Dr Barron Lerner

DATE May 24, 2001 ACCOUNT NUMBER N/A
TIME 12:00 Noon-1:00 PM AUDIENCE N/A
NETWORK NPR
PROGRAM Fresh Air

Interview: Dr. Barron Lerner discusses the history of breast
cancer treatment through the 20th century
TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross.

Many women live in fear of getting breast cancer. Not too long ago, if a
woman went into surgery for a breast biopsy, and the tumor was malignant, she
was likely to wake up and find one of her breasts removed without having had a
chance to consult with the doctor or emotionally prepare herself. Now women
often face the opposite dilemma. They're so involved in difficult decisions
they have to do research on their type of cancer and the latest treatments and
often find themselves overwhelmed by the of information they need to absorb.

My guest Barron Lerner has written a new book about the history of breast
cancer diagnosis and treatment in 20th century America. Lerner is a physician
and medical historian who teaches at the Columbia University College of
Physicians and Surgeons. I asked him why he's studying the history of breast
cancer treatment.

Dr. BARRON LERNER (Author, "The Breast Cancer Wars"): Well, history, I
think, is an important way to understand what we're dealing with these days.
We often think, at times, that science is objective and doesn't have any
influences from the outer culture. But indeed if you look back over time, you
can understand how these cultural factors influence the way doctors and
patients make medical decisions.

GROSS: Now your mother was diagnosed with breast cancer in 1977. What was
the state-of-the-art treatment then?

Dr. LERNER: Well, that was an era of transition. In 1977, the radical
mastectomy, the very large operation that had been used for decades, was
finally beginning to fall out of favor and being replaced by the modified
radical mastectomy, a somewhat smaller operation and in some cases even just
breast removal and lumpectomies. And chemotherapy was coming in as well, and
my mother was one of the earlier patients to receive chemotherapy for her
breast cancer.

GROSS: How did she tolerate the chemo? How did chemo then compare to chemo
now?

Dr. LERNER: Chemo then was pretty rough. It was a tough go for her, and, you
know, she obviously made it through and has done well over time, but I
remember her being in bed a lot, being very nauseated and having a very tough
time of it. Chemotherapy today is much improved with less side effects and
less toxic doses in general, so there's been a lot of progress.

GROSS: How have your thoughts changed from the '70s to now about what's
responsible for her survival from breast cancer?

Dr. LERNER: Well, it was interesting while working on the book that a
lot of
the stories that had circulated in the family for many years got questioned as
I looked at some of the data. So we had told the story over time that my
mother had survived because she'd had an early breast cancer, that it had been
detected early and that the chemotherapy had saved her life. And another
issue that came up was that many of my mother's friends couldn't deal with it
and didn't see her much. And as I researched the book, it became clear that
this story, like many stories of women with breast cancer, get written over
time in interesting ways that women need to do.

So, in fact, my mother's breast cancer was not really detected early, for
example. She had spread to her lymph nodes. And the chemotherapy, which may
have been extremely helpful, may or may not have cured her. It's conceivable
the surgery alone might have cured her. And even the last topic I think
became a little more problematic. I think to some degree my mother herself,
by withdrawing and dealing with the breast cancer in the way that she did, may
have influenced some of her friends not to try to be more sociable and to back
off a little bit. So some of the family myths and lore got questioned.

GROSS: Have you talked to her about some of the ways that you've questioned
the family stories about her survival?

Dr. LERNER: Well, it's been very--it's interesting, when I began working on
the topic, I think she was a little reticent and not thrilled about it,
although she was obviously sort of proud that I was working on it and writing
a
book. But I didn't really discuss it with her until I sent her a copy of my
preface in which I mention her story. And given my typical family situation,
she didn't call me. My father called me, as the interloper, and said, you
know, `We really should talk about how you discuss your mother's story.' And
it was instructive for me, because they had spoken together and I had come up
with my impressions and actually it was very useful because the three of us
talked about it and I came up with what I felt was as good and realistic a
story as possible.

GROSS: And your mother's OK with that?

Dr. LERNER: Yeah. She's OK, and she sort of gave the OK to what I wrote in
the book now. And I think she's hopefully learned a little bit about how she
responded from my understandings of breast cancer in general.

GROSS: Doctors stress the importance of early detection of breast cancer.
Before mammograms and before the emphasis on self exams, how far advanced was
breast cancer typically before it was diagnosed?

