researchers were instrumental in the development of minimally invasive procedures including sentinel lymph node biopsy, using ultrasound to inform decisions during surgery, and advanced plastic surgery techniques aimed at breast preservation and reconstruction.

“Since the beginning of medicine in New Haven, the relationships between the medical school and the hospital have been their strengths,” said Dr. Winer, himself a Yale School of Medicine alum.

Scientific discoveries fill the histories of Yale and New Haven Hospital, with many altering the trajectory of healthcare. There was the 1896 creation of the first X-ray by a Yale physicist; the first use of what would become chemotherapy to treat a cancer patient in the 1940s; the insulin pump to treat diabetes; drugs to combat HIV; and the 1999 discovery of a molecule that would lead to immunotherapy.

“Particularly in the last century, as cancer treatment has grown well beyond surgical removal of the disease, Yale researchers have been critical contributors to the breakthroughs that have revolutionized treatment,” Dr. Winer said.

The dedication to continuously advance research and treatment for patients with breast cancer, and all cancers, drives YCC’s six research programs and much of the work of its more than 300 members. The membership includes physicians at Smilow Cancer Hospital and its 15 centers around Connecticut and Rhode Island, and researchers who focus on all aspects of cancer from Yale’s schools of medicine, public health, engineering, and more.

Collaboration among those diverse disciplines has led to cutting-edge cancer discoveries and treatments. New treatment approaches are offered to patients daily across the Smilow network through YCC’s clinical trial program that evaluates the newest discoveries.

Ian Krop, MD, PhD, the chief clinical research officer and associate cancer center director for clinical research at YCC, explains to dozens of audiences a year the role that clinical trials play in the development of each new cancer therapy. Not only are several rounds of trials required by federal agencies assessing whether to approve a new drug, but valuable information is gleaned from patients treated with the newest discoveries.

Breast cancer is a high priority of Yale Cancer Center. The highest incidence of cancer in Connecticut is breast cancer in women of all ages, at a rate of about 138.5 cases per 100,000 population per year. That is higher than the national rate of 127 cases per 100,000 people. Connecticut adults under age 50 also had higher rates of breast cancer than the same population nationally.

While Connecticut has a lower mortality rate for breast cancer than the national rate, there are far too many people who lose their lives from the disease. The cancer center remains focused on building an even more robust collaboration between researchers and clinicians, a hallmark of academic medical centers.

YCC researchers plan to apply for a National Cancer Institute grant designed for translational research work in which physicians at Smilow and scientists collaborate to uncover and conduct trials of the next breakthroughs in treating breast cancer. The cancer center already has such NCI support for lung, head and neck, and skin cancers.

Personalized Medicine in the Broadest Sense

Academic medical centers hold a unique position in the US health system and include medical schools that are the primary site for medical student education. They are a small minority—only 6% of US hospitals are considered AMCs—but strongly influence standards of care.

The process at Smilow, and most academic medical centers, often begins with the patient meeting the entire team that will be involved in all aspects of their care.

“The surgeon, in major academic medical centers, will often see patients alongside other members of the cancer team,” explained Rachael A. Greenup, MD, MPH, chief of breast surgical oncology at Smilow Cancer Hospital. She added that in many other health systems patients often are seen first by the surgeon who provides confirmation of a breast cancer diagnosis, and then are referred to sub-specialists to consult for other aspects of multi-disciplinary treatment.

“Historically, the surgeon has been described as the ‘captain’ of the breast cancer team, [but] that landscape has evolved as treatment sequences have changed over the last decade or so,” Dr. Greenup said.

Newly available therapies, and discussion among the specialists on a breast cancer team, have changed the standard practice landscape. Where surgery was once the first-line treatment, for example, it might today be preceded by chemotherapy aimed at reducing tumors prior to surgery to preserve better quality of life for the patient. Or there might be a recommendation for hormonal therapy alone after surgery. Chemotherapy is still given to many patients, but through careful studies clinicians have reduced the use of this approach over the past two decades.

“The fact that we now often…give medical therapy first underscores the importance of a patient seeing a surgeon, a medical oncologist, and often a radiation oncologist from the get-go. Those visits are often all happening on the same day,” Dr. Winer said, describing the multi-disciplinary team approach at Smilow.

Maryam Lustberg, MD, MPH, co-director of the Center for Breast Cancer at Smilow Cancer Hospital and chief of breast medical oncology at Yale Cancer Center, emphasized the commitment to multi-disciplinary

care. “We need to think about putting our patients and families first as we envision growth, programs, research, and advocacy. This viewpoint helps guide priorities and advances breast care in the most personalized, whole-person centered, way of care.”

Prioritizing patient needs means depending on the expertise of many disciplines and specialists including nursing, advance practice providers, physical therapy, occupational therapy, plastic surgery, cardiology, social work, genetics, and more.

“Our vision is to provide the most comprehensive multidisciplinary care to all patients diagnosed with breast cancer in the state of Connecticut and beyond,” Dr. Lustberg said, adding that the single-minded focus on improving breast cancer outcomes depends on “innovative research, technological breakthroughs, national/global collaborations, and patient advocacy partnerships.”

Decades of experience with patients have given the entire team of clinicians a keen understanding of the toll that a breast cancer diagnosis and treatment can take.

“The intensity of a cancer diagnosis followed by facing a series of important decisions, multiple appointments, scans, waiting for data, waiting for results, really can be incredibly overwhelming ” for patients, Dr. Greenup said.

“Knowing that you can trust your team, knowing that you can access your team, knowing that your team is speaking to you in a way that you and your family can process…It is all a really important part of what we do,” she said.

A growing number of studies have reached the same conclusion—that patients with cancer who feel supported have better long-term outcomes.

Alexandra Taylor Mendez—a patient of Drs. Winer, breast surgeon Elizabeth Berger, MD, MS, plastic surgeon Paris Butler, MD, MPH, and radiation oncologist Suzanne Evans, MD, MPH—completed active treatment in the fall of 2024. She described her journey as very much “a we thing, because it’s not just a me thing.”

“It’s everybody…It takes teamwork, from the receptionist to the person scheduling your appointments, believe it or not,” to the person taking your blood, said the mother of two children under 10.

“Listen, there isn’t a doctor’s appointment that I’ve gone to that I’m not nervous,” Ms. Taylor Mendez said. No matter whether “it’s the simplest appointment or not, you are always nervous. And that’s why trust is very important. You learn about faith and I’m not just talking about religion. I’m talking about faith in yourself ” and friends, family and the medical team, some of whom might call on the weekend just to check in with her.

“They make me feel like Alex, not like a patient,” she said.