A History of Lung Cancer

The Recalcitrant Disease

C. Timmermann

• Publisher: Palgrave Macmillan
• Year: 2013
• Print ISBN: 9781403988027
• eBook ISBN: 9781137384232
• Topic: Histoire
• Subtopic: Histoire de l'Europe

The first comprehensive history of lung cancer from around 1800 to the present day; a story of doctors and patients, hopes and fears, expectations and frustrations. Where most histories of medicine focus on progress, Timmermann asks what happens when medical progress does not seem to make much difference.

1

Introduction: The History of a Recalcitrant Disease

Mary Benbow was 50 years old when she was admitted to Guy’s Hospital in London on 19 August 1841, under the care of Dr Richard Bright, one of the city’s leading consultants, and his assistant physician Dr Henry Marshall Hughes, who was known both for his eccentric dress sense and his interest in chest conditions.¹ Hughes recorded Mrs Benbow’s case for the Guy’s Hospital Reports, and what we know about the final months of her life, we know from his report.²

Mrs Benbow had been a remarkably healthy person until about two years before her admission to Guy’s, when what she thought was a nasty cold confined her to her bed for two months. She was a hard-working and temperate woman; as the wife of a soldier, she had followed the army until she found employment as a washerwoman. Following her cold, she had occasionally coughed up blood. Eventually she turned to the Kingston surgeon Mr Edward Kingsford, who bled her on two occasions and also used other traditional remedies, such as acids, acetate of lead, digitalis, and saline purgatives. But her condition failed to improve and nine months later Kingsford referred her to Guy’s Hospital, where he had trained and continued to have contacts. When admitted to the hospital, she looked rather pale but was not in pain, nor was she particularly emaciated. She complained about cough and shortness of breath, and Hughes examined her carefully. He found that the glands in her right armpit and under the collar bone were swollen and noted that the veins directly under the skin on the right side of her abdomen and the lower part of the chest were protruding. The ribs on her right side scarcely moved when she was breathing. When Hughes used his fingers to drum on her chest (a diagnostic procedure known as percussion), there was hardly any sound on the right side. A healthy, air-filled lung would have sounded different. Neither could he hear the typical respiratory murmur through the stethoscope; instead, he noted a ‘little coarse mucous rattle’.³

Mrs Benbow’s symptoms became gradually worse. It became increasingly difficult for her to breathe, and her legs were more and more swollen. About two months after her admission she died, according to Hughes, ‘without any particular suffering, or very great emaciation, … exhausted’.⁴ There was not much the doctors at Guy’s had felt they could do for Mary Benbow; the illness had taken its natural cause, with only palliative treatments (Hughes used this term). As Guy’s was a teaching hospital with its own medical school with physicians interested in research, her body was subjected to a post-mortem examination in order to find out what disease had caused her symptoms. They found that the entire upper part of her right lung had become, in Hughes’ words, ‘a mass of medullary fungus’. There was no fungus in the usual sense, but the mass looked fungal; and when it was pressed, a creamy fluid and a soft, somewhat brain-like matter exuded, which was why Hughes chose the attribute ‘medullary’, following the influential French physician R. T. H. Laennec (more about this in Chapter 2). The middle and lower lobes also contained masses of this ‘malignant growth’, which Hughes, again, described as ‘fungoid matter’. He informed Mrs Benbow’s doctor that she had been suffering ‘from some malignant affection of the lung’.⁵ Had she not been referred to Guy’s and exposed to the new diagnostic techniques employed by doctors there, and had her body not been subjected to a post-mortem examination, it is likely that Mary Benbow’s illness would have been viewed as a sad but fairly common case of ‘consumption’, a set of symptoms also called ‘phthisis’ and then increasingly identified as tuberculosis. As she became one of Bright’s and Hughes’s patients, however, hers is one of the few cases of lung cancer that made it into the medical literature before 1900. Meanwhile, from the 1850s, cancer (in general) had turned from a disease of abnormal tissues into a disease of abnormal cells.

