TIME health

How Doctors of the Past Blamed Women for Breast Cancer

Motherhood
Fine Art Photographic/Getty Images 'Motherhood' by Hector Caffieri, circa 1910

Breastfeeding, corsets and aging: the mysterious dangers of womanhood

History Today

 

 

 

This post is in partnership with History Today. The article below was originally published at HistoryToday.com.

‘I congratulate … [my fair countrywomen] on their present easy and elegant mode of dress’, wrote the surgeon James Nooth, in 1804, ‘free from the unnatural and dangerous pressure of stays.’ Nooth’s concern was not aesthetic. The danger he saw in restrictive bodices was cancer: ‘I have extirpated [removed] a great number of … tumours which originated from that absurdity.’

Breast cancer in the 19th century was a consistent, if mysterious, killer. It preoccupied many doctors, unable to state with any confidence the disease’s causes, characteristics or cures. While the orthodox medical profession in Britain were broadly agreed on cancer’s ultimate incurability, they were less uniform in their understanding of its origin. The disease was thought to develop from a range of harmful tendencies and events acting together. Both the essential biology of being female, as well as typically ‘feminine’ behaviors, were understood as causes of breast cancer.

Breastfeeding was a contentious topic at the end of the 18th century. An image of idealised motherhood emerged that infiltrated concepts of femininity: women were by nature loving, maternal and self-sacrificing. This ideology was expressed through changing social and political attitudes to breastfeeding and an outcry against wet-nursing across western Europe. In 1789 only 10 per cent of babies born in Paris were nursed by their own mothers; by 1801, this number had increased to half of all Parisian infants and two thirds of English babies.

Late 18th-century medical men were explicit about the associations between breastfeeding and breast cancer. In 1772, man-midwife William Rowley wrote: ‘When the vessels of the breasts are over-filled and the natural discharge through the nipple not encouraged … it lays the foundation of the cancer.’ Frances Burney – an aristocratic novelist who underwent a mastectomy in 1811 – attributed her disease to her inability to breastfeed properly: ‘They have made me wean my Child! … What that has cost me!’

Menstruation was seen as particularly hazardous. The surgeon Thomas Denman wrote: ‘Women who menstruate irregularly or with pain … are suspected to be more liable to Cancer than those who are regular, or who do not suffer at these times.’ However, their risk only increased after menopause. Denman considered ‘women about the time of the cessation of the menses’ most liable to cancer. Elderly women were blighted by a dual threat: their gender and their age. While surgeons insisted their theories were based on clinical observation, designating these various female-specific processes as causes of cancer supported their broader thoughts about female biology.

Eighteenth-century theory dictated that all diseases were explained by an imbalance in ‘humours’: black bile, yellow bile, blood and phlegm. Into the 19th century the insufficient drainage of various substances continued to be invoked as a cause of cancer; women’s ‘coldness and humidity’ made them particularly prone to disease. Menstruation was the primary mechanism by which the female body cleansed the system of black bile and its regularity was seen as central to a woman’s wellbeing. Certain situations in which the menses were disrupted or had been terminated were, therefore, especially dangerous: pregnancy, breastfeeding and menopause. Similarly, when the female body and its breasts were not used for their ‘correct’ purpose – childbearing and rearing – the risk of breast cancer increased.

The historian Marjo Kaartinen has noted that 18th-century theorists considered just ‘being female and having breasts’ a threat to a woman’s health. This way of thinking about female biology suggested that women were more likely to suffer from all cancers, not just cancer of the breast. Denman wrote: ‘It can hardly be doubted … that women are more liable to Cancer than men.’

This association between womanhood and disease and between breastfeeding, pregnancy, menopause and cancer is still part of our 21st-century understanding of breast cancer; that certain female-specific processes make you more or less likely to succumb to it. On its website, the breast cancer charity Breakthrough lists various ways you can reduce and increase your chances of disease. According to contemporary research, having children early and breastfeeding them reduces your risk. The later a woman begins her family the higher her risk is. The contraceptive pill, growing older and the menopause also increases your risk of breast cancer.

