Redefining Cancer during the Interwar Period

Abstract

The implementation of radiation technologies within the British hospital system was a significant element in the establishment of the managerial organization of medicine in the interwar period.

One aspect of this implementation process was that, in order to install cancer patients within the “radiotherapy factory,” British medical officers of health adapted their organizational cultures from being environmentalists to being administrators of medical services.

One of the consequences of this change was the accomplishment of a much more reductive approach to cancer compared with a more holistic approach to the disease.

WE DETAIL HOW MANAGERIALIST approaches to cancer treatment, featuring hospital-based delivery of radiation therapy, were implemented and negotiated among the medical officers of health in Britain during the period between World War I and World War II (the interwar period). British medical officers of health were charged with focusing on the environment (such as sewerage and food inspection) and communicable diseases. They were also responsible for the water supply, street lighting, housing, road paving, sanitary burials, and so on. We not only contribute to recent debates on the role of medical officers of health in the development of public health in the 20th century and provide new insights about their professional contributions,1 we also address the broader discussion on managerialism in medicine in the analysis of a particular professional constituency and the redefinition of a particular disease: cancer.

Historians and sociologists have recently paid attention to the place of medicine in what has been defined as the managerial state—a historical form of late 19th and 20th century governmentalism characterized by administrative bureaucratization, professionalization—the association of particular kinds of work with expert knowledge and their institutional organization and management—centralization of control, and new forms of social organization.2 Managerialism has also been characterized as a social technology that entails the suppression of face-to-face relationships, including relations of personal trust, in favor of official procedures for regulating social exchanges.3

With medicine specifically, managerialism refers to the shift from an organizational culture of patronage—private practice by medical elite—to a corporate, “scientific” management of patients. The new laboratory medicine was also part of the development of managerialism, or what has been referred to as “administrative thinking”4 and the “industrial and economic organization of medicine.”5 However, as Sturdy and Cooter have emphasized, historians have been inclined to represent science as a form of knowledge independent from its own particular forms of organization, overlooking that managerialism reformulated the scientific understanding of disease with diagnostic categories and standardized treatments.

The managerialist approach can be summarized in the words of its supporters: “co-ordination, planning, [and] centralization for full efficiency.”6 However, implementing radiation technologies according to managerial principles did not entail just the search for efficiency or the transformation of organizational structures in hospitals.7 The implementation of managerial principles in the form of radiation therapy and its attendant professional and institutional reorganization also privileged a specific perception of the disease itself. During the historical period at issue here (1913 to 1945), the ways medical officers of health understood cancer were variously marginalized from and absorbed into a managerialist approach to disease. It was difficult to establish a place for the medical officers of health’s focus on environmental, social, and psychological factors of disease within the highly technological treatment of cancer that was consolidated in the interwar period. In the new treatment of cancer, patients were incorporated into an industrial-like chain of procedures that began with recruitment and diagnosis (categorization of the disease) and continued with referral to radiotherapy units, where patients were treated with standardized experimental treatments and close follow-up.

Although other historians have thoroughly analyzed the transformations in the organization of radium therapy,8 we focus on the impact of managerialism to radium therapy on medical officers of health. We argue that this managerial attitude encouraged a shift from an environmental to an administrative approach to cancer patients among British medical officers of health and emphasized a redefinition of cancer as a clinical, more than an environmental or social, problem.

The problems encountered in the definition of the objectives and tasks specific to public health during the interwar period are evident in the approach taken to cancer, a disease that physicians, the state, and the philanthropic movement had addressed with highly technological methods that were implemented in hospitals guided by managerial principles beginning in the interwar period. More generally, their approach to public health matters during the 20th century has been described as complacent and lacking in the energy to identify tasks that they claimed as their specific remit. This lack of organization on the part of the medical officers of health has been attributed to rivalry or the desire to emulate older systems in place in the muncipal hospital sector. However, recent historiography, based on local studies, has been reconsidering the British medical officers of health’s contribution to public health.11

Although the medical officers of health had to contend with the marginalization of their more environmentalist—and preventative—approach to disease, the medical establishment also had to contend with them. Because of the position of the medical officers of health in the organization of cancer treatment, their full commitment to the principles of organization was necessary for the accomplishment of the managerial and technological approach to cancer.

We focus on the specific historical changes within medical officers of health’s discourse on cancer. By highlighting other understandings of cancer that were held by medical officers of health at the time, we try to clarify how the managerial organization of institutional cancer treatment worked to establish a specific, hegemonic way of understanding cancer.

