Barron H. Lerner, M.D., Ph.D.
Associate Professor of Medicine and Public Health
Center for the Study of Society and Medicine
Columbia University
"Fighting the War on Breast Cancer in the 20^th Century: From the Radical Mastectomy to Genetic Testing"
April 11, 2001

Dr. Lerner: I'm going to be looking, this afternoon, at what the history of breast cancer can teach modern patients and clinicians. I am going to argue that social and cultural factors influence how science is both understood and interpreted. I am going to talk extensively about the use of war metaphors as a tool to understand this process. I am going to talk mostly about what occurred in the United States during the 20^th century as far as breast cancer control. I am not going to talk about other countries. I am going to talk on the war of breast cancer as opposed to the war on other cancers. So let's move into the treatment area. When one talks about breast cancer treatment, the famed figure in the United States was William Hoffstead. Hoffstead was a surgeon at Johns Hopkins University -- Johns Hopkins Medical College -- beginning in the late 19^th century. He was a noted surgical innovator in many areas, but particularly in the area of breast cancer. What he did was to popularize an operation called "the radical mastectomy." This is a diagram of his radical mastectomies from one of his papers. What I want you to notice is here is the breast cancer, and what Hoffstead believed you needed to do was to remove the breast, the underarm lymph nodes, and both chest wall muscles on the side of the breast cancer. A picture of a woman who has had that operation is shown here, and it's hard to see, but you can tell where the ribs are showing and she's again lost, not only the breast and the underarm nodes, but both chest wall muscles on that side. Why did he think such and extensive operation was necessary? Well for one thing, in those days breast cancers were much larger than they are now (and I'll say more about that later). But he also drew on what the understanding of cancer spread was in this era. People believed that cancer started from a small focus in the breast and grew very gradually in a centrifugal manner getting larger and larger and actually stayed in the breast for a long period of time only then going to the lymph nodes and other places in the body. So Hoffstead thought that if you did a big enough operation early enough, you could get all the cancer cells. That is why he felt such dramatic surgery was necessary. And indeed, the radical mastectomy became the treatment of choice for cancer for decades. I'm going to talk more later about why the radical mastectomy was held to be the most effective surgery if done early. This was very much part of what Hoffstead believed.

Hoffstead supported his theories with data. I'll just show you a couple quick examples. In 1898 he reported that 53% of women who had his radical mastectomy survived for 3 years and he compared that to a baseline sample of women who had not had a radical mastectomy who only survived at the rate of 10-20%. A study done by some of his followers in the 1930's also suggested that radical mastectomy could be affective, particularly if done early enough -- stage one cancers, women now surviving five years at the rate of 62%. Again, if the cancer had spread to the lymph nodes or beyond, they only survived 21%, even with the radical mastectomy. Again, putting this notion that early, aggressive surgery could be very effective in what was felt to be a very devastating and dramatic disease.

Even though data is a big part of the story here, I am going to argue that the social and cultural factors that influenced the interpretation of this data made an even bigger impact. This helps to explain more forcefully why radical mastectomy became so popular. One major factor that occurred is what I will call the "professionalization of surgery." Hoffstead not only devised this and other operations but really was at the forefront of developing surgery into a true profession. He went to the laboratory, did studies of anatomy and physiology, and said, "if you can understand the science of surgery, you can understand how best to treat patients." Surgeons can them become "scientists" in the operating rooms. The larger point is the science of surgery--these were not just surgeons who went in willy-nilly, but they understood why they were doing these types of operations. Hoffstead,himself, was revered by surgeons everywhere, particularly in the United States. This is a pedigree that a doctor came up with in 1952 that showed how Hoffstead had trained 17 surgeons, and then these surgeons had gone out to become professors, etc. Hoffstead indeed devised the first surgical residency training program in this country, and in this way was able to disseminate his teachings widely. His image was further vurninshed by the fact that it turned out that Hoffstead was suffering from a series of addictions throughout his career--initially cocaine, and later morphine. The fact that he achieved what he did despite these addictions further cemented him as sort of the ideal surgeon of the era and led him to popularity in the types of surgery he recommended. Surgeons of the era also benefited from the fact that they served as pathologists in many of their cases. Pathologists in the early 20^th century often limited themselves to just doing autopsies. Surgeons wanted to know (as surgery became more scientific) what was going on during an operation. If they cut a piece of breast tissue they wanted to know was it cancer? Did it seem to have spread? They then would use this information to inform what type of operation they were going to do. The surgeons became what was known as surgical pathologists. During the operation, they would leave the operating room and go look under a microscope. The surgeons were incredibly powerful. They saw the women in the office, felt the lump, diagnosed the cancer that way, then looked at the slides during the operation, decided what type of operation was necessary, and then performed the operation. The surgeons really had total hogeminy over breast cancer as a disease because of this.

