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Does Bigger Mean Better? British Perspectives on American Cancer Treatment and Research, 1948

Elizabeth Toon

From the Centre for the History of Medicine and Disease, Durham University, Queen's Campus, Thornaby, Stockton-on-Tees, United Kingdom

Address reprint requests to Elizabeth Toon, Wolfson Research Institute, University of Durham, Queen's Campus, University Blvd, Thornaby, Stockton-on-Tees, TS17 6BH, United Kingdom; e-mail: elizabeth.toon{at}durham.ac.uk

ABSTRACT

In the summer of 1948, a delegation representing the British Empire Cancer Campaign (BECC) toured North American cancer treatment and research facilities, and reported their observations back to their organization's executive board. This historical article contextualizes the British delegation's observations of US treatment and research, and discusses what the delegation made of the United States' new, "bigger" approaches to cancer surgery and chemotherapeutic research. I argue that the BECC delegation used their observations of US practice to reinforce a positive sense of British distinctiveness, thus reassuring themselves and their colleagues that Britain could still be a leader in the increasingly international field we now call oncology.

INTRODUCTION

In the summer of 1948, six representatives of the British Empire Cancer Campaign (BECC), one of the United Kingdom's largest cancer control organizations, departed for a lengthy visit to North America.¹ They attended meetings of the American Medical Association and other professional societies, and like transatlantic visitors before and since, they even managed to fit in a little shopping—albeit for the latest radiotherapy and laboratory apparatus rather than the usual tourist souvenirs. However, a major purpose of their trip, revealed in a report stamped "confidential" and addressed to the board of the BECC, was a reconnaissance mission of sorts. For much of that July, the delegation toured medical facilities in the United States and Canada, observing the state of cancer treatment, research, and organization from Boston and New York to Vancouver and Los Angeles. Their timing was excellent: they came at what we now know was a pivotal moment in the history of North American cancer control. In elite US postwar facilities, new supportive care technologies had allowed North American surgeons to refine, expand, and reevaluate operations for cancer patients, whereas scientists sought and clinicians experimented with new hormonal preparations and chemotherapeutic compounds for previously unmanageable cancers.^2-5 Supporting this work was the reorganized American Cancer Society, with its advertising-oriented campaign raising enormous sums for research, complemented by the US federal government's own substantial investment in both bench and clinical investigation.⁶ The British delegation's report thus provides a unique contemporaneous portrait of the new approaches to treatment and research that would undergird the next half-century's worth of North American anticancer activity.

However, as this article will show, the BECC delegation's report also reveals much about British cancer treatment and research at the time. When these experts delivered their opinions on approaches to cancer in North America (and particularly in the United States), they did so by comparing them to the situation back home. There, a generation of elite clinicians worked to expand and coordinate surgical and radiotherapeutic services at centers such as Manchester's Christie Hospital, while the government launched its reorganization of the nation's medical provision under the new National Health Service. Bench researchers, meanwhile, devoted particular attention to such subjects as hormone biochemistry and radiobiology, drawing support from an assortment of charities large and small and from government bodies such as the Medical Research Council.⁷ But in a Britain exhausted and nearly bankrupted by war, the scientific and clinical elite fretted about the profile and direction of their cancer control efforts, especially given the increasing domination of the postwar biomedical world by the United States. The United States' approach to cancer, the BECC's delegation would conclude, was certainly "bigger" than their own. Treatment appeared to be more aggressive, and research was definitely organized and supported on a much larger scale. However, these observations left the delegation with a difficult question: was bigger cancer treatment and research necessarily better? In addition, if the bigger United States' approach was better, what did that suggest about the future of British treatment and research? In this article, I suggest that the BECC delegation used their observations of US practice to reinforce a positive sense of British distinctiveness, thus reassuring themselves and their colleagues that Britain could still be a leader in the increasingly international field we now call oncology.