OPTING FOR RADIUM IN THE MANAGERIAL SCENE

A medical hypothesis of cancer as a contagious disease was still accepted in the 1920s and was consistent with the medical officers of health’s traditional environmental view of public health concerns. For example, at the 1924 Conference of Medical Officers, Joseph Cates highlighted the need to adopt approaches to cancer similar to those implemented for other infectious diseases. Indeed, in the same year, the public health committee of Hampstead, England, approved the medical officers of health’s proposal to disinfect houses and destroy the belongings of those who died of cancer.12 Some medical officers of health also associated the incidence of cancer with social factors and industrial society. For example, they advocated collective prevention of the so-called trade cancers, such as cancer of the scrotum suffered by mule spinners, and the provision of appropriate universal dental treatment as a preventive measure for lip cancer.13

Although the medical officers of health’s environmentalist approach to cancer was never completely eliminated, the medical officers of health were faced with institutional changes at the governmental level that challenged the traditional understanding of cancer and also the medical officers’ role in its treatment. To understand how they confronted this challenge, it is necessary to consider the scope of the broader transformation, which can be seen as making radiotherapy the principal treatment for cancer. This transformation, in turn, is linked to the sudden increase in the supply of radium at the end of World War I as the Ministry of Munitions, charged with conducting military research during the war, proposed donating its exceedingly expensive remaining radium stock (2.5 g) for the purpose of civilian therapeutic research. Following research in Middlesex, England, that grew out of this donation, in 1921 the Medical Research Council implemented a new, clinically oriented inquiry on radiation: The Medical Research Council Radium Research Scheme. The scheme extended the use of radium to almost all cancers and standardized dosage and treatment systems to a considerable degree and centralized the distribution of radium. It also favored the coordination of clinical work among several centers, and it helped hospitals pay for radium.14 This system would disrupt the old one, in which doctors who specialized in different branches of radiation therapy competed for access to closely guarded radium.

As already mentioned, the new approach to cancer can be seen as part of a larger shift to managerialism, or the managerial state. In medical practice, the focus on individual care shifted to the regulation of health at the level of the population, which entailed the hierarchical ordering of patient management, the coordination of medical specialists, and the rationalization (systematic organization and distribution) of resources and large-scale hospital services. Efficiency, calibrated in the measurement and evaluation of therapeutic outcomes, was also a feature of this shift.

In accordance with these principles, in 1928 the British government centralized and took control of radium and its distribution by setting up the Radium Sub-Committee under the recently (1925) formed Committee of Civil Research, which was charged with giving scientific advice regarding national economic development and was a predecessor of the Economic Advisory Council of 1930.15 The 1928 International Conference on Cancer also recommended a more decisive—and managerialized—government intervention in the treatment of cancer.16 In its March 1929 report, the Radium Sub-Committee recommended that radium delivery be centralized in radium centers and suggested the foundation of 2 new committees: the National Radium Trust, which would undertake the acquisition and management of funds, and the National Radium Commission (NRC), a group of experts on radium therapy charged with supervising the allocation and use of radium.

Overall, the Radium SubCommittee’s proposals called for a national cancer program focused on the delivery and regulation of radium, rather than, for example, health measures for the prevention of cancer or a more general approach aimed at addressing cancer patients’ needs.17 Inspired by managerial thinking, the Radium Sub-Committee’s scheme circumscribed radium therapy to specialized centers under the strict control of the NRC, thereby establishing a monopoly over radium distribution.

Only 12 national centers were selected (7 in England, 4 in Scotland, and 1 in Wales). Although many municipal hospitals were equipped with radium therapy facilities, they did not obtain the NRC’s recognition (e.g., Bradford and Bristol).18 The NRC gave priority to Royal Infirmaries (large, often regional hospitals) instead (Aberdeen, Cardiff, Edinburgh, Leicester, and Newcastle-upon-Tyne) and to the establishment of the national centers network within the general voluntary hospitals system. Like the new public health committees developed under the 1929 Local Government Act, the NRC was committed to increasing specialized medical practice and technical development specifically in the infirmaries.19

