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c h a p t e r f i ve The Origins of Screening  “Be Quick!” The Call for an Early Detection of Cancer 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 precancerous lesions became closely intertwined with public health interventions . The growing popularity of these campaigns led in turn to a significant increase in the number of people (nearly exclusively women) diagnosed with precancerous changed in tissues and advised to undergo a preventive treatment.1 Screening for cancer is a voluntary measure that has to be accepted by those being screened,hence the central role of education of the public in its promotion. Also by the first half of the twentieth century, experts and cancer charities already enthusiastically advocated early detection of malignant tumors, presented as the most efficient way to reduce cancer-related mortality. This approach was summarized in a title of a 1928 leaflet of Massachusetts Department of Public Health: “Cancer. Be Quick! Cancer Control Is a Race against Time.”2 Only rarely one could hear dissenting voices, such as the opinion expressed by James Ewing in 1926:“It appears more and more evident that early diagnosis alone is not capable of accomplishing the desired reduction in death rate. Every experienced observer (s) knows that the patient coming with an early diagnosis all too often fails completely of a cure . . . I think it should be frankly recognized in all public propaganda that the intelligent use of all present knowledge of prevention, early diagnosis and modern treatment, will still leave cancer the greatest of all natural hazard in the adventure of living.”3 Ewing’s skeptical evaluation of the practical value of early detection of cancer was at odds with the view that dominated twentieth-century discourse on this disease.4 The main educational message of the American Society for the Control of Cancer (ASCC), the British Empire Cancer Campaign (BECC), La Ligue Franco-Americaine Contre le Cancer was the importance of early detection of malignant tumors. This message, it is true, was often conveyed through careful wording. The heir to La Ligue Franco-Americaine Contre le Cancer, La Ligue Française Contre le Cancer had a slogan: “cancer can be cured if detected early” (detecté tôt, le cancer peut être gueri). This slogan could be interpreted in two ways: as accentuating “cure” (of all the cancers that were detected early) or “can” (some cancers can be cured if detected early, but others cannot).5 Physicians knew that the “early detection” principle was valid in selected tumors only. Malignancies of internal organs (such as the lungs, stomach, liver, and pancreas) were nearly always detected at a stage at which medical intervention was of little value. Professor Jean Firket from University of Liège, warned that“one should be very careful when organizing popularization and education campaigns. When calling the public to have regular medical check ups in order to detect cancer, one should always make it clear that while some cancers can indeed be cured if detected early, this is not the case for many other malignancies. Many cancers are beyond the pale of our therapeutic means.”6 Specialists were also aware of the fact that early (that is small and localized) tumors were sometimes borderline or slow-developing growths and thus very different from aggressive cancers.7 Some pathologists and surgeons criticized accordingly the indiscriminate use of the term “early tumor.” The French surgeon Amadé Baumgarten explained in 1908 that the clinical entity of breast cancer lumped together fast-growing and highly malignant tumors and slow-growing, less malignant ones. A small tumor is often also a slow-growing one, with a low capacity to spread in the organism. When detected, it has a favorable prognosis not because it was caught early, but because it belongs to a less virulent type.8 Massachusetts General Hospital surgeon Robert Greenough proposed in 1935 clarifying the meaning of the term early diagnosis in connection with breast malignancies to eliminate the confusion between early in time and early in a natural history of the clinical disease cancer:“‘early diagnosis’ of breast cancer means early in the course of disease, rather than early as measured by...

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