Dr. LERNER: Breast cancer in the early 20th century was a dramatically
different disease than we see today. Women very often watched lumps in their
breasts grow and grow. There was no sense of urgency about what to do because
many women thought it was a death sentence. And the cancers, by the time the
women made it to the doctor, were often inches in diameter, and they often
took up a large, large portion of the breast. It was very, very different
than today and, in fact, the earliest efforts of the American Cancer Society
when it was founded in 1913, was to say, `Look, you can't sit and watch these
things grow. If you see anything or feel anything in your breast, please go
to a doctor right away.'

GROSS: And at the beginning of the 20th century when a woman discovered a
lump in her breast and went to the doctor, what could the doctor do about it?

Dr. LERNER: Well, before William Halsted, who was a famous surgeon, there
wasn't much. They often did a sort of a superficial operation, maybe just
removing the breast, which often just removed the lump itself, which sometimes
had ulcerated and was foul-smelling. What Halsted decided was, `Look, we can
do more for these women. If we do a large enough operation, we can perhaps
get all the cancer out.' So what Halsted decided to do in the early 20th
century was to remove not only the breast, but the lymph nodes near the breast
and both muscles on the chest wall. So this was a dramatically large
operation, but Halsted felt for the first time he could offer cures to women
with breast cancer who otherwise would have died.

GROSS: And he was the creator of the radical mastectomy.

Dr. LERNER: I would say he didn't create it, he popularized it. There were
other doctors who had done similar types of operations before, but he was
really the one who embraced it and said, `Look, this is something we can really
use if we get enough women to take it.'

GROSS: And who eventually challenged him and why?

Dr. LERNER: Well, Halsted--the radical mastectomy retained an enormous
amount of popularity for decades. Halsted himself was a surgical icon, was
actually--had started the training programs for subsequent surgeons. So he
sort of had a group of folks who would listen to whatever he said and were
very impressed with the operations he devised, one of which was the radical
mastectomy. And they sort of went out around the country, became professors
of surgery at other places and taught their trainees the radical mastectomy.

It wasn't really until the 1950s when a few doctors began to question the
radical mastectomy.

GROSS: On what grounds?

Dr. LERNER: Well, they were very clever. What they said was when
Halsted had devised the operation, it was very, very valuable, but what was
happening by the later era was that cancers, when detected, were smaller. By
this point the American Cancer Society was getting women to do breast
self-examination, cancers were smaller. And the doctors who began to question
this, most notably a Cleveland surgeon named George Crile Jr., known as Barney
Crile, said, `Look, this operation is either too much or too little. In cases
where the cancer is small and seems localized to the breast, why are we taking
out so much tissue? Let's just remove the breast itself.'

And on the other hand, if these cancers were actually very widespread, the
operation probably was not enough. There was probably cancer elsewhere in the
body that would eventually kill the woman.

GROSS: Well, in fact, that leads to what you say has been called super
radical surgery, where if the cancer had spread not only was the breast
removed, but other organs and limbs believed to contain cancer were removed.
How far would that surgery go?

Dr. LERNER: Well, you know, this is a story I don't think a lot of people
remember, even people who are in the world of medicine. In the 1950s, there
was an enormous amount of very aggressive surgery done for not only breast
cancer, but other cancers. The sense was that cancer grew in a very orderly
manner, that the cancer started very small, grew gradually larger and larger.
So if you could remove enough tissue in the area that contained the cancer,
you could cure women. So in areas besides the breast, for example, this was
the first time doctors began to remove large portions of patients' livers, up
to 80 percent of patients' livers, in order to try to cure liver cancer.
There was an operation called the exenteration, in which a woman's pelvic
organs were all removed if she had gynecological cancers, cancer of the uterus
that had spread. And in the area of the breast, what the doctors began to do
was actually remove part of the rib cage to try to get to these elusive cancer
cells. So women not only lost the breast and the lymph nodes and the chest
wall muscles, but part of the rib cage. So there was a dramatic degree of
disfigurement for these patients.

GROSS: But was the surgery ever effective?

Dr. LERNER: Well, that's one of these tricky questions. At the time,
obviously, the advocates of such surgery said that while they realized that in
certain cases the surgery was not going to be curative, they did think there
were some women in which they had just gotten enough tissue that the women
were going to be cured. It was very hard in the 1950s to prove any of these
things, because the techniques for evaluating these types of procedures were
in their infancy. But what do we know is that over time even the doctors who
advocated these things began to suggest that they probably weren't that
effective and the women were simply being too deformed by them to continue.
So these things largely disappeared. Once in a while you'll still see them
for someone who has very, very advanced cancer.

