In 2011 the charity Bowel Cancer UK carried out a survey asking people to name the top three cancers they thought themselves most at risk of. Three-quarters of the female interviewees named breast, cervical and ovarian cancer. The correct answer, based on cancer incidence statistics, would have been breast, lung and bowel cancer. Reporting on the results, the tabloid Daily Mail stated that women were âliving in ignoranceâ of bowel cancer. 1 Womenâs perception of their cancer risk, this volume argues, is not the result of âignoranceâ, but a reflection of the success of policies which, since the early 1900s, have consistently targeted womenâs cancers as a major focus of medical and public health intervention. Indeed, it is no exaggeration to say that, in England and in many other Western countries, womenâs cancers have played an outstanding role in positioning cancer in the public domain, thanks to cancer awareness campaigns, screening programmes, specialist charities and fundraising events.
The association of cancer and femininity has a long history in the medical literature. Historian James Olson emphasizes that, throughout history, breast cancer was cancer. 2 Cancer expert Walter H. Walshe, writing in 1844, stated that cancer was originally thought to be an affection peculiarly affecting the breast; as morbid states of a similar character were found to occur in other organs, they were included under the same general name. 3 Whether women were actually more prone to cancer than men throughout history is difficult to say. Edward Shorter has claimed that, until the late nineteenth century, cancer was thought to be primarily a womanâs disease because malignancies of the breast, cervix and other âexternalâ organs were the only ones that could be diagnosed. 4 There is some evidence to suggest that men succumbed to internal cancers more often, and that internal cancers were under-diagnosed. Aetiological explanations of cancer throughout history imply, however, that women are more susceptible to cancer because of some inherent design fault. Galen, for example, claimed that womenâs coldness made them prone to disease. Their blood, corrupted by humidity, instead of being properly heated like it was in men, accumulated, blocked up the small blood vessels and caused all the diseases of which they were habitual victims. 5 During the nineteenth century, the connection between cancer and women was cemented by the theory that womenâs bodies were defined by their sexual functions. 6 Womenâs liability to cancer of the uterus and breast served to confirm the view that reproduction had a much larger place, for good or evil, in the life of woman than in that of man. Indeed, according to sociologist Tammy Duerden Comeau, during this period the gendering of cancer extended to the articulation of cancer classifications and theories about cancerâs origins. A model of cancerous disease emerged which emphasized its reproductive nature, as testified by the use of the term âproliferativeâ to describe the behaviour of cancer cells. 7
Studies of the medical, social and political response to cancer in the twentieth century have highlighted the centrality of gynaecological cancers to the early cancer campaigns, yet there is little historical work on this group of cancers. Furthermore, the bulk of historical attention has focused on American cancer programmes. 8 This volume joins a growing body of work that is beginning to redress the balance, illuminating the history of British and European cancer campaigns. Focusing on cervical and, to a lesser extent, on ovarian cancer, it examines the role this group of cancers has played in the creation of twentieth-century cancer campaigns in England. The focus on gynaecology allows not only an examination of the contribution made by gynaecologists themselves to the development of cancer control policies in this country, but also a study of the part played by others concerned with the gynaecological cancers: radiotherapists, pathologists, voluntary organizations, public health practitioners and government officials.
Cervical cancer occupies an especially important place in the history of British efforts against cancer as the target of the first awareness campaign in 1907 and the model for subsequent campaigns against skin, breast, oral and rectal cancer. The common feature of these very different malignancies is that they reveal themselves at a relatively early stage in the natural history of the disease. Early twentieth-century anti-cancer activists believed that this peculiarity made these cancers particularly suited to approaches based on âearly detection and treatmentâ. Yet even as the scope of the British campaign broadened during the 1910s to include cancers that were not gender-specific, much of the anti-cancer effort continued to be directed at women. It was not until the 1950s that men began to feature more prominently in public discourses about cancer, through the concern with lung cancer. 9 In its broad contours, the British story appears to resemble the US one. In the United States, too, cancer awareness campaigns began in the early 1910s in response to concerns about cervical cancer mortality. The original focus widened in the 1920s to include breast, oral, skin and stomach cancer, but womenâs reproductive cancers remained a major focus of public attention until the 1950s, when concerns about the increase of lung cancer, particularly in males over forty-five, brought about a change in the balance of the sexes, towards men. These apparent similarities mask underlying differences in the financial and structural basis of the healthcare system in each country, in patterns of specialization, and in broader cultural attitudes. These differences have shaped the development of treatment modalities, the provision of routine cancer treatment and the timing and tone of campaigns in each country. The British story thus deserves to be examined in its own right.