In the beginning, the national radium centers had exclusive use of radium, thereby prohibiting its use in private clinics and municipal hospitals. However, this restrictive measure was later modified. The need for care provision across Britain led the NRC in 1931 to recognize additional regional centers (Southampton, Plymouth, and Stoke-on-Trent), and in 1933, the NRC also extended radium distribution to centers that treated private patients (who could not be admitted to the national radium centers). One year later, some new hospital radiotherapy departments also applied to the NRC for their official recognition as national radium centers (Royal Infirmaries in Bradford, Leicester, and Wolverhampton and Victoria Hospital in Burnley).20

With the emphasis on centralization in specialized, well-equipped centers designed to extract the maximum output from the available radium, and the combination of research and treatment through clinical team-work in these centers came the complex tasks of (1) introducing a new, specialized service within the existing hospital system and (2) imposing a nationally organized service on municipal or regional hospitals with their own organizational structures, cultures, agents, and professional hierarchies. The medical officers of health played a role in this task insofar as they were going to be involved in the recruitment and assignment of cancer patients to radiotherapy facilities as well as in the coordination of the cancer services. But they were not simply reacting to the imposition of a new managerialism.

Their negotiation of this new system was bound up with a progressive redefinition of prevention from being associated with environmental and social causes of disease to a clinical understanding that emphasized not only the utility of the laboratory and its research, but also the individual either alone or as member of a community. During the 1920s, some traditional aspects of prevention linked to the cancer “epidemics” still remained. The fact that they could fulfill a familiar and important function in their own eyes may have made it easier to accept managerial tasks now associated with those functions that were less familiar—and potentially undesirable. Later, in the 1940s, the government embedded administrative tasks in a research project to be carried out by the medical officers of health aimed at assessing British health needs. This promised to be less monotonous than simply carrying out those administrative tasks alone, while implicitly blending these very tasks into medical officers of health standard work practice.

We suggest that in addition to introducing new administrative tasks to the medical officers of health’s work, a rhetorical transformation of the “radium problem” into the “cancer problem” worked to incorporate the medical officers of health into the new managerial scheme. In addition to this rhetorical shift, medical authorities argued that provision of care for cancer patients was a natural extension of the medical officers of health remit because it involved a social dimension of medicine. Public health was increasingly defined in terms of the functions the medical officers of health performed rather than a more programmatic definition. The fragmentation and weakening of the medical officers of health’s environmental discourse made it difficult for them to resist their incorporation into a more strictly managerialist scheme of health provision.

More generally, the redefinition of public health in terms that fit a managerial approach to cancer could not ultimately constitute an effective opposition to managerialism. The weakness of the environmental discourse, in turn, facilitated the eventual acceptance by the medical officers of health of the linkage between cancer prevention and the management of hospital-based radiotherapy and, consequently, of their role as administrators of services.

In 1923, before the advent of the Radium Sub-Committee and the NRC, the shape of things to come was foreshadowed when the Ministry of Health’s Departmental Committee on Cancer instituted the first official regulation involving medical officers of health and cancer. The regulation was addressed primarily to local authorities and provided basic guidelines for prevention and offered a view of the regulated managerial and clinical approach to come. It promoted measures such as immediate medical consultation, warning against quacks, and promoting hygienic measures in specific cancerous sites, such as the mouth, on the basis of the irritation hypothesis (the idea that cancer can be produced by irritants).

Attention was also given, however, to occupations involving contact with hazardous materials, a problem that had resulted in previous regulations. Significantly, the Departmental Committee on Cancer clearly stated that it would not provide a national care provision scheme for cancer patients.22 Consequently, responsibilities for the provision of diagnosis, treatment, and transport for patients, as well as for the education of both physicians and citizens, fell to local health authorities—that is, the medical officers of health—as well as voluntary hospitals, insurance committees, Boards of Guardians (ad hoc authorities that administered Poor Law from 1835 to 1930), physicians, local committees against cancer, and the private sector.

In the 1924 Ministry of Health’s memorandum on cancer, Neville Chamberlain, from the Baldwin cabinet, emphasized once again the local health authorities’ responsibility for the provision of cancer treatment.23 The memorandum also suggested a linkage between radioactive therapeutic means and public health tasks that was to become crucial in the transformation of the medical officers of health’s understanding of their own role in public health. As we will illustrate, this linkage is part of a wider transformation in medical culture, which now conceives of public health as an aspect of clinical and laboratory medicine, rather than as an environmental or social approach. With regard to the medical officers of health actual tasks, this transformation meant that they would become primarily occupied with the organization of radiotherapy services.

