The Breast Cancer Wars

October 1, 2002

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

United States seems to have apredilection for declaring "war" on its internal problems, be theypoverty, drugs, or cancer. In the latter part of the past century particularly,military metaphors became part of the vocabulary used by Americans to approachthe emotionally charged issues surrounding breast cancer. Phrases like "thefight," "the war against," "weapons against thedisease," and "slash, burn, and poison," as well as mortalitystatistics and runs and walks, became symbols of the fierce battle we wageagainst this disease. But when practicing physician and medical historian BarronH. Lerner titled his new book The Breast Cancer Wars, he had a larger picture inmind. Subtitled Hope, Fear, and the Pursuit of a Cure in Twentieth-CenturyAmerica, this rich and nuanced history of breast cancer diagnosis and treatmentexamines how these aspects of a major disease have been driven not only bymedical research but by American culture and politics. And, one might add, notalways to the benefit of women.

Why the military mindset? Is it a reflection of blind faith incurative procedures and scientific research? Most importantly, how do womennavigate the perilous waters of dealing with mortality—fearing disfigurementand wishing at the same time to be cured? In seeking to answer these questions,Lerner began with a simple premise: "Disease cannot be understood outsideits social and cultural context." He then spent 5 years studying thousandof documents written by doctors, researchers, and women with breast cancer. Whatresulted was not only the story of breast cancer and its changing treatment, buta compelling view of how American culture understands and treats disease. Thoughthe book covers the entire century, it focuses on the years 1945 to 1980, and indoing so, makes a read as compelling as any good novel.

The author carefully dissects the militaristic approach into itsupside and downside. The upside, he points out, reflects our culturalinclination to "do more." This applies to women with breast cancer aswell as surgeons. Most women will tell you they want to fight their disease. Thedownside, says Lerner, may lead to both overtreatment on the part of doctors andoverly high expectations on the part of patients. Doctors have to preserveoptimism and hope while not getting too caught up in the battle.

Trenchant issues such as these are so carefully woven throughthe text they never break its admirable pacing. We gradually perceive howchanging medical, diagnostic, and treatment strategies not only result fromscientific advances but are also profoundly influenced by the cultural settingin which they take place. Thus, the introduction and subsequent embrace of thetwo-step surgical system, and the gradual abandonment of the disfiguring anddisabling Halsted radical mastectomy—which had ruled breast cancer treatmentsince the turn of the century—came about not so much through theconsciousness-raising of the surgical community as via the broader advancementof women toward equality with men in many other areas.

Many colorful and intriguing personalities emerge in thispicture. There is William Halsted, the acerbic Baltimore surgeon who pioneeredthe radical mastectomy at the turn of the century, leading to its almostuniversal acceptance as the best treatment for breast cancer. But rather thanwriting Halsted off as one of the imperious physicians of the time, Lerner’sanalysis points out that Halsted’s message—"Get here early and we cancure you"—was not in fact a quid pro quo, because it did not apply to allwomen. Despite the fact that early, radical surgery saved some lives, many womenwho had the procedure died anyway; others who delayed did not.

Many were treated to benefit a few, a concept that was upheld bysurgeons like Jerome Urban, who took radical surgery to its limits under thebanner of "lesser surgery is done by lesser physicians." This notionwas accepted by women, however reluctantly, with the imprimatur of the AmericanCancer Society, which presented radical surgery in the light of a"war" against cancer.

By the 1950s, however, the message began to change, due to theiconoclastic Cleveland surgeon George Crile, Jr, who earned the scorn of theprofessional community after he abandoned radical breast surgery when his wifedeveloped the disease, and Bernard Fisher, a Pittsburgh surgeon who almostsingle-handedly introduced more scientific methodology to breast cancerresearch, resulting in the truly valid beginning of treatment options. ThoughLerner is admirably fair in presenting both the patient’s and the practitioner’sviews, he does not hesitate to point out the contribution to the status quo of amale-dominated society in devaluing the breasts of what were regarded as agingwomen.

We meet several of the women who challenged the system,including Babette Rosmond, an opinionated New York writer who bucked thesurgical authority of the era in 1971, by refusing to allow radical surgeryshould her breast lump prove malignant. Before proceeding with treatment,Rosmond’s research—and writing about it under the name of Rosamond Campion—helpedmake the true notion of "informed consent" available to many.

But perhaps the person most responsible over the long term forraising the public consciousness was the feisty, outspoken Maryland journalistRose Kushner. Diagnosed in 1974 with a breast lump, she branded as inhuman theaccepted treatment mode of putting a woman to sleep for a biopsy and removingthe breast immediately if any disease was found. Moreover, she asserted that theHalsted radical, with its mandatory removal of the pectoralis muscles, was anoutdated and unnecessary operation. Kushner proceeded to interview 18 surgeonsbefore she found a 19th who agreed to remove her lump, wake her up, and thendiscuss options. Because she was against radiation, she ultimately decided tohave a modified radical mastectomy, but the decision was hers.

Bitten by the activist bug, she began a lifelong, one-womancrusade against the radical mastectomy and the cruel one-step procedure, whichdeveloped into a sophisticated strategy to inform women about their rights asbreast cancer patients. Rose came along when women were beginning to understandthat this disease did not confer shame, but rather the need to hold up a handand ask questions. She also paved the way for many other women writers eager toshare their breast cancer experiences, good and bad.

The autocratic and paternalistic era of "doctor knowsbest" was being replaced by one in which medicine saw a lessening ofreliance on the radical mastectomy and a growing interest in lesser surgeryfollowed by radiation. Women could consider and weigh options for the treatmentof their own bodies, especially later, when studies showed that lumpectomy andradiation provided survival equivalent to mastectomy for early tumors. This, inturn, made the value of regular professional checkups obvious and probablyplayed a major role in the recent downturn in the otherwise steady mortalityrate 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 thisunwieldy and emotion-laden subject. Packed with medical, political, and socialfacts, the book manages never to be dry yet holds many important lessons forcontemporary patients and their physicians. It fascinates and resonates and is agreat read for anyone, especially those interested in cultural and socialhistory and how the two affect the way medicine is practiced in this country.