Fighting the War on Breast Cancer: Debates over Early Detection, 1945 to the Present

The recent consensus meetings on screening mammography for women 40 to 49 years of age generated great controversy. Critics of the consensus statements, particularly the January 1997 decision by a National Institutes of Health (NIH) panel not to recommend routine screening, used language that was often vitriolic and accusatory [1-3].

In attempting to explain why these efforts at consensus generated such antagonism, various commentators have convincingly argued that these debates were not really about the scientific value of mammography. Indeed, it has been claimed that there is broad agreement on what the data show [4]. Instead, as Fletcher [5], Ernster [6], and others [7, 8] have asserted, public acrimony reflected the entrance of political, economic, legal, and interest group concerns into the screening process [9]. A related issue has received less attention: how the language of advocacy may itself polarize scientific discussion, leaving physicians and patients without adequate guideposts for applying early detection of breast cancer to clinical practice.

I argue that the rhetoric of a decades-old “war” against breast cancer framed the recent arguments about breast cancer screening. Although efforts to control other cancers and other diseases have also used military metaphors, breast cancer provides one of the most vivid examples of how metaphoric language enters scientific debate and, in turn, may influence such debate.

This paper will examine two historical controversies: 1) debates over whether early detection of cancers improved survival and 2) debates over biologically indeterminate “precancers” that early detection often revealed. By revisiting the role of military metaphors, history can help explain why these debates have been so divisive and why the value of early detection has, at times, been oversold. This analysis has direct implications for genetic testing, where the next “battle” is already being fought.