Women's Cancers (Paperback)

Chapter One

Victoria Harmer and Maureen Royston-Lee

Women and health

Throughout history, women have been considered the weaker sex. Health surveys repeatedly illustrate that females have higher rates of illness, disability days and health service utilization than do males (Verbrugge 1979). This is in spite of women giving priority to fulfilling their work responsibilities over their discomfort (Amin and Bentley 2002); indeed those with employment or who have an ill child are significantly less likely to cut down on their activity because of symptoms (Woods and Hulka 1979).

Women and mental illness

Women are commonly believed to be more susceptible to emotional breakdowns and mental illness, as they are deemed to be not as psychologically durable as men.

The notion of nymphomania developed during the second half of the seventeenth century. A third of all patients in Victorian asylums apparently suffered from this condition. Described as an irresistible desire for sexual intercourse and a female pathology of over-stimulated genitals, it was associated with a loss of sanity. It was believed that without treatment these women would become raving maniacs, robbed of their minds. Cures for nymphomania included separation from men, induced vomiting, cold douches over the head, bloodletting, warm douches over the breasts, solitary confinement, leeches, straight-jackets, bland diets and occasionally clitorectomies.

Spinsters and lesbians were also considered a threat to society during the nineteenth century. Any women, who went outside the social norm and made their own decisions, were thought to be mentally ill, as doctors claimed being without male interaction over the long term would result in irritability, anaemia, tiredness and fussing. Again women were admitted to the asylum or forced into marriage, as it was assumed their condition could be cured by repeated sexual interaction with men.

During the mid-nineteenth century came the idea of the 'wandering womb'. Madness was associated with menstruation, pregnancy and the menopause, and the womb was thought to wander throughout the body acting like an enormous sponge, sucking life from vulnerable women (Ussher 1991). Thus women became more synonymous with madness and generally thought to be emotional and unstable.

In developed countries such as Britain, women are more likely than men to be admitted to hospital for psychiatric treatment, and both first-time and total admissions to psychiatric hospitals are dominated by women (Miles 1988; DH 1995; Payne 1995). Women are also more likely to be treated by general practitioners and community psychiatric teams for mental health problems. Whilst women and men are equally represented amongst admissions for schizophrenia, women are twice as likely to be admitted due to depression and anxiety (Payne 1995; DH 1995). Older women and women from minority ethnic groups are the most likely to be given a psychiatric diagnosis and to receive treatment for that condition (Doyal 1998).

Eating disorders

Anorexia is an eating disorder and a mental health condition that usually develops over time, most commonly starting in the mid-teens. In teenagers and young adults, the condition affects about 1 in 250 females and 1 in 2000 males (DH 2008a).

Anorexia was officially recognised as a disease in 1873 (Wiederman 1996), and flourished throughout the nineteenth century as women wanted to accentuate their femininity. The physical and spiritual ideal of anorexia became a status symbol for women, showing them to be middle to upper class, as working-class women could not afford to become anorexic as they needed to eat in order to work. Once more, treatment was by admission to an asylum, where the women could rest and be excessively fed.

Breast cancer in ancient Egypt and Greece

Breast cancer was first 'discovered' by the ancient Egyptians over 3500 years ago. In 460 bc, Hippocrates, the father of Western medicine, described breast cancer as a disease of one of the 'humours' in the body. There were four 'humours', blood, phlegm, yellow bile and black bile. Hippocrates suggested that cancer was a result of an excess of black bile or 'melanchole'. The breast, if left untreated, would become black and hard and would eventually break open and black fluid would ooze from it.

In 200 AD, Hippocrates' successor, Galen, also described cancer in terms of 'excessive black bile', but he felt that some tumours were more serious than others. The treatment available for breast cancer at the time of Galen included opium, castor oil, liquorice and sulphur. Surgery was not an option as it was felt that the cancer would reappear at the site of the surgery or elsewhere in the body (Garrison 1966).

For the next 2000 years, physicians considered breast cancer as a systemic disease, as the dark bile was thought to travel around the entire body, causing tumours in other organs.

It was not until 1680 that a French physician, Francois de la Boe Sylvius, began to challenge the notion of breast cancer as a 'humoural' disease. He felt that cancer was caused by a chemical process that resulted in lymphatic fluids becoming acrid instead of acidic (Olson 2002).

An interesting hypothesis was put forward by Bernardino Ramazzini in 1713, who noted the higher than normal occurrence of breast cancer in nuns, and concluded that the origin of breast cancer was sexual. The absence of sexual activity in nuns was thought to affect the reproductive organs, including the breast, which started to decay resulting in cancer (Olson 2002)!

