January 31, 2024 • 42 mins
The history of mammography begins with the discovery of X-rays in 1895. But it took a very long time for breast imaging to advance, in part because it wasn't prioritized.
Research:
- “The St George’s Four: Meet the women that shaped St George’s.” St. George’s University of London. 3/8/2019. https://www.sgul.ac.uk/news/the-st-george-s-four-meet-the-women-that-shaped-st-george-s
- American Physical Society. “This Month in Physics History.” November 2001 (Volume 10, Number 10). https://www.aps.org/publications/apsnews/200111/history.cfm
- Bassett, Lawrence W. and Richard H. Gold. “The Evolution of Mammography.” AJR 150:493-498, March 1988.
- Bhidé, Amar et al. “Case Histories of Significant Medical Advances: Mammography.” Harvard Business School Working Paper 20-002. 2021.
- CROWTHER, J. Röntgen Centenary and Fifty Years of X-Rays. Nature 155, 351–353 (1945). https://doi.org/10.1038/155351a0
- Davis, Devra. “The Secret History Of Mammography.” HuffPost. 11/17/2011. https://www.huffpost.com/entry/the-secret-history-of-mam_b_364733
- Haus, Arthur G. “Historical Technical Developments in Mammography. Technology in Cancer Research & Treatment. ISSN 1533-0346. Volume 1, Number 2, April (2002)
- Kalaf, José Michael. “Mammography: a history of success and scientific enthusiasm.” Radiol Bras. 2014 Jul/Ago;47(4):VII–VIII. http://dx.doi.org/10.1590/0100-3984.2014.47.4e2
- Lerner, Barron H. “’To See Today With the Eyes of Tomorrow: A History of Screening Mammography.’” CBMH/BCMH I Volume 20:2 2003 / p. 299-321.
- Lerner, Barron H. “Why Was the US Preventive Services Task Force’s 2009 Breast Cancer Screening Recommendation So Objectionable? A Historical Analysis.” The Milbank Quarterly, September 2022, Vol. 100, No. 3 (September 2022). https://www.jstor.org/stable/10.2307/48713998
- Lienhard, Dina A., "Mammography". Embryo Project Encyclopedia ( 2018-03-25 ). ISSN: 1940-5030 https://hdl.handle.net/10776/13056
- Mao X, He W, Humphreys K, et al. Breast Cancer Incidence After a False-Positive Mammography Result. JAMA Oncol. Published online November 02, 2023. doi:10.1001/jamaoncol.2023.4519
- Mekasut, Nitida. “Mammography: From Past to Present.” The Bangkok Medical Journal. February 2011. https://www.bangkokmedjournal.com/sites/default/files/fullpapers/2010-1-Mekasut.pdf
- Nicosia, Luca et al. “History of Mammography: Analysis of Breast Imaging Diagnostic Achievements over the Last Century.” Healthcare 2023, 11, 1596. https://doi.org/10.3390/healthcare11111596
- Ritvo, Max. "The Role of Diagnostic Roentgenology in Medicine." New England Journal of Medicine 262, no. 24 (1960): 1201-09.
- Skloot, Rebecca. “Taboo Organ: How a Pitt Alum Refused to Let Mammography Be Ignored.” Pittmed. April 2001. https://www.pittmed.health.pitt.edu/apr_2001/taboo_organ.pdf
- Warren, Stafford L. “A Roentgenologic Study of the Breast.” The American Journal of Roentgenology and Radium Therapy 1930-08: Vol 24 Iss 2.
- Zenger, Ingo. “The history of mammography.” Siemens. https://www.medmuseum.siemens-healthineers.com/en/stories-from-the-museum/history-mammography
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
Welcome to Stuff You Missed in History Class, a production
of iHeartRadio.
Speaker 2 (00:11):
Hello, and welcome to the podcast. I'm Tracy V.
Speaker 1 (00:14):
Wilson and I'm Holly Frye.
Speaker 2 (00:17):
Back at the end of twenty twenty three, I had
more mammograms than has been typical for me so far
in my life. I know, going back for additional imaging
is a routine experience for some folks, and it can
be really scary. For me, this was a new experience. Ultimately,
(00:37):
everything was fine, but of course all of that made
me think about where this all came from. And we
have also gotten some requests for a history of mammography
over the years.
Speaker 1 (00:51):
While I was.
Speaker 2 (00:52):
Working on this, I was astonished at how much of
it happened during hollyson My lifetime. Like I had sort
of imagined my grandmother's going to get a baseline mammogram
in some kind of old timey mammography machine in the
fifties or early sixties. There were not even old timy
(01:16):
mammography machines at that point. Uh. And something I want
to be super clear about from the top of the
show is that we are going to be talking about
some of the recommendations on who should get a mammogram
and when, and some questions and controversies about mammography and
(01:37):
other kinds of breast imaging. This is not medical advice.
Holly and I are not doctors. Please do not especially
avoid getting a mammogram based on our summary of debates
about it from the seventies or whatever like.
Speaker 1 (01:55):
No, that's for a doctor discussion.
Speaker 2 (01:58):
There are still debates, they are ongoing. My advice is,
I know this is hard, especially in the United States,
but try to find a provider you trust and discuss
it with them. Yes.
Speaker 1 (02:13):
The history of mimography begins with the discovery of X rays.
In November of eighteen ninety five, Wilhelm Conrad Runkin was
experimenting with a Crooks tube. This is a type of
cathode ray tube, named for Sir William Crooks, who was
one of several people to develop similar tubes in the
eighteen sixties and seventies. This was a vacuum sealed container
(02:34):
made of glass with electrodes allowing a current to pass
through it that would cause the tube to glow.
Speaker 2 (02:41):
Uh. That is not the most precise explanation of what
this was, but I feel like we're not a physics podcast,
So It's okay. Runkin's discovery is often described as accidental,
but he was intentionally experimenting to try to figure out
if the Crooks tube was emitting something other than visible light.
(03:03):
He had placed an opaque wrapper around the tube, and
when he started the current to make sure that rapper
was blocking out all the light, some very un platino
cyanide on a piece of cardboard several feet away started
to glow. So you could describe that one moment as
an accidental discovery because he was basically checking on his
(03:24):
setup when he noticed this glow, but it was in
the context of a deliberate investigation. He had been studying
light phenomena for a while. The accident was that he
got data back sooner than he expected.
Speaker 1 (03:38):
To write. Soon, Runkin realized that whatever the cathodeery tube
was emitting could affect a photographic plate in addition to
passing through the shroud he was using to block the
visible light. These mysterious rays seemed to pass right through
various substances, including a plywood door, but they were blocked
by a strip of beating that had been stuck to
(03:59):
the or with lead. When he put his wife's hand
in front of the photographic plate. The resulting image clearly
showed her bones and the rings she was wearing.
Speaker 2 (04:09):
That image, of course, is often described as the first
X ray. Runkin reported his discovery at the end of December,
using the term X rays because the nature of these
rays was at the time unknown. Today we know that
X ray radiation is part of the electromagnetic spectrum, with
a higher frequency than visible or ultraviolet light. By mid
(04:33):
January eighteen ninety six, so almost immediately after Runkin made
his announcement, doctors and researchers were finding medical and dental
uses for X rays, like producing images of broken bones,
foreign objects in the body, and teeth. Most soft tissue
doesn't show up well on an X ray, but soon
doctors had figured out that they could X ray the
(04:53):
digestive system if the patient ingested a contrast agent like
barium sulfate. He also figured out that controlled exposure to
X rays could treat certain cancers. Runkin was awarded the
Nobel Prize in Physics for his discovery in nineteen oh one,
and the field of radiology is also called runkinology. For years,
(05:16):
X ray images were also known as Runkin photographs. But
of course, at this point people didn't have a clear
sense of how long exposure should be, or how best
to position people, or the damaging effects of too much
radiation exposure. Accounts from the first years after Runkin's discovery
describe exposure times of thirty minutes or an hour, or,
(05:40):
in the case of William Levy in July of eighteen
ninety six, a whole series of exposures lasting from eight
in the morning until ten at night. This was done
at his requests. They were trying to locate a bullet
that had been in his head since being shot by
a bank robber ten years before. Although doctors did obtain
a good image of the bullet, Levy was one of
(06:01):
many patients who was harmed by this radiation exposure. His
whole head became blistered and swollen, he lost all of
his hair on one side, and his lips cracked and bled.
