A Brief History of Breast Cancer. Chapter 7

In this chapter I will give a brief history of cancer. I used many sources to put this history together including web sites: http://www3.cancer.org; http://.harvard.edu/html/sch00028.html ;
http://www.freevas.demon.co.uk/students/Halstead.htm ; www.rainbowofhope.org ; http://undelete.org ; http://www.bcsc.ca/bsca_html/about/about_historybc.html . And I used books: he Breast Cancer Wars: Hope, fear and the pursuit of a cure in Twentieth-Century America by Barron Lerner. Dr. Susan Love’s Breast Book by Dr. Susan Love. Take Charge of Your Breast Cancer by John Link M.D. And The Great Influenza, by John Barry.


I waited for a week for Dr. Sullivan's office to call. They never did,
I had called them about the results of my biopsy. The woman who answered the phone had no idea what I was talking about. She said that she would look in to it and call me back. This was the first clue, or maybe the second (remember the missing x-rays?) that this doctors office was staffed by idiots.
The next day I went to work hoping that sometime during the day I would hear from Dr. Sullivan. At work I was helping a woman who was looking for information on 17th century France when I notice a friend of mine named Erin walk in to the library. We waved to each other as I rushed past her. A few minutes later I saw Mark walk into the library, which was a rare because he usually only comes to the library when he was dropping off or picking up our daughters. Since both girls were in school I wondered what he was doing there. He looked sad. I found the books on France that the woman needed then I walked over to Mark. He took my hand and led me to an empty section of the library. He held both of my hands, there were tears in his eyes. He told me that the doctor's office finally called with the test results…the tumors were malignant…I had breast cancer.
I paused for a few seconds then thanked his for coming to the library to tell me. He wanted me to go home with him. I told him that I was staying and that I that I would see him after work, and then I sent him home. Erin walked over to chat, I was hanging on by a thread and I didn't want her to see me burst into tears so I told her that I was very busy and that I would talk to her at another time. I walked back to the circulation desk, hoping that work would distract me. There was a pile of books that needed to be checked-in so I starting checking them in when my supervisor Caroline walked over to me. She stood next to me for a minute not saying a word. I turned to her and said:
"The tumors are malignant." Then I continued to check-in books as if nothing was wrong. She asked me if I wanted to go home. I said no. I kept checking-in books. Then I started to shake, me knees became weak, my eyes filled with tears and I whispered to her that maybe…I should leave.
I walked home and fell into Mark's arms. We didn't say anything; we just held each other and cried.
-
I was thirteen the first time that I heard the term breast cancer, it was the summer of 1969 and I was spending a week at my girlfriend Mandy Scott's house. Earlier that year my family had moved from Michigan to New Jersey. In July we drove back to Michigan for a family event. Instead of driving back with my family, I was allowed to stay with Mandy's family for a week then fly back to New Jersey. It was a trip of firsts for me. I had never been away from family that long, and I had never been on a plane before, I felt very grown up.
Mandy's mother was having a great time playing hostess; she took us to her in-laws summer home on Lake Michigan and on other adventures. She treated Mandy and I as if we were grown-ups, I was having a blast.
One afternoon the three of us were sitting around the livingroom, Mrs. Scott was entertaining us with another one of her funny stories.
"…so, I was sitting on the couch next to my sister talking, when her two-year-old crawled in to my lap and pinched my nipple. Seeing this, my sister whispered for me to yell 'ouch' I asked why, then she pointed to her son holding my fake breast and said 'if you don't yell it will confused him.' So I started yelling:
"OUCH, OUCH!!! Mandy and Mrs. Scott started laughing. Then Mrs. Scott noticed the look of confusion on my face then said:
"Ten years ago I had a mastectomy." She went on with her story thinking that her explanation was sufficient. I had no idea what she was talking about, so I made a mental note to ask my mother about it when I got home.
-
Modern day magazine articles sometimes give their readers the false impression that in the old days nothing was done to try to help women with this disease, yet there was Mrs. Scott, a woman who had her surgery in the late fifties. I got curious and wanted to know more about breast cancer, so I asked myself two questions. One: What is Breast Cancer? And Two: How long have people known about the disease?
I can give a very basic description of breast cancer, keep in mind that I got straight C's in science in High School and College. The first thing I needed to understand was why if two different people have cancer that spreads through out their bodies, why one person is said to have-say breast cancer and the other person-liver cancer. Isn't cancer just cancer? No, I found out, it isn't. What I learned is that cancers are named after the body part where the cancer originated, breast cancer starts in the breast, liver cancer starts in the liver, and so on. So, no mater what parts of the body the cancer spreads to, it will always be referred to by its first location.