Drawing attention to such historical continuities questions the social and cultural environments that make certain medical assumptions possible. The causes of cancer suggested by Denman, Nooth and friends were informed by their understandings of female biology and female inferiority more generally. They were working within a school of thought that suggested any deviation from ‘appropriate’ womanhood could have hazardous consequences for a woman’s health. While the role of the historian might not be to deny the validity of 21st-century medical research, it is part of our remit to question cultural assumptions that continue to have some effect on both the conclusions of scientists and the way those conclusions are accepted by the broader public.

Agnes Arnold-Forster is a PhD candidate at King’s College London.

TIME celebrities

Rita Wilson Undergoes Double Mastectomy After Breast Cancer Diagnosis

EE British Academy Film Awards 2014 - Red Carpet Arrivals
Mike Marsland—WireImage Rita Wilson attends the EE British Academy Film Awards 2014 at The Royal Opera House on February 16, 2014 in London, England. (Mike Marsland--WireImage)

Says husband Tom Hanks was by her side

Rita Wilson announced Tuesday that she has been diagnosed with breast cancer, and has undergone a double mastectomy and reconstructive surgery in order to fight the disease.

The actress revealed her diagnosis and treatment in a statement to People, and said the prognosis is good. “I am recovering and most importantly, expected to make a full recovery,” she said. “Why? Because I caught this early, have excellent doctors and because I got a second opinion.”

Wilson has recently appeared on Girls and The Good Wife and recently took a leave from the play A Fish in the Dark because of her health. Wilson said that her husband Tom Hanks was “by my side” through it all.

Read more at People.com

TIME Cancer

What to Do If You Have a Cancer Scare

doctor-patient-standing
Getty Images

Don’t over-rely on Dr. Google

Late last month, Angelina Jolie announced that she had surgery to remove her ovaries and fallopian tubes with the aim of reducing her cancer risk. In her New York Times op-ed, she noted that she had recently had a cancer scare: Her doctor was concerned about some unusual blood test results, and sent her for further scans.

“I went through what I imagine thousands of other women have felt,” she wrote. “I told myself to stay calm, to be strong, and that I had no reason to think I wouldn’t live to see my children grow up and to meet my grandchildren.” Fortunately, the follow-up tests showed no signs of cancer.

Chances are at least once in your life you’ll have some sort of cancer scare—a strange mole that needs to be biopsied, a repeat mammogram, an abnormal Pap smear. In most cases, it’s nothing to worry about: “This happens every day in doctors’ offices all across America,” says Richard Wender, MD, chief cancer control officer at the American Cancer Society.

But it can be hard to stay calm when it’s actually happening to you. Here are five things to keep in mind:

Take a step back

Abnormal cancer screening results happen all the time: As many as 35% of women over the age of 40 report having had an abnormal Pap smear or mammogram at some point. “The most common resolution of that abnormal test is finding that you don’t have cancer,” Dr. Wender says.

Remember, the reason these tests have such high cancer-detection rates is because they screen women for any small thing—like calcification on a mammogram—that could potentially indicate cancer.

Read more: 19 Medical Tests Everyone Needs

Make sure you’re hearing your doctor

“Sometimes, when I explain a screening test result to a patient, I can sense that she’s so anxious she’s not processing what I’m saying,” says Dr. Wender. Research shows that almost half of the details remembered from a doctor’s visit are incorrect.

Don’t rely on your memory, especially at an emotional time like this. Either jot down exactly what the doctor says (and don’t be afraid to have them repeat it) or make sure a friend or family member is either in the office with you or on the phone when you speak to your physician.

Read more: What Doctors Don’t Tell You (But Should)

Try not to stress about additional waiting

If suspicious mammogram findings mean your doctor recommends a biopsy, don’t worry if it’s several weeks away. “Waiting three weeks will not change the prognosis and outcome at all if it does turn out to be cancer,” says Dr. Wender.

You also shouldn’t necessarily be alarmed if your doctor doesn’t recommend more invasive testing—such as a colposcopy or biopsy—and instead suggests simply returning for follow-up screening in six months.

“Oftentimes a doctor or technician will see something that doesn’t look like cancer, but they just want to double check it in a few months to be safe,” explains Dr. Wender.

