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Phenomenal Woman

A History of Breast Cancer

Breast cancer is an ancient disease, and it has been mentioned in almost every period of recorded history. Physicians have consistently noted that breast cancer is visible to even the untrained eye, progressing from a small lump to large tumors. Unlike other fatal diseases (heart conditions and most other cancers), breast cancer announces itself in a tangible fashion (Leopold 1999). Yet, despite the visibility of the disease and the powerful reverberations breast cancer has had, for women specifically and society in general, any discussion of breast cancer was found only in medical journals before the 1970s. Historically, the breast carries with it many cultural expectations for women, specifically their nurturing and sexual obligations. Perhaps it is because the breast holds such cultural power that the disease was considered by many to be a taboo subject and many of its sufferers often felt ashamed or embarrassed to openly discuss the disease. This previous void in literature outside medical journals stands in stark contrast to the extremely visible presence the disease holds in contemporary culture. Today there is no public forum in which breast cancer is not discussed (Leopold 1999). Since the success of breast cancer activism in the 1990s, the symbol of breast cancer--the pink ribbon--is ubiquitous in American culture, and politicians and healthcare officials are acknowledging the role that political and cultural assumptions play in finding a cure.

Ancient Egypt and Greece: Breast Cancer as a Systemic Disease

Ancient Egyptians were the first to note the disease more than 3,500 years ago. Both the Edwin Smith and George Ebers papyri contain descriptions of conditions that are consistent with modern descriptions of breast cancer. For example, one nameless ancient Egyptian surgeon describes “bulging tumors” in the breast and states that “there is no cure.” In 460 B.C., Hippocrates, the father of Western Medicine, described breast cancer as a humoral disease. In other words, for Hippocrates, the body consisted of four “humors” (blood, phlegm, yellow bile, and black bile), which mirrored the building blocks of nature (air, fire, earth, and water)--and any imbalance of the system of humors caused sickness or even death. For Hippocrates, cancer was caused by the excess of black bile, or “melonchole.” This logic made sense to Hippocrates because the appearance of an untreated breast tumor would be black and hard, eventually erupting through the skin with black fluids. He named the cancer karkinos, a Greek word for “crab,” because the tumors seemed to have tentacles, like the legs of a crab. Hippocrates considered surgery dangerous because those who had the tumor excised “perish quickly; while those who are not excised lived longer (Olsen 2002).

In A.D. 200, Galen, Hippocrates successor, also describes cancer as excessive “black bile” but, unlike Hippocrates, Galen also realized that some tumors were more dangerous than others. Galen also discusses a wide range of pharmaceutical agents to treat breast cancer, such as opium, castor oil, licorice, sulpher, and a variety of salves, as well as incantations to the gods. For humoral physicians, surgery to remove the tumor or entire breast was not even considered to be an option for a cure since they assumed the cancer would just reappear near the surgical site or somewhere else in the body. For Galen and physicians succeeding him over the next 2,000 years, breast cancer was a systemic disease, which meant it was a disease of the entire body, not just one localized part. The dark bile was believed to course throughout the entire body--so even if a tumor were removed, the bile would still remain in the body, ready to create more tumors.

Until the seventeenth century, physicians assumed that Galen had the final word on breast cancer and that there was nothing left to discover. However, in 1680, French physician Francois de la Boe Sylvius began to challenge the humoral theory of cancer by arguing that cancer did not come from an excess of black bile but from a chemical process that transformed lymphatic fluids from acidic to acrid. In the 1730s, Paris physician Claude-Deshais Gendron also rejected the humors theory and insisted that cancer developed when nerve and glandular tissue mixed with lymph vessels (Olson 1999).

