Robert A. Aronowitz, M. D.

Project

Contrary to Nature: Breast Cancer, Risk, and American Society

In the early 19th century, cancer in the breast was devastating for affected women, but the disease was not such a visible, feared, and contested public concern. This project explores the emergence of our immense individual and collective risk of breast cancer and associated risk factor interventions. This historical change involves the beliefs and values of women and their doctors, but also medical knowledge and technology, clinical and public health practices, and the biological impact of the disease.
Our modern constructions of breast cancer risk are not, in my view, a self-evident way of conceptualizing and communicating about danger, choice, cause, or responsibility. I will suggest that the major significance of modern risk discourse and practices is as a style of representing timeless problems raised by breast cancer and other diseases - and therefore revealing of conflicting values and interests - more than as a revelation of new etiological, preventive, or therapeutic insights.<br>
I expect this project will suggest the need for greater lay and clinical innovation from established norms, less fear of cancer qua cancer and more focus on mortality, and less hubris about scientific progress and the significance of many risk factors and associated interventions. We may have oversold both the fear of breast cancer and the effectiveness of prevention and treatment, resulting in many problematic consequences for individuals and society.

Recommended Reading
Aronowitz, Robert A. "Lyme Disease: The Emergence and Social Construction of a New Disease." The Milbank Quarterly 69 (1991): 79-112.
-. Making Sense of Illness: Science, Society, and Disease. Cambridge, UK and New York: Cambridge University Press, 1998.<br>
-. "Do not Delay: Breast Cancer and Time, 1900(1970." The Milbank Quarterly 79 (2001): 355-386.

Colloquium, 14.02.2006

An unnatural history of breast cancer in American society, from private suffering to everyone at risk

This project explores the change over the last two centuries from isolated, private fears to immense individual and collective risk of breast cancer. It emphasizes the largely social processes through which breast cancer and cancer risk have entered the bodies and concerns of so many American women.
The project builds on my earlier work in the social history of disease and public health, and my experiences as a primary care doctor. In today's talk, I will try to give a sense of the project's scope and findings and how I think about disease, cancer, and risk. Following the organization and approach of the book I am writing, I will intersperse specific examples of women with breast cancer with overviews of clinical and public health practices and ideas at particular moments.
I will emphasize several key continuities. One is the long history of women and doctors making extremely difficult decisions under great medical uncertainty, such as consenting to breast amputations when surgeons were pessimistic about cure and before the introduction of ether anesthesia. To make these decisions, women and doctors have often drawn on a small set of heuristics such as avoiding "anticipated regret," aligning their decisions in the direction of apparent progress, following the law of small numbers, and fighting evil with an equal or greater evil. Another continuity has been the way decision making at the end of life has often involved a tragic and untidy balancing of hope, trust, and truth. I will also highlight several important, yet often underappreciated changes. Medical developments in the early 20th century led to an entirely new, highly intervened-in stage of disease without necessarily impacting the mortality from breast cancer. I will also emphasize the self-perpetuating, cascade-like quality to the way breast cancer became a mass disease and prevention and treatment came to be understood as effective.
These continuities and changes have brought us to our problematic era of breast cancer risk. Today, one in eight American women will get the diagnosis in their lifetime. Many women are waiting for the axe to fall. Yet this high incidence and heightened sense of risk is not a simple reflection of the disease's increased biological impact. Instead, we have had repeated, self-reinforcing cycles of public health intervention, mass behavior change, new patterns of disease diagnosis, transformed perception of the efficacy of interventions, leading to more behavior change, and so on. At the same time, we have "lent" many aspects of the older breast cancer experience and decision making to breast cancer risk, resulting in paralyzing fear, overselling of the efficacy of prevention, iatrogenic harm, market exploitation of fears, and other clinical and policy miscalculations.

Publications from the Fellows' Library

Aronowitz, Robert A. (Cambridge [u.a.], 2007)

Unnatural history : breast cancer and American society

Aronowitz, Robert A. (Cambridge [u.a.], 1998)

Making sense of illness : science, society, and disease Cambridge history of medicine