Other patients also experienced things like burns and hair loss,
and a number of practitioners who were exposed to X
ray radiation over the course of years developed cancer later
(06:24):
in their lives. While there were medical uses for X rays,
pretty much immediately after their discovery, it took some time
before researchers tried to X ray breast tissue. The first
person known to have done this is Albert Solomon, who
was working at the University Hospital in Berlin. He studied
(06:45):
tissue from three thousand breasts, and some accounts that I
read described this as coming from patients who had had mastectomies.
Others described it as tissue that had come from the morgue.
I could not find a scan of this publication anywhere
in any language. I am not clear on the details.
Speaker 1 (07:04):
Solomon compared the tissue to the images shown in the
X rays, and in nineteen thirteen he published a paper
in German titled Contributions to the Pathology and Clinical Medicine
of Breast Cancer and that describes how runken photographs could
show the existence and spread of breast cancer, as well
as revealed the presence of cancer that couldn't yet be
felt through touch. Although soft tissue doesn't show up well
(07:27):
on an X ray, breast cancer usually has a different
density than the tissue around it, and some cancers also
cause micro calcifications or calcium deposits. All of that is
visible on an X ray To be clear. These were
not very clear X rays at all, but they were there.
Solomon's work was interrupted by World War One, during which
(07:49):
he worked as a doctor with the German military. He
returned to the hospital after the war was over, but
in nineteen thirty three, as the Nazis came to power,
he was removed from his position because he was Jewish.
After the November Pogram, also called krystel Nacht, he was
interned at a concentration camp and the family fled Germany
(08:09):
after his release. His daughter Charlotte was sent to live
with grandparents in southern France, but she was captured and
killed at Auschwitz. Solomon and his wife were interned a
second time, but escaped, and they survived the rest of
the war by hiding in the Netherlands. They lived in
Amsterdam after the war was over and Solomon went into
(08:29):
private practice. He had had to recertify in medicine because
his German credentials were not recognized there. Some other researchers
worked with X rays and breast tissue during these years,
but not until almost fifteen years after Solomon first published
the first person known to take an X ray of
a living person's breast was German surgeon Otto Kleinschmidt. In
(08:52):
nineteen twenty seven, he was working under the direction of
surgeon Edwin Peer.
Speaker 2 (08:58):
In nineteen thirty, radiologists Stafford Leake Warren at the University
of Rochester in New York published on a technique that
he had developed for compiling X rays taken from two
different angles. To get a stereoscopic view of the breast,
he had patients lie on their side with their arm
raised above their head, sort of stretching out the tissue
(09:19):
a bit. This stereoscopic view offered us somewhat more detailed
and accurate look at density changes within the breast. Warren
took X rays of the breasts of one hundred and
nineteen patients who had already been diagnosed with some kind
of breast issue and were scheduled for surgery. Using those images,
he concluded that fifty eight of them had breast cancer.
(09:43):
After their surgeries, he compared those results to the breast
tissue that had been removed and confirmed that fifty four
of those patients did have cancer. Four other patients had
breast cancer that Warren had not detected through his X rays. Yeah,
so basically there were four patients who he thought had
breast cancer but did not, and another four that he
(10:05):
had not thought had breast cancer but did. Other patients
in Warren's study, rather than having had cancer, had chronic
mastitis or benign tumors, absesses, some other issue that was
not cancer, and Warren's paper detailed what these looked like
in the X rays. This was pretty impressive, considering that
(10:26):
the images in Warren's X rays were not very clear
or detailed. Like if you look at a mammogram today
and you don't know how to read it, I would
say it can look not very detailed to you. These
were very blobby, like just a lot of white blobs
in vague shapes. A year after this, German researcher Walter
(10:49):
Vogel published a paper on using X rays to differentiate
between different types of tumors, including how to tell benign
breast lesions from malignant ones. The term mammography was coined
in nineteen thirty seven by Nymphis Frederic Hicken, a physician
and surgeon in Salt Lake City, Utah. His article Mimography
(11:10):
the rent Genographic Diagnosis of Breast Tumors by Means of
Contrast Media was published in the Journal Surgery, Gynecology and Obstetrics.
He was one of several people in the nineteen thirties
and forties who were looking at the use of contrast
media to get better images in breast X rays. Contrast
enhanced mimography is still around today and it's typically used
(11:31):
after someone has already had a mammogram without contrast, like
if that mammogram showed something that required further investigation or
to monitor progress during breast cancer treatment, especially in people
who can't get an MRI for some reason. We will
look into how mammography evolved in the nineteen forties and
fifties after a sponsor break. If you have never had
(12:03):
a mammogram. Today there is a machine involved, one that
is made specifically for mimmography and it compresses the breast.
But the researchers we've been talking about so far, we're
using basic X ray equipment that had not been made
specifically for breast imaging, and they also weren't compressing the
(12:24):
breast tissue to X ray it. The first person known
to compress the breast to try to get a better
image of it was Raoul Lebourne, who was a radiologist
from Uruguay in nineteen forty nine. He found that compressing
the breast produced clearer images and made it easier to
(12:44):
distinguish between cancerous and benign masses. He also found that
using a double emulsion film improved the image quality even further.
He described the presence of micro calcifications that could be
used to help identify certain cancers. Lebourne started publishing his
findings on all this in nineteen fifty one.
Speaker 1 (13:04):
Lebourne wasn't using equipment made specifically for mammograms, though basically
the person stood in front of a table that was
about breast height. The breast to be x rayed was
placed on the table with the photographic film in an
envelope under it. Then there was a cone. The X
ray emitter was at the little end and the big
(13:25):
end was placed on the breast, applying what he described
as a slight pressure. Lebourne used a small cone when
a specific area of the breast needed to be imaged,
and a large cone to image the whole breast.
Speaker 2 (13:38):
One of the other people working on breast imaging in
the nineteen fifties was Robert Egan, who started his work
during his residency in radiology. Over the course of his research,
he concluded that mimmography could use lower power X rays
than other diagnostic imaging did, and that radiologist could adjust
the power based on breast size and density. He pinpointed
(14:01):
a more sensitive X ray film that could provide more
detailed images and intensifying screens that could reduce blurring. He
also suggested the use of cardboard cutouts to position the
breast for the best view. Like several other researchers before him,
Egan x rayed the breasts of people who had been
diagnosed with cancer or another breast disease, comparing the X
(14:25):
ray image to the diagnosis they had already received. He
also compared the X rays of that breast to the
patient's other, presumably healthy breast. He sometimes detected tumors in
the other breasts that the patient and doctor had not
been aware of. Egan's initial focus had been on helping
doctors visualize known or suspected cancers in order to make
(14:48):
diagnoses and treatment plans, but his research also suggested that
mimography could be used as a screening tool. Between nineteen
fifty six and nineteen fifty nine, he and his colleagues
at m D. Anderson Cancer Center imaged the breasts of
a thousand patients who didn't have obvious signs of breast cancer,
(15:08):
and in two hundred and thirty eight of them, mimography
revealed a previously undetected tumor. Most of these tumors were
so small that they could not be felt at all.
One of them was only eight millimeters in diameter. Egan
became a proponent of the idea of screening mammograms and
later traveled all around the country training other radiologists to
(15:30):
do them. There was even a national study to confirm
that his techniques could be successfully taught to other people,
who could then get similar results in the mammograms they performed.
Egan was not the only one advocating for screening mammograms
around this time. Others were Jacob Gershan Cohen, and Helen Ingleby.
