By Dr Ananya Mandal, MD
Breast cancer has been known to mankind since ancient times. It has been mentioned in almost every period of recorded history. Because of the visible symptoms especially at later stages the lumps that progress to tumors have been recorded by physicians from early times. This is more so because, unlike other internal cancers, breast lumps tend to manifest themselves as visible tumors.
Earlier, however, it was a matter of taboo and embarrassment that meant detection and diagnosis was rare. The mention of breast cancers in literature beyond medical journals and books was rare. Involvement of more women and actively bringing out the disease into the open is a recent phenomenon that is around three or four decades old. In the 1990’s the symbol of breast cancer - the pink ribbon – brought out a revolution against this cancer.
Ancient Greece and Egypt
Ancient Egyptians were the first to note the disease more than 3,500 years ago. The condition was described fairly accurately in both Edwin Smith and George Ebers papyri. One of the descriptions refers to bulging tumors of the breast that has no cure.
In 460 B.C., Hippocrates, the father of Western Medicine, described breast cancer as a humoral disease. He postulated that the body consisted of four humors - blood, phlegm, yellow bile, and black bile. He suggested that cancer was caused by the excess of black bile. In appearance of the breast cancer too black, hard tumors are seen that burst forth if left untreated to yield a black fluid. He named the cancer karkinos, a Greek word for “crab,” because the tumors seemed to have tentacles, like the legs of a crab.
Thereafter in A.D. 200, Galen described the cancer as well. He also suggested excessive black bile but, unlike Hippocrates, he postulated that some tumors were more dangerous than others. He suggested medications like opium, castor oil, licorice, sulphur, salves etc. for medicinal therapy of the breast cancers. During this time of history breast cancer was a disease that affected the whole body and thus surgery was not considered.
Breast cancer in the 17th and 18th Century
Until the 17th century Galen’s theories on breast cancer were believed. In 1680, French physician Francois de la Boe Sylvius began to challenge the humoral theory of cancer. He hypothesized that cancer did not come from an excess of black bile. He suggested it came from a chemical process that transformed lymphatic fluids from acidic to acrid. In 1730s, Paris physician Claude-Deshais Gendron also rejected the systemic theory of Galen and said that cancer developed when nerve and glandular tissue mixed with lymph vessels.
In 1713 Bernardino Ramazzini's developed a hypothesis that high frequency of breast cancer in nuns was due to lack of sex. Ramazzini said that without regular sexual activity, reproductive organs, including the breast may decay and develop cancers. Yet another researcher Friedrich Hoffman of Prussia postulated that women who had regular sex but still developed cancer were practicing “vigorous” sex. This could be leading to lymphatic blockage.
Other theories included Giovanni Morgagni blaming curdled milk, Johanes de Gorter blaming pus-filled inflammations in the breast, Claude-Nicolas Le Cat from Rouen blaming depressive mental disorders, Lorenz Heister blaming childlessness, and yet others blaming sedentary lifestyle.
It was in 1757 when Henri Le Dran, a leading French physician suggested that surgical removal of the tumor could help treat breast cancer, as long as infected lymph nodes of the armpits were removed. Claude-Nicolas Le Cat argued that surgical therapy was the only method to treat this cancer. This lasted well into the twentieth century and led to the creation of the radical mastectomy or extensive removal of the breast.
The 19th and 20th Century
By mid-nineteenth century, surgery was the available option for breast cancer. The development of antiseptic, anesthesia and blood transfusion during this time also made survival after a surgery more possible.
William Halstead of New York made radical breast surgery the gold standard for the next 100 years. He developed radical mastectomy that removed breast, axillary nodes (nodes in the armpits), and both chest muscles in a single en bloc procedure or in a single piece to prevent spread of the cancer while removing each of these individually.
Radical mastectomy was the mainstay of treatment for the initial four decades of the twentieth century. Although radical mastectomy helped women survive longer, especially if performed early, many women did not choose it since it left them disfigured. In addition there were problems like a deformed chest wall, lymphedema or swelling in the arm due to lymph node removal and pain.
In 1895, Scottish surgeon George Beatson discovered that removing the ovaries from one of his patients shrank her breast tumor. As this caught on, many surgeons began removing both ovaries and performing a radical mastectomy for breast cancers. This reduction of the tumor after removal of the ovaries was due to the fact that estrogen from ovaries helped in growth of the tumor and their removal helped reduce the size of the tumor.
What came next was that in these women without ovaries, estrogen was produced by the adrenal glands. In 1952 Charles Huggins began removing a woman’s adrenal gland (adrenalectomy) in an effort to starve the tumor of estrogen. Rolf Lefft and Herbert Olivecrona began removing the pituitary gland – another site of estrogen production stimulation.
Development of the systemic theory
In 1955, George Crile suggested that cancer was not localized but rather is spread throughout the body. Bernard Fisher also suggested the capability of cancer to metastasize. In 1976, Fisher published results using simpler breast-conserving surgery followed by radiation or chemotherapy. He noted that these were just as effective as radical mastectomy.
With advent of modern medicine, by 1995, less than 10 percent of breast cancer-inflicted women had a mastectomy. This time also saw the development of novel therapies for breast cancer including hormone treatments, surgeries and biological therapies. Mammography was also developed for early detection of the cancers. Scientists then isolated the genes that cause breast cancer: BRCA 1, BRCA2 and ATM
Reviewed by April Cashin-Garbutt, BA Hons (Cantab)