In the early twentieth century, a growing number of cases of lung cancer were detected, leading to debates as to whether this disease was in fact becoming more common, or whether the increase in incidence was an artefact of better means of diagnosis. A steep increase in diagnosed lung tumours in the 1940s convinced most observers that this was no artefact, and the international debate turned to possible causes, homing in on tobacco consumption and air pollution. By the late 1950s most experts agreed that cigarettes were to blame: they had been mass-produced since the 1880s – and clearly not the cause of Mary Benbow’s cancer. As epidemiologists were busy pinning down the main cause of lung cancer, the practitioners treating lung cancer patients were no longer as helpless as those treating Mary Benbow. From the 1940s, surgery was turning into a standard treatment, at least in better equipped hospitals, especially those with chest units. Finally there was something that could be done. One of the patients being subjected to lung cancer surgery was King George VI in 1951 (more on this in Chapter 5). But few lives were significantly prolonged by the intervention – even the king died four months after his operation. Other treatment modalities – namely radiotherapy developed between the wars, and the later methods of cancer chemotherapy – failed to make much of a difference.

By the 1990s, surgery was still the standard treatment, with other modalities employed to palliate, or when the tumour had recurred and it was felt that ‘something had to be done’. This was the pattern, even if none of the medical interventions was likely to prolong a patient’s life, let alone improve its quality during the final months or weeks. Consider Frank Craig, for example, the husband of the British religious broadcaster and author Mary Craig, who was diagnosed with a lung tumour in 1991.⁶ The Craigs had suspected that something was seriously wrong with him when he coughed up blood a few months earlier. A chest X-ray revealed a shadow on the lung and he underwent a procedure known as a bronchoscopy: a flexible tube was inserted which allowed doctors to see into his bronchus and which could also be used to remove a tissue sample. The examination of this sample under the microscope revealed cancerous cells. This procedure, known as a biopsy, also showed that Craig’s tumour was not of the ‘small cell’ type, a particularly malignant type that metastasized rapidly and was generally not treated by surgery. Frank Craig was fit enough for an operation, and soon after the diagnosis a surgeon removed a section of his lung. About a quarter of the lung cancer patients who undergo surgery survive this operation for five years, and about 15 percent for a further five years or longer. (At specialist chest units with experienced surgeons, this rate has changed very little since the 1950s). Unfortunately Frank Craig was one of the majority of patients whose cancers return within five years. In 1993 there were suspicious symptoms and in 1994 he was diagnosed with secondary growths. This is where the standard pathway ended. Other treatment modalities were applied: radiotherapy and some chemotherapy, and boundaries blurred between curative and palliative intentions. But Frank Craig’s illness progressed and he became increasingly dependent, both on his wife and a growing number of helpers; he found it harder and harder to leave his bed. Frank Craig died two days after the fourth anniversary of the lung cancer operation, which, according to his wife, ‘had at the time seemed so successful’.⁷ Unlike Mary Benbow a century and a half before, he was killed not by the primary tumour but by secondary growths. As in Mary Benbow’s case, this happened following a period of bodily disintegration.

Impotence and interventionism

This book is a history of lung cancer. While my case studies and examples are mostly from the UK, and to a lesser extent from the US, this is also a book about one of the great dilemmas of modern medicine: how do we deal with medicine’s greatly improved powers to explain illness and to identify causes in circumstances where these improvements do not save patients’ lives? The chances of a patient diagnosed with lung cancer in Britain in the early twenty-first century to survive the following five years are not a great deal better than they were 30 years ago. In fact, the standard treatment for non-small cell lung cancers has not changed greatly over the past half century. It is true, some types of cancer which used to be seen as hopeless a few decades ago – namely childhood cancers, lymphomas and leukaemias – have been viewed as curable since the 1970s, thanks to new and experimental regimes of chemotherapy.⁸ Treatment outcomes for other types of malignant disease, such as breast or colon cancers, also appear to have improved significantly over recent years.⁹ However, many other malignant diseases are much more like lung cancer, with only marginal gains in survival, seemingly defying the common assumption that money spent on cancer research is investment in survival time. The increase in life expectancy for an average American due to reduced cancer mortality between 1970 and 2000 was less than three months, in spite of the research efforts (and colossal expenses) associated with the ‘War on Cancer’.¹⁰ Translations from fundamental research into tangible improvements that changed treatment outcomes for the cancers with the highest incidence and death rates, have been rare. Recalcitrance has been the rule and not the exception.