The Eighteenth Century: Breast Cancer as a Localized Disease and the Rise of Surgery

By 1769, the humoral theory had lost much of its currency. To disprove the humoral theorists, French physician Jean Astruc took a piece of breast cancer tissue along with a slice of beef and burned them both in an oven and chewed them. Both tasted the same, and he concluded the tumor tissue did not contain unusual amounts of bile or acid. With the humoral theory disproved, physicians began to search for a new origin of breast cancer, and many argued that its origin was sexual. Physicians knew of Bernardino Ramazzini's 1713 hypotheses that the high frequency of breast cancer in nuns was due to lack of sex; according to Ramazzini, without regular sexual activity, reproductive organs, including the breast, started to decay and cancer was the result. Friedrich Hoffman of Prussia posited that women who had regular sex but still developed cancer were practicing “vigorous” sex that could result in lymphatic blockage.

But there were other, nonsexual theories also presented. Giovanni Morgagni blamed curdled milk. Johanes de Gorter in the 1750s claimed that tumors came from pus-filled inflammations in the breast that mixed with blood, lodged in the milk gland, and dried into a tumor. Claude-Nicolas Le Cat from Rouen claimed that depression caused cancer by constricting the blood vessels and trapping coagulated blood. Lorenz Heister placed childless women at high risk, while others blamed a sedentary lifestyle which slackened bodily fluids. Though there was no lack of theories, the cause of breast cancer was still as mysterious to them as it was to the ancients. But unlike the ancients, eighteenth-century physicians gradually became more certain that breast cancer was a localized disease. This had enormous implications, because in contrast to humoral theories which considered mastectomy a tangential treatment due to the systemic nature of cancer, doctors were rapidly becoming skeptical of anything but surgery (Olson 1999).

In 1757, Henri Le Dran, a leading French physician, argued that surgery could actually cure breast cancer as long as the infected axillia lymph nodes were removed. Similarly, Claude-Nicolas Le Cat argued that the scalpel was the only way to cure cancer. Le Cat would amputate the breast, cutting out the lymph nodes as well as the pectoralis major muscle. These physicians were convinced that the presence of a tumor did not necessarily imply a more serious problem, but was a single-site disease that could be surgically removed locally before it spread. This theory lasted well into the twentieth century and led to the creation of the radical mastectomy (Hellman 1993).

William Halstead and the Radical Mastectomy Paradigm

By the mid-nineteenth century, most physicians held that because cancer was a localized disease, surgery was the only hope. The development of antiseptic, anesthesia, blood transfusion, and cellular biology--as well as increased public trust in the medical field--made radical surgery possible. Gone were the days of pre-anesthesia which necessitated speed and dexterity with an often resistant patient. Surgeons now had time for deliberate precision, and William Halstead of New York made radical breast surgery the gold standard for the next 100 years. Halstead wanted to reduce the recurrences of the disease which often afflicted patients within a year of their initial surgery and to help even the most advanced-inflicted patients. Whereas earlier surgeons would remove the breast, axilla nodes, and pectoralis muscle, that was not enough for Halstead. He knew that cancer was a cellular disease and worried about his own role in spreading it. He argued that lifting away the excised breast with surgeon hands probably scattered tumor cells. This led him to call for a radical mastectomy—removal of the breast, axillary nodes, and both chest muscles in a single en bloc procedure. He would cut widely around the tumor, removing all the tissue in one piece.

During the first four decades of the twentieth century, the radical mastectomy dominated breast cancer treatment. Halstead himself performed hundreds of radical mastectomies and urged that inflicted women should receive a radical mastectomy before the tumor spread to regional lymph nodes. While the radical mastectomy may have extended life slightly and eased the pain of diseased breasts, it was not an unmixed blessing. Some women avoided the surgery because it would leave them wounded and disfigured for the rest of their lives. Women had to deal with a deformed chest wall, hollow voids under the collar bone and the armpit, chronic pain, and lymphedema or swelling in the arm because the removed underarm lymph nodes could no longer process circulatory fluids efficiently. Halstead dismissed these effects as necessary evils; besides, the women’s average age was “nearly fifty-five years [and t]hey are no longer active members of society” (Olson 1999).

Halstead also gave some thought to shoulder amputation. For Halstead and his followers, cutting away more and more tissue was the only way to treat breast cancer. Jerome Urban, the architect of the super-radical mastectomy in 1949, would remove the breast, the axillary nodes, the chest muscles, and internal mammary nodes in a single procedure, often on patients who had tumors less than one centimeter large.

