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c h a p t e r o n e Biopsy  The Redefinition of Cancer as a Pathologist’s Disease 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 confirmed by a pathologist. This rule, established in the early twentieth century, is still valid a century later.1 The maintenance of pathologists’ quasi-absolute control over diagnosis and monitoring of malignancies is unusual. The decades after World War II were a period of an intensive “molecularization” of biology and medicine,a process driven by the rapid expansion of biological and biomedical research and accelerated by introduction of instruments that automatically performed laboratory tests.2 Standardized tests, often performed by machines, play an increasingly large role in the definition and follow-up of human diseases. Diagnosis of cancer continues, however, to be grounded in the very specialized realm of the pathologist. Tests that reveal abnormal levels of biological markers linked with cancerous growths (e.g., PSA for prostate cancer, C-125 for ovarian cancer) are seen mainly as indications to start a search for transformed cells or, alternatively, to refine a diagnosis of cancer, not to establish one. In 2010, too, a patient has cancer because a pathology report said so. A pathologist’s verdict is indispensable in obtaining access to treatments in a national health system, reimbursement of medical expenses by health insurance, or a leave of absence from work. It is also the point at which an individual acquires a new identity as a“cancer patient”—and then, if he or she is lucky and enters a long-term remission— becomes a “cancer survivor.” Pathologists obtained control over cancer diagnosis roughly between 1910 and 1930. Before it became a pathologist’s domain, cancer diagnosis was made by surgeons , and before that, by general practitioners. Until the second half of the nineteenth century, surgeons rarely operated on cancer patients. Physicians and lay persons alike believed that cancer was hereditary and incurable. Moreover, surgical operations for cancer were dangerous, and their success rate was very low. Even if the patient survived the operation, he or she usually died promptly when the disease returned.3 The success of Fanny Burney’s surgery for breast cancer in 1811 was later seen as a proof that she probably had a benign tumor of the breast. (She provided a gruesome description of her ordeal of surgery without anesthesia .)4 The advent of anesthesia in the 1840s and then the development of aseptic techniques beginning in the 1860s made some surgeries for malignancies more acceptable. Those included hysterectomies (surgical ablation of the uterus) and oophorectomies (surgical ablation of ovaries) and dissection of tumors in other parts of the body.5 It also made the development of radical surgery possible— large and often mutilating excisions of malignant growths. The term radical surgery was proposed in 1906 by U.S. surgeon George Washington Crile, who developed a new technique of dissection of lymph nodes of the head and the neck in patients with cancers of this region and introduced in the discussion of this technique a distinction between radical and less radical surgical approaches. Only the former, he argued, could lead to a cure.6 Crile coined a new term but not a new concept. Many surgeons of his time had already adopted the principle of extensive excision of malignant growth together with the surrounding tissues, an approach usually linked with the development of the “complete surgery ” for breast cancer by Johns Hopkins surgeon William Steward Halsted.7 Radicalism in breast cancer surgery preceded, however, the development of Halsted’s mastectomy. Halsted followed ideas developed by surgeon Charles Hewitt Moore from Middlesex Hospital, London, while Moore was inspired by German surgeons Lothar Heindenhain and Richard vonVolkman.Volkman added the dissection of axillary lymph nodes to the ablation of the breast. Moore proposed in 1867 that every surgery for malignant tumors of the breast, even a very small one, should be as extended as far as technically possible and should include the ablation of axillary lymph nodes. Halsted’s main innovation was to add the systematic removal of both pectoral muscles and large portions of the skin.8 The...

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