GROSS: My guest is Dr. Barron Lerner, author of "The Breast Cancer Wars."
More after a break. This is FRESH AIR.

(Soundbite of music)

GROSS: If you're just joining us, my guest is Dr. Barron Lerner, and he's a
professor of medicine and public health at the Columbia University College of
Physicians and Surgeons. He's also the author of the new book "The Breast
Cancer Wars," and it's basically a history of how breast cancer has been
treated through the 20th century.

You mention that Barney Crile was the surgeon who most effectively challenged
the radical mastectomy, and he started performing operations in which he just
removed the breast or just removed the tumor. His wife had breast cancer and
died, and then he remarried. His second wife had breast cancer, too, and I
believe she survived. What kind of treatment did he recommend to his wives?

Dr. LERNER: Well, this, of course, is one of the fascinating stories that I
was able to uncover. Barney Crile, again, had begun to say, `Look, you did
not need to do these very aggressive operations for women with breast cancer.'
Then in 1959, his first wife, named Jane Crile, developed a breast cancer, and
the surgical community was sort of waiting with bated breath to see what was
going to happen once the word got out. And I think that most of the surgeons
believed that in his heart of hearts Barney Crile would suggest to his wife
that she get the Halsted radical mastectomy. It was one thing to sort of be a
crusader in general for women, but it was another thing when it was your wife.
You had to do the best.

What was quite amazing is that Crile stuck to his guns and said, `It's my
wife, yes, but I believe the best treatment for her is what I would recommend
for any woman in the circumstance. I believe she should just have her breast
removed.' What wound up happening, unfortunately, was that Jane Crile
developed metastases, the spread of the cancer, to her brain and died in 1963.

The other doctors in the medical community, not surprisingly, were quite
appalled by this and felt that in a sense he had, quote, "murdered" his wife.
And obviously they didn't say it to his face, but they really felt that they
couldn't believe that he had done this. But to his credit, he stuck to his
guns and said, `Look, as much as this death is terrible and this hurts me, the
fact is that she undoubtedly had small amounts of that cancer sitting in her
brain at the time of the original surgery, and if she'd had a much larger
operation the fact is she would have spent the few remaining years of her life
with a very large, disfigured area on her chest wall, and we were able to
spare her that.'

So that was the story of Jane Crile. Ironically, when Barney Crile got
remarried to Helga Sandberg, who's actually the daughter of Carl Sandburg, she
developed breast cancer. This was in 1974. And a not dissimilar thing
occurred and Helga Sandberg, this now being the 1970s, an era in which women
themselves were much more involved in making the decision, but in consultation
with Barney, Helga and Barney decided that a lumpectomy was going to be
adequate for her breast cancer that was very small. And again, when I
interviewed Helga Sandberg, she told me that at medical meetings doctors sort
of snuck up to her when Barney wasn't around and said, `Look, Helga, please go
get yourself a mastectomy. You shouldn't be doing this.' And she stuck to her
guns and in this case, fortunately, everything has worked out well, as she's
now, I think, about a 27-year survivor.

GROSS: Now when did the lumpectomy become an accepted procedure?

Dr. LERNER: Well, people had begun to experiment with the lumpectomy as
early as the 1950s. By the 1970s, it was getting much more attention,
although it was not recommended by most doctors. But a patient who came in
and really was insistent and had a small, small cancer that seemed not to have
spread, doctors began to be willing to do this. But it wasn't really until
the late 1980s when lumpectomy, usually accompanied by radiotherapy, became a
standard treatment for breast cancer. And that's because in 1985 the New
England Journal published randomized controlled trials, in other words, the
gold standard for evaluating medical procedures. These were randomized
controlled trials that showed, indeed, that women treated with lumpectomy and
radiation did as well as women who had larger operations, be it a regular
mastectomy or a radical mastectomy.

So all of that speculation that had been going on for decades by people like
Barney Crile turned out to be true.

GROSS: You studied medicine in the 1980s. What are some of the things that
you were taught about breast cancer and about women who had breast cancer?

Dr. LERNER: Well, I have--it's an interesting connection to all of this. I
was a medical student at Columbia University, and one of the most famous
breast cancer surgeons of the 1950s and '60s was at Columbia University, a
doctor named Cushman Hagenson(ph), who really put breast cancer on the map.
And Hagenson used to do these very elaborate five- and six-hour radical
mastectomies where he tied off each individual blood vessel and refused to use
a cautery, which burns away tissues. And there are these legendary stories of
students and residents standing there for hours and hours while he did this
very, very meticulous operation that had become practically legendary.