Read more: A Complete Guide to Breast Cancer Screening

Don’t go overboard on Dr. Google

Sometimes, Google can be reassuring: “If you type in ‘abnormal pap smear’ or ‘abnormal mammogram’ or even ‘suspicious mole,’ you’ll see how common the false positive rate is,” says Dr. Wender.

But other times, you’ll just scare yourself unnecessarily. “I had a patient recently who had some tests come back suggestive of a very lethal form of uterine cancer,” recalls Dr. Wender. “When I called her, I said, ‘Don’t research it on the Internet. Just don’t do it.’ She didn’t—and six weeks later, when we learned after a surgical biopsy that the results were benign, she was tremendously relieved.”

Read more: 9 Scary Symptoms You Don’t Need to Worry About

Ask lots of questions

If you’ve got fears, articulate them. “If you ask your doctor what the likelihood is that your test result indicates cancer, they may not have exact numbers but they should be able to respond to you in a general way, which is usually reassuring,” says Dr. Wender.

And if they brush off your worries, or refuse to answer you, it may be time to seek out another doctor—or at least get a second opinion.

Read more: How Good Is Your Doctor?

This article originally appeared on Health.com.

Read next: This Is What Getting Cancer Looks Like on Social Media

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MONEY Health Care

Who Covers the Costs of Preventive Surgery Like Angelina Jolie’s

Actress Angelina Jolie
Matt Sayles—Invision/AP

Faced with a genetic predisposition to cancer, Angelina Jolie opted for a preventive surgery to remove her ovaries and fallopian tubes. But can other women afford to do the same?

This week, actress and director Angelina Jolie took to the New York Times to announce a big decision: She had her ovaries and fallopian tubes surgically removed, a preventive measure meant to decrease her risk of ovarian and breast cancer. This surgery followed her preventive double mastectomy in 2013.

After losing her mother, grandmother, and aunt to cancer, Jolie underwent genetic testing and learned that she had a mutation in one of her BRCA genes, a tumor-suppressor gene. That means she too has an increased risk of developing breast cancer and ovarian cancer.

“I feel feminine, and grounded in the choices I am making for myself and my family,” Jolie wrote. “I know my children will never have to say, ‘Mom died of ovarian cancer.'”

The good news: If you share Jolie’s predisposition to cancer, the same treatment options are probably available to you. Most insurers will cover preventive surgery for women with a BRCA mutation, says Lisa Schlager, vice president for community affairs and public policy at Facing Our Risk of Cancer Empowered (FORCE), a nonprofit organization devoted to hereditary breast and ovarian cancer. (Generally, Medicare and Medicaid aren’t as generous, Schlager says.)

That’s been true for a long time—a 2001 study found that 97% of preventive surgeries for women with BRCA mutations were fully covered by insurance (except for deductibles and copays).

The surgery can be costly. According to HealthSparq, a health care costs transparency firm, the average national cost for the surgical removal of the ovaries and fallopian tubes is $12,381.

That’s the average insurer-negotiated price, based on actual claims data from 67 health plans. In other words, that’s the average price insurers have agreed to pay hospitals and health providers for the procedure. You can expect to pay a smaller portion of that cost, depending on your health plan’s deductible, co-pays and co-insurance.

Today, the average deductible for Americans with single, employer-subsidized health coverage is $1,217, which means most need to pay more than a grand out-of-pocket before insurance begins to cover the bulk of their costs, according to the Kaiser Family Foundation.

“It really depends on your insurance and your deductible,” Schlager says. “Some people have a very high deductible, and we’re referring them to services that provide financial assistance.”

Prices can also vary significantly by region. According to HealthSparq, the average cost of the procedure is $8,693 in Maryland, but $20,763 in San Francisco, a $12,070 price gap.

Market Average Cost
San Francisco – San Jose CA $20,763.06
San Diego CA $16,508.06
Miami – Fort Lauderdale FL $16,441.37
LA – Orange County CA $16,378.38
Houston TX $14,687.49
Austin – San Antonio TX $13,617.29
New York City – White Plains NY $13,591.84
Dallas – Fort Worth TX $13,404.92
New Orleans LA $12,049.43
Cinncinati – Dayton OH $11,987.74
Columbus OH $11,335.80
Albany NY $9,559.04
Washington DC – Arlington VA $8,747.73
Maryland $8,692.77
AVERAGE NATIONAL $12,380.55
PRICE GAP $12,070.29

But generally, insurers will cover the surgery. After all, “the surgeries are less expensive to the private insurers than if you were to get cancer,” Schlager says.

