Preventive Strikes: Women, Precancer, and Prophylactic Surgery (review)

At the beginning of Preventive Strikes, Ilana Löwy describes her observations at a French cancer center, where counsellors advised women diagnosed with BRCA mutations that they had two preventive paths open to them: intensive medical surveillance or prophylactic surgery. Löwy was struck and bewildered, as she puts it, by the contrast between the sophisticated diagnostic technology employed and the “crudeness” of the solution offered (p. 1). Her effort to comprehend and explain this contrast has resulted in this excellent, wide-ranging, and thorough study. In eight chapters, Preventive Strikes examines how changing models of disease causation, heightened perceptions of risk, and increasing technological proficiency have converged to produce the category of “precancer.” Pathology and genetics have radically improved medicine’s ability to find precancer, while a deep fear of cancer and a persistent faith in the logic of early detection has driven highly interventive, even aggressive, responses to the presence of potential malignancies. Löwy’s goal, then, is to track the intertwined evolution of new diagnostic categories and new approaches to managing risk, which together have created a new way of “living” with cancer—without symptoms but with intensive surveillance and intervention.

Preventive Strikes speaks to multiple but overlapping audiences, as Löwy brackets her rich historical account with a science studies analysis of precancers as intermediate objects, poised between the normal and the pathological. Early-twentieth-century doctors and public health advocates, she shows, outlined a model of cancer’s development pivoting on a linear progression from suspicious cells to full-fledged disease, and once suspicious cells were redefined as precancer, it became increasingly difficult to see them as anything other than the first stages of disease. But even though generations of skeptics tried to pick apart this notion and tease out the underlying complexities and uncertainties inherent in borderline conditions, precancer had become thoroughly linked with the interventive surgical traditions of gynecology, and new medical and organizational practices were built around and upon it. Löwy is also particularly strong at showing how many different sets of actors—especially pathologists, surgeons, and the architects of early diagnosis campaigns and screening programs—dealt with the uncertainties posed by precancer; this book is thus a must for anyone interested in the relationships connecting laboratory science, clinical practice, and public health policy.

As the description above suggests, this is not a simple book. Löwy does not track a single disease, a single practice, or a single set of experiences; instead, she shows how the many phenomena that have, at various times, been seen as precancer were constituted and managed in several national contexts. Her main focus is on comparing approaches to understanding and managing cervical and breast conditions such as cervical dysplasia and ductal carcinoma in situ, but she also comments on how their management related to that of other premalignancies such as familial adenomatous polyposis. Furthermore, Preventive Strikes is built on a simultaneously broad and deep range of research, bringing together archival materials and medical literature from the United States, the United Kingdom, and France—but with occasional detours to Germany, Canada, Brazil, and other nations. This allows Löwy to reveal the interchanges between globally shared scientific knowledge and local therapeutic practices; however, it also makes for a complicated storyline, and the reader will encounter a few especially sudden changes of gear. But these are minor, and do not detract from a book that is ambitious, insightful, and invaluable.