This was just fading out when I was a medical student, so some of the doctors
that Dr. Hagenson had trained who I scrubbed in with on surgery weren't quite
the perfectionists that he was, but some of them still did these very, very
long breast operations where they felt that if they did anything wrong at all
they might risk putting a cancer cell into the bloodstream, and you had to be
very, very meticulous. So that was just the tail end of the era in which this
type of surgery was done.

Chemotherapy was coming in as I was a medical student, and this was getting
much more emphasis, the notion that breast cancer is probably a systemic
disease. In other words it's probably spread around the body, often in an
invisible way, even at the time that a small lump is found. So this was just
coming in, and this was exciting, but it really threw the understandings of
breast cancer on its head.

GROSS: Were the doctors who taught you believers in the radical mastectomy,
and is that the procedure that you were taught?

Dr. LERNER: By the time I was a student, the modified radical mastectomy was
really being done almost exclusively. Periodically a woman would still get a
radical mastectomy. But I think that the lore of the radical mastectomy died
slowly, and the notion that this very carefully performed surgery and that
bigger operations were still better was still hanging around. And it was very
hard for many people, many of the teachers I had, to really give up on that.
They'd all been trained that way. They all had a hunch still that more was
better. And the studies were starting to show that what they had learned and
what they believed for so, so long was probably not true. It's very difficult
for anybody, probably particularly a surgeon, to say toward the middle or the
end of their career, `You know, all that stuff that you learned, probably
untrue and you've got to change your ways.' There were some surgeons who were
able to do that, but others really stuck to their guns for too long.

GROSS: Dr. Barron Lerner is author of the new book "The Breast Cancer Wars."
He'll be back in the second half of the show. I'm Terry Gross, and this is
FRESH AIR.

(Soundbite of music)

(Soundbite of "Highway 61 Revisited")

Mr. BOB DYLAN: (Singing) Oh, God said to Abraham, `Kill me a son.'

GROSS: Today is Bob Dylan's 60th birthday. Coming up, rock critic Ken Tucker
considers Dylan's recent works. And we continue our conversation with Dr.
Barron Lerner, author of "The Breast Cancer Wars."

(Soundbite of "Highway 61 Revisited")

Mr. DYLAN: (Singing) The next time you see me coming you better run. Well,
Abe says, `Where do you want this killing done?' God says, `Out on
Highway 61.' Well, Georgia Sam he had a bloody nose, Welfare Department
they wouldn't give him no clothes. He asked poor Howard, `Where can I go?'
Howard said, `There's only one place I know.' Sam said, `Tell me quick, man,
I got to run.' Ol' Howard just pointed with his gun and said, `That way down
Highway 61.'

Well, Mack the Finger said to Louie the King, `I got 40 red, white and blue
shoe strings and a thousand telephones that don't ring.'

GROSS: This is FRESH AIR. I'm Terry Gross.

We're back with Dr. Barron Lerner. He's a physician and medical historian
who's written a new history of breast cancer diagnosis and treatment in 20th
century America. It's called "The Breast Cancer Wars." He teaches at the
Columbia University College of Physicians and Surgeons.

Let's get to the 1970s and this is the era in which the feminist health care
movement starts to take a really active role in addressing breast cancer. And
you have a lot women who became known for their breast cancer activism,
including, Rose Kerchner(ph), Betty Rollin, Betty Ford had breast cancer
during this period. What were some of the feminist critics of how the medical
profession was dealing with breast cancer?

Dr. LERNER: The way medicine dealt with breast cancer in the 1970s was
incredibly different from now. In the 1970s most physicians who treated
breast cancer were male, most physicians were male. And they had been doing
it their way for many, many years. This obviously usually entailed the
radical mastectomy. But beyond the radical mastectomy, the way that decisions
were made were that a woman would come into the office, the doctor would feel
a lump, perhaps that the woman had found, and the doctor would simply tell the
woman, `You need to check into the hospital and I'm going to do an operation.
And, here, sign this form.'

And the form was an early version of a consent form that not only gave the
doctor the ability to do a radical mastectomy, but gave the doctor the ability
to do that while the woman was under anesthesia.

GROSS: You mean to make the decision while she was under anesthesia.

