Unnatural History: Breast Cancer and American Society (review)

American women today have a lifetime risk of one in eight of being diagnosed with breast cancer. Is it a wonder, then, that cancer inspires more fear in the twenty-first century than it did at the beginning of the nineteenth, the starting point of this study?

Clinician and medical historian Robert Aronowitz invites us to look beyond the headline-grabbing statistics and place current concerns about breast cancer risk within the long "unnatural" history of this awful disease. The central development he analyzes is the historical change in the last two centuries from isolated, private fears of breast cancer to immense individual and collective concern over breast cancer risk. Aronowitz sides with those historians who have argued that disease cannot be reduced to its biological components. In his narrative, breast cancer is an unstable object, the product of changing values, beliefs, and practices.

The broad contours of this history are already well known. The shift from systemic to local understandings of the disease, the rise of radical surgery, the development of detection technologies, and the backlash against radical treatments from the 1950s onward have already been explored by a number of scholars, including Barron Lerner, James Olson, and Kirsten Gardner. Aronowitz, however, is more concerned with reconstructing the meaning, perception, and experience of breast cancer in both the clinical and public health setting than with exploring its macropolitics. Thus William Halsted, the turn-of-the-century pioneer of the "complete" mastectomy operation, is of interest not so much because of his iconic status in the history of breast cancer surgery but because of what his writings can reveal about changing attitudes toward the disease. Halsted's extensive correspondence with patients and fellow clinicians provides a means of exploring concerns about medical responsibility and competence and changes in the management of patients' hopes and fears. In a similar vein, the exchanges between environmentalist Rachel Carson and Dr. George "Barney" Crile, one of Carson's physicians during her long struggle with breast cancer, serve to illuminate the negotiated and contingent nature of the clinical encounter. As Aronowitz himself recognizes, this kind of analysis has its limitations, not only because it is potentially distorted by the author's selective sampling but also because it rests on materials produced by a tiny group of elite surgeons and their upper- and middle-class patients. We just don't know whether the attitudes and practices of individuals like Halsted, Carson, or Crile can be generalized to the rest of the nation. Limited though it might be, Aronowitz's account of the ways in which patients and clinicians balanced hope, trust, and truth is nonetheless invaluable for what it adds to our knowledge of the history of breast cancer.

Aronowitz writes with sensitivity and compassion about the strategies patients and their physicians have employed in the past in order to make treatment decisions and sustain hope in the face of a rapidly advancing deadly disease. He sees the current focus on breast cancer risk as modern society's attempt to bring order to the idiosyncrasy and diagnostic complexity associated with breast cancer. Risk-factor discourse makes it appear that we know more than we do about the precise causes of breast cancer and the relative import of different risks, and yet the fundamental issues this disease has raised historically are still with us. What is breast cancer? Who is responsible for deciding? What are the consequences of one definition or another? Thanks to Aronowitz's finely nuanced and illuminating study, we are now better equipped to answer these questions.