Architectures of genetic medicine: comparing genetic testing for breast cancer in the USA and the UK

This paper compares the development of genetic testing for breast cancer (BRCA testing) in the USA and the UK. It argues that national political cultures played an important role in how these genetic testing technologies were shaped, and that the shapes of these technologies had important implications for the users of these systems. In order to demonstrate the roles of national social and political elements in the development of new genetic testing technologies, I introduce the concept of a technology's architecture, which is made up of components and the specific ways in which these components are assembled to fulfill particular functions. In the USA, four very different BRCA testing systems initially emerged. However, one biotechnology company, Myriad Genetics, eventually used its legal and economic position to become the sole provider of testing. It offered BRCA testing the way many other laboratory tests were provided in the USA, available to anyone through any physician. The shape of this testing service had important implications for its participants, defining the client as a consumer who could demand access to any of Myriad's laboratory services, but could not choose among testing systems. In the UK, the government-run National Health Service provided testing through regional genetics clinics, using family history information to assess risk and triage care. Clients in the UK were defined as citizens and patients, who had the right to equal access to the testing system but could not demand any specific services.

BRCA patients and clinical collectives: new configurations of action in cancer genetics practices

Since the late 1980s, in France and in a number of other countries, cancer genetics testing has become a clinical reality, particularly for hereditary breast and ovarian cancer. BRCA tests allowing for the assessment of an increased cancer risk among patients and their healthy relatives are now being routinely performed as part of clinical practice. Based on fieldwork on French clinical cancer genetics and on the French Cancer Genetics Collaborative Network, this paper examines the configuration of entities, actors and activities mobilized by the performance of BRAC testing, and argues that the development of clinical molecular genetic practices is predicated upon the development of new forms of collaborative work that lead to a transformation of the content and organization of medical activities and judgements. The paper analyses three major collective configurations - local multidisciplinary collectives, data collectives and new clinical collectives - and argues that they not only provide the material conditions needed to carry out the relevant activities, but also articulate a series of distinctive bio-clinical interventions. These interventions provide an interface with research activities, produce the epidemiological measurements and tools that are a sine qua non for clinical work in this field, and, most importantly, establish the conventions that underlie practices, which define the criteria that turn tools and novel entities into operational components of clinical settings. It thus appears that in the field of clinical cancer genetics, bioclinical collectives, as a locus of expertise, have replaced the individual judgement of the practicing clinician.

[Sir Geoffrey Keynes 1887-1982. Surgical pioneer, medical historian, humanist]

Sir Geoffrey Keynes (1887 - 1982), was a pioneer in the surgery of breast cancer and thymic deseases, n.b. in patients suffering from myastenia gravis. He strongly disapproved of the longstanding dogma of so called radical mastectomy in breast cancer, and advocated a more limited surgical approach, followed by radiation therapy. This was done more than fifty years before breastconserving surgery has become the therapy of choice and against considerable opposition from the surgical establishment of his days. He also became a pioneer in the surgical treatment of myastenia gravis by thymectomy, at a time when there was no real understanding of the pathophysiology of the disease and when considerable controversy existed as to the importance or non importance of concomitant tumour formation in the thymus. Besides being a busy surgeon Sir Geoffrey was a medical historian, writing the biography of among others William Harvey, a bibliographer with a special interest in the poet and artist William Blake and a bibliophil with a large book collection of great value to medical history.

The origin of cancer metastasis

Little was known about cancer in 1829. Cancer was regarded as scirrhous, encephaloid and melanotic hard, soft and black. Deep-seated cancer was almost inevitably fatal, as was breast cancer. Surgical treatment of breast cancer was ineffective, and often fatal. Post-operative infection was very common. Radical mastectomy was 30 years in the future, and in the 1880s had a mortality rate of 25% in the hands of Billroth; even by 1900, the “safe” radical mastectomy of Halsted had a three-year cure rate of 57%. In 1829, a French surgeon, J. C. A. Récamier, (1774–1852) in his book on cancer, gave the first clear reference to metastasis — “métastase.”