Dr. LERNER: To make the decision. So in other words, what they would do
would be to do the biopsy while the woman was under anesthesia, go to the
laboratory and see if it was cancer or not. And if it turned out to be
cancer, the doctors would then proceed with the radical mastectomy. As a
result, women awoke from surgery without knowing whether or not they were
going to have had a breast removed or not. For many years, most women did not
object to this state of affairs. But by the 1970s as feminism and women's
liberation were emerging, this type of arrangement was increasingly
unsatisfactory for many women.

Women had begun to question health care in other areas. Most notably, if one
thinks back to Our Bodies, Ourselves and other publications like that, women
had begun to question the ability of male doctors to make decisions during
reproduction and when women were giving birth. And in the case of breast
cancer, the same thing happened. Women began to go to doctors and say, `You
know, wait a minute. I want to wake up and help make the decision. I want to
make the decision. I'm willing to take your advice but I would like to know
whether or not I have cancer. And then to be able to talk about it with other
people, perhaps to see other doctors, and then to make a decision about what
type of operation that I want.'

GROSS: Now wasn't part of the medical thinking here that time is of the
essence? `Let's not waste another week while a woman studies up and makes up
her mind. Let's perform it right now before more cancer cells spread.'

Dr. LERNER: That's quite true. At this time, people thought that breast
cancer and other cancers, for that matter, were emergencies, that you needed
to get to these cancers as soon as possible, to do as large as an operation as
possible right away. In retrospect, that wasn't true as we know now. So that
was part, I think, of what was going on. It was a true medical belief that
this was something that was urgent. But I think also what was going on was an
issue of control. I mean, I think that doctors at that time really didn't
want to hear women questioning what they were going to do. They didn't want
women to go see other doctors and get second opinions and the state of affairs
as it was enabled them in essence to silence women patients. They weren't
doing this because they were horrible people, but male doctors were used to
running the show and they didn't like women interfering with the way things
were occurring.

GROSS: Is the medical belief now that breast cancer spreads much more slowly
than they believed it spread in the '70s?

Dr. LERNER: Well, we know now that none of these operations are really
emergencies at all and breast cancers grow very, very slowly. Women who find
a lump in their breast that perhaps one or two centimeters in size, we know
that that's probably been growing five to 10 years. And, as a result, whether
you get an operation in three days or three weeks really doesn't matter that
much. Now it matters, oftentimes, from an emotional perspective and I
understand completely how women, once they find a cancer there, they want the
doctors to get it out right away. And that's understandable. But it's
important for them to know that from a medical perspective, they're not going
to really do any worse if the operation's delayed a little bit.

GROSS: So what do you think are the most important ways that the women's
health care movement changed the way the medical profession dealt with breast
cancer.

Dr. LERNER: Well, I think the women's health movement contributed in many
ways. The first and most important way was that they forced doctors, male
doctors in particular, even women doctors, to listen to the patient. Again,
the standard in the 1970s was for doctors to make the decisions. Occasional
patients would object but most patients would simply do what the doctor said.
And what women in breast cancer activism did for women with many diseases, for
all women in fact, announced through women's journals--I'm sorry, women's
magazines, for example, and newspaper articles, that it was OK to talk back to
your doctor, it was OK to even go to the library and read up about your breast
cancer. It was OK to talk to other women and, in fact, other women often knew
as much or more about certain aspects of breast cancer than doctors did.

For example, doctors paid very little attention to the emotional aspects of
breast cancer. I heard a story about a doctor who once said to a woman who
was complaining about the fact that she'd lost her breast and emotionally
devastating it was, said to her,`Oh, come on. Go stuff an old stocking in
your bra and get on with your life.' Now that was a particularly harsh way of
dealing with this patient, but the attitude was not dissimilar of other
doctors. Many people at that time felt, `Look, isn't it most important that
we save your life? Can't you deal with the loss of a breast?'

Another thing that women emphasized to doctors and Betty Rollin, being a very
important person in this regard, saying it was OK for women not only to think
about their lives but also to think about how they were going to look and how
they were going to feel after their operation. It was OK, as Betty Rollin put
it, to feel--to announce to a doctor, `Hey, I'm vain. I not only want to live
from this disease but I also care about how I'm going to feel.

GROSS: Well, I'll tell you what, let's take a short break here and then we'll
talk some more. My guest is Dr. Barron Lerner. His new book "The Breast
Cancer Wars" is a history of how breast cancer has been treated by the medical
profession during the 20th century. This is FRESH AIR.

