Breast cancer is a disease that inspires controversy.  On one hand, at least some cases of breast cancer can be strongly linked to genetic causes, leading to calls for further genetic research.  On the other, recognition of the array of environmental carcinogens that may play a key role in the development of those cases of breast cancer that have no clear genetic aspect (the vast majority of cases) have fueled calls for a broader research agenda that focuses on those cases of breast cancer that we might be able to prevent.  And while a number of campaigns — both grass roots and corporate — aim to raise both awareness and research funding, other groups point out that some corporate campaigns are sponsored by companies whose products or manufacturing processes increase exposure to carcinogens, or whose actual contribution to cancer research is minimal in comparison with the profits that they make by associating themselves with "pink ribbon" campaigns.  And in the academic literature, there is a history of debate over how best to treat cancer, to prevent recurrence, and to understand the ways in which medical and scientific approaches to breast cancer influence — and are influenced by — broader cultural and political forces.  The contributions to The Voice of Breast Cancer in Medicine and Bioethics do not aim to resolve these controversies, but make a valuable contribution by mirroring and illuminating the complexity of this disease.  The editors of this volume, Mary C. Rawlinson and Shannon Lundeen, have assembled papers that come from diverse disciplinary and personal perspectives, and the result is a powerful book that is both academically rigorous and emotionally engaging.

The book is divided into four sections that largely reflect disciplinary approaches.  The first section contains papers by scholars in the humanities who all address, in one way or another, the influence of language on our reactions to breast cancer, both at the level of science and medicine and at a personal level.  The second section takes up the theme of the personal level, presenting four personal accounts of life with breast cancer.  The third section looks at what research in the sciences and social sciences can contribute to the treatment of breast cancer, but, in keeping with the approach of the book as a whole, views such research as involving a broader and more diverse set of participants than the medical research community.  The final section describes how writings on breast cancer can be used in classes to explore issues in women's studies, health studies and bioethics.

The issues raised in the first section regarding the various "discourses of breast cancer" set the tone for the volume as a whole.  Susan Sherwin's paper addresses the way in which the political forces that shape our views of breast cancer affect individual women making decisions about their own illness and calls for the development of alternative frameworks for understanding breast cancer, which would enhance women's autonomy in dealing with their health.  In particular, the metaphor of a "war on cancer" has been particularly destructive in that it encourages both "heroic" (usually drastic and invasive) responses on the part of the (largely male) medical and scientific communities and passive, "patient" responses by women.  The influence of the metaphor of war is also clear in Barron Lerner's contribution, which traces the rise of breast cancer activism in the 1970s.  Lerner shows both how far we have come in the past few decades, since the time when a standard and acceptable way of dealing with the detection of a lump in a woman's breast was a "one step" procedure in which a surgeon finding breast cancer during a biopsy would immediately decide whether or not to proceed with surgery while his patient was still under anesthetic, and how much progress remains to be made in ensuring that the range of choices and responses that women can make in response to breast cancer are respected.

Both Gwynne Gertz and Lisa Diedrich offer detailed studies of the language used to understand breast cancer.  Gertz uses Bakhtin's concept of authoritative discourse to analyse the reasons for the continuing influence throughout the 20^th century of Halstead's theories, and of the radical mastectomy which was the favored treatment for breast cancer, largely on the basis of these theories.  Diedrich examines how language can influence patients' responses to breast cancer by contrasting the illness narratives of Susan Sontag and Eve Kosofsky Sedgwick.

The second section of the book consists of four women's personal narratives of their own experience of breast cancer, which vary both in literary style and in the issues that the author chooses to discuss.  Anita Ho's diary excerpts chronicle her response to her initial diagnosis of breast cancer.  Her description of her fear and confusion, and feelings of being overwhelmed by her experience of the medical system are especially powerful.  If a patient who is not only intelligent and articulate, but also a teacher of bioethics and therefore familiar with the criticisms of the provider-patient relationship, can feel so powerless and alienated by the medical system, this is an indication of how much work is still needed to ensure that patients' voices are heard. The next two contributions in this section focus on the effects of breast cancer on family relationships and on the authors' experiences of their bodies during and post-treatment.  Debra Gold's essay describes her responses to her mother's breast cancer and reflects on how her own cancer will affect her daughter.  The series of poems by Leatha Kendrick describe her experiences over the course of her illness.  All three of these contributions show how simplistic are the dominant visions of women with breast cancer as brave and patient victims, or as feisty survivors.  The final paper in this section, by Gail Weiss, addresses the inherently relational nature of an individual's illness by using journalist Cathy Hainer's columns describing her experience of breast cancer to challenge Heidegger's claim that we cannot communicate the experience of facing death.

In the third section, the contributions cover various aspects of breast cancer research, but in the spirit of the book as a whole, they challenge the view that research is a purely scientific endeavor that takes place in isolation from broader social concerns.  John Kovach describes both recent and current research on breast cancer and calls for greater public discussion of appropriate areas of focus for future research.  Loretta Kopelman notes that part of the success of the activism of breast cancer patients in the 1970s was due to the fact that research could not occur without the consent of participants — and that this fact allowed women a say in how research ought to be conducted.  She argues that the issues raised in the context of breast cancer research show that it is rational to insist that research be a cooperative venture between researchers and research participants.  In the final paper of this section, Anne Moyer and Marci Lobel emphasize the importance of psychosocial research in informing the treatment of breast cancer.

The last section of the book shows how writings on breast cancer can be used in the classroom to clarify the complex relations between issues of race and gender, medical and epidemiological research, the media and social and historical trends.  The authors of the first two chapters, Helen Rodnite Lemay and Tanfer Emin-Tunc, both felt that they and their students benefited from the classes.  The final entry, by Sofya Maslyanskaya, is a response to the chapter by John Kovach, and urges greater participation on breast cancer research so that new and better treatments can be developed.

Despite the diversity in this volume, the overall message of the book is coherent.  As Rosemary Tong notes in her introduction, the tone is "one of self-reflectiveness, cooperation and serving women's best interests" (p. xix).  As a complex and contested condition, breast cancer has the potential to provoke the kind of interdisciplinary discussion that is required to achieve this reflective understanding.  This book is an example of the kind of discussion that is needed.

© 2007 Robyn Bluhm

Robyn Bluhm, Ph.D., Departments of Psychiatry and Philosophy, The University of Western Ontario

Categories: Ethics