Constructing Cancers

“Cancer offers an ideal window onto the dynamics of 20th-century medicine,” says Professor John Pickstone, leader of the ‘Constructing Cancers’ research programme at the University of Manchester’s Centre for the History of Science, Technology and Medicine.

By looking at the histories of specific cancers – leukaemias and lymphomas, breast cancers and lung cancers – the research team is examining the relationships between research and treatment and what the changing modes of treatment (first surgery, then radiotherapy, then chemo- and hormone therapy) meant for researchers, clinicians, institutions and patients in the UK.

The researchers’ international collaborations have enabled them to construct a comparative history of how new treatment forms were negotiated in different countries, and of the long-term consequences for services and specialisation.

The Christie Hospital and Holt Radium Institute in Manchester.

Surgery and radiotherapy

The story of modern cancer treatment began with surgery in the 19th century, after the introduction of anaesthetics such as chloroform and ether, and then of antiseptics and aseptics. Surgery remains the mainstay of therapy for many cancers today.

Early in the 20th century, radium came to be used for some ‘inoperable’ cancers. “Radium became a very popular project in Edwardian England. People raised money to be able to use it at their hospitals as it was very expensive,” says Professor Pickstone. In the 1930s, radiotherapy was a vanguard of state medicine in the UK, exemplifying a centralised health policy, and what Pickstone calls the analytical, rationalising mode in modern medicine. “The MRC [Medical Research Council] had a strong interest in it, and physicists worked with medical researchers to optimise therapy, using survival statistics to judge different dosages of radium for the treatment of different cancers.” France and Sweden were world leaders, but the so-called Manchester System of dosage – developed at the Christie Hospital and Holt Radium Institute in Manchester – was influential across the Commonwealth.

But in the USA, surgeons were rarely challenged as the major professional force in cancer hospitals. They used the radium needles, while their radiology colleagues tended to combine X-ray therapy with their diagnostic work. Both groups were suspicious of government radium schemes, and for most of the last century, US radiotherapy failed to find a comprehensive institutional base.

A technician monitoring and recording radiotherapy treatment.

Chemotherapy

“Chemotherapy, by contrast, was very US-led,” says Professor Pickstone. Despite the doctors’ preference for free markets, US chemotherapy benefited after World War II from large government investments. Drug development for cancer built on wartime research on antibiotics and nutrition, and clinical research developed in the 1950s through innovative but often controversial trials on people with cancer. These practices exemplified a mode of research that seemed more inventive and experimentalist than radiotherapy.

Trials of chemotherapy on leukaemias and lymphomas transformed cancer into an ‘experimental’ disease. But the US trials prompted thorny questions about ethics and efficacy for UK clinicians who believed that the Americans were testing extremely harsh treatments on people – many of them children – who were going to die anyway.

Nevertheless, these aggressive or ‘heroic’ trials on leukaemia led to a major breakthrough, achieving substantial remission rates. Cancers of the blood soon became a model for cancer more generally. Some clinicians began to specialise in medical oncology, and the term ‘chemotherapy’ came to refer specifically to cancer.

Anti cancer drug binding to DNA.

The cancer specialists in Britain who took up chemotherapy in the 1960s and 1970s were mostly employed on research contracts and focussed on clinical trials. For some of the rare child cancers, which responded well to chemotherapy, very high proportions of patients were included in such trials, as specialists collaborated between centres to build adequate numbers for statistically meaningful results. For lung cancer, by contrast, only a minority of patients were entered into trials.

Child cancers also attracted particular attention in terms of patient education. Books, such as ‘Henry and the White Wolf’ (a tale about a hedgehog who learns the true meaning of being a hero as he battles his way back to health) were written to help children come to terms with the disease and their treatment. A second generation of books were produced by the young patients themselves.

Epidemiological and social studies

Cancer also serves as a model for epidemiological and social studies. There were campaigns by the Nazis in Germany to stop people smoking. They thought tobacco was a noxious substance and was linked to lung cancer, but the research had little impact outside Germany.

Innovative epidemiological studies in the UK and elsewhere in the 1950s soon left little doubt among experts that the main culprit was cigarette smoke: “They checked smoking habits and lung-cancer patients and found a clear correlation: they then showed that if people stopped smoking, their life expectancy went up.”

In 1970, Christie researchers conducted the first clinical trial of tamoxifen, proving its value in advanced breast cancer.

Meanwhile, breast cancer was an early focus for social investigations into public attitudes towards cancer. In the UK in the 1950s, many specialists and policy makers were wary of raising awareness about the disease for fear of generating panic and overloading GPs and the NHS.

Later, in the 1970s and 1980s, breast cancer would be the first cancer to ‘go public’, as intimate accounts by people who had it offered powerful critiques of breast cancer care, prefiguring today’s world of patient blogs and celebrity narratives.

The research by the Manchester team also considers how health education and patient activism and involvement in their treatment have shaped public understanding and experience of the disease. “In the US, patients are encouraged to take part in clinical trials and choose their hospital accordingly. They want to feel they are helping to push back frontiers,” says Professor Pickstone.

Outcomes

The main products of the research are a series of books exploring key issues in the recent history of cancer, to be published by Palgrave Macmillan in 2010. A handbook of cancer history will be aimed at a wider public as well as health professionals and policy makers. The team has also launched a website to exchange findings with international collaborators and showcase the research more widely.

It was a central goal of the programme to develop collaborations with other scholars interested in the history of cancer both nationally and internationally. This proved very effective, chiefly through three international conferences, and a follow-up in April 2009 that furthered links with cancer policy.

New research projects have emerged from the collective work, including a history of cervical and breast cancer screening in the UK, and a project on medical physics, which historically was largely derived from radiotherapy.

Together these extensive outputs give an idea of the pervasive influence of cancer on many aspects of medicine – from laboratory science, high technology, clinical practice and epidemiological and social studies through to patient activism and involvement in trials, philanthropy and the emergence of hospices.

Image credits: Dr Carsten Timmermann (top). The Christie Hospital Archives (Special Collections, John Rylands University Library of Manchester). PJ Smith & L Patterson, Wellcome Images.