(Soundbite of music)

GROSS: If you're just joining us, my guest is Dr. Barron Lerner. He is a
professor of medicine and public health at the Columbia University College of
Physicians and Surgeons. He's also the author of the new book "The Breast
Cancer Wars." And it's a history of how the medical profession has dealt with
breast cancer over the course of the 20th century.

There is still a strong emphasis on early detection and early treatment of
breast cancer and mammography is considered very important in that equation.
The detection of early breast cancers and the detection of what's called
precancerous cells has become kind of controversial. What is the controversy
around the detection of these, quote, "precancerous cells?"

Dr. LERNER: Many years ago when the breast cancers were very, very large,
early detection was a crucial thing to inform women about. If you came to a
doctor with a breast cancer that was a few inches in diameter, you were very
likely to die. And the early activists insisted to women that they had to try
and find these things earlier. And a lot of progress has resulted from that.
Cancers that are, for example one centimeter or two in diameter, compared to
the larger ones, do better on average.

What we've come to now, though, is many of the early detection modalities that
are used find not only very, very, tiny cancers, but things that are called
precancers or abnormal cells. Thinks like carcinoma in situ. And while it's
important to find these things, our ability to help women with them is less
dramatic than our ability to help women with actual cancers. In other words,
if you find a cancer and take it out, it's pretty clear that that cancer,
sitting there for long enough will probably do harm. But it's less clear in
the case of carcinoma in situ and other precancerous lesions that you might
find in the breast. But because early detection has gotten so much emphasis,
the fact that there are limits to what early detection can accomplish and that
early detection leads to a lot of biopsies that are unnecessary and a lot of
unnecessary worry, often gets downplayed.

GROSS: So what are both sides saying now about who should get mammography,
who should get mammograms?

Dr. LERNER: Well, mammograms are very controversial, particularly for women
in their 40s. The folks who advocate mammography are the strong early
detection advocates. They say that if you do mammograms in this population
you will find cancers that would ultimately cure women and it's crucial to do
this. They realize that there are possible side effects, that there are
unnecessary biopsies, but when you have the opportunity to cure women, you
should go and do it.

The opponents really don't disagree with a lot of that, and part of what I
found is that there's not a lot of disagreement about what the data show for
women in their 40s with respect to mammography. What matters is the way in
which the existing data gets spun. So the advocates spin it by saying, `Look,
if you do enough mammograms, you're going to lower the mortality rate and cure
some women.' But what the people who are cautious about this suggest is,
`Well, you might do that, but, meanwhile, you're going to spend an enormous
amount of money, you're going to have to screen thousands of women to find one
cancer that you can cure. And we need to think about how we devote our health
care resources to a problem like this. Maybe, even if there's a possibility
that you're not going to cure every single woman, maybe we should reexamine
the dogma of early detection.'

GROSS: What do you think is the most exciting prospect on the horizon in
treating breast cancer?

Dr. LERNER: Well, there are a lot of exciting things that are going on. I
think that probably the main development over the past few years that people
are excited about is Perceptin, which is a new type of treatment, a biological
agent that attacks specific types of cancer cells in women with metastatic
breast cancer and possibly women who have earlier cancers. There are trials
going on now. The exciting thing about a treatment like this is that instead
of chemotherapy which kills all cells in the body as a way to kill the breast
cancer cells. These biological therapies or more directed therapies are aimed
specifically at the cancer cells themselves and, in general, are better
tolerated for women than chemotherapy.

On the other hand, to switch gears, another exciting thing which is occurring,
I think is that there's growing attention to the environment and potential
environmental causes of breast cancer and this is an area that hasn't gotten
enough attention, I think, over time. And people again are starting to ask
what they can do, what can women do, what can government do to try to look at
least at the issue of toxic exposures and the potential that toxic exposures
predispose women to breast cancer. It's not nearly as sexy a topic as an
exciting, new biological agent, but the hope is that both of these types of
areas of inquiry can go along together.

GROSS: With the new knowledge about genetics, some women have been able to
find out that they are genetically predisposed to breast cancer. And some of
those women who know that they're genetically predisposed have chosen to have
one or two breasts removed as preventives. I mean, they haven't had any
cancerous cells detected. But this is to prevent cancer of the breast from
ever developing. Did you do any research into that? Have you given that a
lot of thought about the kind of social and medical significance of that
preventive surgery?

