Medical: The Pursuit of a Cure for Breast Cancer

11Breast cancer 100 years ago was not subtle. Well before mammography, pink ribbons and the Race for the Cure, breast cancers often occupied a quarter of the breast by the time they were diagnosed. Doctors often described them in terms of fruit--plums or even oranges. When William Halsted, famed Professor of Surgery at Johns Hopkins University, devised an operation to treat these breast cancers, it was understandably extensive. Halsted removed not only the affected breast but the adjacent underarm lymph nodes and both chest wall muscles on the side of the cancer. Only by performing such a dramatic procedure, Halsted believed, could all the cancer cells potentially be removed and women possibly be cured. Unfortunately, after surgery, breast cancer patients were often disfigured, left with swollen arms as well as a deep hollow area on the chest wall.

Despite their willingness to perform such an extensive operation, both Halsted and his colleagues knew that women with smaller breast cancers tended to do better. So the American Cancer Society, founded in 1913 as the American Society for the Control of Cancer, entreated women to see their doctors immediately if they noticed a suspicious lump."Early cancer is a curable disease," society publicity optimistically stated. By the 1950s, women were being urged to perform breast self-examination in the hopes of finding smaller cancers. By the 1970s, mammography helped physicians detect even smaller tumors. Activists equated this search for smaller cancers with a military mission, urging women to"fight" their breast cancer. A woman's examining fingers, one physician wrote, were her"weapons" against the"enemy."

Interestingly, however, the standard operation for breast cancer--the radical mastectomy--persisted even as cancers became smaller. Indeed, some physicians even removed parts of the ribcage in search of elusive cancer cells. Why was this the case? For one thing, Halsted and his successors had come to be seen as American heroes, performing dramatic surgery on a dread disease. As in actual war, trying harder seemed to matter."Breast cancer is such a formidable enemy," one surgeon wrote,"that it is our duty to make our dissection as radical as possible." Another even stated that"Lesser surgery is done by lesser surgeons." Patients and families appreciated this mindset, eagerly asking if the surgeon had"gotten it all" at the end of the operation.

But in the 1950s, a small group of physicians began to question the standard assumptions about breast cancer. Led by the surgeon George Crile, Jr., a provocateur who reveled in challenging the status quo, they asked why up to three-quarters of women who underwent radical mastectomies died anyway. Now that cancers were being found earlier, they added, might not less extensive operations be as effective?

By the 1970s, feminist voices had joined the chorus, criticizing not only radical mastectomy but also the unwillingness of breast surgeons to inform women about other treatment options. All women deserved"the right to choose," Babette Rosmond wrote in the pages of McCall's in 1972. Another woman, journalist and breast cancer patient Rose Kushner, became a ubiquitous figure in newspapers, on television, at medical meetings and in Congress, publicizing the disease and challenging the dogma of the medical profession. All of a sudden, Halsted had become a villain. Within a decade, conclusive evidence would exist that radical mastectomy was never indicated in the treatment of breast cancer.

What can modern women and their providers learn from the story of radical mastectomy? For one thing, great progress has occurred in the world of breast cancer. Many breast cancers discovered today are the size of raisins as opposed to plums. Mammography enables physicians to detect"precancers," known as carcinoma in situ, before such tumors have invaded the breast tissue. Surgery, while much less extensive, is as effective. Chemotherapy can cure some women with advanced disease who otherwise would have died. The effect of these improvements can be seen in the overall death rate from breast cancer in the United States, which, having remained stubbornly fixed throughout much of the century, has finally begun to decline.

Yet at the same time, much about breast cancer remains the same. Despite numerous advances, the disease is still the second leading cause of cancer mortality among American women, claiming 40,000 lives annually. We still are at war with breast cancer, continuing to believe, as with radical mastectomy, that more is better. This became quite apparent when bone marrow transplant became available as a treatment for advanced breast cancer. Although physicians, patients and even insurance companies felt confident that this aggressive therapy would be superior than standard chemotherapy, controlled trials have shown equivalent survival. And the ability to discover precancers and, most recently, genetic mutations that indicate a hereditary predisposition to breast cancer, has raised more questions than answers. Is more knowledge always better? Can"treating" future risk of breast cancer do more harm than good?

We are impatient to win the war on breast cancer. But the protracted battle is likely to continue. For now, we should be glad that we have modern-day Halsteds, pushing the envelope on new screening and treatment technologies, modern-day Criles, challenging their colleagues to provide definitive scientific proof that their interventions are effective, and modern-day Kushners, actively promoting women's interests and publicizing the continued epidemic of breast cancer--triumphs and setbacks alike.