Robert Aronowitz's "Unnatural History"

Robert Aronowitz, M.D., is Associate Professor in the Department of History and Sociology of Science at the University of Pennsylvania.

He applied the "Page 99 Test" to his new book Unnatural History: Breast Cancer and American Society, and reported the following:

On P. 99 of my book, Unnatural History: Breast Cancer and American Society, we are in the middle of a late 19th and early 20th century medical controversy. Who should make the cancer diagnosis, the surgeon or the pathologist? On what grounds? William Halsted, reviled today by many people today for his promotion of radical breast cancer surgery, argued that the surgeon should be in charge and that it should be diagnosed based on the look and feel of the tumor in the examining and operating room. “There is a gap between the surgeon and the pathologist which can be filled only by the surgeon,” he wrote in 1898. “A tumor on a plate and a tumor in the breast of a patient, how different! Its blood, its color, its form, its freshness, its consistency are more or less lost when the tumor is removed.” Halsted also argued that surgeons should be in charge because they were ultimately responsible for the patient.

While Halsted ultimately lost this seemingly narrow, technical debate – today cancer is defined and diagnosed by pathologists – the questions raised, like many other clinical issues in the history of breast cancer, are still with us and remain important to doctors and patients. What exactly is cancer? Who gets to decide? What are the consequences of one definition or another?

Cancer diagnosis remains an act of prediction under great uncertainty. Since Halsted, pathologists have defined cancer “earlier” in its natural history, creating different “pre-cancer” diagnoses which have some (constantly changing) statistical probability of causing harm in the future. These diagnoses often create terrible treatment dilemmas for both doctor and patient. What is their real clinical significance? Should they be ignored or treated?

The two most prominent pre-cancer diagnoses are lobular carcinoma in situ and ductal carcinoma in situ. These pre-cancer diagnoses increased an astounding eightfold between 1975 and 2002. This change has contributed to the widely touted and frightening 1:8 lifetime odds of developing breast cancer. The massive increase in breast cancer diagnoses, trumpeted in cancer education and awareness programs, has radically transformed how women perceive and react to this disease. Cancer fear is more widespread and intense. A recent scientific report showed that the number of women with breast cancer choosing a “preventive” mastectomy in the unaffected breast soared from 1.8 percent in 1998 to 4.5 percent in 2003. That’s an increase of 150 percent in just five years.

So who defines cancer and how we define it matters. I hope that my history of breast cancer in American society will empower doctors, patients, and lay people to see many present ideas and practices as not inevitable and therefore open to debate and change.

Read an excerpt from Unnatural History and learn more about the book at the Cambridge University Press website.

--Marshal Zeringue