Tied into this notion was the role of the hospital. In the early 20^th century hospitals were becoming, what one author has called, "temples of science." Whereas hospitals before were somewhere where poor people often went (almost like alms houses when there was nowhere else for them to go), by the early 20^th century, patients being admitted into hospitals were getting exposed to much more sophisticated medical technologies and undergoing medical procedures that were much more modern. Hospitals liked the fact that they could say to patients, "if you come here we will give you the most modern surgery, you will be evaluated by doctors who have scientific training." Hospitals also like the fact that could charge by the patient for these operations, such as the radical mastectomy. It wasn't just the doctors who were promoting this notion of radical mastectomy in scientific surgery. It was a public sense that we had to do more about cancer, and breast cancer in particular.

This is a diagramatic of rates of disease in the United States. You can see, as of 1900, cancer was only the 8^th leading cause of death, but by the 1959, it had become the 2^nd leading cause of death. As a result, cancer increasingly became characterized as a public health problem. Something we needed to do something about. The old notion of cancer as a disease of aging, or something you just got as you got older, was thrown by the wayside. This transformation of cancer and breast cancer and public health issues did not occur simply by itself. There was a group of interested physicians and laypersons in New York City who formed what was the forerunner to the American Cancer Society. In 1913 this organization began and was called The American Society for the Control of Cancer (and later was called the American Cancer Society). These folks believed that the organization, in order to succeed, needed to have a hopeful message about what we have done about breast and other cancers. They settled on the notion of early, aggressive intervention of cancer.

This is one typical, educational pamphlet put out by the American Society for the Control of Cancer. As you can see, this notion was central to the cancer's curable if treated early. You'll note at the bottom, the first of the famous Cancer Society danger signals or warning signals was "any lump, especially in the breast." So, if you were a woman and you found a lump in your breast, you needed to go to your doctor right away so that it could be treated as early as possible, again with the radical mastectomy. The graphics used in this era by the Cancer Society were not very subtle. As you can see here, if you did not go to your doctor early enough, your fate is shown here (gravestone), but if you did, this is your fate (body). The Cancer Society has obviously toned things down, but the message was very powerful--you had the ability to do something about cancer if you found a lump in your breast.

This notion of early resident intervention both drew on Hoffstead's theories and validated them. If you look at some of the writings from the American Society of Cancer Control at this point, you could see how there is sort of a feedback loop. So the Society writes:

"Cancer begins as a local disease. If recognized in time, it can often be completely removed and the patient cured."

This drew on Hoffstead's notion. But once the Cancer Society sort of put it out there, it served to validate what Hoffstead was saying, even more strongly than his own medical data. In this way, it became sort of a feedback loop because again, the only way you could sort of conceive of breast cancer was as a disease that could be controlled aggressively if found early.

Tied into this was the whole notion of war and militaristic imagery. If you look at the Cancer Society images from this era, they are very replete with war type of messages. This is the famous "sword of knowledge", first used in 1927, and hope always is the reigning message. We can get rid of ignorance and fear if we fight cancer with knowledge and get women to the doctors soon enough. The point was that both patients and doctors in this war on breast cancer were soldiers and needed to do what they could as soldiers in the fight to cure this disease. Why the war metaphor so strongly? I think it had a lot to do with the American culture and particularly the American culture of individualism.. In the United States, as you know, this notion of individual ingenuity has always been very strong. The notion that you are personally responsible for you health, that you can act as an individual and accomplish and achieve things. The notion that making enough effort, showing enough courage, can pay off, all sort of lent itself to portraying these efforts to control breast cancer as a war.