(15:50):
All through the nineteen fifties, Grushan, Cohen, and Ingleby collaborated
on research related to the breast and breast imaging, including
various ways that different pathologies could have here in an
X ray, and they also documented normal changes to the
breast due to factors like menstruation, lactation, and age, which
were also visible on X rays. They published numerous papers
(16:12):
together and co authored a book called Comparative Anatomy Pathology
and wrote Ganology of the Breast that was published in
nineteen sixty. So we'll take a moment here to note
that we were about halfway through this episode on mimography
and we have only just now gotten to a woman researcher.
At this point, there were not many women doctors. There
(16:33):
were even fewer women in specialized fields like radiology or oncology.
We have a previous episode on Elizabeth Blackwell, who was
the first woman in the US to earn an MD,
which had happened in eighteen forty nine. Helen Ingleby had
attended the London Medical School for Women, which was England's
first medical school that enrolled women, and one of its
(16:55):
founders was Elizabeth Blackwell. Ingleby was also one of the
Saint George's Four, which was a nickname for the four
first women to begin studying medicine at Saint George's University
of London, which was in nineteen fifteen.
Speaker 1 (17:10):
Ingleby was the first.
Speaker 2 (17:11):
Woman to qualify for the Bachelor of Medicine degree at
the university.
Speaker 1 (17:16):
The lack of women in medicine absolutely affected the field
of mimmography and the understanding of breast cancer and just
breast health in general. There's still so much cultural baggage
around breasts and around gender, and this was even more
true in the nineteen fifties and sixties. A lot of
male doctors were uncomfortable examining women patients breasts, and a
(17:38):
lot of women were uncomfortable being examined by male doctors
or even talking to a male doctor or anyone else
about a concern with their breasts. Robert Egan was known
to complain about the fact that cultural taboos and hang
ups about breasts were getting in the way of medicine,
and some of his colleagues gave him crude nicknames because
of his focus on mimmography.
Speaker 2 (18:00):
They're in the research for this episode. It also really
stood out to me that Helen Ingleby had been a
collaborator on work that really helped document the many ways
that a person's breasts can change due to very ordinary
things like menstruation and aging. With all of those changes
being like in the umbrella of normal, I feel like
(18:22):
she is the original consultant of like, no, yeah, that happens. No,
that's that's not really yeah that happens all the time.
Although Egan, Gershan, Cohen, and Ingleby were all vocal proponents
of mimmography, not a lot of radiologists were actually performing
mammograms by nineteen sixty. The nineteen sixty Annual Oration before
(18:43):
the Massachusetts Medical Society, which was published under the title
the Role of Diagnostic ron Geneology and Medicine in the
New England Journal of Medicine does not mention mimmography or
the breast at all. Egan had published his mimography technique
by then, but most practitioners still didn't know about it yet.
There was also no dedicated equipment to make X raying
(19:05):
the breast easier and more consistent. Even formal research into
mimography was still being done with X ray equipment that
was made for other purposes, and the radiologists who were
X raying the breast were mostly working with patients who
were already showing signs of breast cancer or some other
disorder or disease of the breast. This was not usually
(19:27):
a way to spot previously undetected problems. Although there were
anecdotes about people whose tumors had been discovered on a
breast X ray, there had not been any controlled studies
to determine whether mammograms could be used as an effective
screening tool.
Speaker 1 (19:46):
This started to shift later in the sixties, in part
because the work of radiologist Philip Strax. His wife, Bertha
Goldberg Stras had died of breast cancer in nineteen forty seven,
the age of just thirty nine, and that led him
to focus his career on the detection and treatment of
breast cancer. In nineteen sixty three, he began collaborating with
Sam Shapiro, director of Research and Statistics at the Health
(20:09):
Insurance Plan of Greater New York or HIP or HIP,
and surgeon Lewis Vney on a large scale, randomized trial
into the efficacy of mimmography as a screening tool.
Speaker 2 (20:21):
Uh, I'm just gonna admit I did not go down
the rabbit hole of whether people say this hip or hip.
We're just gonna call it hip. Participants in this study
were HIP members, and sometimes this trial is called the
HIP study. It involved sixty two thousand women between the
ages of forty and sixty four. Half were given annual
(20:41):
examinations that involved an interview, a breast exam, and a mammogram.
Speaker 1 (20:46):
The other half.
Speaker 2 (20:47):
Received their usual medical care without this annual screening, although
if their doctor gave them a breast exam or ordered
them to get a mammogram for some reason, they were
not prevented from getting one, they just were not having
a dedicated annual screening. This was a three year study,
and initially the death rate from breast cancer was reported
as forty percent lower in the group that had received
(21:10):
the annual breast exams. That number was later lowered to
thirty percent, but that was still dramatic. Patients in the
screening group who were diagnosed with breast cancer over the
course of the study were also far more likely to
show no signs of the disease in their lymph nodes,
meaning their cancer was probably locally confined to the breast
(21:30):
when it was detected. The study also acknowledged some of
the realities of the medical system and getting access to
medical care in the United States, like these were all
folks who were part of a health insurance plan, that
is a specific population of people. At the same time,
many of the hospitals in New York where mammograms were
(21:51):
being done were not convenient to the women who were
enrolled in this study, so the team basically turned a
van into a mobile mimography and they drove it to
the places where the women worked so that they could
be screened on their lunch break. Even with that effort, though,
a significant number of participants in this study didn't return
(22:11):
for their follow up exams. That reduced the number of
people who participated in the study all the way to
the end.
Speaker 1 (22:18):
Preliminary results were published in the Journal of the American
Medical Association in nineteen sixty six, and another article followed
in nineteen seventy one, and overall, using mammograms to screen
people for breast cancer seemed like a clear success. Philip
Strax joined Robert Egan, Jacob Gershaan Cohen, and Helen Ingleby
in advocating for screening mammograms.
Speaker 2 (22:41):
Another big breakthrough came about in nineteen sixty five in Strasbourg, France,
when radiologist Charles Gross worked with company generald At Radiology
to develop the CGR centograph. This was the first device
specifically made to X ray the breast. Gross was a
vocal advocate for breast cancer screening as well, and there
(23:02):
are a number of sources that describe him and Philip
Egan as the two people within the medical community who
really did the most to push the idea of screening
mammograms into the mainstream. Of course, there were also developments
that were happening from outside the medical community. In the US,
for example, President Richard Nixon announced a War on Cancer
(23:25):
in nineteen seventy one. A year later, the National Cancer
Institute and the American Cancer Society teamed up to launch
the Breast Cancer Detection Demonstration Project or BCDDP. The American
Cancer Society was heavily invested in this During the nineteen
fifties and sixties, the American Cancer Society had pushed for
(23:46):
routine cervical cancer screening using AP tests, and death rates
from cervical cancer were declining. It was hoped that routine
breast screenings would have a similar impact on deaths from
breast cancer. The BCDDP offered five years of free annual
mammograms to women over the age of thirty five. That
was at twenty nine screening centers located in twenty seven
(24:09):
cities around the US. More than two hundred and eighty
thousand women were screened at one of these centers between
nineteen seventy three and nineteen eighty That exceeded the project's
initial goal by more than ten thousand.
Speaker 1 (24:23):
Interest in screenings also surged in the US in the
fall of nineteen seventy four after Betty Ford, wife of
President Gerald Ford, and Margaretta Rockefeller, known as Happy Wife
of Nelson Rockefeller, each announced that they had been diagnosed
with breast cancer. Although neither of their cancers had been
initially detected in a mammogram, both underwent surgery and survived,
(24:46):
and their public acknowledgment of what had happened helped dispel
some of the stigma and secrecy surrounding the disease.
Speaker 2 (24:53):
It was also evolving that breast cancer was a survivable
and even curable disease if people caught it early, and
this was feeding into that as well. Things moved a
bit more slowly in other parts of the world. For example,
in Europe in the nineteen seventies, only Sweden and Scotland
conducted trials of screening mammograms. In Japan, as another example,
(25:16):
ultrasound was already being used for breast imaging, so there
just really wasn't a big focus on seeing how mimography
would work there.