BIG OPERATIONS AND BIG MACHINES: SURGERY AND RADIOTHERAPY

The delegation that set out for North America represented not only the BECC, but the mixture of interests and backgrounds that constituted Britain's cancer elite. Clinicians Sir Stanford Cade and Professor (later Sir) Brian Windeyer sailed early, as they had other business in the United States: Cade was to receive the American Radium Society's Janeway Medal, and both men were to speak at the AMA's annual meeting. Cade, Russian by birth, was a surgeon at London's Westminster Hospital whose skill in using radium to treat cancer was as well known and respected as his formidable surgical abilities.^8,9 Windeyer, an Australian radiotherapist trained in Paris, headed the prestigious Meyerstein Institute of Radiotherapy at the Middlesex Hospital (London, United Kingdom).¹⁰ The two men who headed the BECC joined them: Lord Thomas Jeeves Horder, a renowned clinician (and physician to royalty) who had helped found the Campaign in the 1920s, and F.B. Tours, the Campaign's executive.^11,12 Finally, Professor Francis Dickens, a biochemist interested in hormones and in tumor metabolism, and Dr. P.R. Peacock, the Director of Cancer Research at Glasgow's Beatson Institute, provided the bench scientist's perspective for the delegation. Singly and in pairs, these men criss-crossed the continent, occasionally gathering as a full group at particularly important destinations.

The delegation found much to see that impressed them. All praised the skill of such careful surgeons as the Presbyterian Hospital's C.D. Haagensen (New York, NY) and the Mayo Clinic's Oscar T. Clagett (Rochester, MN). Although many North American surgeons favored limited resections and operated only on patients with primary cancers, others were making the most of new developments in transfusion, anesthesia, and infection control to perform increasingly extensive procedures, even on patients with disseminated disease. During their visit to Memorial Hospital (New York, NY), for instance, the delegation witnessed surgeon Alexander Brunschwig's efforts to manage abdominal and gynecologic cancers with extensive resection. His patients with advanced uterine disease underwent combined total resection of the bladder, uterus, and rectum, with (at that point) roughly a 50% mortality in the first month after surgery. The delegation's clinicians expressed skepticism about this "super-radical" approach. Radiotherapist Windeyer suggested that although the surviving patients seemed "very well and pleased," he thought many "would receive better palliation from less heroic measures."¹³ Cade, the surgeon, was extremely critical, writing that Brunschwig failed to appreciate "[t]he limitations imposed on rational surgery by the natural spread of the cancer." In his summary, he reiterated this position, insisting that disseminated cancer "cannot be expected to be overcome by ‘bigger and better’ surgery."¹³

The British clinicians objected to the bigger surgery they saw in some US facilities because they believed that the majority of US clinicians had failed to appreciate radiotherapy's usefulness in cancer treatment. Radiotherapy, they and other British authorities insisted, offered more than excellent palliation; they argued it could also help control primary and advanced disease with relatively little trauma to the patient—if properly used. However, the problem, Cade and Windeyer decided, was that a lack of technical acuity had further dampened US confidence in this treatment tool. Most US clinicians had relatively little knowledge of and even less training in dosage measurement and treatment planning, especially by British standards.¹⁴ This lack of systematic training and treatment planning, Cade and Windeyer concluded, meant that most US patients obtained poor and even dangerous results from radiotherapy, which then confirmed preconceptions by US clinicians that this modality had little to offer. The British clinicians were casually withering in their evaluations of radiotherapy in the United States, especially compared with their effusive praise of Canadian facilities. Windeyer reported that at even some of the best US hospitals, treatments "appeared to have been given on an entirely empirical basis," and "the dosage did not seem to be at all precise."¹³ Cade, meanwhile, noted that in several facilities, powerful and expensive machines went unused, while in others even the "ablest" clinicians made do with machines "fifteen years old and quite out of date."¹³ This was especially shocking because the radiotherapy apparatus manufactured in the US was so impressive. In fact, one of Windeyer's tasks on his tour was to evaluate the new 2 million V machines being built at General Electric and Cambridge's X-Ray Industries, many of which were earmarked for British facilities. Although the postwar government was struggling with a massive balance of payments crisis, the Chancellor of the Exchequer had freed up currency to allow the purchase of radiotherapy equipment from US manufacturers—proof of how valued this apparatus was on the other side of the Atlantic.^13,15