Impotence in the face of illness has been a common experience throughout the history of medicine, especially when cancer was concerned. It was so before medicine became modern, and has remained so over the last 200 years. But even when there was good evidence that nothing very effective could be done, this rarely meant that nothing was done. Anne Davies, for example, a London widow and contemporary of Mary Benbow was bled and treated with leeches and belladonna plasters at University College Hospital until she ‘sunk gradually’ and died, with sounds emitted from inside her chest ‘as if the whole lung were breaking up’.¹¹ Today, cancer treatment pathways still involve an arsenal of treatment modalities. This applies especially at the stages where, as in Frank Craig’s case, routine treatments fail to deliver the desired responses – then highly experimental therapies may be tried, often with drastic side effects but limited benefits.¹²

As this book will show, the main routine treatment, surgery, has long been neither revolutionary nor new. It saves the lives of only a minority of lung cancer patients. Many patients are not suitable for an operation, because they are judged too ill to survive it, because their tumour sits in the wrong place or has already spread, or as in Frank Craig’s case, because the cancer returns following the operation. Since the 1980s medical oncologists have promoted chemotherapy as an answer to the question of what doctors could offer to those who are unsuitable for surgery, or where tumours grow back. Desperate patients wanted something done, they argued, and were ‘usually much more willing to undergo intensive treatments associated with substantial toxicity for what health professionals may see as minimal or no benefits in terms of the chance of a cure, prolongation of life or symptom relief’.¹³ This book explores how doctors, patients, and others involved in frequently futile efforts to revolutionize the treatment of a recalcitrant disease, have dealt with this dilemma.

Lung cancer and recalcitrance

Lung cancer, the most common and, with 1.37 million deaths per year, the most deadly cancer worldwide, may be the most visible, but it is certainly not the only recalcitrant disease defying the ideology of progress and action that is so important for the image of modern biomedicine.¹⁴ Survival rates of patients diagnosed with pancreatic cancer, for example, are terrible: three out of four die within a year of diagnosis. For liver cancer, not only are survival figures poor, there has also been a steady increase in incidence over the past three decades, associated by many with problematic drinking habits, although hepatitis infections are an equally likely cause.¹⁵ With its particular history, however, lung cancer provides me with an especially suitable case study to illustrate how medicine over the past two centuries has come to deal with the phenomenon of recalcitrance. Let me explain why.

Lung cancer was largely invisible and considered rare until the mid twentieth century. How rare it really was is difficult to assess, as I discuss in Chapter 2. Because it could only be diagnosed reliably at autopsy and because phthisis, consumption, or tuberculosis were so dominant in the imaginations of both the wider public and those who noted the cause of death on the death certificates, a significant number of the deaths blamed on consumption may well have been deaths from lung cancer. In the first half of the twentieth century, with radical surgery increasingly established as a standard treatment for breast cancer and with surgery inside the chest being developed for the treatment of tuberculosis and other conditions of the lung, as I show in Chapter 3, the surgical treatment of lung cancer became a real possibility. By the 1940s, the available know-how and equipment in chest surgery and anaesthesia allowed surgeons to turn pneumonectomies and lobectomies (the removal of a whole or parts of a lung) into routine operations. This development coincided with epidemiological findings – followed by much public debate, which is the subject of Chapter 4 – demonstrating that, indeed, lung cancer incidence was increasing. That cigarette consumption was the cause of the increase was consensus by the early 1960s among experts outside what the British journalist Peter Taylor has termed the ‘smoke ring’ created and maintained by the tobacco industry.¹⁶ A central question addressed in this book is what this discovery did to the treatment of lung cancer, a disease now increasingly firmly associated with a habit that had come to carry moral connotations – not quite as stigmatizing as sexual transmission, bu...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Figures and Table
• Acknowledgements
• List of Abbreviations
• 1 Introduction: The History of a Recalcitrant Disease
• 2 Lung Cancer and Consumption in the Nineteenth Century: Bodies, Tissues, Cells and the Making of a Rare Disease
• 3 Lungs in the Operating Theatre, circa 1900 to 1950
• 4 Science, Medicine and Politics: Lung Cancer and Smoking, circa 1945 to 1965
• 5 Trials and Tribulations: Lung Cancer Treatment, circa 1950 to 1970
• 6 More Enthusiasm, Please: Preventing, Screening, Treating, Classifying, circa 1960 to 1990
• 7 The Management of Stigma: Lung Cancer and Charity, circa 1990 to 2000
• 8 Still Recalcitrant? Some Conclusions
• Notes
• Bibliography
• Index