Olson (history, Sam Houston State Univ.) lost his left hand and forearm to cancer, an experience that led him to research the history of breast cancer. His narrative history shows that this disease was known in ancient Egypt and that it took the lives of prominent women, including Empress Theodora, wife of Justinian; Anne of Austria, mother of Louis XIV of France; Mary Washington, mother of George; the environmentalist Rachel Carson; and many others. Olson examines the evolution of cancer research, the politics and economics of the disease, the gender dynamics of female patients and male physicians, and the rise of patient activism. The book chronicles advances in breast-cancer diagnosis and treatment and the uncertainty that women must face while making difficult choices. Unlike Ellen Leopold's A Darker Ribbon, which focuses on the relationships of two specific women with their physicians, Olson takes a broader view, showing that there is still a long way to go but that women no longer struggle alone. This historical take on an important topic, backed by extensive notes, is a good choice for public and academic libraries. Barbara M. Bibel, Oakland P.L., CA
Copyright 2002 Reed Business Information, Inc.
James S. Olson has taken on the task of recounting the entire history of breast cancer -- from Queen Atossa, who lived in Babylon in 490 b.c., to Dr. Jerri Nielsen, who was trapped in Antarctica in 1999 -- and has done it in a concise, attractive, enjoyable book. He tells the stories of affected women throughout the ages, including Queen Anne, Mary Washington (the pro-British mother of George), Nabby Adams, Hitler's mother, Betty Ford, Happy Rockefeller, Nancy Reagan, Shirley Temple Black, Rachel Carson, Linda McCartney, and many others. For the first 2000 years, the humoral theory of Galen held sway. Cancers were thought to be caused by an imbalance of black bile, which meant that local therapy was futile. Breast cancer was a particularly horrible disease, since it generally took its time to kill its victims, slowly destroying the body over the course of many years in a very visible, tangible manner. Women delayed seeking treatment for as long as possible -- and with good reason. Systemic treatments such as purging and bleeding were ineffective and only added to the intense suffering. It took Anne of Austria, the queen mother of France and the most influential woman of her time, three years to die, which she did in 1666. The best she could hope for was to die well, surrounded by her family. Dying well was an art that was cultivated in the 17th century as a response to an unavoidable but predictable fate. By the next century, scientific thinking started to replace older theories. Anatomists observed the orderly spread of breast cancer to local groups of lymph nodes. A brave empiricist actually tasted a breast cancer to show that it was not composed of bile. The idea of curing breast cancer through local therapy took hold. The lack of anesthesia did not prevent efforts to perform mastectomies. First-person accounts by women who underwent this procedure are chilling. Nabby, the only daughter of John and Abigail Adams, underwent surgery at the family home under the hand of John Warren while strapped to a chair and held by two physicians, but she ultimately succumbed to the disease. A German physician warned surgeons about the procedure: "Many females can stand the operation with the greatest courage and without hardly moaning at all. Others, however, make such a clamor that they may dishearten even the most undaunted surgeon and hinder the operation. To perform the operation, the surgeon should be steadfast and not allow himself to become discomforted by the cries of the patient." By the time Dr. William Halsted began his career in the late 1800s, anesthesia allowed more humane and complete surgery. Initial results with more extensive local surgery were promising -- so promising that, for the first time, women began to seek treatment when tumors were still small and potentially curable. Although ultimately the Halstedian approach to systematic removal of breast cancer through radical mastectomy proved unnecessary, effective local treatment markedly reduced the suffering of women with breast cancer for the first time. As the hope for a surgical cure for breast cancer waned in the mid-19th century, three new avenues for therapy were under development. Those who worked with radiation in its early stages noticed the damaging effects on skin and thought the same effect might be used to treat cancer. A second-year medical student treated a woman named Rose Lee with radiation in 1896 (only months after Wilhelm Conrad Roentgen's discovery), and the discipline of radiation oncology was born. During both World Wars, pathologists noted the remarkable disappearance of blood cells and lymphoid tissues in victims of chemical warfare. The same alkylating agents were applied to patients with lymphoma, with remarkable results. For the first time, an effective systemic therapy that could be used with curative intent was available, and medical oncology was launched. For many years, a connection had been made between hormones and breast cancer. In the 14th century, breast cancer was known as the nuns' disease because its high frequency among nuns was well recognized. Nulliparity put nuns at a higher-than-average risk, whereas most women at that time bore children at a young age and therefore had relatively low risk. Seven hundred years later, we are better at quantifying the risk, but we still struggle to understand the biologic mechanisms involved. The first oophorectomy was performed as empirical treatment, and its results were dramatic, albeit short-lived. Soon after the first removal of the ovaries, physicians tried adrenalectomy and then excision of the pituitary gland. Unfortunately, the treatment became almost as bad as the disease. However, with the development of pharmacologic agents to block the effects of hormones, the final tool of modern breast-cancer treatment became available. With the failure of radical surgery to cure breast cancer and with the hope for a systemic cure, breast cancer once again came to be viewed as a systemic disease -- in a modern version of Galen's humoral theory. By the time breast cancers became palpable, most that were destined to metastasize had already done so. Well-planned studies showed that conservation of the breast and radiation resulted in survival rates equal or superior to those associated with radical mastectomy. The use of chemotherapy resulted in small but significant improvements in survival. It is more difficult to chronicle the more recent history, since current debates remain unresolved, the protagonists are still active, and we do not have the advantage of hindsight. In addition, the history of breast cancer in the latter half of the 20th century became more complex, thanks to the rise of the women's movement, environmentalism, and the politicization of the disease. Some readers will undoubtedly object to the relative weight Olson gives to one side or another in these debates. The importance of the rising incidence or "epidemic" of breast cancer in the 1980s and 1990s is a good example. Was it due to an environmental cause (e.g., pollution or pesticides), or as seems increasingly likely, was it due to a combination of an aging population, earlier detection by mammography, and lifestyle-related choices (having fewer children later in life, for instance, or breast-feeding for briefer periods or not at all)? Rachel Carson, the mother of the environmental movement, who won many battles in her campaign against environmental pollution, lost her battle with breast cancer. But was she more susceptible because of pollution by chemical companies or because of her own choice to remain childless? The effect of the introduction of screening mammography in the 1980s on the future of breast-cancer treatment and prognosis is another area of active debate. The remarkable shift toward patients' presenting with smaller invasive cancers or with noninvasive cancers cannot be disputed. However, Olson's statement that "mammograms probably caused tens of thousands of needless operations per year" as a result of the detection of ductal carcinoma in situ can be disputed. The recent downward trend in mortality from breast cancer -- the first such decline ever -- could be attributed to the detection and effective treatment of cancer at its earliest stages. In fact, the postmammography era may see yet another paradigm shift. Although most palpable cancers have spread by the time of detection, many cancers that are detected on screening are curable by local surgery. Thus, both Galen and Halsted may yet be proved correct in the upcoming decades.
Susan Lester, M.D., Ph.D.Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.