The Breast Cancer Wars: Hope, Fear and the Pursuit of a Cure in Twentieth-Century America (review)

Lerner is receiving considerable praise for his ability to write well about many aspects of how patients and sometimes their families, clinicians (especially surgeons), researchers, policy makers, and the media experienced breast cancer in the twentieth century. But he concludes the book with advice that does not contribute to public discourse about the difficult choices confronting those who make policy for covering and financing services to persons who are at risk of or diagnosed with breast cancer.

The book addresses its highly charged subject in an introduction, an epilogue, and twelve chapters. The first ten chapters are superb social history of medicine. Lerner bases these chapters on primary sources, including letters, diaries, and interviews. Moreover, he is attentive to the secondary literature, although he occasionally ignores other historians who wrote about matters that are central to his argument—for example, the frequent analogy between war and health or social problems in the rhetoric of American politics. In Chapters Eleven and Twelve he mixes contemporary history, policy analysis, and policy prescription and reveals inexperience in (or perhaps distaste for) the politics of policy making.

The first ten chapters address the history of interventions to prevent and treat breast cancer in the twentieth century. Lerner explains, for example, that the symptoms and course of disease that patients and physicians perceive changed during that century. William Halstead devised the radical mastectomy for patients who presented with different symptoms than most patients did after anticancer campaigns became routine and especially after the Second World War. Moreover, Halstead and his disciples had a different understanding of the biology of cancer than surgeons did later in the century. Many surgeons' adherence to Halstead's radical mastectomy as the treatment of choice for breast cancer after the 1950s should be understood in this context.

Lerner also writes insightfully about the history of research on the effectiveness of measures to identify and treat breast cancer. Americans would be healthier if every physician and medical student absorbed this story of how and why surgeons resisted conducting or basing recommendations to patients on research that is prospective and that employs statistical rigor to analyze the effects of interventions on populations.

Two aspects of Lerner's skill as an author are particularly engaging. He is adept at describing how patients, advocates, and clinicians tell stories within their group and then act on them—particularly stories about the authority of surgeons, the rights and obligations associated with gender, and how Americans and their institutions should confront dread disease. Moreover, Lerner demystifies science because he understands how statistics are used to persuade: they are rhetorical devices that employ numbers along with words. His work complements D. McCloskey's The Rhetoric of Economics.

In the last two chapters, however, Lerner reaches beyond his expertise. The subtitle of the eleventh chapter is "What Can the History of Breast Cancer Teach Us?" But Lerner ignores a vast literature about the many problems raised by this question (for example, Ernest May and Richard Neustadt's Thinking in Time). As a result, he offers opinions rather than evidence-based advice on questions of significance to patients, physicians, policy makers, and journalists.

Moreover, Lerner suggests in the final chapters that he is ambivalent and possibly underinformed about the contemporary science whose value he is urging on these audiences. He writes that the "experimental conditions established to conduct successful randomized controlled trials (RCTs) may differ markedly from the lives of patients expected to heed the results of such trials" (p. 250). A few pages later he insists, "RCTS may have limited applicability for individual women." (p. 258). Trials are, however, about populations, not the lives of particular individuals. The most sophisticated trialists do not want their work to be "heeded" by patients. Instead, they consider RCTs to...