At the end of the 19th century, a New York surgeon determined that the only way to cure breast cancer was with radical surgery. For the next hundred years, millions of breast cancer survivors bore the mark of his disfiguring approach.

Less Radical is the story of Dr. Bernie Fisher, the surgeon-scientist who not only revolutionized breast cancer treatment, but also fundamentally changed the way we understand all cancers. He was an unlikely hero—a Jewish kid from Pittsburgh who had to make it past antisemitic quotas to get into med school. And the thanks he received for his discoveries? A performative, misguided Congressional hearing that destroyed his reputation and haunted him until his death.

Over six episodes, radiation oncologist Dr. Stacy Wentworth will take you into operating rooms, through the halls of Congress, and into the labs where breakthrough cancer treatments were not only developed, but discovered.

If you or someone you know has had breast cancer, Bernie is a part of your story—and you’re a part of his.

For photos, recommended readings, and show notes, visit Dr. Wentworth’s Substack, Cancer Culture.

Transcript

[HEART RATE MONITOR BEEPING]

[SOUNDS OF A BUSY HOSPITAL]

STACY WENTWORTH: Every doctor I know has, at one point, considered becoming a surgeon. There’s nothing quite like that first, up-close glance of a beating heart, or piecing a shattered femur back together, or pulling a newborn baby through an improbably small C-section incision.

As a society, we’ve all agreed that some people are granted this kind of access to, and power over, our bodies. They stop and start our hearts, amputate our limbs, and do whatever they can to keep our bodies working. 

And to be the one to do all that? To walk out and tell a family waiting for news that the operation was a success? That’s a pretty awesome feeling.

Bernie Fisher, however, didn’t make his biggest breakthroughs with a scalpel in his hand. He was a scientist. 

[THEME MUSIC IN]

A researcher. He was a trained surgeon, too, but he came to reject a lot of that training, especially the Halsted Radical Mastectomy.


BERNIE FISHER: For 50 years, surgeons had been trained to do these radical, really radical, mutilating, operations. And they felt that by me doing what I’m doing, just taking the tumor out and leaving the breast behind that that was totally inappropriate.

STACY WENTWORTH: And that’s where our story goes today—to the origins of modern surgery, and the man who developed the Halsted Radical Mastectomy. 

I’m Dr. Stacy Wentworth, and this is Less Radical.

[SHOW OPEN MONTAGE]

NANCY DAVIDSON: Bernie was changing everything.

BERNIE FISHER: Well, at that time, the treatment was draconian to say the least.

GERALD IMBER: The technique was not sterile, it’s [a] perfect atmosphere for an overwhelming infection…Women didn’t come for examinations of their breasts in Victorian times

BERYL MCCORMICK: I think they really couldn’t change the way they thought, they just…couldn’t do it.

BERNIE FISHER: I realized how little was known from the biological aspect of breast cancer and tumor metastases in particular. I also began to realize that the foundations of medical care must be based on science.

VINCENT DEVITA: You could see where they hated him because he wouldn’t give in.  

 

[THEME MUSIC OUT]

STACY WENTWORTH: When we last left Bernie Fisher, it was the 1950s and he was a surgical fellow at the University of Pennsylvania. As an undergraduate in Pittsburgh, Fisher got a taste of research from his great uncle, Dr. Julius Rogoff. 

[MUSIC]

Rogoff’s lab was looking for a treatment for Addison’s Disease, and young Bernie worked on extracting adrenal glands from buckets of cow’s intestines delivered by a local butcher. Not sexy work at all. 

Surgery, meanwhile, was thrilling, challenging, dramatic. It’s where bold men—always men—called the shots and saved lives. And many of these bold men modeled their work, and their attitudes, on the father of modern surgery—William Stewart Halsted.

GERALD IMBER: Halsted was the first scientific surgeon, and he believed in cause and effect, and he followed up on everything he did. So when you did a procedure, you followed up on everybody. 

 

STACY WENTWORTH: That’s Dr. Gerald Imber, a plastic surgeon who wrote the definitive biography on Halsted, Genius on the Edge. Most of the surgical training programs in America were shaped by Halsted’s work. To understand why Bernie Fisher’s later research was so upsetting to the surgical establishment, we need to go back and understand Halsted.

