Preventive Strikes

Contents

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pp. vii-

Acknowledgments

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pp. ix-xi

My first debt is to the institutions that have made this research possible. INSERM— the French Institute of Health and Medical Research—has given continual support to my atypical investigations, while my research center, CERMES, has provided excellent intellectual and material conditions for my work, a rare privilege in a time of reduced support for “useless” studies, those devoid of economic ...

Introduction: Embodied Risk

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pp. 1-18

This study originated in a perplexing observation. For one year I observed the counseling that people with a hereditary risk of malignancies received in a major French cancer treatment center. The oncogenetics department providing this counseling combined innovative research in molecular biology with more traditional family studies and the performance of genetic tests. I was impressed by the ...

CHAPTER ONE: Biopsy

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pp. 19-39

The rise of the concept of precancer and of the aspiration to physically eliminate precancerous lesions is directly linked with the definition of cancer as “pathologist’s disease,” that is, an ailment diagnosed in the pathology laboratory. Even people who present symptoms that strongly indicate the presence of a malignant growth are “officially” classified as cancer patients only when their diagnosis is ...

CHAPTER TWO: Classifications

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pp. 40-54

As discussed in the previous chapter, the first element that shaped the concept of precancer was the generalization of cytological diagnosis of malignancy in the early decades of the twentieth century. The second, and equally important element, was the collection of epidemiological data on malignancies, coupled with attempts to correlate diagnoses and outcomes. Data that were collected ...

CHAPTER THREE: Borderline Lesions

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pp. 55-83

Until the last two decades of the twentieth century, the principle of early detection and surgical elimination of precancerous lesions was applied mainly to the detection and preventive treatment of female malignancies. Biopsies continued to be employed to diagnose other tumors (head and neck, lower digestive tract), and, in selected cases, surgeons asked for frozen sections of suspicious tissue during ...

CHAPTER FOUR: In Situ Cancers

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pp. 84-117

In the second half of the twentieth century, “carcinoma in situ” became the most visible and most often debated precancerous lesion. The term carcinoma in situ describes a cluster of cells that, when examined under the microscope, look exactly like cancer cells but do not invade surrounding tissues. In situ cancerlike lesions were first observed in cervical malignancies. Gynecologists who detected ...

CHAPTER FIVE: The Origins of Screening

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pp. 118-142

In the first half of the twentieth century preventive treatments of premalignant lesions was the exclusive domain of the clinician. Doctors detected suspicious changes in a person’s body and decided (sometimes together with individuals and their families) what to do about these changes. After the Second World War, with the development of mass screening campaigns, preventive treatments of ...

CHAPTER SIX: The Generalization of Screening

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pp. 143-165

The practical success of screening for cervical cancer validated the principle of physical elimination of premalignant lesions and legitimated the extension of this preventive approach to other tumors.¹ The transformation of cervical cancer into a model malignancy was, however, made possible by selective emphasis on some aspects of this tumor. For example, experts brought to the foreground ...

CHAPTER SEVEN: Heredity

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pp. 166-197

Screening for cancer is grounded in the principle that everybody is at risk of this disease. Search for the hereditary tendency to develop malignant tumors is grounded in the opposite supposition. It assumes that some people run much higher risk than others and that preventive interventions should selectively target these people. Precancerous lesions and hereditary predisposition to cancer ...

CHAPTER EIGHT: The New Surgical Radicalism

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pp. 198-225

The recent focus on dilemmas experienced by women diagnosed with BRCA mutations and facing decisions about prophylactic mastectomy have deflected attention from the peculiarity of a comeback of radical surgical solutions. For more than eighty years the accepted view on cancer surgery—and by extension, on surgical treatment of precancerous conditions—was that more is better. This view ...

Conclusion: Uncertainty

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pp. 225-238

Preventive treatment of precancerous lesions is a twentieth-century innovation. Three developments favored the rise of this approach: (a) the transformation of cancer into a “pathologists’ disease” in the 1910s and 1920s; (b) the introduction of mass screening for malignancies, which started in the 1940s with exfoliate cytology but expanded greatly in the 1970s and 1980s; and (c) the introduction, ...

Notes

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pp. 239-322

Index

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pp. 323-328