Speaker 1 (25:26):
There were also doubts and controversies pretty much right away.
Although the Hip study had shown a clear reduction in mortality.
In the group that had regular breast exams. Only forty
four cases of breast cancer had been found only through
mimography over the course of that study. In many other cases,
the patient's medical history, physical exam, or interview had already
(25:48):
suggested the possibility of cancer.
Speaker 2 (25:51):
One of the people to publicly criticize the idea of
screening mammograms was John C. Baylor, who was statistician with
the National Cancer Institute. He published an article called Mimography
A Contrary View and the Annals of Internal Medicine in
January of nineteen seventy six. This is one of the
(26:12):
moments where I was like, this was after I was born.
His criticisms included the fact that many of the early
cancers that were being diagnosed were very slow growing masses
that might not ever reach a point where they were
a risked to the patient's life. He also expressed concerns
that the radiation exposure involved with a mammogram could contribute
(26:35):
to breast cancers later in life. I'll pause to say
the amount of radiation exposure is less now than it
was in nineteen seventy six. He argued that the government
should have been focusing its efforts on further randomized controlled trials,
including trials specifically looking at the question of whether screening
(26:56):
mammograms were worthwhile in patients under the age of fifty,
and studies on more diverse groups of people, rather than
a demonstration project like the BCDDP. Baylor initially criticized all
screening mammograms, but eventually really focused his attention on the
ones performed on women under the age of fifty.
Speaker 1 (27:17):
The same year that Baylor published this article, the American
Cancer Society started recommending mimography for early breast cancer detection.
We'll talk more about that after a sponsor break.
Speaker 2 (27:38):
The American Cancer Society had started educational campaigns recommending that
women examined their own breasts for signs of cancer in
the nineteen thirties and forties. That, plus the increased use
of screening mammograms in the late sixties and seventies, meant
that more people were being diagnosed with breast cancer earlier
than they might have been otherwise. But for decades, the
(28:02):
standard treatment for breast cancer in the US and much
of Europe had involved a radical mastectomy. This surgery was
developed by William Stewart Halstead all the way back in
eighteen eighty two, building on the work of earlier doctors.
This included the removal of the breast and adjacent parts
of the lymphatic system and the pectoralis major muscle.
Speaker 1 (28:26):
That's a major surgery. But when Halsta developed it, most
breast cancers were detected when tumors were large enough to
be obvious and had started to spread beyond the breast.
But at least in theory, cancers that were discovered earlier
might not need such a broad response. This led to
questions of whether mammograms were going to lead to people
(28:47):
having major surgery that they didn't actually need. So this
ties into the history of breast cancer treatment, which of
course could be a whole separate topic. The first chemotherapy
drugs were developed in the nineteen forties and fifties. As
we said, earlier experiments in radiotherapy as a cancer treatment
had started almost immediately after the discovery.
Speaker 2 (29:08):
Of X rays. Surgeon John Madden modified Halsted's methods for
the radical mastectomy in nineteen seventy two, with Madden's techniques
preserving the pectoral missiles. Oncologist Umberto VERNESSI also promoted a
more conservative surgery described as a quadrant ectomy, combining that
(29:29):
with radiotherapy. Studies comparing the efficacy of radical mastectomies with
Vernesi's methods started in Milan in nineteen seventy three, and
this was part of a whole process of figuring out
how to successfully treat breast cancers that were detected earlier
without overtreating them, like, without giving people a more intense
(29:51):
treatment than they actually needed.
Speaker 1 (29:54):
Complicating all of this was the fact that screening mammograms
were identifying growths that were ambiguous. In other words, it
wasn't obvious whether they were or were not cancerous. While
the BCDDP was ongoing, a preliminary report suggested that sixty
six of five hundred six pathological specimens collected so far
had not actually contained any sign of cancer nor carcinoma
(30:17):
in situ. Today, carcinoma in situ is sometimes called stage
zero cancer, and it involves precancerous cells that have not spread,
which may or may not become cancerous. Of those sixty
six specimens that didn't have any evidence of cancerous or
precancerous cells, fifty three had led the patient to undergo
(30:38):
some type of mastectomy. The researcher stressed that the mammograms
were not to blame for this, that other doctors had
performed those biopsies, made those diagnoses, and recommended those surgical treatments.
But all of this added to the ongoing questions about
the idea of overtreatment.
Speaker 2 (30:57):
With all these kinds of questions in play and others,
various states and the US federal government started working to
regulate mammography. Between nineteen eighty six and nineteen ninety two,
a number of laws were passed requiring things like dedicated
mimmography machines at hospitals and inspections on those machines. The
(31:17):
US passed the Mimography Quality Standards Act in nineteen ninety two,
which was meant to help ensure the safety and efficacy
of mimmography, including making sure the amount of radiation patients
were exposed to was low. The American College of Radiology
also developed the Breast Imaging and Reporting Data System or
(31:38):
BIRADS in nineteen ninety three to provide standardized ways to
describe and report mammogram results. Today, the byrad's AT list
includes guidelines for multiple types of breast imaging, including mammography
ultrasound and MRI.
Speaker 1 (31:55):
There were numerous advances in mimography technology and methods in
the late nineteen eighties and nineteen nineties. Digital mimography was
introduced in two thousand and one, and today most mammograms
are digital, so radiologists can see the images instantly rather
than waiting for films to be developed. Digital mimography also
tends to be more accurate in people over the age
(32:17):
of fifty, although the accuracy is about the same in
people younger than that. Digital temosynthesis or three D digital mimography,
was introduced in twenty eleven.
Speaker 2 (32:28):
And there are other methods for breast imaging as well.
Some examples include magnetic resonance imaging or MRI, ultrasound mimography
with contrasts, which we mentioned earlier, positron emission mimography, and
breast specific gammut imaging.
Speaker 1 (32:44):
A lot of these.
Speaker 2 (32:44):
Today are used after a screening mammogram has revealed something
that needs further evaluation, or after somebody has been diagnosed
with breast cancer, to better visualize the tumor and to
monitor progress during treatment.
Speaker 1 (32:59):
In more recent years, there have also been recommendations for
mammography to be paired with automated whole breast ultrasound in
people with dense breasts, and at this point it's usually
recommended in addition to not instead of a mammogram. But
there's also an overall higher false positive rate for breast ultrasounds,
including automated whole breast ultrasound, than there is for mammograms.
(33:23):
Some of the concerns about mimmography that were raised in
the wake of the Hip study continue to be debated today.
Like the Hip study had shown clear evidence that routine
breast cancer screening could reduce the number of deaths from
breast cancer in people over the age of fifty, but
there wasn't clear evidence for women between the ages of
forty and fifty. Screening mammograms really didn't seem to make
(33:46):
much of a difference in this age group. If you're
in that age bracket, which I am, and you've gotten
a mammogram, you may have gotten results describing your breasts
as dense. Basically, younger bread guests contain a lot more
connective tissue and other structures that show up on a mammogram,
and that can make it harder to spot small tumors,
(34:08):
but older breasts usually have less connective tissue and more fat,
so tumors stand out more on a mammogram. In general,
breast cancer risk also increases with age, So what's the
right age for a person to start having mammograms? Guidance
on this has changed repeatedly since the years of the
(34:29):
Hip study, including an incredibly controversial recommendation by the US
Preventative Services Task Force in two thousand and nine. That
recommendation was that women between the ages of forty and
forty nine not be routinely screened. There is still so
much debate about the age at which people should start
getting mammograms and how often they should get them after
(34:51):
that point, and there's often a lack of consensus among
different organizations and governing bodies about what those recommendations should be.
Recommendations for transgender and non binary people are even more
scattered in contradictory and are based on just really limited data.
I read through these and I found them very confusing.
(35:12):
And this is for a community of people. Trans and
non binary people already often having a really high bar
to getting compassionate medical care at all, just making it
more complicated and based on limited data A cynical way
to look at this debate about when and how often
(35:33):
people should get mammograms, especially in places like the United
States where we don't have universal health care, is that
this is all about money and what insurance companies are
willing to pay for, especially when it comes to people
under the age of fifty. There definitely are arguments about
whether routine mammograms are the cost effective way to detect
(35:53):
signs of breast cancer. I read some of those papers.
