For more than a century, we have used military terms – such as wars, battles, survivors and victims – to discuss our relationship with cancer. But some critics are bothered by the implicit suggestion that those who die might not have fought heroically enough.
When the Obama administration launched its anti-cancer effort earlier this year, “moonshot” rhetoric came to the fore, but that, too, drew dissent. Some say it suggests that curing cancer involves a massive engineering effort rather than a multitude of new insights into the biology of hundreds of different diseases.
Barron H. Lerner, author of “The Breast Cancer Wars” and “The Good Doctor,” and a professor in the division of medical ethics at New York University, has spent years thinking about these issues. He recently talked to health-care journalists about the history of cancer activism and answered some follow-up questions posed by The Washington Post.
Q: When did Americans start focusing on cancer?
A: People got interested in the disease in the early 20th century because of declining rates of infectious diseases. In the 19th century, people died of TB and pneumonia. In the 20th century, heart disease and cancer begin going up. In 1913, the precursor to the American Cancer Society was formed: the American Society for the Control of Cancer (ASCC). The group stressed the importance of early detection and aggressive treatments. They talked about danger signs that people should not ignore, like irregular bleeding, sores that don’t heal and lumps that got larger. People in those times tended to wait a long time to go to the doctor, so the question was: How do you change that?
Q: How did they change that?
A: One strategy was the war metaphor, which was being used as early as the 1920s. The ASCC adopted the “Sword of Hope” as its symbol, and in the 1930s started the Women’s Field Army, with khaki uniforms and insignia, to spread the word and raise money.
A big focus was on women because deaths from breast and cervical cancers were very high and women tended to be more motivated than men about their health. The ASCC seized on the Pap smear [the screening test for cervical cancer] when it became available in the 1940s, with leaders barnstorming the country urging women to get tested. It was a home run: Cervical cancer mortality plummeted. That served as a model for other cancers. In breast cancer, for example, the group began pushing for early detection through self-exam.
Q: Was there anything wrong with that?
A: Not at the time, because doctors believed breast cancer was a local disease that was highly curable when found early and treated with the radical mastectomy, sometimes with radiation.
Such aggressive treatment was reinforced by the familiar military language, which was ubiquitous after World War II. We had just won a war against the Nazis and the Japanese, and the mind-set was “We beat the Axis powers, and now we can beat cancer.”
Q: What was the next stage in the effort against cancer?
A: In 1944, the ASCC changed its name to the American Cancer Society, and Mary Lasker, the socialite wife of a prominent advertising executive, decided her goal was to make it a vibrant organization. She worked closely with journalists to publicize it. Life magazine ran a story about cured patients headlined: “Victims Turned Victors.”
Surgery was seen as the best bet for most patients. In 1963, Time magazine wrote: “If they can operate, you’re lucky.” Another common phrase from this era was “A chance to cut is a chance to cure.”
These were the days of the mutilating super-radical mastectomy for certain breast cancers. Surgeons would remove parts of a woman’s rib cage and sternum in addition to the muscles of the chest wall. From our modern physiological standpoint, this makes no sense. These patients weren’t cured, as their cancers had already spread too far. But the idea was that if the surgeons just tried hard enough, good things would result. The surgeons were highly devoted, and their patients loved them. But at some point their zeal to help people got carried away from what the data were saying.
Still, some good things were happening. Breast cancer was increasingly being caught at stages 1 or 2, when it’s more curable. And in the 1960s, chemotherapy even started to cure some women with advanced disease. My mother had breast cancer in her 40s, and by great good luck got into one of the first clinical trials of chemotherapy. She’s still alive today, and that’s why.
The biggest success during these years was with blood cancers. The most common childhood leukemia became a curable disease. Optimism grew about what chemo could accomplish for some cancers, with or without radiation.
Q; What was happening with other types of malignancies?
A: There was no progress on certain cancers, like lung, colon and pancreas. And cancer treatment was often gruesome. Chemo and early radiation were very toxic. Surgery could be extremely disfiguring.
Then, in the early 1970s, we got the War on Cancer legislation that provided tens of millions of dollars for additional research. Mary Lasker used her connections behind the scenes to lobby Congress, and Ann Landers was the journalist who pushed the hardest. President Nixon, at the White House signing ceremony for the law, said that more Americans died every year from cancer than lost their lives in all of World War II.
Q: Did everyone approve of the “war”?
A: No. Attitudes started to shift in the mid-1970s, just a few years after war had been declared. For example, women began challenging doctors about the need for the radical mastectomy when they had only tiny cancers.
Female journalists with breast cancer began researching the procedure and denouncing it. One of them was Rose Kushner, who colorfully wrote, “Vietnam will have to wait while I finish a crusade to tell American women – and through them American doctors – what I have learned.” And critics, such as the writer Susan Sontag, had begun to warn about the faulty assumptions encouraged by war metaphors.
Q: Was the medical establishment starting to question the way breast cancer was handled?
A: Yes. In 1975, John Bailar, a biostatistician and head of demography at the National Cancer Institute, wrote an article titled “Mammography: A Contrary View,” which was highly critical of a mammography screening program being sponsored by his own agency, the NCI, along with the ACS.
He argued that the value of mammography had not been shown, especially for women under 50, and the risks of radiation “may be greater than commonly understood.” In other words, earlier was not necessarily better.
Bailar eventually co-authored two important pieces for the New England Journal of Medicine, one in 1986 titled “Progress against Cancer?” and another in 1997 called “Cancer Undefeated.” He argued that a quarter-century after Nixon declared war on cancer, the United States was losing badly and that mortality rates had not budged. Bailar also believed that cancer prevention, a much more promising approach, had been ignored.
Q: But haven’t we made some progress against cancer since the early 1970s?
A: Yes, since 1971, the cancer mortality rate has gone down about 5 to 10 percent. Much of this, however, is due to the decline in smoking, although there have also been modest declines in mortality from breast and prostate cancer. Unfortunately, pancreatic, liver, kidney and other cancers are actually increasing, despite the War on Cancer and $100 billion having been put into it.
Q: What do you think about using the moonshot analogy, as Vice President Biden has done, in talking about cancer?
A: The moonshot metaphor is not any more subtle than the War on Cancer, and when you use that kind of language, it’s easy to oversell things.
But at least Biden is acknowledging the limits of the moonshot, such as the notion that certain therapies might be used to control – as opposed to cure – cancer.
After Nixon signed the War on Cancer legislation, one cancer specialist at the time was so excited that he predicted that cancer would be wiped out by the 1976 American Bicentennial. Well, not exactly. This story reminds us to be modest about what we can hope to achieve in the next 10 to 20 years.