Next I learned that breast cancer, like most cancers, are caused by cells that grow out of control. Breast cancer starts in breast tissue. About 86% of breast cancer starts in the ducts, another 12% start in the lobules with the remainder starting in the surrounding tissue. Theses rebellious cells then form a tumor. Cells from the tumor can break away and go to other parts of the body where they keep growing. If the cancer spreads, it is said to have metasidzed. Whether the cancer spreads to the other organs or not, can determine who lives and who dies. There are proximally 175,000 new cases of breast each year, with about 40,000 deaths. There are many factors that determined what kind of breast cancer a woman has, and what her chances for survival are. Doctors break breast cancer in to 4 or 5 stages (depending which book I read) 0-4 with each stage being deadlier than the one before it. I was in stage 1, but my oncologist said that I was just on the border of stage 2. This means that with surgery I had between a 75-95% chance of living for five years depending on whose numbers I looked at. But with each added treatment such as chemotherapy or tamoxifen my odds improved.
Describing breast cancer is a complicated, first there are the different stages, then there is the size of the tumor to take in to account, plus whether the nodes are positive or negative, and also if the estrogen receptors are positive or negative and so on. I get a headache just thinking about it.
Okay, now I had a vague idea what breast cancer was, the next thing I wanted to know how long doctors have been trying to treat it. This gets really interesting. There are documented cases I kid you not, dating back to the early Egyptians. The popular treatment back then was to cautery the disease tissue. Which means that the tissue was burned with some kind of branding iron which destroyed any dead or unwanted tissue. Considering they didn't have any kind of anesthesia back then, that must have hurt. Ouch!!!
Next there was Galen (130-200AD) a Greek physician who had served the emperor Marcus Aurelius in Rome and whose books on physiology and anatomy remained popular into the Middle Ages. The strange thing about these books was how inaccurate they were. In Galen's time it was against Roman law to dissect humans, so his books were based from the dissections of animals. Galen believed that a special diet should be the treatment for breast cancer, still some of the people of that time period preferred exorcism or topical applications.
It was during the Renaissance that a Flemish anatomist named Andreas Vesalius (1514-1564) dared to question the thinking Galen. Vesalius did dissect humans, his studies lead him to believed that a mastectomy was the logical treatment. He also used sutures instead of cautery to control the bleeding. Then a physician named Le Dran (1685-1770) was created with being the first doctor to realize that breast cancer spreads through the lymph nodes.
Did any of these treatments work? No one really knows because it wasn't until the middle of the 1800's that doctors started keeping detailed records. By this time many doctors understood that if left untreated the disease would spread, so for many surgeons treatment was the removal of the effected breast and the surrounding glands.
By the late 1800's most surgeons were doing mastectomies. Unfortunately because the doctors didn't have the ability to detect the disease in it early stages, only woman who were in advance stages of the disease were being treated. This meant by the time women sought help their tumors that were very big, some as large as half the size of the breast it self. It was considered a success if a woman lived for three years after her surgery, only 12% of those treated survived for ten years.
It is impossible to write about the history of breast cancer without talking about Dr. William Halstead (1852-1922), a man known as the 'Father of the radical mastectomy'. History portrays Dr. Halstead as either a hero, whose medical discovers were great for woman and saved many lives. Or as a man whose medical discoveries destroyed the lives of the women he saved. It depends on whose point of view I read.
First lets acknowledge his important contributions and influence in medicine. He pioneered treatments not only in breast cancer, but also in thyroid and parathyroid, GI track and bile ducts, blood vessels and treatment for hernias. He was involved in the development of local anesthetics, he introduced surgical gloves in the operating room, and he was the founder of the system of residency that brought structure to surgical training programs in the United States.
I was shocked when I learned that in the 1870's while European medical schools required rigorous scientific training, medical schools in America required its students to attend two, four month terms of lectures (the students didn't even need to pass all of them). Which meant that a person could graduate from an American medical school with out ever looking through a microscope, performing an autopsy or seeing a patient.
Halsted got his undergraduate degree from Yale and received his MD from Columbia University, then he quickly went to Europe so he could actually learn something about medicine. Dr. Halsted developed the radical mastectomy, which entailed the removal of the cancerous breast, the nearby lymph nodes and the two chest wall muscles on the effected side of the chest. 'The Halstead mastectomy' was more than how much tissue was removed, it was also how he removed it. Dr. Halstead believed that all the tissue had to be removed in one piece. He did this because he felt that cutting through cancerous tissue might lead to the spread of any remaining cancer cells. He then taught this method to all of the surgeons in his training programs. Before long these trainees were performing the 'Halsted radical mastectomy' around the world.
Next we move to the 1920's. Some surgeons were 'improving' 'the Halstead mastectomy' by cutting deeper and removing more tissue, while others (mostly Europeans) were questioning the procedure. After all the operation was very disfiguring, painful, and sometime lead to arm swelling known as lymphedema.