GERALD IMBER: He was born in 1852 and at that time, the most fashionable center of New York City was at 14th Street, and his family moved up to 14th Street and Fifth Avenue in a big townhouse. He grew up in Manhattan; he actually was from a very, very wealthy family.

STACY WENTWORTH: Halsted had a very different upbringing than Bernie, but the two men shared a passion for sports and an interest in medicine that came from books—Bernie from his reading as a kid, and Halsted from a chance encounter in college. 

GERALD IMBER: Halsted had gone off to prep school and off to Yale, where he had absolutely no interest in anything but sports. And his second year at Yale, he happened to pick up an anatomy book, Gray’s Anatomy, and went just bonkers about it, and started hanging around everybody in the medical school, and came to his father at the end of his senior year and said, I want to go into medicine. 

STACY WENTWORTH: Halsted’s father was on the board of many venerable institutions in New York, including Columbia Medical College, which gave young William an in.

GERALD IMBER: And at Columbia Medical College, which at that time was a proprietary institution where you didn’t even have to have any sort of degree to enter, and nobody flunked out, and you just paid your dues and you became a physician. He went to medical school at Columbia, did an internship at Bellevue. The internship had no clinical teaching whatever, and it was all didactic. 

STACY WENTWORTH: After medical school, Halsted spent two years in Europe, where many surgeons of privilege finished their training. In the decades after the U.S. Civil War, these facilities were considered the height of medical progress. And thousands of American doctors made the pilgrimage to German, Swiss, and Austrian hospitals to learn state-of-the-art surgical techniques.

While in Europe, Halsted learned about a revolutionary new idea from Dr. Robert Koch—germ theory. Before germ theory, operations and operating rooms were a far cry from the sterile conditions we take for granted today.

GERALD IMBER: During the Civil War, the surgeons were doing amputations to prevent gangrene. They did them in battlefield, un-sterile conditions, and they used heavy hand-cut sutures, which for speed they kept in their mouths so that they could reach out and grab out of their mouth and tie something off. And when they tied off a bleeding vessel, they would also tie off muscle with it. The technique was not sterile. It’s [the] perfect atmosphere for an overwhelming infection.

STACY WENTWORTH: Surgery inside hospitals wasn’t any better.

GERALD IMBER: Halsted tells a story of Frank Hamilton, his favorite surgeon, at Bellevue, who would arrive on a white horse, dismount, go into the hospital, go into the anteroom to the operating theater, take off his frock coat—because he didn’t want to get it dirty—hang it up, and take an old frock coat that was crusted with blood, and take that into the operating room. Didn’t even wash his hands after coming off horseback. And that was the state of surgery.

[MUSIC]

STACY WENTWORTH: Germ theory inspired one of the most influential procedures Halsted witnessed while in Europe. It was performed by two German surgeons. When faced with a woman they suspected had breast cancer, they removed not only the breast that contained the tumor, but also the chest wall muscle down to her ribs. This was the precursor for what would become Halsted’s namesake—the Halsted Radical Mastectomy.

At the time, many doctors believed cancer spread just as germs did—spilling out from a central point like ink on paper. And if they cut into the cancer, they’d cause it to spread. The idea of the radical mastectomy was to remove any contaminated flesh, and to make as generous a cut as possible to avoid nicking a tumor. 

Such massive surgery was newly possible because of the latest in 19th century surgical technology—fine silk sutures which allowed surgeons to delicately close wounds and control bleeding. It was also possible because patients were no longer awake to feel every cut and stitch. 

Ether entered the operating room in the late 1840s. Before that, surgeons valued speed over everything else, racing to complete the operation with the patient fully conscious, and sometimes writhing and screaming. 

Because of these limitations, most surgeries were limb amputations or similarly straightforward operations. The pain was too great to cut into the belly, brain, or chest. And cancer operations were especially rare. 

Today, cancer is the second leading cause of death in the United States, behind heart disease. In the late 19th century, cancer wasn’t a leading cause of death, but not because effective treatments or cures existed. Most people died of infectious diseases like cholera, tuberculosis, and the flu. I just told you about operating room conditions in the time before germ theory, but those were immaculate compared to the everyday conditions of American cities. People dumped their chamber pots into the streets—sometimes from the second story window. Butchers let their pigs roam the streets eating garbage. Horse manure was everywhere. 