I found them irritating. To the National Cancer Institute, more
than seventy five percent of women in the US between
the ages of fifty and seventy four have had a
mammogram within the last two years, but more than half
of breast cancers are discovered by the patients themselves or
(36:16):
their partners, not from a mammogram. So that's like a
question of like, wouldn't it be cheaper to just make
sure everybody's getting regular physical exams.
Speaker 2 (36:27):
I find that I'm like, this is it cheaper? I
find that to be a frustrating way to look at it.
Speaker 1 (36:33):
I have a question about that that we can table
till an so frietay, sure, yes, But beyond all of that,
there are real questions about the efficacy of mimography as
a screening tool, especially in people under the age of fifty.
As we said earlier, it's not just about the fact
that a higher breast density can make small tumors harder
(36:54):
to see. There are also questions around the risks of
false positive and overtreatment. As we're result of earlier annual mammograms.
It's estimated that over the course of ten screenings, roughly
half of patients in the US will experience a false
positive and roughly twenty percent of patients in Europe. And
there are still lingering questions about overtreatment and whether very
(37:17):
small growth seen on mammograms need to be treated or
would ever jeopardize the patient's life in any way.
Speaker 2 (37:24):
So we can't speak from experience about other parts of
the world. Holly and I live in the United States,
but here there are huge disparities and who has access
to screening mammograms, including who has access to the newer
technologies like three D mimography, and these disparities are often
compounded in every step of the process. So a person
(37:45):
who can't get an appointment, or can't get an appointment
at a place that has the most up to date
equipment or can't afford a mammogram at all, or feels
unwelcome at the doctor due to factors like medical racism
and fat phobia and trans phobia. They're gonna have these
same exact issues again when it comes to follow ups
(38:05):
if additional imaging is needed. Treatment can also be incredibly
expensive for breast cancer, even in people who have insurance,
and so all of this contributes to racial and economic
disparities in breast cancer detection rates and survival rates for
breast cancer, with black women in the US in particular
being a lot just disproportionately more likely to die from
(38:29):
the disease. I know that is a kind of dire
place to leave off the episode.
Speaker 1 (38:37):
The Grim de new mal of the episode.
Speaker 2 (38:40):
Yeah, I didn't feel like I could just leave that out.
Speaker 1 (38:43):
Do you have less Grim listener mail?
Speaker 2 (38:45):
Do I have much less Grim listener mail? Fabuloush The
clistener mail came from Dave and Dave's subject line is
just Assassin's Creed origins. Dave wrote, Hi, Holly and Tracy,
I guess I have a PhD in the show. Since
I've been listening to the podcast from the very start,
I've loved the many evolutions of the show over the years,
and I'm grateful for all the hard work you put
(39:07):
into it. Naturally, I've been tempted to write several times,
especially since my hometown of Saint Catherine's, Ontario has appeared
in a number of episodes, but I never felt I
had something worth sharing, well, at least until you talked
about Assassin's Creed. During the Banu Musa episode. You touched
upon how ubsoft tries to add some level of historical
(39:27):
accuracy to the backgrounds in the game. What you may
not realize is that historians and museums have taken note
of that. I volunteer at the Nilson Atkins Museum in
Kansas City. It's a world class museum and I love
giving tours and interacting with guests. Before the pandemic, we
had an episode on Nefertari was an amazing collaboration with
the museum, Egzo and for In Italy. Featured prominently in
(39:51):
the exhibit were animated outtakes from an educational version of
Assassin's Creed origins. You can find these online at Ubusov's
website and there's a link to that. Needless to say,
it was very cool to have these recreated sites next
to actual artifacts, and people love it. So I hope
you enjoy that tidbit and don't get stuck in the
rabbit hole of these Assassin's Creed discovery tours. Here's my
(40:12):
pet tax. What follows is an adorable black kitty cat
asleep on a cream colored carpet. Cricket is a Manx.
This breed typically do not have tails. She's got a
lot of personality and wants a lot of attention. Although
she refuses to be a lap cat. She wants her
tribute on her terms. Keep up the great work, sincerely, Dave.
(40:34):
I love this kitty cat.
Speaker 1 (40:35):
I used to have a Manx and I loved him desperately,
and it was like living with a really fabulous drag queen.
Speaker 2 (40:43):
Oh.
Speaker 1 (40:43):
It would look you up and down and be like
you're wearing that today? Like chess?
Speaker 2 (40:47):
Yeah, the goofiest, sweetest but also slightly attitudinous. Yeah. So
I knew that these discovery tours existed in the Assassin's
Creed games. I have never actually checked any of them
out on my games. I see them there in the menu,
I see that there are achievements for doing them. I
have not actually done any of them. I did not
(41:08):
know though, that they were also used in museums and
educational centers to like add another element to the educational stuff.
I think that is pretty cool. So thanks so much
for this email day. If you'd like to write to us,
we're History podcast at iHeartRadio dot com. We are on
(41:30):
social media at Missing History. That's where you'll find our
Facebook Twitter. It's not even called Twitter anymore. I don't
know why even say it is.
Speaker 1 (41:38):
To me.
Speaker 2 (41:38):
I think it's always Twitter in my heart.
Speaker 1 (41:40):
I refuse to acknowledge.
Speaker 2 (41:44):
And you can subscribe to our show on the iHeartRadio
app or wherever else you like to get your podcasts.
Stuff you Missed in History Class is a production of iHeartRadio.
For more podcasts from iHeartRadio, visit the iHeartRadio app, Apple Podcasts,
or wherever you listen to your favorite shows.
Welcome to Stuff You Missed in History Class, a production
of iHeartRadio.
Speaker 2 (00:11):
Hello, and welcome to the podcast. I'm Tracy V.
Speaker 1 (00:14):
Wilson and I'm Holly Frye.
Speaker 2 (00:17):
Back at the end of twenty twenty three, I had
more mammograms than has been typical for me so far
in my life. I know, going back for additional imaging
is a routine experience for some folks, and it can
be really scary. For me, this was a new experience. Ultimately,
(00:37):
everything was fine, but of course all of that made
me think about where this all came from. And we
have also gotten some requests for a history of mammography
over the years.
Speaker 1 (00:51):
While I was.
Speaker 2 (00:52):
Working on this, I was astonished at how much of
it happened during hollyson My lifetime. Like I had sort
of imagined my grandmother's going to get a baseline mammogram
in some kind of old timey mammography machine in the
fifties or early sixties. There were not even old timy
(01:16):
mammography machines at that point. Uh. And something I want
to be super clear about from the top of the
show is that we are going to be talking about
some of the recommendations on who should get a mammogram
and when, and some questions and controversies about mammography and
(01:37):
other kinds of breast imaging. This is not medical advice.
Holly and I are not doctors. Please do not especially
avoid getting a mammogram based on our summary of debates
about it from the seventies or whatever like.
Speaker 1 (01:55):
No, that's for a doctor discussion.
Speaker 2 (01:58):
There are still debates, they are ongoing. My advice is,
I know this is hard, especially in the United States,
but try to find a provider you trust and discuss
it with them. Yes.
Speaker 1 (02:13):
The history of mimography begins with the discovery of X rays.
In November of eighteen ninety five, Wilhelm Conrad Runkin was
experimenting with a Crooks tube. This is a type of
cathode ray tube, named for Sir William Crooks, who was
one of several people to develop similar tubes in the
eighteen sixties and seventies. This was a vacuum sealed container
(02:34):
made of glass with electrodes allowing a current to pass
through it that would cause the tube to glow.
Speaker 2 (02:41):
Uh. That is not the most precise explanation of what
this was, but I feel like we're not a physics podcast,
So It's okay. Runkin's discovery is often described as accidental,
but he was intentionally experimenting to try to figure out
if the Crooks tube was emitting something other than visible light.