âUterineâ cancer (a term still used in the early 1900s to denote cancer of both the neck and body of the uterus) acquired public visibility in the early 1900s as a relatively hopeful malignancy. Fin-de-siècle optimism was based on the premise that the combination of early detection and âradicalâ surgery (i.e., surgery aimed at eradicating the disease) would prove curative. The philosophy of surgical radicality, I show in Chap. 3, was not new. In the early decades of the nineteenth century, a few surgeons had attempted to develop radical surgical procedures for benign conditions such as hernia and ovarian cysts, as well as for malignant conditions such as cervical and breast cancer. Radical surgery was risky, but justifiable if it could permanently relieve the patient of a troublesome and potentially fatal disease. The problem with radical surgery for malignant disease was that it did not produce permanent cures. True cancer had a tendency to recur â and indeed, for most of the nineteenth century the notion of recurrence was integral to the definition of malignancy. In the first half of the nineteenth century concerns about the dangers and ineffectiveness of radical solutions for cancer prompted most medical writers to recommend that operative interference should be contemplated only as a last resort. Around the middle of the nineteenth century, however, the introduction of anaesthesia and the development of new techniques aimed at reducing the risks of surgery encouraged surgeons to offer operations more frequently and at an earlier stage of the disease. Further support for a more aggressive approach to the treatment of malignant disease came from a statistical study of the results of surgery for breast cancer at Londonâs Middlesex Hospital, which showed that patients who were operated upon survived longer than those who did not have the surgery. Operations for cancer became increasingly extensive during the last quarter of the century, in the belief that recurrences were due to âinadequateâ excision of tissue. This strategy did not in fact work: by 1900 leading surgeons and gynaecologists privately admitted that even the most extensive surgery did not permanently eradicate the disease. Yet they continued to promote radical solutions for malignant disease, supported by a new narrative of therapeutic failure. Advocates for surgery asserted that a period of disease-free survival (the âsurgical cureâ) counted as a âcureâ, and that surgery would be successful, if only patients would not delay seeking medical advice. Historians of medicine have emphasized the importance of the âmessage of hopeâ in the war on cancer. Sociologists and anthropologists have drawn attention to the âdiscourse on hopeâ in modern oncology, highlighting its significance at a number of levels: individual, interpersonal and institutional. 10 A considerable investment rests on hope, and hope has become synonymous with curative treatment â if not now, then sometime in the future. There is now a growing literature on the âsociology of expectationsâ, a strand of Science and Technology studies which deals with the role of expectations in shaping scientific and technological change. 11 Moreira and Palladino have discussed the tensions in modern biomedicine between a âregime of hopeâ characterized by the view that new and better treatments are always about to come, and a âregime of truthâ based on the view that most medical therapies are, most often than not, less effective than claimed. This volume makes a contribution to this discussion by exploring how the aspirational discourse of hope came to be used by surgeons and gynaecologists as a means of legitimating operative interference, justifying further investment in a treatment that simply was not working as expected.
During the 1920s, developments in the application of X-rays and radium to the treatment of a range of malignancies raised new hopes that the âcure of cancerâ may be just around the corner. As I show in Chap. 5, cervical cancer proved to be particularly sensitive to the effects of radiation. Statistical studies undertaken in the late 1920s appeared to show that treatment by radium or X-rays relieved the symptoms of incurable cancer, and that it produced results comparable to those of surgery in operable cases. In addition, there was much evidence that radiation therapy was significantly safer than surgery. But enthusiasm for the radiation treatment of cervical cancer was also generated by the belief that it provided an alternative to âmutilatingâ gynaecological surgery. Many doctors and public health officials claimed that fear of surgery and its consequences deterred women from seeking early medical advice. When the treatment was less drastic and hazardous it was easier to persuade women to consult the doctor. The development of radiotherapy of cervical cancer was thus also shaped by cultural beliefs about the effects of surgery when womenâs reproductive organs were involved.
Chapter 5 examines another aspect of the gendered politics of radiotherapy: the role medical women played in the standardization of radium treatment of cervical cancer. Radium therapy of cervical cancer was of interest to female practitioners for two main reasons. First, it confirmed their established role as providers of healthcare to their own sex. Women doctors had managed to find a niche in medicine as the guardians of the physical and moral health of women and children. Campaigners for womenâs entry to medicine had argued that women doctors were badly needed to preserve the modesty of women patients, especially in cases of gynaecological disease requiring intimate examinations. There was thus widespread agreement that patients suffering from cervical cancer would prefer to be treated by a female clinician. Second, radiotherapy provided an opportunity to further feminist efforts to reform medicine, both as a practice and as a profession. Its development opened up new career paths for women in an area of medicine which, though still marginal, already had a reputation for modernity and leading-edge technology. It was thus also attractive as a means of challenging the gender-role stereotypes which prevented girls and young women from pursuing opportunities in science.
In parallel with efforts to find women at an earlier stage in their personal history of cancer, another quest gathered momentum in the laboratory. Between approximately 1925 and 1945, methods aimed at detecting cervical cancer in its earliest, âpre-cancerousâ or ân...