Today, patients with cancer routinely go to the hospital for exams, surgeries, and other treatments. But in Halsted’s time, if someone had cancer, the diagnosis often wasn’t confirmed until their autopsy, if ever. Many people believed that dying of cancer was simply the will of God. Breast cancer was especially rare to diagnose in the prudish Victorian era. 

GERALD IMBER: Women didn’t come for examinations of their breasts in Victorian times, and when they had a lump in their breast, they definitely didn’t come for examination. And the physicians were all males, so they definitely, definitely, definitely didn’t come. It was verboten. They didn’t do it. So by the time women with breast cancer were seen, they were fungating lesions, or the large, baseball-sized lesions, and they were beyond cure.

STACY WENTWORTH: Once he was back in New York, Halsted started work that would make breast cancer less of a death sentence. Inspired by what he saw in Europe, he performed his first radical mastectomy in 1882.

In Halsted’s early operations, an assistant placed an ether cone over the patient’s face, delivering a near-fatal dose of anesthesia. Halsted and his assistants held the patient down as she resisted the feeling of suffocation. As soon as she stopped moving, Halsted began cutting. Starting under her arm, he guided his scalpel under the clavicle, down the breastbone, under the breast, and back up to the armpit where he started. 

GERALD IMBER: So Halsted’s mastectomy, his idea was to take the entire tumor out en bloc, meaning the tumor and all the tissues around it, and never cut through it, so you wouldn’t spread it. And he felt that the way to cure these patients was to take do an en block dissection of the breast, the tumor, the breast that contained it, the pectoralis major, pectoralis minor, and the lymph nodes all around it.

STACY WENTWORTH: What was left was a bloody teardrop of tissue which Halsted delicately removed in one piece, another technique Halsted brought back from his studies abroad. 

GERALD IMBER: He believed that you should not crush tissue. You should hold it gently, never crush it in the forceps, pick it up gently, put a suture of the thinnest material possible through it, and tie it down in a way that holds what’s not it doesn’t make it look like a roast beef.

STACY WENTWORTH: Halsted then turned from the open wound filled with hundreds of tiny clamps to control the bleeding and left the operating room to examine the specimen.  Medical assistants and residents sewed each artery shut with fine silk. A few days later, doctors brought the woman back to the operating theater to cover the exposed ribs with a skin graft, crafted from pieces of skin harvested from her own thigh. The procedure was complicated, brutal, and incredibly time-consuming.  

Over the next five years, Halsted did the surgery fifty more times. He was building a reputation as a bold surgeon. The same year he did the first radical mastectomy, Halsted removed gallstones from his mother on her kitchen table. When his sister was hemorrhaging to death after childbirth, he rolled up his sleeve and transfused his own blood into her.

And in 1884, he read a paper on a new type of anesthesia.

GERALD IMBER: There was a neurologist in Vienna by the name of Sigmund Freud, who had written something about cocaine, and one of Freud’s interns was an ophthalmologist, and he had used cocaine drops on the eye, and found that he could operate on the eye without pain and without general anesthetic. And he wrote a paper that was immediately delivered in America.

[MUSIC]

STACY WENTWORTH: Doctors, including Freud and soon Halsted, experimented with cocaine to prevent pain. And they used themselves as test subjects.

GERALD IMBER: And at that time he [Halsted] was surgeon to the outpatient department at Roosevelt Hospital, and he did a thousand operations under cocaine regional block. But while he was doing it, to learn the dosage, he, his students, and his residents all became addicted.

STACY WENTWORTH: Halsted became so hooked on cocaine that multiple times his friends sent him on long journeys to detox. On one of these trips, his craving was so intense that he broke into the steamship’s pharmacy and stole their entire supply of morphine. After a brief clean stretch, he returned to the U.S. and immediately relapsed. He went to rehab, where doctors treated his cocaine addiction by giving him…morphine, which he remained addicted to for the rest of his life.

GERALD IMBER: Even when he was feeling good. I mean, he knew how to time his morphine doses so that he was good during the day. But he would often say to the resident, “You finish, you know, how I would do it.”