(03:03):
He had placed an opaque wrapper around the tube, and
when he started the current to make sure that rapper
was blocking out all the light, some very un platino
cyanide on a piece of cardboard several feet away started
to glow. So you could describe that one moment as
an accidental discovery because he was basically checking on his
(03:24):
setup when he noticed this glow, but it was in
the context of a deliberate investigation. He had been studying
light phenomena for a while. The accident was that he
got data back sooner than he expected.
Speaker 1 (03:38):
To write. Soon, Runkin realized that whatever the cathodeery tube
was emitting could affect a photographic plate in addition to
passing through the shroud he was using to block the
visible light. These mysterious rays seemed to pass right through
various substances, including a plywood door, but they were blocked
by a strip of beating that had been stuck to
(03:59):
the or with lead. When he put his wife's hand
in front of the photographic plate. The resulting image clearly
showed her bones and the rings she was wearing.
Speaker 2 (04:09):
That image, of course, is often described as the first
X ray. Runkin reported his discovery at the end of December,
using the term X rays because the nature of these
rays was at the time unknown. Today we know that
X ray radiation is part of the electromagnetic spectrum, with
a higher frequency than visible or ultraviolet light. By mid
(04:33):
January eighteen ninety six, so almost immediately after Runkin made
his announcement, doctors and researchers were finding medical and dental
uses for X rays, like producing images of broken bones,
foreign objects in the body, and teeth. Most soft tissue
doesn't show up well on an X ray, but soon
doctors had figured out that they could X ray the
(04:53):
digestive system if the patient ingested a contrast agent like
barium sulfate. He also figured out that controlled exposure to
X rays could treat certain cancers. Runkin was awarded the
Nobel Prize in Physics for his discovery in nineteen oh one,
and the field of radiology is also called runkinology. For years,
(05:16):
X ray images were also known as Runkin photographs. But
of course, at this point people didn't have a clear
sense of how long exposure should be, or how best
to position people, or the damaging effects of too much
radiation exposure. Accounts from the first years after Runkin's discovery
describe exposure times of thirty minutes or an hour, or,
(05:40):
in the case of William Levy in July of eighteen
ninety six, a whole series of exposures lasting from eight
in the morning until ten at night. This was done
at his requests. They were trying to locate a bullet
that had been in his head since being shot by
a bank robber ten years before. Although doctors did obtain
a good image of the bullet, Levy was one of
(06:01):
many patients who was harmed by this radiation exposure. His
whole head became blistered and swollen, he lost all of
his hair on one side, and his lips cracked and bled.
Other patients also experienced things like burns and hair loss,
and a number of practitioners who were exposed to X
ray radiation over the course of years developed cancer later
(06:24):
in their lives. While there were medical uses for X rays,
pretty much immediately after their discovery, it took some time
before researchers tried to X ray breast tissue. The first
person known to have done this is Albert Solomon, who
was working at the University Hospital in Berlin. He studied
(06:45):
tissue from three thousand breasts, and some accounts that I
read described this as coming from patients who had had mastectomies.
Others described it as tissue that had come from the morgue.
I could not find a scan of this publication anywhere
in any language. I am not clear on the details.
Speaker 1 (07:04):
Solomon compared the tissue to the images shown in the
X rays, and in nineteen thirteen he published a paper
in German titled Contributions to the Pathology and Clinical Medicine
of Breast Cancer and that describes how runken photographs could
show the existence and spread of breast cancer, as well
as revealed the presence of cancer that couldn't yet be
felt through touch. Although soft tissue doesn't show up well
(07:27):
on an X ray, breast cancer usually has a different
density than the tissue around it, and some cancers also
cause micro calcifications or calcium deposits. All of that is
visible on an X ray To be clear. These were
not very clear X rays at all, but they were there.
Solomon's work was interrupted by World War One, during which
(07:49):
he worked as a doctor with the German military. He
returned to the hospital after the war was over, but
in nineteen thirty three, as the Nazis came to power,
he was removed from his position because he was Jewish.
After the November Pogram, also called krystel Nacht, he was
interned at a concentration camp and the family fled Germany
(08:09):
after his release. His daughter Charlotte was sent to live
with grandparents in southern France, but she was captured and
killed at Auschwitz. Solomon and his wife were interned a
second time, but escaped, and they survived the rest of
the war by hiding in the Netherlands. They lived in
Amsterdam after the war was over and Solomon went into
(08:29):
private practice. He had had to recertify in medicine because
his German credentials were not recognized there. Some other researchers
worked with X rays and breast tissue during these years,
but not until almost fifteen years after Solomon first published
the first person known to take an X ray of
a living person's breast was German surgeon Otto Kleinschmidt. In
(08:52):
nineteen twenty seven, he was working under the direction of
surgeon Edwin Peer.
Speaker 2 (08:58):
In nineteen thirty, radiologists Stafford Leake Warren at the University
of Rochester in New York published on a technique that
he had developed for compiling X rays taken from two
different angles. To get a stereoscopic view of the breast,
he had patients lie on their side with their arm
raised above their head, sort of stretching out the tissue
(09:19):
a bit. This stereoscopic view offered us somewhat more detailed
and accurate look at density changes within the breast. Warren
took X rays of the breasts of one hundred and
nineteen patients who had already been diagnosed with some kind
of breast issue and were scheduled for surgery. Using those images,
he concluded that fifty eight of them had breast cancer.
(09:43):
After their surgeries, he compared those results to the breast
tissue that had been removed and confirmed that fifty four
of those patients did have cancer. Four other patients had
breast cancer that Warren had not detected through his X rays. Yeah,
so basically there were four patients who he thought had
breast cancer but did not, and another four that he
(10:05):
had not thought had breast cancer but did. Other patients
in Warren's study, rather than having had cancer, had chronic
mastitis or benign tumors, absesses, some other issue that was
not cancer, and Warren's paper detailed what these looked like
in the X rays. This was pretty impressive, considering that
(10:26):
the images in Warren's X rays were not very clear
or detailed. Like if you look at a mammogram today
and you don't know how to read it, I would
say it can look not very detailed to you. These
were very blobby, like just a lot of white blobs
in vague shapes. A year after this, German researcher Walter
(10:49):
Vogel published a paper on using X rays to differentiate
between different types of tumors, including how to tell benign
breast lesions from malignant ones. The term mammography was coined
in nineteen thirty seven by Nymphis Frederic Hicken, a physician
and surgeon in Salt Lake City, Utah. His article Mimography
(11:10):
the rent Genographic Diagnosis of Breast Tumors by Means of
Contrast Media was published in the Journal Surgery, Gynecology and Obstetrics.
He was one of several people in the nineteen thirties
and forties who were looking at the use of contrast
media to get better images in breast X rays. Contrast
enhanced mimography is still around today and it's typically used
(11:31):
after someone has already had a mammogram without contrast, like
if that mammogram showed something that required further investigation or
to monitor progress during breast cancer treatment, especially in people
who can't get an MRI for some reason. We will
look into how mammography evolved in the nineteen forties and
fifties after a sponsor break. If you have never had
(12:03):
a mammogram. Today there is a machine involved, one that
is made specifically for mimmography and it compresses the breast.
But the researchers we've been talking about so far, we're
using basic X ray equipment that had not been made
specifically for breast imaging, and they also weren't compressing the
(12:24):
breast tissue to X ray it. The first person known
to compress the breast to try to get a better
image of it was Raoul Lebourne, who was a radiologist
from Uruguay in nineteen forty nine. He found that compressing
the breast produced clearer images and made it easier to
(12:44):
distinguish between cancerous and benign masses. He also found that
using a double emulsion film improved the image quality even further.
He described the presence of micro calcifications that could be
used to help identify certain cancers. Lebourne started publishing his
findings on all this in nineteen fifty one.