THE INDUSTRIAL MODEL FOR CANCER RESEARCH: CHEMOTHERAPY

In sharp contrast to the apparent "stagnation" the British delegation decried in US radiotherapy was the explosion of US biochemical, biophysical, and chemotherapeutic research, which they eagerly chronicled. Windeyer, for instance, enthusiastically compared US clinicians' experimentation with stilbestrol and testosterone for advanced breast cancer to that being done in Britain, whereas Cade wrote that the systemic control of disease through endocrine therapy made this "the most promising field of research."¹³ Biochemist Dickens was especially attentive to work being done on hormone metabolism and steroid excretion patterns—a line of research also pursued by several British groups.^7,16 The whole delegation also was full of interest in and praise of US isotope research, describing what they termed the "unlimited possibilities" of work being done at places such as the University of California, Berkeley's Donner Laboratories.¹³

Chemotherapy research programs received particular attention, and deservedly so. At Sidney Farber's clinic (Boston, MA), delegation members discussed the results of the team's new work with folic acid antagonists, as well as previous experience with pteropterin. The laboratory men were impressed. Despite the criticisms they had heard of these compounds' high toxicity, biochemist Dickens endorsed Farber's "immediately practical results" with aminopterin, while researcher Peacock praised both the "carefully controlled" treatment and Farber's "scientific attitude to the investigation."¹³ But it was the Sloan-Kettering Institute's (New York, NY) screening program that made the most substantial impression on the BECC delegation. As several scholars have described, the activities at this Memorial Hospital research department embodied a belief in "Big Science" applied to medicine, an attack on cancer that would, its supporters hoped, be as successful as the war-time atomic bomb and penicillin manufacturing projects. Funder Alfred P. Sloan, President of General Motors, and board member Charles Kettering, GM's Director of Research, encouraged director Cornelius P. Rhoads to adopt the industrial research model at the Institute that now bore their names, and Rhoads embraced this vision. Together with other facilities that adapted the industrial model to biomedical investigation, the Sloan-Kettering promised that coordinating and directing the efforts of researchers from multiple disciplines would provide a scientific solution to the cancer problem.^4,5

In their report to the BECC's board, several delegation members depicted the Sloan-Kettering Institute as an exemplar; it was, they claimed, simultaneously a model for other institutions engaged in cancer research and an initiative that was somehow quintessentially "American." Cade considered screening to be an application of the " ‘mass production’ method," and thus especially well-suited to both the "American mentality" and the seemingly inexhaustible US pocketbook.¹³ More interesting, though, were the comments by biochemist Dickens, whose work had been supported by the Medical Research Council since the early 1920s and who had just 2 years before had been promoted to a chair which "gave him complete freedom of choice so that he could choose his activities."¹⁷ Dickens was simultaneously impressed by and wary of the Institute's organization. Research planning there, he argued, was "very rigid," and he further criticized what he saw as a lack of latitude allowed to researchers regardless of seniority. This rigidity, he reported, even worried some other US researchers, "lest a similar regime be imposed on them also." Nevertheless, he concluded, such programs displayed "outstanding efficiency," and "[e]ven with the great financial resources available, few men could have achieved so much that is excellent so soon."¹³

IMPRESSIONS AND SELF-IMAGE

Back home, the delegation members submitted individual reports, and the final product was circulated to the BECC's board in March 1949. (Although the report was marked "confidential," its contents were likely to have become known to the other British organizations and agencies engaged in cancer control, given that the members of the delegation and the BECC's board were important players in those other groups as well.) The delegation viewed the tour as a success marked by friendliness and enthusiasm on both sides, and recommended strengthening relationships through equipment exchanges and fellowship programs. I have not seen sources documenting the BECC board's exact reaction to the delegation's observations, nor do there appear to be records showing what the North Americans thought about that summer's visitors. Nevertheless, it is hardly a leap to see this report as a factor encouraging the expanded cooperation, exchanges, and collaboration that developed in the following decades, even when Cold War politics intervened.^18,19