FROM ENVIRONMENTALISTS TO ADMINISTRATORS

The medical officers of health’s journals from the 1920s reflected the widening scope and greater diversity of public health discourse about cancer, a discourse that relied on a similarly transformed definition of prevention. The medical officers of health’s concerns at that time extended beyond infectious diseases to include chronic ailments such as cancer and heart disease.24 Prevention for these and other diseases ranged from a more strictly environmentalist perspective to a combined solution closer to the new “personal preventive clinical medicine,” based more directly on the individual.25

Bertram Wright Nankivell, medical officer of health for Hornsey, linked cancer to the poisoning effect of preservatives and growth-producing vitamins contained in food. Prevention, in this case, would not require eliminating the environmental causes, but rather the promotion of a self-regulatory “healthy” lifestyle, with dietary restrictions on salt and meat.26 C. E. Paget, from Northamptonshire, associated the increase of cancer mortality during the war with combat anxiety and argued that improvements in living conditions would reduce the incidence of the disease. Furthermore, in the 1924 conference, some medical officers of health including Weldon Champneys of Willesden, rejected the notion of “cancer houses”—the idea that houses could incubate and prompt cancer in their occupants. They also rejected the hereditary hypothesis of cancer as old-fashioned and argued for educational measures and the provision of clinics, hospital beds, and transport for patients.27 He insisted that hygienists’ priorities should be reoriented to include administrative duties, arguing “[s]urely we are firstly practitioners of medicine, and secondly administrators, endeavoring to administer to the best advantage the knowledge gained.”28 In this way, Champneys folded a managerial mode into the medical officers of health’s prevailing view of their professional remit.

The publication in 1927 of a report on “the late results of operation for cancer of the breast” provides a convincing example of how medical officers of health’s traditional ways of understanding disease through epidemics and their prevention played a role in helping medical officers of health to accept the managerialization of cancer radiotherapy as part of their tasks.29 As in the case of epidemics, urgent action was required to prevent the spread of the disease, according to the 1927 report. Thus, early intervention was crucial for “preventing the spread of cancer,” reducing patient deaths, and increasing the positive outcome of breast cancer treatment. Still, the danger posed here was not to the population at large, but to the patients themselves. Whereas infectious diseases required early detection to protect others, in this case, early intervention was focused on the cure outcome for the patient.30 This idea was extended by analogy to other types of cancer as well.31 Once patient access to treatment was assumed to be a preventive routine—or as the document put it, an “administrative action”—similar to that used against infectious diseases, the medical officers of health’s duties could be easily transformed into administrative tasks, consisting primarily of facilitating patient access to early treatment to be cured.

Many medical officers of health also insisted that there was a need to provide health education for the public to change popular conceptions of cancer as a death sentence. In fact, many argued that the deeply rooted belief that cancer was incurable was an important impediment in providing treatment.32 Although some claimed that patients should be taught how to avoid cancer (avoid occupational diseases, unhealthy food, and tobacco and restrict alcohol consumption),33 many claimed that education should be grounded in a more medicalized and individualistic approach to prevention. This meant persuading people of the curative effects of surgery in the early stages of the disease and of the need for medical surveillance of chronic irritation and other precancerous conditions.34 The individual focus of such education comes alive in medical officers of health’s claim that public health education should be used “to impress on the public the value of a system of periodic physical examinations,” to inform about warning signs (so people could “search themselves for themselves”35), and to emphasize the need for immediate medical examinations of any suspected site.36

The 1929 Local Government Act empowered local or municipal health authorities to provide treatment for cancer patients. One of its objectives, noted in the 1930 ministerial report “Memorandum on Cancer as a Subject for the Attention of Local Authorities” (HMSO Circular 1136), was again to link treatment with prevention. The memorandum, a new step in the attempt to transform medical officers of health’s tasks, redefined their duties by ingeniously blending research and administration. In doing so, the memorandum invoked the clinical (broadly speaking, experimental) side of public health. Research, here, consisted of analyzing the impact of cancer on patients, their relatives, and the surrounding community while considering the environmental, economic, and social conditions of patients. This collection of tasks became a means of introducing the management of hospital treatment into the work of local authorities, with the goal of improving control of the disease.37

Another ministerial enquiry, proposed by the Committee on Cancer in 1930, tried to encourage medical officers of health to participate in a similar way: “As a result of the bringing of the Health department into contact with sufferers, and of the information obtained following the enquiries made, it is hoped that local authorities may be induced and put into a position to do something on a collective scale for the condition as a whole.”38

