Book review: Radical ideas

The breast cancer wars: hope, fear, and the pursuit of a cure in twentieth-century America Barron H. Lerner New York: Oxford University Press; 2001 383 pp. $52.50 ISBN 0-19-514261-6 If it's true that those who can't remember the past are condemned to repeat it, this book is a must for anyone whose work involves breast cancer. The opening scene, in which a surgeon casually demeans his bare-torsoed, one-breasted patient in a medical school amphitheatre, is guaranteed to make readers squirm. And that's just the prelude to 300 pages (plus copious end-notes) that detail the rise and fall of one of medicine's most egregious mistakes, William Halsted's radical mastectomy. Far from sensationalizing his material, Barron Lerner, an associate professor of medicine and public health at Columbia University, takes pains to be even-handed. At the same time, he doesn't back away from examining the “active, often acrimonious debates” that characterized discussions about breast cancer diagnosis and treatment of breast cancer throughout the last century — and that show no sign of abating today. The ominous moral to Lerner's tale is that the same culture that gave Americans the radical mastectomy continues to shape contemporary responses to the disease. As a social historian, Lerner rejects the traditional hagiographic chronicling of “great men” and their achievements in science. Rather, he seeks to understand breast cancer in its social and cultural context. Throughout the book he gives weight to the patient's perspective. Reflecting on the early years, he culls comments from letters written by unidentified women to their physicians, often in gratitude. By the 1970s, Lerner relates, patients were “in revolt” and feminist leaders such as Babette Rosmond and Rose Kushner were publicly challenging the power of male physicians. In the final chapters, Lerner explores the diversity within the contemporary breast cancer movement. Not that great men are absent from this account, or their achievements denied. The book is alive with profiles of physicians whose work and ideas shaped a century of medical research and practice in breast cancer. But men like William Halsted, Cushman Haagensen, George Crile Jr, and Bernard Fisher are depicted as actors in a complex drama, their warts and egos exposed. Halsted, who devised and popularized the radical mastectomy, comes across as undisputedly brilliant, though a social dolt. Among the kinder comments on his lack of social grace was colleague William Osler's observation that Halsted and his wife were both “a little odd. They cared nothing for society, but were devoted to their dogs and horses.” Lerner sympathetically traces Halsted's career as the American who brought scientific medicine from Europe to the United States and as one of the eminent early faculty at Johns Hopkins, where he earned a reputation as an innovator (he introduced the use of rubber gloves in surgery). He believed the radical mastectomy was a cure for breast cancer. The fact that he was wrong matters less today than understanding why Americans embraced this mutilating treatment long after surgeons in Canada and England had moved on to kinder, equally effective, procedures. The popularity of the Halsted mastectomy is a fascinating enigma. All through the 20th century, the operation had its critics, both within the US and abroad. It was revered by devotees as “scientific,” but scientific evidence was never on its side. Yet it remained the treatment of choice for a majority of American surgeons and patients until the mid-1980s. The 1950s even saw a movement toward “superradical” mastectomies, in which the surgeon split the patient's clavicle, ribs and sternum “in pursuit of cancer cells.” American ethnocentrism, paternalistic arrogance and Halsted's legendary stature all served to maintain the faith — but, ultimately, says Lerner, the cult of the radical mastectomy could not have thrived for so long without an underlying culture to nurture it. Americans embraced the operation, he concludes, because it embodied an optimistic promise that spoke to America's soul: aggressive attack will vanquish an enemy. Despite the perception that the radical mastectomy belongs to America's past, Lerner argues that Halsted's spirit lives on in other extreme treatments for breast cancer. In the 1990s, American patients bypassed clinical trials to receive stem cell transplants, which have never been shown to be effective. Today, radiotherapy, toxic chemotherapy combinations, hormonal treatments and prophylactic mastectomies are used to treat early lesions or, with the advent of genetic testing, mere risk, despite slender-to-absent evidence of gain. Halsted's lasting legacy is the belief that disease, if detected early and treated aggressively, can be cured. Americans continue to embrace extreme treatments because Halsted's “search-and-destroy” motto sits well with American individualism and belief in progress, and with the nation's profit-driven medical system. Although this ideology champions individual choice, the belief system actually excludes certain equally reasonable choices — such as watchful waiting, the refusal of screening, or the rejection of aggressive treatment for advanced cancer. In the “war” against breast cancer, prevention is worse than excluded, it's the talk of traitors. Lerner develops his thesis against the backdrop of other countries, including Canada, where the exchange of extreme pain for modest gain has never held the same sway as in the US. At a time when our health care system is under review and oncology services are strained, this thoughtful look at America's great surgical folly offers insights into the big picture of systemic choices and their consequences. A bonus is the sheer pleasure of an absorbing tale well told. And while Lerner offers no pat answers, The Breast Cancer Wars is a rare book that could change the course of breast cancer treatment for the better. Sharon Batt Elizabeth May Chair in Women's Health and the Environment Dalhousie University Halifax, NS

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