How do you know if you’re at risk? According to guidelines from the National Comprehensive Cancer Network, you should get screened for genetic abnormalities if any of your family members develop ovarian or fallopian tube cancer, breast cancer in both breasts, breast and ovarian cancer, breast cancer before age 50, male breast cancer, or other signs of hereditary breast-ovarian cancer syndrome. You should also get tested if more than one blood relative on the same side of your family has breast, ovarian, fallopian tube, prostate, pancreatic, or melanoma cancer. The U.S. Preventive Services Task Force, which helps implement the Affordable Care Act, made similar recommendations.

Schlager says the cost of genetic testing has “dropped substantially” in recent years, to between $1,500 and $4,000. Most insurers will cover genetic testing if you meet the national guidelines, but if your insurer refuses, some labs have financial assistance programs to limit your out-of-pocket cost to about $100, Schlager says.

Then you should meet with a genetic counselor. The Affordable Care Act mandates that health insurers cover genetic counseling with no cost-sharing if you have an increased risk of breast or ovarian cancer. That is to say, genetic counseling is a women’s preventive service that should be free to you, like birth control.

Jolie was quick to note that her choice isn’t the answer for everyone. “A positive BRCA test does not mean a leap to surgery,” Jolie wrote. “I have spoken to many doctors, surgeons and naturopaths. There are other options.”

A genetic counselor should help you understand the implications of preventive surgery and consider other less invasive—but less effective—measures, like increased cancer screenings. “It’s a very personal decision, and every family is different,” Schlager says. “Your first step is to talk to your doctor.”

TIME Cancer

Why Angelina Jolie Chose to Have Her Ovaries Removed

"This surgery decision is more straightforward than the decision to have the breasts removed.”

In an op-ed in the New York Times, Angelina Jolie Pitt announced that she recently had surgery to remove her ovaries and fallopian tubes. The procedure put her into menopause at age 39, and she will take replacement hormones for another decade or so.

“It is not easy to make these decisions,” she writes. She describes how she felt she “still [had] months to make the date” for her operation as she prepared herself both physically and emotionally to end her reproductive years.

MORE: The Angelina Effect

But cancer experts say that Jolie did the right thing. While her decision to remove both her breasts before she developed breast tumors was controversial, her latest choice to have her ovaries removed is less so, although equally difficult from both an emotional and physical point of view. “This surgery decision is more straightforward than the decision to have the breasts removed,” says Dr. Karen Lu, chair of gynecologic oncology at MD Anderson Cancer Center. “And it’s definitely a stronger recommendation than for the bilateral prophylactic mastectomy.”

For women like Jolie, who harbor either of the BRCA1 or BRCA2 mutations (Jolie is positive for BRCA1), their risk of breast cancer is anywhere from 80% to 90% higher than that of women without the genetic aberrations. But there are ways that doctors can screen for even the smallest tumors in the breast and therefore get a heads up when the cancer is growing. That allows many women to choose to keep their breasts and have a lumpectomy followed by radiation, with more frequent and vigilant screening for any additional or recurrent growths.

There isn’t that luxury with ovarian cancer, which is often caught once the cancer has progressed and is harder to treat. Women with the BRCA mutations have an up to 50% greater chance of developing this type of cancer, and there are no good ways of screening for it; a blood test that picks up a protein common to ovarian tumors isn’t specific to the cancer, so it could provide false positive or false negative results. In most cases, the cancer is well advanced before doctors, or patients, even know it’s there. “It is incurable in most cases for the vast majority of women,” says Lu.

That’s why the National Comprehensive Cancer Network, and the American Congress of Obstetricians and Gynecologists strongly recommend that women with BRCA1 mutations have their ovaries and fallopian tubes removed by age 40, and those with BRCA2 mutations by age 45.

