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. Oxford: Oxford University Press, 2001. xvi + 383 pp. Ill. $30.00 (cloth: 0-19-514-261-6).

Breast cancer is a baffling disease from several different points of view. Age-adjusted death rates in America today are about what they were in 1930, despite more than a decade of breast cancer activism, billions of research dollars, and radical revisions in diagnosis and treatment. The topic remains heavily charged, as controversies persist about the appropriate direction of research, the most effective methods of treatment, and the steps to be taken for prevention.

Lerner concentrates on the aspect of most immediate interest to breast cancer sufferers--how to treat. The rise and fall of William Halsted's radical mastectomy is charted from the end of the nineteenth century, when blood transfusions allowed ever-greater interventions, through the "extended" and "superradical" mastectomies of the 1950s, on into critiques by surgeons such as George Crile and Bernard Fisher, who argued for a more limited removal of tissue, culminating in the lumpectomy of the 1970s and 1980s. Lerner shows how changes in each case followed new conceptions of metastasis and new theories of risk, and eventually also new sensitivities to women's wishes.

There is a great deal of rich history here. Lerner shows how Halsted doctored his statistics to obtain unrealistically high rates of apparent "cure," and how snip-happy surgeons in the 1950s and 1960s cut ever deeper into the female anatomy in search of errant cancer cells. George T. Pack (a.k.a. "Mack the Knife") in 1951 was apparently not unusual in claiming that the duty of the surgeon was "to divorce the patient from his cancer," an obligation limited "solely by the ability of the human remnant to survive" (p. 76).

The strongest part of this book is the discussion of how and why the radical mastectomy lasted as long as it did, given the limited evidence of efficacy and the critiques from physicians, who as early as the 1950s had begun to mock the "superradical" and "extended" forms of the operation as a form of "humanectomy" (p. 69). Legal concerns were clearly an issue, since physicians who might not have wanted to cut so deeply were afraid of being sued in the event of cancerous recurrences. Lerner links the heroic surgical mentality to Cold War militaristic extirpationism, though I for one was led to wonder: What do people really mean when they say a war must be waged against a disease? The nature of war itself changed dramatically over the period in question, and it would be nice to hear how medico-military metaphorics may have shifted in tandem.

Lerner does have a fine touch for detail and loaded language, citing characterizations of the female breast as "an American national treasure" (p. 55) and the revealing radical-era aphorism that "lesser surgery is done by lesser surgeons" (p. 78). He comments on the sexual titillation that some physicians obtained from X-ray imaging and breast exams more generally--which reminded me of my own mother's story that women were not even supposed to touch their breasts in the 1950s, for fear of sexual arousal (in Texas, at least).

One shortcoming of this otherwise fine book is its near-exclusive focus on diagnosis and treatment. Little attention is given to long-standing debates over what is actually causing the disease; there is no exploration of the rancorous disputes over how important obesity, food additives, radiation, or environmental pesticides may be in breast carcinogenesis. There is also no mention of the fact that women today are far more likely to die of lung cancer--from smoking--than from breast cancer. Women today seem to be more worried about...