The Breast Cancer Wars: Hope, Fear and the Pursuit of a Cure in Twentieth Century America (review)

Barron H. Lerner. The Breast Cancer Wars: Hope, Fear and the Pursuit of a Cure in Twentieth Century America. New York, Oxford University Press, 2001. xvi, 383 pp., illus. $30.

A chance to cut is a chance to cure! During the 1950s, when public confidence in surgeons reached new heights and the scalpel ruled triumphant, surgeons had little doubt that the best treatment for breast cancer was to remove the affected breast completely, as well as the pectoralis muscles and the axillary lymph nodes. This procedure, pioneered by William Halsted at Johns Hopkins near the turn of the century, was known as the Halsted radical mastectomy and performed routinely by every breast surgeon in the United States. Yet forty years later only a few old codgers were treating breast cancer this way, and more limited and less deforming procedures had become common. Barron Lerner’s sensitive account of the decline and fall of this once dominant approach gives equal space to the ways in which scientific change and social activism combined to alter surgical practice, perhaps the most highly conservative branch of medicine.

Lerner begins with a straightforward account of Halsted’s invention of the radical mastectomy. Halsted believed that the disease spread locally, so it was critical to lift out the breast and pectoralis muscles as a block to avoid transmission of malignant cells to underlying tissue via the scalpel blade. The axillary lymph nodes were also completely removed, in the hope of containing metastatic disease to the first station on the way out, the lymph node. This procedure left women with a weakened, swollen arm on the side of the mastectomy and a concavity in the chest wall. Still, it gave them the hope that the cancer might actually be cured. But “cure” was a slippery concept, as Lerner demonstrates. Did it mean no disease recurrence at three, five, ten years from time of surgery? Or did it mean survival to the same endpoints? The data about the success of breast cancer surgery was accordingly slippery, and it was not until controlled clinical trials organized by Bernard Fisher in the 1970s and 1980s that solid evidence about therapy became available. And it showed that more limited surgery, accompanied by radiation, could be just as successful.

The first physician critics of Halsted’s procedure appeared in the 1950s, but well into the 1960s surgeons arguing for a more limited approach were shouted down at surgical meetings with cries that they were killing their patients. Critics had to fight against a compelling assumption about breast cancer therapy—that doing more has to be more effective than doing less. More tissue taken at surgery, more radiation, or stronger chemotherapy seems the logical way to go as long as the therapy is not one hundred percent successful. Push harder, be even more heroic! It took careful, controlled trials to show that less could be better, not just in conquering the disease but in promoting the patient’s quality of life. In telling this tale so convincingly, Lerner’s book becomes an admirable object lesson for evidence-based medicine.

During the 1970s and 1980s American surgeons increasingly turned to less radical procedures accompanied by adjuncts such as radiation therapy and chemotherapy. Lerner gives due credit to the individuals within the medical profession who argued for this change and generated the scientific evidence to support its safety. But he grants concomitant weight to the role of activists outside the profession, especially Rose Kushner, who pushed the patient’s point of view to the forefront, raising women’s consciousness about the options for limited surgery, choice in treatment, and the destigmatization of mastectomy and breast cancer. Lerner highlights the role of celebrity figures such as Betty Ford, Betty Rollin, and others in bringing the disease into...