It is important to note that the linkage between radioactive therapeutic means and public health tasks that the Ministry of Health now insisted upon was part of a wider transformation in medical culture, which at that time, conceived public health as an aspect of clinical and laboratory medicine rather than an approach that addressed environmental and social causes of illness.39 George Newman, one of the most significant defenders of this newer individualized and nonenvironmental conception of cancer, had already argued that prevention was less a matter of eliminating “external and environmental nuisances” than one of individual surveillance—that is, a matter of clinical medicine. It has been generally claimed that in the interwar period, the approach to cancer shifted from being environmentally oriented to focusing on the prevention of disease through individual medical care and therapy. In particular, this shift meant that medical officers of health would become occupied primarily with the organization and administration of medical services to facilitate individual treatment to patients.40 The designation of funds fixed by the Ministry of Health in 1930 for the implementation of radium in Bradford and Ply-mouth as “new developments in public health work” provides a succinct example of the redirection of public health toward the administration of individual treatment to cancer patients.41

Although there is certainly ample evidence for some medical officers of health’s wholehearted adoption of a more managerial approach and the interest of the health administration to implement it, commentators such as Oscar Holden of Dewsbury, as well as the 1924 conference proceedings, suggested that extensive adherence to the new managerial tasks among medical officers of health was minimal in the mid-1920s. Subsequent directives were aimed at further incorporating the apparently reluctant medical officers of health into the national scheme to cope with cancer. Even in 1935, the need to establish a network of tumor clinics for early diagnosis and treatment, now connected to the national radium centers, was still under discussion.42 Medical officers of health complained that physicians were still not required to report cases of cancer to health authorities. This made it necessary for medical officers of health to collaborate with general practitioners to obtain information about cancer patients.43 By this time, the resistance to the new administrative tasks by the medical officers of health was clearly publicized in professional journals. For example, The Medical Officer’s editor complained in 1930 about the transformation of “public health work into a gigantic hospital.” However, other medical officers of health sustained more intermediary positions and accepted the organization of municipal hospitals as a public health development, actually defined by the tasks being undertaken.44 The problem of providing care for cancer patients was thus identified not as a “radium problem” but as a “cancer problem,” a renaming that the 1939 Cancer Act reinforced.45 This rhetorical re-denomination, focusing on the disease instead of highly technological therapy, accorded with the medical officers of health’s hygienist culture and might also have helped in their acceptance of medical services administration as a central task.

To cope with the cancer problem within their terms of prevention, the medical officers of health identified the facilitation of the diagnosis of cancer sufferers as a key step. A ministry regulation of 1932 (HMSO Circular 1276) integrated cancer diagnosis into arenas of local health care (maternity, child welfare, venereal disease, and others).46 Robert Hughes Parry, an active medical officer from Bristol, urged local authorities to coordinate the work of diagnostic cancer clinics with the network of national radium centers.47 Since the late 1920s, several cancer or tumor clinics had been operating in Leicester, Bradford, Greenwich, and Willesden within anti-tuberculosis dispensaries or health centers. But as doctors’ skills in cancer diagnosis improved, the diagnostic capacity of general clinics in the hospital system challenged the effectiveness of special tumor clinics. Indeed, the Leicester center was closed in 1933 because of the low number of patients it attracted (43 in 1932, only 3 of whom suffered from malignant diseases).48 That is, once the utility of the special cancer centers was put into question, the medical officers of health’s role in cancer screening was also compromised. Their particular role in cancer prevention was still to be defined.

In 1933, Robert Hughes Parry noted that it was impossible to confine public health to prevention and emphasized the need to take on the task of coordinating hospital services and the care of incurables as part of the profession’s standard duties. Three years later, Parry redefined prevention by claiming that the provision of treatment for poor patients was part of a social preventive task. In so doing, Parry provided a key and effective argument commonly repeated in subsequent years: “When we provide free medical advice and treatment for all cases of (or possible) cancer, we shall be taking a definite step in the prevention of the disease.”49 Continuing the trend of encouraging medical officers of health to take up the new administrative tasks as a matter of public health, in 1936, the chief medical officer insisted that “when making investigations on the adequacy of facilities for advice and treatment [medical officers of health] should consider in what ways their Councils, sometimes in co-operation with other Councils, could promote the work of the centers” to obtain “the welfare of the patients.”50 When only 1 out of 5 patients in the country who could have been treated received radiotherapy, the chief medical officer claimed that the medical officers of health were responsible for their “lack of appreciation of their powers in relation to promoting the utilization of the modern facilities for treatment.”50