Remember this was about the time doctors first started using X-rays to look for tumors, so the cancer was being found earlier which improved the survival rate. Doctors now spoke of a woman living for 'five-years' instead of 'three-years' after her surgery. Also the ten-year survival rate had jumped to 50% (getting better).
It was also in the late twenties that doctors' starting debating about the use of radiation. Some thought that used by itself or in conjunction with a less invasive mastectomy, the new treatment was as or more effective as a radical mastectomy.
Treatment slowly improved as medical knowledge improved. Early radiation was kind-of a guessing game, with doctors still refining the equipment and learning what voltage to use. The thirties saw a gradual improvement with the equipment, which could now direct a higher voltage of radiation into the cancer yet do less damage to healthy tissue. It was also in the thirties that women's clubs and magazines started to encourage woman to look for early signs of cancer and seek treatment as soon as possible.
Even though European doctors were promoting breast self-exam (BSE) to their female patients as early as the nineteen twenties, it wasn't until the fifties that American doctors started promoting BSE to their female patients. Making up for lost time the fifties also saw American doctors declare their own war on cancer. For many, the objective was to get every last cancer cell in the patient. For women this lead to the super-radical mastectomy, which encompassed the splitting of a patients clavicle, ribs and sternum.
The fifties was an interesting time, while some surgeons were hacking off body parts, other surgeons were experimenting with the less invasive modified radical mastectomy (removing the breast only). Meanwhile improved statistical analyses was questioning claims that the radical and/or super radical mastectomies were really increasing longevity of women with breast cancer.
It was in the fifties that other ideas for treatment started also, one those ideas was chemotherapy. During World War II it was discovered that nitrogen mustered gas inhibited cell growth. It was this discovery that lead to chemotherapy, I'll talk more about that later. At first chemotherapy was only used on patients with move advanced cancer, but in 1958 the National Cancer Institute started researching using chemotherapy on a wider range of cancer patients. Another change was a small group of medical people who wanted to do statically studies comparing the radical mastectomy vs. a modified radical mastectomy vs. lumpectomies (removing only the tumor). But American doctors refused to participate in these studies
Each decade or so doctors' were able to detect breast cancer earlier and earlier. In Hastead's era by the time a woman came into a doctor's office the tumor was usually around egg size. As women became more aware of what to look for they went to their doctors with smaller and smaller tumors. BSE really help, by the fifties the tumors were usually no bigger than two centimeters in diameter when the average woman sought treatment. In the sixties with the improved mammogram doctors were able to detect tumors at about one centimeter, which as too small to be felt.
Researchers at the University of California made the next big discovery, they found that certain genes in normal body cells somehow become abnormal (what?). I don't understand why, but this discovery helped unlock the mystery of cancer. Something about being able to identify some genes that can spur cancerous growth.
By the late sixties surgeons in other countries had gradually abandoned radical mastectomies, replacing it with surgery that was less invasive, yet in America 70% women were still being treated using the radical mastectomy.
The seventies changed everything. America was going through some major changes. One of which was talking out loud about subjects that people use to whisper about, like cancer. Prominent women such as First Lady Betty Ford and Actress Shirley Temple went public their breast cancer, which gave American women permission to talk about their own bouts with the disease.
It was also the height of the American woman's movement female writers started to fill the media with questions about the necessity of a radical mastectomy and the lack of quality of life that the surgery gave it survivors. The most famous of these writers was a woman named Rose Kushner (1929-1990).
Ms. Kushner was a journalist from Baltimore who was diagnosed with breast cancer in 1974 and was horrified with how she was treated by the medical profession. First she wrote an article about everything she went through during her treatment for the Washington Post, and the story was reprinted in hundreds of newspapers across the country.
Then in 1975 she published a book titled Why me? What Every Woman Should Know About Breast Cancer to Save her Life. In those days the biopsy and mastectomy were done in the same surgery. I can't imagine what it must have been like to go into surgery with a small lump on your breast and waking up with a huge scar where the breast once was. Ms. Kushner had to call eighteen different surgeons before she found one who would do the procedure in two steps. Rose Kushner and other female writers helped women learn how to stand up the doctors and become involved in their treatment.
It was in 1977 that the drug tamoxifen was first approved. Its antiestiestrongenic actions (whatever that is) were shown to help reduce the chanced of the cancer coming back.
The eighties to the present have seen many improvements in cancer treatment. Earlier diagnose, better mammogram machines, improved chemotherapy, more lumpectomies, better reconstruction surgery, sentinel node biopsies, better communication between doctors and their patients, more female doctors, bone marrow transplants, stem cell research, a wider use of tamoxifen for cancer patients, and I am sure other stuff that I never heard of.