History of medical screening: from concepts to action

The objective of medical screening is to identify disease in its preclinical, and therefore hopefully still curable, phase. This may have been an old quest in medicine but it became historically possible when at least four conditions were met: the availability of simple, valid and acceptable forms of tests, the discovery of effective treatments, the establishment of a theory of screening, and the wide access to health care. Five selected examples that illustrate the history of medical screening are reviewed: screening for psychiatric disorders in the United States army as it is one of the oldest screening programmes; screening for syphilis as it used one of the earliest screening tests; screening for diabetes as one of the first modern forms of mass screening; screening for cervical cancer using the Pap test as one of the greatest successes of screening; and screening for breast cancer by mammography as this offers a good opportunity to discuss the development of modern evaluation of screening programmes. The evaluation of the impact of screening on human health slowly progressed, from obvious changes in the vital statistics such as the decline in incidence of syphilis, to less obvious changes such as the decline in mortality of cancer of the uterus, to finally more subtle changes, such as the impact of mammographic screening on breast cancer mortality. Methods of evaluation had therefore to adapt, evolving from simple surveys to case-control studies and randomised trials. The history of screening is short, but very rich and mostly still to be written.

Inherited predisposition to cancer: a historical overview

The hereditary predisposition to cancer dates historically to interest piqued by physicians as well as family members wherein striking phenotypic features were shown to cluster in families, inclusive of the rather grotesque cutaneous findings in von Recklinghausen's neurofibromatosis, which date back to the sixteenth century. The search for the role of primary genetic factors was heralded by studies at the infrahuman level, particularly on laboratory mouse strains with strong susceptibility to carcinogen-induced cancer, and conversely, with resistance to the same carcinogens. These studies, developed in the 19th and 20th centuries, continue today. This article traces the historical aspects of hereditary cancer dealing with identification and ultimate molecular genetic confirmation of commonly occurring cancers, particularly of the colon in the case of familial adenomatous polyposis and its attenuated form, both due to the APC germline mutation; the Lynch syndrome due to mutations in mismatch repair genes, the most common of which were found to be MSH2, MLH1, and MSH6 germline mutations; the hereditary breast-ovarian cancer syndrome with BRCA1 and BRCA2 germline mutations; the Li-Fraumeni (SBLA) syndrome due to the p53 mutation; and the familial atypical multiple mole melanoma in association with pancreatic cancer due to the CDKN2A (p16) germline mutation. These and other hereditary cancer syndromes have been discussed in some detail relevant to their characterization, which, for many conditions, took place in the late 18th century and, in the more modern molecular genetic era, during the past two decades. Emphasis has been placed upon the manner in which improved cancer control will emanate from these discoveries.

Framing as a cultural resource in health social movements: funding activism and the breast cancer movement in the US 1990-1993

Disease-specific funding activism in the US has required health social movements (HSMs) to draw on both structural and cultural resources in order to persuade audiences and to redefine dominant conceptions of disease. Using a social constructionist analysis of Congressional testimony and media accounts of breast cancer funding activism between 1990-1993, this paper demonstrates that the use of culturally resonant frames served as an important cultural resource for breast cancer activists in the early 1990s. The breast cancer movement's use of three interconnected and culturally resonant frames aided the movement in redefining breast cancer as a problem of individual women to a major public health problem in need of governmental attention. This research contributes to both social movement and HSM scholarship by demonstrating that cultural resources, in the form of movement frames, are as central to social movement analysis as structural resources.

The history of breast ultrasound

What began as a laboratory-based spin-off of military technology has matured over the past 50 years into an integral part of the breast imaging armamentarium. It has revolutionized the evaluation of breast abnormalities and has provided a rapid, cost-effective, and accurate guidance method for a wide range of interventional techniques. Subsequent improvements in technology will only serve to further enhance its pivotal clinical role.

History of surgery for breast cancer: radical to the sublime

The historic milestones that have brought the surgical management of breast cancer to its current state are recounted. The Halsted radical mastectomy, once considered the ideal cancer operation, no longer has a place in the routine management of patients with breast cancer. Breast conservation in the form of segmental mastectomy, axillary node dissection, and radiation is often chosen over the modified radical mastectomy, popular in the 1980s. Axillary lymphadenectomy, shown to be of questionable therapeutic value in breast cancer, is certainly of prognostic significance. Studies are ongoing to establish the validity of the less-invasive sentinel node biopsy in determining axillary nodal status. Perhaps the most significant change in today's approach to breast cancer is the reliance on well-controlled prospective studies to evaluate outcome and determine the appropriate surgical procedure.