MORE: Angelina Jolie’s Double Mastectomy: What We Know About BRCA Mutations and Breast Cancer

That doesn’t mean it isn’t still a difficult one to make. For women who learn they have a BRCA mutation in their 20s or 30s, for example, and have no history of cancer — yet —they have to decide whether they want to have children at all, or whether they want to continue adding to their family if they already have, or whether they are ready to enter menopause. For such pre-vivors of cancer, who are at higher risk of the disease but haven’t yet developed tumors, the choice between invasive surgery, and a theoretical risk of something occurring in the future, is agonizing.

For them, there may be other options soon. Researchers at MD Anderson, for example, are testing whether women and keep their ovaries for a little longer if they have their fallopian tubes removed first, since there are signs that ovarian cancer may start in the tubes. Jolie writes about promising studies that suggest birth control pills can lower the risk of ovarian cancer in women with BRCA mutations, but the data is still conflicting.

For now, the option that gives women with BRCA their best chance of avoiding ovarian cancer is surgery.”We are absolutely trying to develop medicinal approaches to reducing risk, and understand the disease better,” says Dr. Larry Norton, medical director of the Evelyn H. Lauder Breast Center at Memorial Sloan Kettering Cancer Center. “But right now, as of this minute, there is no medicinal or herbal approach to reduce risk anywhere close to what we can do with surgery.”

“I feel deeply for women for whom this moment comes very early in life, before they have had their children,” Jolie writes. “But it is possible to take control and tackle head-on any health issue. I feel at ease with whatever will come, not because I am strong but because this is a part of life. It is nothing to be feared.”

MORE: Angelina Jolie’s Double Mastectomy: It’s Not the Only Option

TIME health

Angelina Jolie Says She Had Her Ovaries Removed

Angelina Jolie arrives at the 20th annual Critics' Choice Movie Awards at the Hollywood Palladium on Jan. 15, 2015 in Los Angeles.
Matt Sayles—Invision/AP Angelina Jolie arrives at the 20th annual Critics' Choice Movie Awards at the Hollywood Palladium on Jan. 15, 2015 in Los Angeles.

"I feel feminine, and grounded in the choices I am making for myself and my family"

Angelina Jolie said Tuesday that she underwent preventative surgery to remove her ovaries and fallopian tubes, two years after she sparked a debate on women’s health by getting a preventative double mastectomy.

Writing in the New York Times, the Hollywood actress and U.N. envoy said her decision, made because she carries a mutation in the BRCA1 gene that gave her a 50% risk of developing ovarian cancer, was not an easy one.

“It is not easy to make these decisions,” she said. “But it is possible to take control and tackle head-on any health issue.”

The procedure forces a woman into menopause and Jolie will now take hormone replacements.

Jolie, 39, who wrote about her decision to have a double mastectomy after learning she had the gene mutation two years ago, said she wants to help provide information to women going through similar experiences.

“You can seek advice, learn about the options and make choices that are right for you,” she said.

Read more at the Times

Read next: Angelina Jolie: The World Must Do More for Syrian and Iraqi Refugees

Listen to the most important stories of the day.

TIME Cancer

Diagnosed With Breast Cancer? Get a Second Opinion

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Ben Edwards—Getty Images

A new study reveals that pathologists don't always see a biopsy the same way

A new study shows that when it comes to diagnosing breast cancer, doctors do not always agree on what the biopsy slides reveal.

Every year, about 1.6 million women in the United States undergo a breast biopsy. In some cases, the biopsy results are obvious; a woman has breast cancer or she doesn’t. But other cases are more uncertain.

According to new research in the journal JAMA, when it comes to less obvious cases, the doctors making the call—pathologists—only agree with outside experts about 75% of the time.

In the study the researchers asked 115 U.S. pathologists to assess 240 breast cancer biopsy slides and make a diagnosis. Their responses were then compared to what a panel of three highly regarded experts determined to be the correct diagnosis.

Fortunately, when it came to diagnosing invasive cancer, there was broad consensus; the pathologists agreed with the panel 96% of the time. When it came to non-cancerous biopsies, the pathologists agreed 87% of the time, but 13% of the time they misdiagnosed.

When it came to more challenging cases—like atypia, where breast cancer cells are abnormal but not cancerous—the pathologists only agreed 48% of the time. In 17% of the cases, the pathologists diagnosed atypia when the expert panel did not, and 35% of the time the pathologists missed the diagnosis.

