- A History of Lung Cancer: The Recalcitrant Disease by Carsten Timmermann
Carsten Timmermann’s history of lung cancer is a welcome addition to the growing literature on the varieties of cancer. Focused on the United Kingdom, with gestures toward the United States and Europe, the book is less about the familiar story of smoking and lung cancer, than about the difficulties of detecting, diagnosing, and treating the disease, and how medical practitioners have responded to a lack of progress. Where the tobacco story can point to “successes,” such as the discovery of the causal links between smoking and cancer, the development of preventive measures based on these discoveries, and the ongoing struggles to bring the tobacco industry to heel, Timmermann’s story is more downbeat. Indeed, the identification of smoking as a cause of lung cancer contributed to the problems Timmermann describes, for it meant that from the 1960s prevention garnered attention at the expense of therapy, and that those with lung cancer were stigmatized as the cause of their own ills. [End Page 836]
The book begins in the nineteenth century when the disease was a rare condition, easily confused with other lung diseases, and Timmermann traces medical innovations that shaped how lung cancer was subsequently classified, diagnosed, and treated. This includes a litany of unsuccessful efforts to treat the disease: surgery, radiotherapy and chemotherapy all failed to offer effective treatments (except for occasional small gains in survival), as did their various combinations with each other. Efforts to detect the disease were equally frustrating. It proved impossible for clinicians to develop reliable means of screening either for pre-malignant lesions or early cancers. Radiography did not provide a method, nor did cytological examination of sputum, nor computed tomography (CT) scans. Screening was dealt a further blow in the 1970s by studies that that suggested that it might detect tumors that would not have killed their human hosts. Lung cancer tumors grow at different rates, so that heavy smokers often die of other conditions before their slow-growing tumors caused them problems. Although the Americans warned against abandoning screening, the British scaled back—mass radiography services were dismantled as tuberculosis rates fell, and screening for lung cancer was never institutionalized.
It was against this depressing backdrop that increasing attention focused on prevention. The expectation of new treatments and means of detecting lung cancer never disappeared, but it took second place to smoking cessation, and its relegation continues today. Current hopes focus on the controversial spiral CT scanning and targeted drug therapies (and the consequent balkanization of lung cancer into a variety of diseases each defined by a molecular target, the putative object of therapy). However, it is unclear whether these new interventions will have more success than their predecessors. Survival rates remain poor, and most attention continues to focus on prevention.
So what to do for those who contracted such a difficult disease? One option was to help people die, and Timmermann briefly outlines the work of hospice organizations such as MacMillan Cancer Care and Marie Curie Cancer Care in transforming the ways in which people in Britain died of this and other cancers. (More could have been said about this and the emergence of palliative medicine as it relates to cancer.) Another was to sidestep a direct attack on the disease, and to focus on fundamental research into the mechanisms of cancer. (A strategy that carried the risk of supporting much that was tenuously related to lung cancer). And a third involved destigmatization. Critics argued that the stigma associated with the disease meant that patients could be denied care if they continued to smoke, and that it also tended to undermine efforts to raise money for research and to develop new screening, diagnostic, and therapeutic interventions. Yet, Timmermann’s depressing message is that destigmatization did not have the success that its advocates desired. Indeed, it is the persistence of the view of lung cancer as a self-inflicted wound, he argues, that accounts for its recalcitrance as much as...