Unnatural History: Breast Cancer in American Society (review)

How did breast cancer go from being a private worry of individual women to the highly publicized, dreaded disease it is today? This is the central question that Robert Aronowitz addresses in this excellent addition to the historical literature on breast cancer. He chose the title “unnatural history” to emphasize the social forces that shaped the understanding and experience of breast cancer in the United States over the past two centuries. According to Aronowitz, the heightened awareness of breast cancer is not the result of the changing biology of the disease. Rather, he uses case studies of individual women patients and the clinical records and correspondence of prominent physicians to demonstrate that our current anxieties about this disease emerged from historical developments in how physicians and patients understood and reacted to perceptions of breast cancer risk.

Aronowitz begins his story in the nineteenth-century when Anglo-American medical and popular understandings of what was then called “cancer of the breast” underwent dramatic changes. At the century’s outset, physicians and patients believed cancer was a constitutional disease that led to a general breakdown of the entire body. From the mid-nineteenth century onward, physicians gradually redefined cancer as a localized disease confined to a specific anatomical region. The major result of this shift was “a heightened sense of surgical responsibility for cancer” (p. 87). Although the outcomes for patients actually changed very little, William S. Halsted and other leading surgeons held out the hope that total eradication of a tumor would lead to cure.

Further advances in surgery, along with technological advances in screening and early detection through blood tests and mammography, raised patients’ expectations about medical intervention, while at the same time heightening awareness and fears about breast cancer. Public health campaigns in the early twentieth century encouraged individuals to “not delay” seeking medical treatment if they experienced any of the signs of cancer such as lumps or changes in the appearance of the breast. This “delay” public health message, Aronowitz argues, placed responsibility for disease on individuals, women especially. It also “allowed physicians to blame time or the patient rather than their surgery or disease concepts if bad outcomes ensued” (p. 157). The rise in surveillance that grew out of this public health campaign gradually included not only cancer but precancerous conditions such as lobular carcinoma in situ, leading one surgeon to quip, “the female breast is a precancerous organ” (p. 179).

While Aronowitz recognizes the patronizing, even sexist, attitudes of twentieth century physicians, he avoids portraying female cancer patients as victims. Like Regina Morantz-Sanchez’s¹ work on the female surgeon Mary Dixon Jones, Aronowitz shows how women were key players in medical decisions over cancer treatment. In an effort to exert some control over this dread disease, women “demanded more medical guidance and surveillance and more closely attended to their own bodies for clues of cancer recurrence” (p. 143). Aronowitz devotes an entire chapter to Rachel Carson’s experiences with breast cancer to exemplify how physician and patient “balanced hope against increasingly discouraging realities and unsatisfying clinical options” (p. 184). Although environmental cancer activists have used Carson’s experiences to advance their arguments about the environmental causes of breast cancer, Aronowitz argues that Carson’s fierce protection of her privacy during her lifetime suggests she would have looked “askance at some of the ways her life and work have been appropriated” and “objected to the kitsch sentimentality of pink ribbons in a disease she understood as her ‘private little hell’” (p. 209).

This ability to balance physicians’ accounts with patients’ stories and experiences is the main strength of this book. Aronowitz skillfully finds a middle ground between hagiography and demonization of leading cancer surgeons and researchers. He also expresses skepticism about the “troubling uses” to which our current understandings of breast cancer risk factors are put. In an effort to exert some measure of control over the disease, Aronowitz argues, Americans have come to accept ever more expensive and...