Another challenging diagnosis is ductal carcinoma in situ (DCIS), which happens when the cancer is inside the milk ducts but considered non-invasive. When it came to DCIS biopsies, pathologists agreed 84% of the time. Three percent of the time they diagnosed DCIS, and 13% of the time they missed it.

Though the study did not examine the clinical impact of incorrect diagnoses, the findings raise concern about cancer over-diagnosis and over-treatment, as well as missed opportunities to catch true cancer early.

“These findings are disconcerting but perhaps not altogether surprising,” write the authors of a corresponding editorial. (The editorial authors were not involved in the study.) In the real world, pathologists do have the opportunity to consult with others, they note. They conclude that the findings underline the value of having a second opinion in more ambiguous cases.

“The agreement on the diagnosis of invasive carcinoma was quite high, and that should be reassuring,” says Dr. Benjamin Calhoun of the anatomic pathology department at the Cleveland Clinic, who was also not involved in the study. He sees the results as an opportunity to improve continuing medical education for pathologists. “Instead of a lecture from an expert with a few carefully chosen representative images, pathologists need a more ‘hands-on’ experience,” he says, “and the opportunity to compare their diagnoses with an expert panel.”

For now, more research is needed to understand how such findings may be affecting patients.

TIME Cancer

Lung Cancer Now Kills More Women Than Breast Cancer in Developed Countries

The lingering effects of the tobacco epidemic are partly driving the shift

For years, breast cancer has been the leading cause of cancer death among women in developed countries, but according to a new report on the incidence of cancer worldwide from the American Cancer Society, lung cancer now surpasses it.

A combination of early breast cancer detection efforts and the lingering effects of the tobacco epidemic drove the shift, says lead report author Lindsey Torre, an American Cancer Society researcher. The study, which was published in CA: A Cancer Journal for Clinicians and used data from 2012, reported that lung cancer killed 209,000 women in developed countries in 2012, while 197,000 women died of breast cancer.

“We know now that in a lot of developed countries among women, smoking is on the decline,” says Torre, noting that new lung cancer infections today are the result of habits formed decades ago. “The good news is that we can probably expect to see these lung cancer mortality rates peak and start to decline as times go by.”

Read more: The Cancer Breakthrough With Big Implications

The report emphasized the growing incidence of cancer in the developing world. Lung cancer was the leading killer of men in developing countries and breast cancer the leading cause of death for women.

In part, these growing numbers can be attributed to an aging population, a trend that is affecting the world at large. And as the developing world continues to westernize, people in developing countries are increasingly likely to smoke, be overweight and rarely engage in psychical activity, Torre says.

“We’re seeing the burden of cancer shift to developing countries, so they’re taking on an increasing portion of the global cancer burden,” she says.

Cancer killed 8.2 million people worldwide and 1.6 million in the United States in 2012.

TIME diseases

U.S. Breast Cancer Deaths Fell Dramatically in the Past 20 Years

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Getty Images

The 34% decline in deaths represents more than 200,000 lives saved

The past 20 years have seen a sharp drop in the number of deaths from breast cancer in the U.S., the latest government statistics indicate.

The number of deaths fell from 33 to 22 per 100,000 women between 1990 and 2011, USA Today reports. This decline — about 34% — represents more than 200,000 lives saved, the American Cancer Society said.

Experts say the downward trend, which they estimate has continued in the past four years as well, can be attributed to better treatment, rising awareness and more frequent checkups.

[USA Today]

TIME Cancer

Many Breast Cancer Patients Don’t Understand Their Condition, Study Says

The disparity is particularly pronounced for minority women

Many breast cancer patients don’t understand the details of their disease, according to a new study. While many believed they understood the grade, stage and type of tumor, only 20% to 58% identified those characteristics correctly.

The study, published Monday in the journal Cancer, found that minority women fared particularly poorly in identifying their tumor characteristics, a finding that remained true even as researchers controlled for factors like education. The lack of understanding about their own disease makes it difficult for patients to make informed medical decisions and to follow prescribed treatments, said study author and Harvard Medical School professor Rachel Freedman.

“Our results illustrate the lack of understanding many patients have about their cancers and have identified a critical need for improved patient education and provider awareness of this issue,” Freedman said.

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