STACY WENTWORTH: In the late 1880s, with his addiction putting his career in danger, Halsted left New York for Baltimore. But he didn’t exactly go in shame. He took a position at the newly opened Johns Hopkins Hospital. Despite his addictions, Halsted pushed the hospital to innovate. He imported the residency program he’d seen in Europe, where students learned from doctors through increasing levels of clinical responsibility. And he continued another European practice he’d started in New York—following up on his patients. 

GERALD IMBER: So he wrote letters to every single patient that had been operated on and had made sure they came back so he could follow up, learn whether the technique was proper or not. Nobody did those things. I mean, he had all of his patients come back. He had his patients so in his thrall that he would do little procedures of learning about how skin grafts take and things like that, and on a patient that didn’t even need it, and have them come back from another state a month later for him to look at it. 

STACY WENTWORTH: Before Halsted, surgeons would tell patients only to come back if they had any problems. Now, with his patients living longer, Halsted kept in contact with them—or, in the case of his female patients, with their husbands or their male family doctor. 

[MUSIC]

The long operation, the follow-up appointments—they worked. Of the fifty breast cancer patients Halsted operated on, only three had recurrences of cancer. This was huge. We can’t be totally sure of the statistics since no one had been tracking patients after surgery, but the recurrence rate at the time was thought to be around 50%. That’s nearly ten times what Halsted was reporting. In 1898, Halsted presented his results at a surgical conference in New Orleans. After he finished his remarks, he looked out in the crowd to a stunned silence that gave way to applause. He thanked the audience for their acceptance of his procedure and what he called “the biological hypothesis” of cancer spread. A colleague declared that: 

HALSTED SURGICAL PEER: He deserves, and has, our grateful acknowledgments for the brilliant light which he has thrown upon these dark places of surgery.

STACY WENTWORTH: William Halsted, despite his drug use and his penchant for experimenting on relatives, was a hero. He was doing what had seemed impossible. As radical and as bloody as his mastectomy was, it worked. And it was being done with more knowledge, and in a more sanitary way than ever before. 

[MUSIC]

The Halsted radical mastectomy was a major breakthrough. And it would not only set the standard for surgical treatment of breast cancer, it would establish the surgeon—even if he’s addicted to morphine—as the expert and savior. Halsted was a blue-blood by birth and a swashbuckling surgeon by reputation. Other doctors were in awe of him. He was a showman in what were called “operating theaters” at the time. If you go to my Substack, Cancer Culture, you can see a photo of Halsted performing an operation in front of an audience of men in suits. Other surgeons followed him in practice and in swagger. The knife was the cure. And the man who wielded—and it was always a man—was the hero.

BERNIE FISHER: And I want you to remember one thing about all this, this happened in my lifetime, it is what I saw, and what I still remember. And this was not an uncommon way to see a patient with breast cancer.

STACY WENTWORTH: Bernie again. Bernie Fisher started his surgical training at the University of Pittsburgh in 1943, twenty-one years after Halsted died. But it was still Halsted’s world. Surgery was the cure, and surgeons called the shots. In 2004, Bernie reflected on learning how to perform the Halsted Radical Mastectomy.

BERNIE FISHER: Well at that time the treatment was draconian, to say the least.  And I did operations in my surgical training such as this.

STACY WENTWORTH: But one person would eventually steer Bernie away from Halsted’s practice. Dr. Isadore Schwaner Ravdin was head of the department of surgery at Penn when Fisher arrived in 1950 to participate in one of the only surgical fellowships at the time. Even more unusual was that Ravdin’s fellows studied both surgery and research. During Fisher’s time, I.S. Ravdin was a strict practitioner of the residency system and he ran a tight ship. He was also a national hero, having served as the head of the General Hospital in Assam, India, during World War II.

Ravdin took to Bernie, mentored him. He must have seen promise in his young student. He even nominated Bernie for the prestigious Markel Award. Coming from Ravdin, this was a big deal. He had an eye for finding and boosting influential doctors. His acolytes went on to become distinguished professors, university department heads, and in the case of C. Everett Koop, Surgeon General of the United States. 

The research requirement in Ravdin’s program encouraged surgeons to enter new and expanding fields of medicine. At Penn, Bernie became fascinated with liver regeneration and transplantation, even though he remembered other doctors telling him the organ was a career dead-end.