There were of course other theories that did not involve sex, including depression, which constricted the blood vessels and trapped coagulated blood, again resulting in breast cancer. Another theory postulated that the cause lay in a sedentary life, causing bodily fluids to become sluggish.

The eighteenth century onwards: breast cancer and surgery

There was no shortage of theories but there was a major shift in opinion amongst eighteenth-century physicians who began to see breast cancer as a more localised disease. The implications of this were enormous, as it meant that surgery now had a significant part to play in the treatment. In 1757, Henri Le Dran, argued that surgery could actually cure breast cancer, provided that it also included the removal of the infected axillary lymph nodes.

By the mid-nineteenth century, breast cancer was accepted as a localised disease and surgery was the treatment of choice. This view was enhanced by the vast improvements in anaesthesia, antiseptic procedures, blood transfusion and the public trust in medicine. William Halstead, an American surgeon, emerged as the leader in the field of breast surgery, when he pioneered the Halstead Mastectomy that became the 'gold standard' for the next 100 years (Olson 2002). This was a radical mastectomy that involved removal of the breast, axillary nodes and both chest muscles in a single block procedure. Halstead performed hundreds of radical mastectomies but the procedure was not without severe side effects. Women had to cope with a poor cosmetic result, including a deformed chest wall and hollow areas under the collar bone, chronic pain and lymphoedema due to the removal of the lymph glands. Halstead felt that this was a small price to pay, as the women's average age was 'nearly fifty-five years and they are no longer active members of society' (Olson 2002).

Twentieth-century breast surgery

A major advancement in the treatment of breast cancer was made by the Scottish surgeon, George Beatson, in 1895. He discovered that when he removed the ovaries from his patients, their breast cancers shrunk significantly. This resulted in many surgeons carrying out oophorectomy routinely, which resulted in debilitating side effects, as they were unaware that not all breast tumours had oestrogen receptors.

Fast forward to 1976, when Bernard Fisher published results indicating that breast conserving surgery, followed by radiotherapy or chemotherapy, were just as effective as radical mastectomy, and often even more so (Hellman 1993).

Gynaecological cancers

In the nineteenth century, cancer was seen predominately as a 'woman's disease'. This notion was based on the prevalence of cancer in the breast and uterus and the incidence of cancer being three times higher in women than in men (Walshe 1846).

Walshe felt that women were at greater risk of getting cancer because of their biological role in reproduction and the menopause. His contemporaries believed that problems of nutrition due to repeated pregnancies made women more prone to cancer.

By the mid-nineteenth-century, physicians began to take the view that cancer was more a systemic disease, with a hereditary component making it incurable. The hereditary issue is interesting, as it carried with it a stigma and evoked undesirable qualities that meant people's lives were adversely affected socially, economically and emotionally. There was also the notion that predisposing causes could also be acquired as well as inherited. These included temperament and immoral habits! Cervical cancer was associated with excessive sexual activity and breast cancer was associated with trauma.

The treatment of women's cancers in the first half of the nineteenth century was somewhat harsh. There was a brief period when gynaecological cancers were treated surgically by amputation of the cervix but thankfully that 'fashion', which carried a high mortality rate, was short-lived. In the second half of the nineteenth century, there was a new understanding that these cancers were more of a local disease and surgical techniques improved accordingly.

In 1896, leading obstetrician, William Japp Sinclair (1896), believed that there was a strong connection between poor social conditions and the development of cancer (Sinclair 1902). Cervical cancer was usually associated with lack of personal hygiene, venereal disease and the recurrent lacerations and infections caused by multiparity and poor obstetric care.

In the late 1880s, there was a belief that the origins of cancer existed outside the body. Germs and parasites were detected in cancer cells and this led to controversy at the time. In 1902, a general practitioner remarked that 'the loose and open arrangement of the nether garments of the majority of women would naturally favour access to the generative organs of the infective micro-organism' (Brand 1902). It would appear that the medical profession had 'it in for' women, and the vast majority of medical doctors at the time would have been men.

Nineteenth century onwards

By the end of the nineteenth century, a new risk factor liable to cause gynaecological cancer emerged, that of unclean male genitalia (Mort 1987). The social purity movement, comprising feminists, medics and nonconformist Protestants, were involved in reshaping the nation's morals and took a view that male sexuality was a source of 'moral pollution'. There was a drive to denounce the 'double standards' of sexuality that existed between men and women. Within this context, a major public health hazard was identified, that of men's foreskins, where germs were harboured and led to cervical cancer. Doctors made a connection between the low incidence of cervical cancer, as well as syphilis and gonorrhoea, amongst the Jews (Darby 2003).