In 1939, still only 27% of the patients with cancer that could benefit from radium actually received the treatment, with large differences between rural and urban areas in the radiotherapy equipment available. Sholto Mackenzie, author of the 1939 report on the availability of therapy for cancer therapies, attributed the local authorities’ meager compliance with Ministry directives to their lack of knowledge about the value of radium therapy and the difference between curative and palliative treatments, and to the economic restrictions imposed by the Local Government Act.51

However, the continuing criticism by the medical officers of health of their new role in preventive health was evident in a Medical Officer’s editorial of 1938: “The cancer service would be at first almost entirely administrative and we could offer no promise that it would ever be mainly preventive. All that it could do at present is to organize existing facilities and augment them where necessary.”52 Indeed, the medical officers of health’s criticisms of the Cancer Act underlined once again that the broader environmental discourse of prevention was still alive. Some noticed the exclusion of any preventive measure or any epidemiological inquiry on cancer.53 W. M. Frazer, from Liverpool, also noticed that the act would reinforce the option for a treatment with highly unsatisfactory results while ignoring other relevant problems that needed to be addressed, such as patients’ pain.54

The difficulties in establishing an organization program for cancer patients’ treatment exemplified the lack of consensus among the medical officers of health on the need for coordinated regional planning of hospital services, which was not broadly perceived as a more efficient procedure in the provision of care.55 But these obstacles also inform the complex historical processes that contribute to the shaping of administrative thinking among the same medical officers of health. In particular, as we have seen, they reveal the conflicts among medical officers of health not only on the definition of their tasks, but also on prevention as a fundamental aspect of their duties.

Although many local governments had initiated the implementation of cancer facilities, they only became legally bound to do so by the Cancer Act, adopted in March 1939. Its main objective, like that of the Public Health (Tuberculosis) Act of 1921, was to make local authorities (medical officers of health) responsible for care provision and in so doing encourage the use of existing national radium centers inside the voluntary hospitals. However, the Cancer Act was not implemented at the national level until the National Health Act passed in 1946. In 1945, the chief medical officer’s annual report detailed the medical officers of health’s meager success in organizing cancer facilities, although the report showed hope of improvements in the future was still had. The medical officers of health had “started discussions on how these facilities can be increased.”56 The National Health Service Act of 1946 diminished the medical officers of health’s responsibility to implement diagnostic centers.57

It is clear that during the inter-war period local authorities were never totally involved in the administrative tasks necessary to supply cancer schemes according to the assembly-line logic of the strictly managerial approach: recruitment by medical officers of health, rough diagnosis by the general practitioner, followed by the determination of the standardized stage of the disease, and surgery or radiotherapy treatment planning by surgeons or radiotherapists, all within centrally coordinated and efficient institutions at a regional and national level. There is no doubt that the onset of war, along with budgetary deficits, contributed further to the local authorities’ lack of full involvement.58 However, it also seems clear that, in negotiating the new managerial approach to cancer promoted from above, the medical officers of health underwent a period of transition in which their understanding of the disease shifted gradually from a primarily environmentalist view of prevention to a more individualistic and medicalized one, which has become the hegemonic way of understanding cancer.

This shift did not come about from a lack of resistance, but because of the absence of a clear alternative based in environmentalism that would have more effectively counterbalanced the managerial discourse. To be sure, medical officers of health resisted, renegotiated, and even rearticulated managerialism in their own terms. In the debate about the means and not the ends of a cancer program, a more holistic understanding of cancer, which was available in the medical officers of health’s environmental approach, could not prevail. The medical officers of health’s reluctance to align themselves with a managerial and highly technical approach to cancer did, however, play a role in delaying the introduction of radiation technologies as the sole approach to cancer. But the managerialized policy on cancer substantially contributed to the understanding of this complex disease as a local, staged, and progressive disorder, and to radiotherapy (or surgery) as the only logical solution for cancer treatment. Thus, a new “mode of co-ordination”59 that relied on concepts of individual and medical “prevention” privileged a reductionist knowledge of cancer that is still the medical-dominant view of the disease.60