Can Tempering Aggressive Language Help Women "Fight" Breast Cancer?

NEW YORK, NY, July 10, 1998 -- Can words and, specifically, war metaphors affect screening and treatment decisions in the "fight" against breast cancer? Very possibly, says Barron Lerner, M.D., Angelica Berrie Gold Foundation Assistant Professor of medicine at Columbia University College of Physicians & Surgeons, in an article titled "Fighting the War on Breast Cancer: Debates Over Early Detection, 1945 to the Present," appearing in the July 1, 1998, issue of The Annals of Internal Medicine, published by the American College of Physicians.

There has been a lot of good news about breast cancer lately, Dr. Lerner notes: Mortality rates are down, new treatments are on the horizon, and screening is proving effective for many women. But, he writes, military metaphors have become commonplace. It is nearly impossible to discuss breast cancer without using such terms as "fighting the disease" or "battling the enemy." Dr. Lerner believes such metaphors may raise false hopes for some women, citing history to argue that sometimes the war language may mitigate against reasoned considerations in assessing treatment options and, in these times of genetic testing, evaluating a woman's risk for breast cancer.

The "often vitriolic and accusatory" language that greeted a recommendation by National Institutes of Health scientists that women between 40 and 49 years of age not have routine mammograms raised warning flags for Dr. Lerner, who is both a primary care physician and a medical historian. Rather than reflecting rational discourse about the NIH data, many comments "reflected the entrance of political, economic, legal, and interest group concerns into the screening process." The arguments reminded Lerner of earlier skirmishes in the war against breast cancer. Dr. Lerner, whose research is supported by the Robert Wood Johnson Foundation and the Arnold P. Gold Foundation, is writing a book about the history of breast cancer treatment.

For Dr. Lerner, the language used in 1997 reminded him of the early 1950s, when the accepted treatment for any breast cancer was radical mastectomy. He writes that at the time, a few researchers found that "early detection and aggressive treatment had little effect on the natural history of breast cancer. Instead, they argued, biological factors, such as tumor virulence and immune response, determined the fate of patients." The criticism that faced these scientists and clinicians, known as biological predeterminists, was similar in tone to arguments against the 1997 NIH findings. In fact, one dissenting physician of the 50s compared a biological predeterminist colleague to the devil, and another recommended tearing the predeterminists "limb from limb."

The historical perspective proves the two-sided nature of the war metaphor, Dr. Lerner argues. On the one hand, it has helped to increase funding and raise public awareness about breast cancer, but it also has "discouraged physicians and patients from acknowledging the ambiguous results that early detection often produced; limited warfare held little appeal," he writes.

While Dr. Lerner does not dismiss the value of early detection and the hope that tamoxifen and other new treatments are offering in the war against breast cancer, he urges that we avoid overreacting when screening tests reveal ever-smaller lesions that may never develop into cancer and when genetic tests show that some women are genetically prone to breast cancer. "The war metaphor may raise expectations," says Dr. Lerner. "If the language is less polarized, both patients and doctors can approach different treatments rationally and reach a constructive consensus about the best way to manage the disease."



Barron Lerner, Internal Medicine, NIH, NY