Speaker 1 (13:04):
Lebourne wasn't using equipment made specifically for mammograms, though basically
the person stood in front of a table that was
about breast height. The breast to be x rayed was
placed on the table with the photographic film in an
envelope under it. Then there was a cone. The X
ray emitter was at the little end and the big
(13:25):
end was placed on the breast, applying what he described
as a slight pressure. Lebourne used a small cone when
a specific area of the breast needed to be imaged,
and a large cone to image the whole breast.
Speaker 2 (13:38):
One of the other people working on breast imaging in
the nineteen fifties was Robert Egan, who started his work
during his residency in radiology. Over the course of his research,
he concluded that mimmography could use lower power X rays
than other diagnostic imaging did, and that radiologist could adjust
the power based on breast size and density. He pinpointed
(14:01):
a more sensitive X ray film that could provide more
detailed images and intensifying screens that could reduce blurring. He
also suggested the use of cardboard cutouts to position the
breast for the best view. Like several other researchers before him,
Egan x rayed the breasts of people who had been
diagnosed with cancer or another breast disease, comparing the X
(14:25):
ray image to the diagnosis they had already received. He
also compared the X rays of that breast to the
patient's other, presumably healthy breast. He sometimes detected tumors in
the other breasts that the patient and doctor had not
been aware of. Egan's initial focus had been on helping
doctors visualize known or suspected cancers in order to make
(14:48):
diagnoses and treatment plans, but his research also suggested that
mimography could be used as a screening tool. Between nineteen
fifty six and nineteen fifty nine, he and his colleagues
at m D. Anderson Cancer Center imaged the breasts of
a thousand patients who didn't have obvious signs of breast cancer,
(15:08):
and in two hundred and thirty eight of them, mimography
revealed a previously undetected tumor. Most of these tumors were
so small that they could not be felt at all.
One of them was only eight millimeters in diameter. Egan
became a proponent of the idea of screening mammograms and
later traveled all around the country training other radiologists to
(15:30):
do them. There was even a national study to confirm
that his techniques could be successfully taught to other people,
who could then get similar results in the mammograms they performed.
Egan was not the only one advocating for screening mammograms
around this time. Others were Jacob Gershan Cohen, and Helen Ingleby.
(15:50):
All through the nineteen fifties, Grushan, Cohen, and Ingleby collaborated
on research related to the breast and breast imaging, including
various ways that different pathologies could have here in an
X ray, and they also documented normal changes to the
breast due to factors like menstruation, lactation, and age, which
were also visible on X rays. They published numerous papers
(16:12):
together and co authored a book called Comparative Anatomy Pathology
and wrote Ganology of the Breast that was published in
nineteen sixty. So we'll take a moment here to note
that we were about halfway through this episode on mimography
and we have only just now gotten to a woman researcher.
At this point, there were not many women doctors. There
(16:33):
were even fewer women in specialized fields like radiology or oncology.
We have a previous episode on Elizabeth Blackwell, who was
the first woman in the US to earn an MD,
which had happened in eighteen forty nine. Helen Ingleby had
attended the London Medical School for Women, which was England's
first medical school that enrolled women, and one of its
(16:55):
founders was Elizabeth Blackwell. Ingleby was also one of the
Saint George's Four, which was a nickname for the four
first women to begin studying medicine at Saint George's University
of London, which was in nineteen fifteen.
Speaker 1 (17:10):
Ingleby was the first.
Speaker 2 (17:11):
Woman to qualify for the Bachelor of Medicine degree at
the university.
Speaker 1 (17:16):
The lack of women in medicine absolutely affected the field
of mimmography and the understanding of breast cancer and just
breast health in general. There's still so much cultural baggage
around breasts and around gender, and this was even more
true in the nineteen fifties and sixties. A lot of
male doctors were uncomfortable examining women patients breasts, and a
(17:38):
lot of women were uncomfortable being examined by male doctors
or even talking to a male doctor or anyone else
about a concern with their breasts. Robert Egan was known
to complain about the fact that cultural taboos and hang
ups about breasts were getting in the way of medicine,
and some of his colleagues gave him crude nicknames because
of his focus on mimmography.
Speaker 2 (18:00):
They're in the research for this episode. It also really
stood out to me that Helen Ingleby had been a
collaborator on work that really helped document the many ways
that a person's breasts can change due to very ordinary
things like menstruation and aging. With all of those changes
being like in the umbrella of normal, I feel like
(18:22):
she is the original consultant of like, no, yeah, that happens. No,
that's that's not really yeah that happens all the time.
Although Egan, Gershan, Cohen, and Ingleby were all vocal proponents
of mimmography, not a lot of radiologists were actually performing
mammograms by nineteen sixty. The nineteen sixty Annual Oration before
(18:43):
the Massachusetts Medical Society, which was published under the title
the Role of Diagnostic ron Geneology and Medicine in the
New England Journal of Medicine does not mention mimmography or
the breast at all. Egan had published his mimography technique
by then, but most practitioners still didn't know about it yet.
There was also no dedicated equipment to make X raying
(19:05):
the breast easier and more consistent. Even formal research into
mimography was still being done with X ray equipment that
was made for other purposes, and the radiologists who were
X raying the breast were mostly working with patients who
were already showing signs of breast cancer or some other
disorder or disease of the breast. This was not usually
(19:27):
a way to spot previously undetected problems. Although there were
anecdotes about people whose tumors had been discovered on a
breast X ray, there had not been any controlled studies
to determine whether mammograms could be used as an effective
screening tool.
Speaker 1 (19:46):
This started to shift later in the sixties, in part
because the work of radiologist Philip Strax. His wife, Bertha
Goldberg Stras had died of breast cancer in nineteen forty seven,
the age of just thirty nine, and that led him
to focus his career on the detection and treatment of
breast cancer. In nineteen sixty three, he began collaborating with
Sam Shapiro, director of Research and Statistics at the Health
(20:09):
Insurance Plan of Greater New York or HIP or HIP,
and surgeon Lewis Vney on a large scale, randomized trial
into the efficacy of mimmography as a screening tool.
Speaker 2 (20:21):
Uh, I'm just gonna admit I did not go down
the rabbit hole of whether people say this hip or hip.
We're just gonna call it hip. Participants in this study
were HIP members, and sometimes this trial is called the
HIP study. It involved sixty two thousand women between the
ages of forty and sixty four. Half were given annual
(20:41):
examinations that involved an interview, a breast exam, and a mammogram.
Speaker 1 (20:46):
The other half.
Speaker 2 (20:47):
Received their usual medical care without this annual screening, although
if their doctor gave them a breast exam or ordered
them to get a mammogram for some reason, they were
not prevented from getting one, they just were not having
a dedicated annual screening. This was a three year study,
and initially the death rate from breast cancer was reported
as forty percent lower in the group that had received
(21:10):
the annual breast exams. That number was later lowered to
thirty percent, but that was still dramatic. Patients in the
screening group who were diagnosed with breast cancer over the
course of the study were also far more likely to
show no signs of the disease in their lymph nodes,
meaning their cancer was probably locally confined to the breast
(21:30):
when it was detected. The study also acknowledged some of
the realities of the medical system and getting access to
medical care in the United States, like these were all
folks who were part of a health insurance plan, that
is a specific population of people. At the same time,
many of the hospitals in New York where mammograms were
(21:51):
being done were not convenient to the women who were
enrolled in this study, so the team basically turned a
van into a mobile mimography and they drove it to
the places where the women worked so that they could
be screened on their lunch break. Even with that effort, though,
a significant number of participants in this study didn't return
(22:11):
for their follow up exams. That reduced the number of
people who participated in the study all the way to
the end.
Speaker 1 (22:18):
Preliminary results were published in the Journal of the American
Medical Association in nineteen sixty six, and another article followed
in nineteen seventy one, and overall, using mammograms to screen
people for breast cancer seemed like a clear success. Philip
Strax joined Robert Egan, Jacob Gershaan Cohen, and Helen Ingleby
in advocating for screening mammograms.