The end of the nineteenth century saw surgery as the treatment of choice for gynaecological cancers, and some of the major developments in surgical procedures occurred in gynaecology. At this time in Britain, maternal health and infant mortality emerged as major public concerns, as there were huge gaps between the rich and poor in terms of morbidity. There was a drive to improve the health of the nation to provide a strong workforce and armed forces. It was against this background that cancer of the cervix began to emerge as a major focus and public health concern.

Cervical screening

The initiative to educate women in the early recognition of cervical cancer was first discussed at a meeting of the British Medical Association in 1907. The big question for doctors was how to get the message across to the uneducated masses. It was deemed inappropriate to place advertisements in newspapers, because of the taboo nature of the subject. References to the 'morbid and lurid aspects' of cervical cancer, such as abnormal bleeding and vaginal discharges, were deemed 'too shocking for the sensibilities of the public' (Childe 1914).

Midwives and health visitors became involved with instructing women on the early signs of the disease and they were instrumental in emphasising the importance of seeking medical advice from professionals rather than 'healers'. Upper middle-class ladies were taken on board to instruct the 'unreading and unthinking' members of the public (Childe 1923).

The BMA created an advice leaflet about early detection of cervical cancer for midwives and general practitioners, to give out to women following childbirth. The message was very clear: early detection saves lives.

Screening as a tool for cancer

Survival from cancer depends on the type and the stage at which it is treated; prognosis is invariably better for those treated at an early stage. Evidence illustrates that many cancers are potentially avoidable, and could be prevented or diagnosed earlier using knowledge that is already available. The purpose of screening is for early detection of cancer and to interrupt its natural course, preventing it from progressing and causing death (Austoker 1995).

Breast cancer is the most common cancer for women in the UK and one where there is much information. The Forrest Report (Forrest 1986) showed favourable evidence against the criteria required to establish a screening programme. Thus in 1988 the National Health Service Breast Screening Programme was set up in the UK, aiming to reduce mortality from breast cancer by 25% in the population screened. Certainly, in all randomised trials of women aged 50 and over, mortality from breast cancer is reduced in those offered screening compared with unscreened controls.

Health services were already providing regular smear tests in the mid-1960s, although women at greatest risk were not necessarily being tested and follow-up procedures for those with a positive test were inefficient (DH 2008b). However, in 1988, the Department of Health established a computerised call and recall system and their first external quality assessment schemes for laboratories.

These programmes are quality assured and regularly reviewed to monitor standards, and to ensure that more sophisticated screening practices are introduced as technology and knowledge develop.

A more recent development in cancer screening is the NHS Bowel Cancer Screening Programme; launched in 2006, it is the first screening programme to target both men and women (DH 2008b).

Breast screening attendance – are their differences based on ethnicity?

Using the methodology of focus groups, Scanlon (2004) identified that Asian and Arab women share common themes with white British socially disadvantaged women, for example poor general knowledge about breast cancer. However, the Asian and Arab women's ideas were based on historical and cultural practices and beliefs. A lack of breast awareness information in different languages and formats was therefore required.

Another study (Scanlon and Wood 2005) highlighted that Black and Minority Ethnic (BME) women had less knowledge about breast cancer, its symptoms and risk factors, when compared to the general population. BME women were less likely to be breast aware and 43% stated they did not know what to look for. This group of women also reported a lower uptake of breast screening. Therefore, it appears that they are at a higher risk of letting symptoms go unnoticed. Ironically black women are three times more likely to have triple negative tumours (tumours negative for HER2, oestrogen or progesterone receptors); a characteristic associated with a poorer prognosis (Stead et al. 2009). Thus the group most likely to experience aggressive tumours are the ones less likely to have these tumours identified early.

Breast screening attendance – other variables

Partner gender is not associated with any barriers to screening and women who partner with women, women who partner with only men, and women who partner with women and men have comparable attendance records (Clark et al. 2009). As expected, academic women have a strong relationship between breast screening and a health promoting lifestyle (Oran et al. 2008).

Health promotion/education/screening

Health promotion strategies are not focused on a specific health problem, more on enabling a person to increase the control over and to improve their health. Health promotion activities demand participation and it is only through achieving this, that they can be successful.

(Continues...)

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Excerpted from Women's Cancers Copyright © 2011 by Blackwell Publishing Ltd.. Excerpted by permission of John Wiley & Sons. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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