The paperback edition of Barron Lerner's gripping medical and cultural history of breast cancer in twentieth-century America, first published in 2001, contains a postscript about the latest ‘breast cancer war’. As historian, clinician, scientist, he saw that the same themes were being played out in the near pandemonium that ensued from a front-page story in the New York Times. This new skirmish between screening sceptics and believers revolved around the findings of a systematic review by Olsen and Götzsche (Lancet, 2001; 358: 1340-2) showing that there was no evidence that mammographic screening reduced mortality from breast cancer and that it led to more aggressive treatments. For Lerner the episode was a further demonstration of how social and cultural factors can influence the interpretation of scientific data. Evidence is still an ineffective weapon against belief.
The Breast Cancer Wars teaches us that disease cannot be understood outside its social and cultural context: culture, philosophy and attitude determine the acceptability of a course of action. In this exciting and wide-ranging narrative, Lerner opens our eyes to appreciate that evaluation of diagnostic and therapeutic interventions has always depended on time and place. The personal accomplishments of colourful and influential characters from Sir William Halsted onwards are placed in their proper historical context, set against the larger social system in which they worked. Although mortality statistics remained unchanged, belief in Halsted's radical mastectomy kept it going for three-quarters of a century. Mid-century challenges by proponents of biological predeterminism, who using new statistical approaches proposed that the inherent biology of individual breast cancers—as opposed to early intervention—most influenced whether patients lived or died, were vigorously resisted by surgeons. Rose Kushner, American journalist and breast cancer patient, posed a conspicuous challenge to the traditional authoritarian physician/patient relationship, radical surgery and the one-step procedure, in a vigorous, intelligent and well-researched campaign. In Breast Cancer: a Personal and Investigative Report (Harcourt Brace Jovanovitch, 1975) she questioned surgeons' blind adherence to Halsted's methods. Kushner's main target, as a civil libertarian, was the arrogant way the medical profession went about its business. The language of the rallying call to women to ‘have a finger in their own destiny’ and engage as powerful combatants in this new-style battle was irresistible. Activism was born.
Armed with the insight that Lerner's riveting history can provide, clinicians, patients, medical journalists, the media, politicians, policy-makers and scientists could learn to reduce the bloodshed and collateral damage inflicted on women by over-zealous detection and eradication. Today, as in Halsted's time, so much of what we do and what we believe hinges on the perennial disagreement over the value of early detection. The latest skirmish again demonstrates the limits of scientific evidence to resolve contentious clinical issues. A soldier fears maiming more than death: saved lives must not be at the expense of damaged lives.