Twentieth-Century Surgeries: Oophorectomy, Adrenalectomy, and Hypophysectomy

In 1895, Scottish surgeon George Beatson discovered that removing the ovaries from one of his patients shrank her breast tumor. This news spread and soon surgeons were performing “prophylactic” oophorectomies, which involved removing both ovaries and performing a radical mastectomy. The operations were debilitating and the results unpredictable since the surgeons had no way of determining which tumors possessed estrogen receptors. Because of this, by 1920 most surgeons employed an oopherectomy only as a last resort. What modern oncologists now know is that some breast tumors have estrogen receptors that feed on estrogen. Removing the ovaries in some cases starved the tumor, at least temporarily. The tumor would always regrow because the body compensated by secreting estrogen-like substances from the adrenal and pituitary glands. In 1952, approximately the same time as Urban’s super-radical mastectomy, Charles Huggins began removing a woman’s adrenal gland (adrenalectomy) in an effort to starve the tumor of estrogen. Rolf Lefft and Herbert Olivecrona began performing hypophysectomies, or the removal of the pituitary gland. Side effects included impaired vision, personality changes, and cognitive difficulties. Even with these extreme surgeries, the tumors still returned to kill.

A New Beginning: Moving Away from the Halstead Mastectomy

The Halstead mastectomy was based on the premise that breast cancer was a localized disease that could be treated by surgically removing the diseased part of the body. George Crile in 1955 began to argue that cancer was not localized but rather is spread throughout the body. Bernard Fisher also revolutionized cancer treatment by revising metastasis theory which, like Hippocrates, argued that cancer cells traveled throughout both the circulatory and lymphatic systems and that surgery could not cure cancer because cancer cells were floating throughout the body in the circularity system. In 1976, Fisher published results indicating that simpler breast-conserving surgery followed by radiation or chemotherapy were just as effective as the radical mastectomy, and usually more so (Hellman 1993). By advocating a more systemic approach to breast cancer, Fisher and Crile directly challenged the surgeon’s role as the primary source of breast cancer treatment. Yet physicians were reluctant to abandon the Halstead mastectomy until the sexual revolution and modern feminism.

With the decline of the Halstead radical mastectomy and a revised theory of metastasis, physicians hypothesized about the origins of breast cancer and, during the 1990s, everything ranging from diet, chemical pollution, race, delay in having children, and breastfeeding was up for debate. Despite this uncertainty, there were still advances. After an in initial increase in breast cancer rates, the number of deaths plateaued in 1995 and then started to decline. By 1995, less than 10 percent of breast cancer-inflicted women had a mastectomy. Improvements in chemotherapy, radiation, hormone treatments (particularly Tamoxifen), mammography, and surgery helped move breast cancer from an urgent disease to a chronic condition. Significantly, scientists isolated the genes that cause breast cancer: BRCA2 and ATM. Today, advances in molecular and genetic sciences are creating novel therapeutic strategies that give both women and men not only hope but also more choices about their bodies.

New Hope for the Twenty-first Century: Changing Public Perception

The ultimate cure for breast cancer remains elusive. The disease is so complex, diverse, and so subtly connected to genetic and environmental variables that finding a cure can often seem remote if not impossible. While a cure has not yet been found, public perception surrounding breast cancer has changed dramatically. Once a disease that women felt ashamed to discuss, breast cancer now has lost much of its stigma, providing the opportunity for politicians and health care officials to acknowledge that economic and political considerations bear on the success of breast cancer treatment as much as advances in medical science.

-- Posted February 27, 2008

References

Hellman, Samuel. 1993. “Dogma and Inquisition in Medicine.” Cancer. 71.1: 2430-2433.

Leopold, Ellen. 1999. A Darker Ribbon: Breast Cancer, Women, and their Doctors in the Twentieth Century. Boston: Beacon Press.

Olson, James. 2002. Bathsheba’s Breast: Women, Cancer, and History. Baltimore: John Hopkins Press.