United States seems to have a predilection for declaring "war" on its internal problems, be they poverty, drugs, or cancer. In the latter part of the past century particularly, military metaphors became part of the vocabulary used by Americans to approach the emotionally charged issues surrounding breast cancer. Phrases like "the fight," "the war against," "weapons against the disease," and "slash, burn, and poison," as well as mortality statistics and runs and walks, became symbols of the fierce battle we wage against this disease. But when practicing physician and medical historian Barron H. Lerner titled his new book The Breast Cancer Wars, he had a larger picture in mind. Subtitled Hope, Fear, and the Pursuit of a Cure in Twentieth-Century America, this rich and nuanced history of breast cancer diagnosis and treatment examines how these aspects of a major disease have been driven not only by medical research but by American culture and politics. And, one might add, not always to the benefit of women.
Why the military mindset? Is it a reflection of blind faith in curative procedures and scientific research? Most importantly, how do women navigate the perilous waters of dealing with mortalityfearing disfigurement and wishing at the same time to be cured? In seeking to answer these questions, Lerner began with a simple premise: "Disease cannot be understood outside its social and cultural context." He then spent 5 years studying thousand of documents written by doctors, researchers, and women with breast cancer. What resulted was not only the story of breast cancer and its changing treatment, but a compelling view of how American culture understands and treats disease. Though the book covers the entire century, it focuses on the years 1945 to 1980, and in doing so, makes a read as compelling as any good novel.
The author carefully dissects the militaristic approach into its upside and downside. The upside, he points out, reflects our cultural inclination to "do more." This applies to women with breast cancer as well as surgeons. Most women will tell you they want to fight their disease. The downside, says Lerner, may lead to both overtreatment on the part of doctors and overly high expectations on the part of patients. Doctors have to preserve optimism and hope while not getting too caught up in the battle.
Trenchant issues such as these are so carefully woven through the text they never break its admirable pacing. We gradually perceive how changing medical, diagnostic, and treatment strategies not only result from scientific advances but are also profoundly influenced by the cultural setting in which they take place. Thus, the introduction and subsequent embrace of the two-step surgical system, and the gradual abandonment of the disfiguring and disabling Halsted radical mastectomywhich had ruled breast cancer treatment since the turn of the centurycame about not so much through the consciousness-raising of the surgical community as via the broader advancement of women toward equality with men in many other areas.
Many colorful and intriguing personalities emerge in this picture. There is William Halsted, the acerbic Baltimore surgeon who pioneered the radical mastectomy at the turn of the century, leading to its almost universal acceptance as the best treatment for breast cancer. But rather than writing Halsted off as one of the imperious physicians of the time, Lerner’s analysis points out that Halsted’s message"Get here early and we can cure you"was not in fact a quid pro quo, because it did not apply to all women. Despite the fact that early, radical surgery saved some lives, many women who had the procedure died anyway; others who delayed did not.
Many were treated to benefit a few, a concept that was upheld by surgeons like Jerome Urban, who took radical surgery to its limits under the banner of "lesser surgery is done by lesser physicians." This notion was accepted by women, however reluctantly, with the imprimatur of the American Cancer Society, which presented radical surgery in the light of a "war" against cancer.
By the 1950s, however, the message began to change, due to the iconoclastic Cleveland surgeon George Crile, Jr, who earned the scorn of the professional community after he abandoned radical breast surgery when his wife developed the disease, and Bernard Fisher, a Pittsburgh surgeon who almost single-handedly introduced more scientific methodology to breast cancer research, resulting in the truly valid beginning of treatment options. Though Lerner is admirably fair in presenting both the patient’s and the practitioner’s views, he does not hesitate to point out the contribution to the status quo of a male-dominated society in devaluing the breasts of what were regarded as aging women.
We meet several of the women who challenged the system, including Babette Rosmond, an opinionated New York writer who bucked the surgical authority of the era in 1971, by refusing to allow radical surgery should her breast lump prove malignant. Before proceeding with treatment, Rosmond’s researchand writing about it under the name of Rosamond Campionhelped make the true notion of "informed consent" available to many.
But perhaps the person most responsible over the long term for raising the public consciousness was the feisty, outspoken Maryland journalist Rose Kushner. Diagnosed in 1974 with a breast lump, she branded as inhuman the accepted treatment mode of putting a woman to sleep for a biopsy and removing the breast immediately if any disease was found. Moreover, she asserted that the Halsted radical, with its mandatory removal of the pectoralis muscles, was an outdated and unnecessary operation. Kushner proceeded to interview 18 surgeons before she found a 19th who agreed to remove her lump, wake her up, and then discuss options. Because she was against radiation, she ultimately decided to have a modified radical mastectomy, but the decision was hers.
Bitten by the activist bug, she began a lifelong, one-woman crusade against the radical mastectomy and the cruel one-step procedure, which developed into a sophisticated strategy to inform women about their rights as breast cancer patients. Rose came along when women were beginning to understand that this disease did not confer shame, but rather the need to hold up a hand and ask questions. She also paved the way for many other women writers eager to share their breast cancer experiences, good and bad.
The autocratic and paternalistic era of "doctor knows best" was being replaced by one in which medicine saw a lessening of reliance on the radical mastectomy and a growing interest in lesser surgery followed by radiation. Women could consider and weigh options for the treatment of their own bodies, especially later, when studies showed that lumpectomy and radiation provided survival equivalent to mastectomy for early tumors. This, in turn, made the value of regular professional checkups obvious and probably played a major role in the recent downturn in the otherwise steady mortality rate of breast cancer in this country.
Lerner is an exceptionally good writer, with the sensitivity, style, and even-handedness that make him the ideal person to have tackled this unwieldy and emotion-laden subject. Packed with medical, political, and social facts, the book manages never to be dry yet holds many important lessons for contemporary patients and their physicians. It fascinates and resonates and is a great read for anyone, especially those interested in cultural and social history and how the two affect the way medicine is practiced in this country.