Dr. LERNER: Well, the preventive surgery that's going on now, in a sense
brings us full circle from the early part of the 20th century. One hundred
years ago, Halstead(ph) argued that more surgery was necessarily better. And
while that lessened over time, it's come back now in an interesting way.
Because women can be genetically tested, they can find out, in fact, if they
are at very, very high risk of having breast cancer in the future. Now
there's no guarantee that they will get breast cancer at all. The estimates
range from 50 to 80 percent chance. But an individual woman may never get
breast cancer. But some of the women who test positive for the genetic
mutations are indeed opting to have their breasts removed, as well as their
ovaries because the gene also predisposes to ovarian cancer.

What I think is important is that we emphasize that this is probably something
that is right for a small number of women but not most women. There are
certain women who have either had breast cancer themselves or whose families
have been entirely damaged by cases of breast cancer. And indeed the breast,
as one woman told me, becomes almost an albatross around their neck. They're
so nervous about getting breast cancer that it practically interferes with
their getting on with life. If they test positive and they think about it and
want their breasts removed, it might be a very logical thing for them to do.
It will probably lower their chance, although not to zero, of getting breast
cancer in the future.

But I think most women and other women should not rush into this. It's not a
cure-all. There's still a chance you might get breast cancer and there's a
chance that you might regret having done this after the fact. There's a good
possibility that these women will develop breast cancer but it's far from a
guarantee. And the genetic technology is only in its infancy and we're only
beginning now to understand how it works.

GROSS: How can a woman who has a breast removed eventually still develop
breast cancer?

Dr. LERNER: Well, you can't ever get all the breast tissue. So when they
remove both breasts preventively, they try to get as much of it as they can.
But there's always a little bit left behind. And the same forces in the body
that would make you develop cancer in a complete breast can conceivably cause
breast cancer in the small areas of tissue that remain near the chest wall or
near the shoulder.

GROSS: When you decided to do a medical history, why did you focus on breast
cancer? Why not another form of cancer or another disease altogether?

Dr. LERNER: Well, I think that breast cancer is a very important story for
several reasons. It's become the quintessential activist disease, I think.
If you look over time it's always--people involved in breast cancer have
always been trying to push it to the forefront and saying, `If we can do
something about breast cancer, it can help us with cancers in general.' I
think this has happened because the breast holds such cultural significance.
On the one hand, for many years it was very difficult to talk about breasts in
public in the United States. And I think that impeded some of the early
efforts of the Cancer Society. But once that changed in the 1970s and society
became more open about discussing breasts, it became an opportunity to say,
`Look, breasts are very important, breasts hold an important cultural status
in the United States, let's do what we can to preserve breasts and to make
sure that women don't die from breast cancer.'

So in an interesting way, the earlier secrecy was channeled into a new type of
activism and I think it's no surprise that women have been successful at
getting attention in Congress by wearing a pink ribbon and talking about
breast cancer. Indeed, activists for other cancers, I think, are at times
envious of the success that the breast cancer activists have had. And I think
that it stems from the fact that it's of natural interest to people that the
whole issue of sexuality, do you have to lose your breasts or not, how are you
going to look after your cancer treatment--these are all very compelling
issues and that made it interesting for me to study as a historian.

GROSS: Dr. Lerner, I want to thank you very much for talking with us.

Dr. LERNER: OK.

GROSS: Dr. Barron Lerner is the author of "The Breast Cancer" wars. He
teaches at the Columbia University College of Physicians and Surgeons.

Today is Bob Dylan's 60th birthday. Coming up, rock critic Ken Tucker on
Dylan's recent work.

This is FRESH AIR.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Commentary: Bob Dylan turns 60 and is still going strong
TERRY GROSS, host:

Bob Dylan turns 60 today. Few rock music figures have remained as productive
and as well-regarded. He won an Oscar this year for a song he contributed to
the movie "Wonder Boys," and on the newly-released second collection of music
from the HBO series "The Sopranos," Dylan has recorded a new version of an old
Dean Martin hit "Return to Me." Rock critic Ken Tucker has these thoughts on
the new senior citizen.

(Soundbite of music)

Mr. BOB DYLAN (Singer/Songwriter): (Singing) Return to me. Oh, my dear I'm
so lonely. Hurry back, hurry back, oh my love, hurry back, I am yours.
Return to me. For my heart wants you only. Hurry home, hurry home, won't you
please hurry home to my heart. My darling...

KEN TUCKER reporting:

Bob Dylan's version of "Return to Me" aired on the May 13th episode of "The
Sopranos," deployed with a muted restraint typical of the show, slid gently
under a scene that used the tune's theme of romantic longing for un-ironic
poignancy. If the notion of Bob Dylan tackling a schlocky 1958 ballad, made
famous by the sort of saloon singer his own folk rock was supposed to
supplant, surprises you, well, I'd think you'd have to be pretty thick-headed
to be surprised by Bob Dylan in 2001. Each step of his career has led him
forward, backward, sideways, leaping heavenward or veering off into the
nearest tree. There's no such think as progression in Dylan's career. Which
is one reason it's to be cherished.

