Surgeons, Women, Cancer And The Battles Of The Breast

Advances in medicine are not driven entirely by science, physician and historian Barron Lerner, author of The Breast Cancer Wars, said March 13 in a seminar in Washington for health journalists, held by the National Press Foundation.

“Scientific knowledge has been constructed as an objective entity for so long, but scientific data is filtered through a social context,” Lerner said.

It is no coincidence that William Halstead’s disfiguring mastectomy operation—the standard breast cancer treatment for 60 years—began to be challenged at the beginning of women’s liberation in the 1960s and 1970s, Lerner said.

Some of the foremost challengers were women journalists-turned-activists, including Rose Kushner, a Kensington, MD, writer. After finding a lump in her breast, Kushner didn’t go to a doctor’s office. She went to the National Library of Medicine and read articles on breast cancer biology and treatment. She refused to have the anguishing “one-step” procedure, in which a patient went under anesthesia for a biopsy and did not know until she awoke whether her breast would still be there.

Kushner was turned down by nine surgeons until she found one at Roswell Park Cancer Institute who agreed to perform only a biopsy. Kushner later served on an NIH Consensus Conference panel that, among other things, recommended that physicians end the “one-step” procedure.

Lerner, an associate professor of medicine and public health at the Columbia Presbyterian Medical Cancer, said his goal in writing a book chronicling the treatment, early detection, and prevention of breast cancer in the 20th Century was “to place the science and medicine in a social and historical context.”

The book was published last summer by Oxford University Press.

The book also helped Lerner understand his family history. His mother was diagnosed with breast cancer in 1977, when Lerner was 16. His memories of her treatment and recovery were “fragmented,” in part because of her reticence to talk about the experience.

“I came to believe that my mother had lived because she dutifully discovered her cancer at an early stage and because of the aggressive treatment she had received,” Lerner wrote. “I also assumed that the happiness of surviving cancer was necessarily tempered by the negative consequences of having had the disease. After all, my mother had never resumed several of the activities and friendships that she had enjoyed before becoming ill.

“As a medical student in the 1980s, I learned how my family’s collective memories about my mother’s illness drew on both reality and myth,” Lerner wrote. “My research for this book further demonstrated this point.

“In contrast to what we had come to believe, chemotherapy and other therapeutic interventions actually ‘cured’ only a fraction of those who received them. Other women would have recovered even without such treatment. Similarly, tumor biology— not just how promptly a woman discovered her cancer—played a major role in determining how long she would survive.

“Finally, it hardly required extensive research to realize how women diagnosed with breast cancer in the 1990s seemed to make friends rather than lose them.” Breast cancer in the U.S. “has become a national phenomenon, perpetually discussed in magazines and on television and the Internet. Survivors meet each other at races, support groups, and corporate-sponsored galas.”

Long before the era of galas, breast cancer was a battlefield, and Lerner writes engagingly about the skirmishes and their participants. Halstead, for example, was deeply commited to scientific knowledge and pursued research that supported his surgical procedure. He pioneered the use of surgical gloves—initially not to limit infections, but to protect his nurse’s hands from the irritation caused by mercuric chloride used during surgery. He later married the nurse, Caroline Hampton.

It’s important to remember how shocking it was to the medical profession, used to private scientific debate, when surgeons George Crile Jr., of Cleveland, and Oliver Cope, of Boston, “went public” with their doubts about the Halstead procedure by talking to women’s magazines.

These physicians were vilified by colleagues like Jerome Urban, of Memorial Sloan-Kettering, who once said, “Lesser surgery is done by lesser surgeons.”

Physicians who harnessed the power of emerging areas of science, such as sophisticated statistical methodology, were more successful in advancing their treatment methods, Lerner said. The book chronicles the rise of Pittsburgh surgeon Bernard Fisher, whose “sonorous and authoritative” advocacy of randomized clinical trials “represented a true threat to business as usual in the world of surgery.”

Fisher and other RCT advocates successfully invoked science to rhetorically denigrate critics and push the new agenda to the forefront—just as Halstead did in his day, Lerner wrote.

Will the breast cancer wars ever end? Just one skirmish, the war over mammographic screening, has taken place for 30 years and there is no end in sight, Lerner said.

“Having eight randomized controlled trials [of mammographic screening] is an amazing amount of data,” Lerner said. “There are problems with the trials. The trials are old now, but were well thought out at the time, yet still there is sincere disagreement. It’s reasonable to expect that disagreement to persist.

“My view is, six of the eight trials show some benefit especially for 50 and over. So for women 50 and over, there’s no reason to change anything.

“I tell patients that there’s a debate going on and some of the faith that people had in mammography is waning.”

Lerner noted that the American Cancer Society has always supported aggressive early detection and treatment, while some statisticians have spoken out opposing screening guidelines. “None of these people ever publishes an article in which they change their minds,” Lerner said. “I’d like to see that happen just once.

“When I interviewed Art Holleb, [longtime ACS medical director] and I suggested that maybe some people didn’t share the [ACS] view on mammograms, he looked at me like I was crazy,” Lerner said.

The society “still sees itself as the major force behind the war on cancer,” Lerner said. “There has been success in early detection with cervical cancer and colon cancer. It’s probably pretty hard for an organization to step back and say, ‘You know that war on cancer? We’ve had more success with some cancers than other cancers.’

“It’s interesting to me that to some extent, the groups that have been content to have the PSA choice take place between the man and his doctor have been less content to have the mammography choice between the woman and her doctor,” Lerner said.

Media interest in breast cancer can be directly traced to the American Cancer Society starting its annual Science Writers’ Conferences, Lerner said. Though the conferences were aimed at promoting the society’s views and highlighting its funded research projects, some of the journalists who attended the conferences went on, as Kushner had, to learn the science, read journals, go to other scientific meetings, and challenge the accepted medical dogma.

“Journalists have been valuable at times in giving voice to the critics of the system,” Lerner told the journalists at the seminar.

Lerner’s book serves as a valuable history of the patient advocacy movement, which never has been a simplistic story of women patients versus male surgeons. While Kushner and others directly challenged the medical profession and fought for change, other breast cancer survivors took a more conservative approach. Marvella Bayh, for instance, served as a spokesperson for the American Cancer Society until her death in 1979.

It is often thought that current breast cancer activists learned techniques from the AIDS activists of the 1980s. That’s not entirely the case, Lerner said. “A lot of the technique of the AIDS activists was based on what Rose Kushner did,” he said.

According to Lerner, the key elements of each skirmish in the breast cancer wars involve:

—The ability of science to generate answers.

—The involvement of patients in making decisions.

—Debate about which direction to take scientifically and clinically, whether that involves prevention, early detection, or treatment.

Originally, Lerner wanted to write a history of breast and prostate cancer, but dropped prostate cancer early in the project.

“The prostate cancer story follows the breast cancer story by about a 10- or 20-year lag,” Lerner said.

Oncologists be forewarned.

The Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth-Century America, by Barron Lerner, Oxford University Press