Noninvasive papillary proliferations

The diagnosis of noninvasive papillary tumors begins with categorization of the lesions as macropapillary or micropapillary. Macropapillary lesions include papilloma, papillary carcinoma, and papilloma harboring carcinoma. Papillomas consist of a few broad fronds, abundant stroma, and an epithelium containing both luminal and myoepithelial cells. Papillary carcinomas have many irregular fronds, small amounts of stroma, and a uniform population of malignant glandular cells. Papillomas can give rise to both conventional ductal hyperplasia and carcinomas. One analyzes proliferations on the surface of a papilloma as one would analyze those in a duct. Proliferations within the stalk of a papilloma require especially careful attention; one must observe large masses of cells demonstrating both cytological and architectural atypicality and devoid of intervening stroma to make the diagnosis of low-grade ductal carcinoma in-situ involving the stalk of a papilloma. Micropapillary proliferations represent either ductal hyperplasia or ductal carcinoma in situ. The former shows slight dilatation of ducts, micropapillae of similar size and shape, maturation of cells, lack of dishesion and necrosis, and lack of cytological atypicality. Micropapillary ductal carcinoma in situ exhibits extreme dilatation of ducts and lobules, micropapillae varying in size and shape, lack of maturation, dishesion and necrosis, and cytological atypicality.

The prospects for the control of cancer through screening-1976-today-the future

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[Thirty years of breast pathology in an anticancer center]

Looking back to three decades of professional experience allows to evidence the dramatic changes of the role of the pathologist in breast cancer clinical management. Increasing means, fruitful exchanges within pathologists, and closer collaborations with other specialists have been key mediators of this evolution.

Assay-assisted treatment selection for women with breast or ovarian cancer

Although women suffering from advanced cancer of the breast or ovary are unlikely to be cured, several active agents are available that can prolong their lives. The use of these agents is based on demonstrated benefit in large randomized clinical trials, and the clinical activity of these chemotherapy regimens is initially high, with 60%-70% of patients responding. Unfortunately, their benefit in the second-line setting is often limited, with less than 30% of patients showing significant disease response. Thus some 70% of patients may undergo ineffective treatment during the course of their disease, while still suffering from significant chemotherapy-related toxicity. Having some foreknowledge of a given agent's expected result before its administration would therefore benefit the individual patient. In vitro drug response testing, first developed to assist in the selection of antibiotics for patients with bacterial infections, has recently been demonstrated to accurately predict how cancer patients will respond to chemotherapy. This review discusses the historical development of in vitro testing for cancer patients, some of the pitfalls encountered, and offers an assessment of their current utility. Results of various clinical trials that evaluated correlations between in vitro tumor response and clinical outcomes are described. These data suggest that in vitro drug response assays can accurately predict drug resistance and can identify patients who are more or less likely to benefit from a given agent.

The history of breast cancer advocacy

There have been four key steps in the advent of breast cancer advocacy: priming the market, engaging consumers, establishing political advocacy, and taking the advocacy mainstream. Breast cancer was surrounded by secrecy until the 1980s, when brave individuals such as former First Ladies Betty Ford and Nancy Reagan, and founder of the Susan G. Komen Foundation, Nancy Brinker (Susan Komen's sister), began speaking publicly about the personal impact of the disease, which increased awareness of breast cancer and made it more acceptable to talk about it openly. At the same time, statistics about breast cancer were presented in new ways that the public could understand. Public health advocates played a key role in the second step, engaging consumers, when they established guidelines in the 1980s that encouraged women to perform breast self-examinations (BSEs) and have screening mammograms and clinical breast examinations (CBEs). Other events that helped engage consumers were increased media coverage of breast cancer issues, the founding of the Komen Race for the Cure in 1983, and the establishment of other programs that both educated the public and raised funds. Funds from these efforts enabled advocates to hold educational forums and produce educational materials in different media and tailored to different audiences and to become active in the funding of research. The third step, political action, became possible when breast cancer advocates joined together in the 1980s and 1990s to work toward legislative, regulatory, and funding changes, such as passage of the Mammography Quality Standards Act and increased funding for the National Cancer Institute. These efforts contributed to a more than quadrupling of federal funding for breast cancer research in the 1990s. Going mainstream, the final step in the advocacy process, entailed establishing a solid base of support to ensure that the message about breast cancer stays strong and fresh. This has been achieved by engaging the business, government, and scientific communities as partners in advocacy.