(Soundbite of music)

Mr. DYLAN: (Singing) A worried man with a worried life, no one in front of
me and nothing to hide. There's a woman on my back and she's drinking
champagne. That white skin got a thousand eyes. I'm looking up into the
somehow gentle skies and wondering, waiting on the last train. Standing on
the gallows with my head in a noose. Any minute now I'm expecting all hell to
break loose. People are crazy and times I swear. I'm locked in tight, I'm
out of air. I used to care, but things have changed.

TUCKER: Do you remember Dylan's slit-eyed performance of "Things Have
Changed" at the Oscars a few months back? Broadcast live by satellite from
Australia, Dylan was the biggest star of the night. The next day, people were
commenting on the harshness of the lighting, how the old man had to squint
into the bright glare of the camera thrust in his face. But there were also
reports that this was Dylan's own last-minute choice of choice of
mise-en-scene. His mug was nearly as pale as it was during his own film
career. Remember the white pancake makeup from his 1978 tour movie "Renaldo
and Clara?" His teeth were an admission of the nicotine that lesser stars
whiten their choppers to disguise. Dylan's literal warts and all Oscar ramble
through "Things Have Changed" was pretty exhilarating. He likes to mess with
his image in a way some of his most ardent admirers have never understood.

(Soundbite of "It Ain't Me, Babe")

Ms. LUCY KAPLANSKY (Singer): (Singing) Go away from my window, leave at your
own chosen speed. I'm not the one you want, babe, I'm not the one you need.
You say you're looking for...

TUCKER: That's Lucy Kaplansky making like Joan Baez on a new CD called "A Nod
to Bob," an artists' tribute to Bob Dylan on his 60th birthday. Which, with a
couple of exceptions, is a perfectly awful array of Dylan covers. It features
performers like Greg Brown, John Gorka, and Dylan's folk era contemporary
Ramblin' Jack Elliot, who rambles way too much. The CD is excessively solemn
and no one has an original take on Dylan's work.

If you're listening for me now to get choked up and pull out a cut from the
"Freewheelin' Bob Dylan" or "Blonde on Blonde," sorry. One reason I love
Dylan's music is that it denies cheap sentiment and cuts across the grain of
the expectations we bring to it. Happy birthday, Mr. Dylan, and thanks for
the decades of revelatory music and ideas, including the generous reminder
that Dean Martin understood the deep emotions that can run beneath schlock.

GROSS: Ken Tucker is critic-at-large for Entertainment Weekly.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Satire: Richard Belzer laments on what Bob Dylan might have
sounded like at his bar mitzvah and as a senior citizen
TERRY GROSS, host:

Well, today is Bob Dylan's 60th birthday. Fourteen years ago on FRESH AIR,
comic Richard Belzer imagined what Dylan sounded like as a boy and what he was
going to sound like as a senior citizen.

Mr. RICHARD BELZER (Comic): (From previously recorded show) When I was a
teen-ager and we started first getting in to Bob Dylan and then we found out
his real name is Zimmerman and he's a Jew from Minnesota and this was like a
revelation to have a hero that's a Jew. So I said if his name is Zimmerman,
he must have had a bar mitzvah. So I fantasized what Bob Dylan's bar mitzvah
must have been like, you know. (Speaks in Bob Dylan gibberish)

And then when he gets older, you know (in old Jewish voice) `Oy, oy, once upon
a time, you dressed so fine, you threw the bums a dime in your prime, didn't
you? People called, said, "Beware, doll, you're bound to fall." You thought
they was all kidding you.'

(Soundbite of "Like a Rolling Stone")

Mr. BOB DYLAN (Singer/Songwriter): (Singing) Once upon a time you dressed so
fine, threw the bums a dime in your prime, didn't you? People call, say,
`Beware doll, you're bound to fall.' You thought they were all kidding you.

(Credits)

GROSS: I'm Terry Gross.

(Soundbite of "Like a Rolling Stone")

Mr. DYLAN: (Singing) Now you don't talk so loud. Now you don't seem so
proud about having to be scrounging your next meal. How does it feel? How
does it feel to be without a home, like a complete unknown, like a rolling
stone?
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