Women played a major role in this. Again it was not just doctors. In the 1930's, the so-called Women's Field Army was formed in conjunction with the Cancer Society, but run by women. About probably 500,000 women enlisted in the Women's Field Army, got Army uniforms, got stripes if they enrolled other women, and basically got other ran around the country attempting to get women to join the Field Army. What was the point of joining it? The point was to publicize women's cancers--uterine cancer and breast cancer in particular--and again this notion that you had to act early.

The war on breast cancer came into full fruition, I would argue, after World War II. Again, I think it has to do with what was going on in American society. World War II had been a remarkably successful endeavor for the United States with victory over both Japan and Germany. Indeed, if one looks at the medical literature in this era, one sees people saying, "We've defeated the axis powers and cancer is now our next enemy." The surgeons, many of whom had been over seas and had served during the war, saw their role as being able to transfer what they learned on the battlefield medicine to their home front. Although many of these operations were not necessarily cancer operations, a lot of the surgery that was done was very aggressive--trying to take out bullets and other types of aggressive trauma surgery. Surgeons came home sort of imbued with this notion, again, that more surgery is better.

The place that this happened most dramatically was at Memorial Sloane Caterine Cancer Hospital in New York. One of the doctors involved in this was George Pack, a cancer surgeon known among many other accomplishments as the surgeon who operated on Evita Perone for her cervical cancer in the 1950's. Pack, probably the most early voice with this notion that more surgery was better, began a series of operations for cancer at Sloane Hospital that had never been done before. He performed surgeries such as: the total gastrectomy (removal of the entire stomach), removal of actual arms and limbs of patients (they were called "four-quarter" and "hind-quarter" operations), removal of 80% of the liver for patients who had cancer of the liver, and finally, "pelvic exemploration," a procedure in which women with gynecological cancer had all of their pelvic organs moved as a preventative measure.

Now, what about in the case of breast cancer? The doctor who pushed most aggressively in this area was Gerome Urban. Urban designed an operation called, "the extended radical mastectomy." (Showing slide) You see here that the woman undergoing the operation, not only lost breast, muscles and underarm lymph nodes, but they literally opened up her ribcage. The point here was to go in and find the internal mammory arteries, the lymph nodes. If you went in and got those through such a dramatic operation, you could do more for the patient. These were not done everywhere, but at many hospitals in the 1950's.

What promoted this sort of aggressive surgery post WWII? Another breast surgeon from the year named Cushman Haagenson who was at Columbia. I am going to show you some quotations by doctors who get at this notion of how the effort that went into doing breast cancer surgery became conflated with the outcomes--in other words, if you just tried harder, things had to be better, even if the data was not necessarily supporting it. Again, I am trying to argue that there was this cultural notion that you (and America) wanted to support and believe.

"Breast cancer is such a formidable enemy that it is our duty to make our dissection as radical as possible." -- Cushman Haagenson, MD 1946

"I have preferred the sharp knife, a stout heart and unquenchable optimism, and have regarded the widest radical surgery untrammeled by ancilliary radiation as the method of election in almost every case." -- Gordon Gordon-Taylor, MD 1948

"Disease still stands relentlessly barring our way. We shall have to wrestle with it often and fiercely before the final conquest. For today, the victory must lie in the struggle itself." -- George T. Pack, MD 1953

"Lesser surgery is done by lesser surgeons." -- Dr. Urban

Another factor that played in was the notion of risk. I think historically that Americans have been risk-aversed when it comes to breast cancer. The notion that it is better and safer to do more is very powerful. The notion of treating the many to save the few--even in the acknowledgement that maybe a large amount of women did not need this radical surgery, but only a small percentage needed it--was somehow a worthy operation for everyone because it was hard to tell who would or would not need it. This notion of risk and trying to avoid risky situations played an important role. So, you started to see this type of language by the early 1960's that any lesser surgery would be the equivalent to playing Russian Roulette with your life.