BERNIE FISHER: I was at the Mercy Hospital, one of the most impressive people was a medical doctor down there, who always said, “Two things you must keep away from is the liver and cancer because you’ll just get lost in the woods.”

STACY WENTWORTH: After graduating from Penn in 1950, Fisher went home, where he founded the University of Pittsburgh’s Laboratory of Surgical Research.

This was a busy time. Not only was he leading the department, he was conducting research in the areas he’d been captivated by—liver regeneration and organ transplants. Eventually, he’d even perform the first kidney transplant in Pittsburgh. Bernie was living up to the potential Ravdin had seen in him, earning praise and awards. Looking at photos of Bernie from this time, he looks driven. He’s got a square jaw; kind, dark eyes; and short, curly hair. You might take him to be a football player who became the coach everyone loved. He didn’t take much time to pose, and even when he did, he seemed to be looking to the distance, thinking about something ahead—something he was bound to discover. When he smiles, he seems to be saying, “How long do I have to sit here when I could be back in the lab?” 

He was content leading his lab at Pitt. That is, until his old mentor reached out.

BERNIE FISHER: I received a very unexpected telephone call in 1957.

STACY WENTWORTH: It was Ravdin, who was now even more of a national hero. The year prior to this phone call, Ravdin had performed an emergency surgery on President Dwight D. Eisenhower, making the controversial decision to reconnect pieces of inflamed bowel, rather than perform the standard surgery, which would have left the president with a colostomy. Now, Ravdin was the president’s go-to doctor for big, important projects. The White House put him in charge of the first government program to try to find a cure for cancer—something other than the knife. 

He needed surgeons who were willing to challenge decades of surgical practice, to deny Halsted and rebuke the armies of their peers who believed in their prowess above all else.

BERNIE FISHER: I was invited to help conduct the first breast cancer clinical trial ever done. Well, I had absolutely no interest in that disease, not even remotely. I already had a career in research, laboratory research, for more than a decade.

[MUSIC]

STACY WENTWORTH: Bernie didn’t want to set aside his life’s work and get involved with the second of two areas of medicine he’d been told to avoid. But Ravdin was persistent. And Bernie couldn’t say no to a two-star general, let alone his mentor. Bernie would leave the meeting with the seed planted for a whole new way of practicing medicine.

BERNIE FISHER: As a result, I realized how little was known from the biological aspects of breast cancer and tumor metastases in particular. I also began to realize that the foundations of medical care must be based on science. 

STACY WENTWORTH: Ravdin wasn’t alone in wanting to find a new way to treat breast cancer. Next week, on Less Radical, it’s the story of the race to find the “magic bullet” to cure cancer. 

BERNIE FISHER: Clinical trials are a mechanism, I can’t emphasize that too thoroughly. They’re like a flow cytometer, or like an electron microscope, or like a spaceship to explore outer space, that’s what a clinical trial is. 

VINCENT DEVITA: The idea that you could cure cancer with drugs was considered insanity.

And this Saturday, join me for a bonus episode. We’ll hear from one group whose voices weren’t even part of the breast cancer conversation—women.

BETTY FORD: I was terribly frightened about having breast cancer, of course. 

LOUISE GRAPE: I remember asking my mom to see her scars, and she had—oof, wicked, it was wicked. 

Less Radical is produced by me, Stacy Wentworth, and the team at Yellow Armadillo Studios: Melody Rowell, Gabe Bullard, and Sam Gebauer.

Fact checking is by Ryan Alderman. Our artwork is by Arianna Egleston. We get marketing support from Tink Media, and music is from Epidemic Sound.

Special thanks to Dr. Gerald Imber, and Bobby Dixon.

If you want to bring the conversation about cancer out of the exam room and into your inbox, subscribe to my Substack, Cancer Culture. There, you can also see extensive show notes for Less Radical, including photos and links to read more about Bernie Fisher and the history of breast cancer. It’s at cancerculture.substack.com. And you can follow me on Instagram at drstacywentworth.

And be sure to follow or subscribe to Less Radical in your favorite podcast app so you don’t miss a single chapter of Bernie’s story. While you’re there, please leave us a five star review. 

Thanks for listening.