However, the delegation's assessments of North American cancer work also accomplished something less tangible: the report allowed these elite visitors to articulate, through comparison, what they believed to be distinctive and worthwhile about British cancer treatment and research. Certainly the mix of admiration and skepticism the British clinicians expressed about US cancer treatment, with its emphasis on surgery and relative neglect of radiotherapy, was long-lasting. British surgeons tended to agree with Cade that bigger was not necessarily better. After some initial experimentation, most leading British figures rejected the "super-radical" approaches to cancer surgery embraced at some leading US and European institutions.³ Cade's and Windeyer's acid remarks about surgery's aggressiveness and radiotherapy's torpor in the United States reveal their belief, shared by several of the British institutional leaders active in the 1940s and 1950s, that closer cooperation between surgeons and radiotherapists was the key to advances in patient care. Granted, British surgeons and radiotherapists in the middle 20th century did not always have the smoothest relationship, but leaders in both fields—including Cade—promoted multidisciplinary clinics and teams as the ideal organization for cancer treatment.²⁰

The magnitude of US cancer research was undeniably impressive, the British delegation agreed. Even more so was the willingness and ability to support large, expensive, specialized research programs, evidenced by amply equipped laboratories. However, despite the variety of facilities visited, the experience at Sloan-Kettering seems to have made the deepest impression on the delegation, and reverberated in their collective opinion about US research. Lord Horder, the BECC's head, introduced the final report by writing that the US clinicians "have the latest equipment and their technological developments are doubtless ahead of ours. But this same wealth of opportunity provided by abundant machinery seems at times to lead to a somewhat limited outlook on a particular piece of work, the bearing of which on the main problem is not very obvious."¹³ The report's conclusion returned to this sentiment, contending that compared with some US research centers, "Original thought is perhaps given freer play in the UK, where the individual worker has greater latitude to follow his own line of reasoning...[.]"¹³ The official conclusion—that cancer workers in each country could learn from their colleagues in the other—thus had a reassuring corollary: despite the impressive US effort, Britain still had something unique and important to offer in the fight against cancer. Considering the challenges facing British medicine and science in 1948, that was a heartening conclusion indeed.

SUMMARY

The BECC delegation agreed that in cancer work, continued advances would come through combining the US and British temperaments rather than struggling on alone, and that combined efforts would benefit the world. However, they also were careful to note that the US researchers seemed "no nearer to a solution of the fundamental problem" than were the British.¹³ The delegation was not in any way gloating; rather, their tone strongly suggests that these cancer experts wanted to reassure themselves and their colleagues at home that their work was still important and useful. These worries were a subset of those preoccupying their contemporaries in British politics and science, the pervasive fears that despite enduring the war, Britain had fallen behind. What, then, can the delegation's assessment of British differences, strengths, and weaknesses tell us? This analysis contributes to recent scholarship comparing different configurations of cancer treatment and research, which helps historians and policymakers think about why, for instance, treatment pathways in different national contexts take some forms and not others.²⁰ But like these historians, I do not wish to simply attribute any differences between US and British cancer work to different national temperaments. Many similarities and connections have always bound US and British cancer workers more tightly than their differences could ever divide them, and easy generalizations about national temperament mask the political, economic, organizational, and individual factors that have shaped medical work—in 1948 and now. Rather, the BECC report shows that British cancer workers drew on a sense of distinctiveness for reassurance in difficult times, but also believed that such distinctiveness was a positive asset mandating their continued international cooperation and collaboration.

Author's Disclosures of Potential Conflicts of Interest

The author(s) indicated no potential conflicts of interest.

ACKNOWLEDGMENTS

I thank John Pickstone, Carsten Timmermann, Emm Barnes, and Helen Valier for their input, and the staff of the Wellcome Library for their assistance. Special thanks to Gretchen M. Krueger for her advice about and comments on earlier drafts of this article.

NOTES

Supported by Wellcome Trust Grant No. 068397, Constructing Cancers, 1945-2000, at the Centre for the History of Science, Technology and Medicine, University of Manchester, Manchester, United Kingdom.

Author's disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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Submitted August 29, 2007; accepted September 25, 2007.

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This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Toon, E. Search for Related Content PubMed PubMed Citation Articles by Toon, E. Social Bookmarking                            What's this?