This mindset did start to get challenged in the 1950's. The first person who really challenged it was George Kryle Jr, known as Barney Kryle. He was a surgeon at the Cleveland Clinic and the son of another famous American surgeon, George Washington Kryle who had done pioneering work in WWI on the notion of surgical shock. A second surgeon was Oliver Pope who worked at the Mass General Hospital in Boston. What these and other heretics, really, started to argue that smaller operations for breast cancer were just as effective as larger operations. They asked why do such large operations if you have to hunt for so many of these nodes and the cancer has probably spread beyond where the scalpel can get. If the cancer is localized why do such large operations when you can probably do smaller operations. They argued that these big operations did not make any sense at all from a medical perspective. You can either do small operations--removal of the breast and even doing just a lumpectomy (which was complete heresy in the 1950's--or even not doing an operation at all because you were not going to get it all. This notion of radical surgery was misguided. Kryle, Pope and these other physicians were harshly criticized. To use the war language, they were seen as "traitors" in a time of war. They did not accomplish much as a result.

The shift away from radical mastectomy in the United States which only occurred in the 1970's, was really effected by women who began to challenge their doctors directly. I'll talk about a few, although there are many interesting characters and figures in this era. A woman named Babbette Rosmand who is entirely forgotten in history books. She was diagnosed with breast cancer in 1971. She was a New York City writer at Seventeen Magazine. She knew a couple of women who had radical mastectomies and had a lot of side effects from their surgery. She basically made up her mind that with her very small lump that she found was not going to have radical surgery. She set about finding a doctor who was willing to just take out the lump. She characterized, in subsequent articles and a book, her pursuit of this as the right to choose. She basically said that if there are other options to radical surgery she should know about them and have the right to choose. From a modern perspective, this is hardly that surprising, but it was only thirty years ago that women who put forward this notion were thoroughly dismissed by many physicians and surgeons in this country. The rise of the notion of patients' rights was intimately tied into feminism, the rise of women's health issues in the 1970's as well, and the growing notion of consumerism at this time. Physicians responded variably to women who came in the office and were requesting smaller operations. Many of them responded in a favorable way and it started to see that Kryle and Pope were onto something. But many other physicians saw women coming into the office often with tape recorders as a threat to medical authority, and you start to see quotations like this one:

"Now the surgeon is faced with a patient who presents herself with a lump in her breast, a copy of an article from Vogue Magazine, a quotation from the Today Show and a preconceived notion of how she should be treated." -- John Wilson, MD 1974

Today, obviously, this is mandatory, but it was a foreign notion at that time. There was another woman who followed the lead of Rosmand. Rose Cushner-- who was a Washington D.C. journalist who developed breast cancer in 1974--until she died of breast cancer 16 years later was on a very monolithic focus to get out issues of breast cancer to women, the notion that radical mastectomy was not necessary, and the notion that women needed to talk to their doctors and could go to scientific literature to learn things to discuss with their doctors. Indeed, by the early 1980's, it appeared that Kryle, Pope, Cushner and all these other folks had been right. Studies done by Bernard Fisher, a surgeon at the University of Pittsburgh, showed that less extensive surgery, often accompanied by either radiotherapy or chemotherapy indeed gave the same outcome as the larger operations. So this notion that bigger had to be better was scientifically disproven. What happened by the 1970's was that we were able to supplement with mammography. If you could find smaller lumps by purposefully examining your breasts, how about doing an X-ray? The technology for mammography has actually been available for decades, but the quality of the imagery had been very poor. It was not until the 1960's and 70's that doctors really tried to use this technology to find even smaller cancers--often as small as one centimeter in diameter--again could be treated if found early. Like the surgeons in earlier era, radiologists in this era are sort of categorized as the "saviors" of women in their ability to do mammography and find these small and curable cancers.

The latest and last chapter written at this point is genetics. In the world of genetics, we are not even talking about the early detection of small cancers anymore. If we look historically what transpired was Hoffstead was just trying to get women to doctors if they found a big lump. Then by the 1950's women were being urged to try to find small lumps by themselves and go to the doctor. By the 1970's you could get mammography that could find small cancers and VCIS/LCIS--very murky pre-cancers that were even harder to get. But, in each case you were finding abnormal tissues that you had to decide what to do about. In the world of genetics, if you are tested for the BRCA-I or the BRCA-II (which indicates a very high predisposition to cancer), you are not really doing early detection at all, you are merely determining if you have a higher risk.