Fighting the War on Breast Cancer
How a Metaphor has Shaped the Debate on Early Detection and Treatment
By Barron H. Lerner86
More than 20 years ago, Susan Sontag pointed out that disease metaphors were not simply words, but often acquired a striking literalness and authority. In the case of cancer, war has been the dominant metaphor, implying that the disease is an actual enemy to be vanquished on a medical battlefield. I propose that the use of this metaphor has significantly influenced the scientific debate about diagnosis and treatment of cancer, especially breast cancer.
The war on cancer has had important benefits, both in publicizing breast cancer and in generating substantial research funding, which have helped reduce mortality. War metaphors may also inspire individual women who are confronting the disease. However, they have also polarized the scientific debate about breast cancer, promoting the use of vitriolic and accusatory language that discourages reasoned consideration of all treatment options. Military language has also fostered an aggressive attitude toward the disease that favors action in the face of ambiguous results. As a result, the value of early detection and treatment has, at times, been oversold.
This pattern surfaced most recently in January 1997, during the heated debate about mammogram screening for women 40 to 49 years of age. But previous debates have demonstrated the same characteristics. An appreciation of this influence will be important in discussions of genetic testing, the next front in the war against breast cancer.
Although Richard Nixon initiated the U.S. governments war on cancer in 1971, that war had been raging since at least 1936 when activists formed the Womens Field Army. The Armys war cry was for trench warfare with a vengeance against a ruthless killercancer. Since then, it has been almost impossible to discuss breast cancer without using military terminology. One breast cancer activist has been described as a modern-day warrior doing battle for women. And U.S. Sen. Olympia Snowe, R-Maine, has urged Americans to wage war against a brutal and merciless enemy: breast cancer.
By 1950, the standard strategy for breast cancer was early detection of cancerous lumps, followed by an extensive, deforming operation known as radical mastectomy. This was based largely on data showing that stage I cancers, which were contained within the breast, carried a better prognosis than did those that had spread to other parts of the body. But in the early 1950s, a small group of physicians began to question the reigning model of the disease, the value of early detection, and the universal need for radical mastectomies. These critics pointed to data that showed no consistent association between a delayed diagnosis and the extent of the cancer or between the size of the primary lesion and the cancers spread to other sites. They also noted the failure of radical mastectomies to reduce national mortality rates. They proposed a model of biological predeterminism, which attributed the fate of patients more to biological factors, such as tumor virulence and immune response, than to early detection.
The data were ambiguous, pointing definitively in neither direction. But the scientific debate reflected none of that. Instead, scientists chose sides and launched aggressive volleys at each other. One rebel called the existing paradigm of breast cancer all nonsense and contradicted by practical experience. A supporter of the status quo suggested that his colleagues might want to tear the rebel limb from limb.
The vitriolic tone of the debate left little room for rational analysis of a thorny problem. It discouraged physicians and patients from acknowledging the ambiguous results that early detection often produced; limited warfare held little appeal. A similarly aggressive attitude would characterize debates about lesions that were not cancers at all.
Physicians had long identified breast lesions resembling cancer that had not invaded the basement membrane. By the 1930s, pathologists, believing that such lesions were precancers, began to term them ductal or lobular carcinoma in situ. Carcinoma in situ raised two questions: 1) Were such lesions inevitably precancerous? and 2) Did detection mandate mastectomy? Debates about lobular carcinoma were particularly intense.
A few surgeons, including P&Ss Cushman Haagensen, favored a conservative approach, calling such lesions lobular neoplasia and advising only observation. However, most physicians, using familiar military metaphors, essentially equated breast cancer predisposition with the actual disease. Ultimately, viewing lobular carcinoma in situ as a powder keg, surgeons generally recommended mastectomy.
Treatment of the lobular carcinoma in one breast led to scrutiny of the other breast. Studies had reported that women with lobular cancer in one breast developed cancer in the other breast in as many as 25 percent of cases. Mammography was most often used to find lesions, but some surgeons recommended a more aggressive approach: random biopsy of the second breast. Such biopsies were of high yield, generating contralateral carcinoma in situ or cancer up to 59 percent of the time. In such cases, mastectomy of the second breast usually followed.
Some surgeons pushed early detection and treatment even further. Fearing that biopsies would miss existing lesions, they performed routine prophylactic removal of the second breast in women diagnosed with lobular carcinoma in situ. The war on breast cancer may have reached its pinnacle when a marker of possible future cancer in one breast became a rationale for bilateral prophylactic mastectomy in women without other risk factors.
By the mid-1970s, the use of mastectomy for lobular carcinoma in situ was being challenged as it became clear that most women treated only with lumpectomy never developed breast cancer, and those who did often developed ductal carcinomas, which could not have emanated from the lobular lesions. In addition, extensive controlled trials performed in the 1970s and 1980s demonstrated that radical mastectomy is not necessary for the treatment of actual breast cancer.
In January 1997 vitriolic debate about early detection of breast cancer broke out once again, when an NIH panel decided not to recommend routine screening mammograms for women 40 to 49 years of age. The debate had little to do with the scientific value of mammography; it has been claimed that there was broad agreement on what the data show. Instead, the antagonism had much more to do with political, economic, legal, and interest group concerns. Beyond that, the rhetoric of war once again polarized the discussion. Physicians and patients were left without adequate guideposts for applying early detection of breast cancer to clinical practice.
The next front in the war against breast cancer will be the genetic battlefield. Tests identifying BRCA1 and BRCA2 genetic mutations, which are already being termed time bombs, represent a powerful new method for obtaining early information about potential breast cancers. Healthy women who test positive for the BRCA1 or BRCA2 genetic marker are at very high risk for the disease. In order to decrease their likelihood of developing breast cancer, some women are choosing to have bilateral prophylactic mastectomy.
Lacking knowledge about the actual value of genetic testing, history warns us not to conflate the ability to find these markers with the need to find and act on them. In the past, an all or nothing wartime mentality has encouraged aggressive intervention. While prophylactic mastectomy may be the correct choice for some women, careful counseling about the limitations of the operation remains mandatory.
This article is adapted from Barron Lerners original, Fighting the War on Breast Cancer: Debates over Early Detection, 1945 to the Present, which appeared in the July 1, 1998, issue of the Annals of Internal Medicine. It will be part of a book Dr. Lerner is writing on the history of breast cancer. Dr. Lerner, a 1986 graduate of P&S, is assistant professor of medicine in the Center for the Study of Society and Medicine at P&S.