Speaker 2 (22:41):
Another big breakthrough came about in nineteen sixty five in Strasbourg, France,
when radiologist Charles Gross worked with company generald At Radiology
to develop the CGR centograph. This was the first device
specifically made to X ray the breast. Gross was a
vocal advocate for breast cancer screening as well, and there
(23:02):
are a number of sources that describe him and Philip
Egan as the two people within the medical community who
really did the most to push the idea of screening
mammograms into the mainstream. Of course, there were also developments
that were happening from outside the medical community. In the US,
for example, President Richard Nixon announced a War on Cancer
(23:25):
in nineteen seventy one. A year later, the National Cancer
Institute and the American Cancer Society teamed up to launch
the Breast Cancer Detection Demonstration Project or BCDDP. The American
Cancer Society was heavily invested in this During the nineteen
fifties and sixties, the American Cancer Society had pushed for
(23:46):
routine cervical cancer screening using AP tests, and death rates
from cervical cancer were declining. It was hoped that routine
breast screenings would have a similar impact on deaths from
breast cancer. The BCDDP offered five years of free annual
mammograms to women over the age of thirty five. That
was at twenty nine screening centers located in twenty seven
(24:09):
cities around the US. More than two hundred and eighty
thousand women were screened at one of these centers between
nineteen seventy three and nineteen eighty That exceeded the project's
initial goal by more than ten thousand.
Speaker 1 (24:23):
Interest in screenings also surged in the US in the
fall of nineteen seventy four after Betty Ford, wife of
President Gerald Ford, and Margaretta Rockefeller, known as Happy Wife
of Nelson Rockefeller, each announced that they had been diagnosed
with breast cancer. Although neither of their cancers had been
initially detected in a mammogram, both underwent surgery and survived,
(24:46):
and their public acknowledgment of what had happened helped dispel
some of the stigma and secrecy surrounding the disease.
Speaker 2 (24:53):
It was also evolving that breast cancer was a survivable
and even curable disease if people caught it early, and
this was feeding into that as well. Things moved a
bit more slowly in other parts of the world. For example,
in Europe in the nineteen seventies, only Sweden and Scotland
conducted trials of screening mammograms. In Japan, as another example,
(25:16):
ultrasound was already being used for breast imaging, so there
just really wasn't a big focus on seeing how mimography
would work there.
Speaker 1 (25:26):
There were also doubts and controversies pretty much right away.
Although the Hip study had shown a clear reduction in mortality.
In the group that had regular breast exams. Only forty
four cases of breast cancer had been found only through
mimography over the course of that study. In many other cases,
the patient's medical history, physical exam, or interview had already
(25:48):
suggested the possibility of cancer.
Speaker 2 (25:51):
One of the people to publicly criticize the idea of
screening mammograms was John C. Baylor, who was statistician with
the National Cancer Institute. He published an article called Mimography
A Contrary View and the Annals of Internal Medicine in
January of nineteen seventy six. This is one of the
(26:12):
moments where I was like, this was after I was born.
His criticisms included the fact that many of the early
cancers that were being diagnosed were very slow growing masses
that might not ever reach a point where they were
a risked to the patient's life. He also expressed concerns
that the radiation exposure involved with a mammogram could contribute
(26:35):
to breast cancers later in life. I'll pause to say
the amount of radiation exposure is less now than it
was in nineteen seventy six. He argued that the government
should have been focusing its efforts on further randomized controlled trials,
including trials specifically looking at the question of whether screening
(26:56):
mammograms were worthwhile in patients under the age of fifty,
and studies on more diverse groups of people, rather than
a demonstration project like the BCDDP. Baylor initially criticized all
screening mammograms, but eventually really focused his attention on the
ones performed on women under the age of fifty.
Speaker 1 (27:17):
The same year that Baylor published this article, the American
Cancer Society started recommending mimography for early breast cancer detection.
We'll talk more about that after a sponsor break.
Speaker 2 (27:38):
The American Cancer Society had started educational campaigns recommending that
women examined their own breasts for signs of cancer in
the nineteen thirties and forties. That, plus the increased use
of screening mammograms in the late sixties and seventies, meant
that more people were being diagnosed with breast cancer earlier
than they might have been otherwise. But for decades, the
(28:02):
standard treatment for breast cancer in the US and much
of Europe had involved a radical mastectomy. This surgery was
developed by William Stewart Halstead all the way back in
eighteen eighty two, building on the work of earlier doctors.
This included the removal of the breast and adjacent parts
of the lymphatic system and the pectoralis major muscle.
Speaker 1 (28:26):
That's a major surgery. But when Halsta developed it, most
breast cancers were detected when tumors were large enough to
be obvious and had started to spread beyond the breast.
But at least in theory, cancers that were discovered earlier
might not need such a broad response. This led to
questions of whether mammograms were going to lead to people
(28:47):
having major surgery that they didn't actually need. So this
ties into the history of breast cancer treatment, which of
course could be a whole separate topic. The first chemotherapy
drugs were developed in the nineteen forties and fifties. As
we said, earlier experiments in radiotherapy as a cancer treatment
had started almost immediately after the discovery.
Speaker 2 (29:08):
Of X rays. Surgeon John Madden modified Halsted's methods for
the radical mastectomy in nineteen seventy two, with Madden's techniques
preserving the pectoral missiles. Oncologist Umberto VERNESSI also promoted a
more conservative surgery described as a quadrant ectomy, combining that
(29:29):
with radiotherapy. Studies comparing the efficacy of radical mastectomies with
Vernesi's methods started in Milan in nineteen seventy three, and
this was part of a whole process of figuring out
how to successfully treat breast cancers that were detected earlier
without overtreating them, like, without giving people a more intense
(29:51):
treatment than they actually needed.
Speaker 1 (29:54):
Complicating all of this was the fact that screening mammograms
were identifying growths that were ambiguous. In other words, it
wasn't obvious whether they were or were not cancerous. While
the BCDDP was ongoing, a preliminary report suggested that sixty
six of five hundred six pathological specimens collected so far
had not actually contained any sign of cancer nor carcinoma
(30:17):
in situ. Today, carcinoma in situ is sometimes called stage
zero cancer, and it involves precancerous cells that have not spread,
which may or may not become cancerous. Of those sixty
six specimens that didn't have any evidence of cancerous or
precancerous cells, fifty three had led the patient to undergo
(30:38):
some type of mastectomy. The researcher stressed that the mammograms
were not to blame for this, that other doctors had
performed those biopsies, made those diagnoses, and recommended those surgical treatments.
But all of this added to the ongoing questions about
the idea of overtreatment.
Speaker 2 (30:57):
With all these kinds of questions in play and others,
various states and the US federal government started working to
regulate mammography. Between nineteen eighty six and nineteen ninety two,
a number of laws were passed requiring things like dedicated
mimmography machines at hospitals and inspections on those machines. The
(31:17):
US passed the Mimography Quality Standards Act in nineteen ninety two,
which was meant to help ensure the safety and efficacy
of mimmography, including making sure the amount of radiation patients
were exposed to was low. The American College of Radiology
also developed the Breast Imaging and Reporting Data System or
(31:38):
BIRADS in nineteen ninety three to provide standardized ways to
describe and report mammogram results. Today, the byrad's AT list
includes guidelines for multiple types of breast imaging, including mammography
ultrasound and MRI.
Speaker 1 (31:55):
There were numerous advances in mimography technology and methods in
the late nineteen eighties and nineteen nineties. Digital mimography was
introduced in two thousand and one, and today most mammograms
are digital, so radiologists can see the images instantly rather
than waiting for films to be developed. Digital mimography also
tends to be more accurate in people over the age
(32:17):
of fifty, although the accuracy is about the same in
people younger than that. Digital temosynthesis or three D digital mimography,
was introduced in twenty eleven.
Speaker 2 (32:28):
And there are other methods for breast imaging as well.
Some examples include magnetic resonance imaging or MRI, ultrasound mimography
with contrasts, which we mentioned earlier, positron emission mimography, and
breast specific gammut imaging.
Speaker 1 (32:44):
A lot of these.
Speaker 2 (32:44):
Today are used after a screening mammogram has revealed something
that needs further evaluation, or after somebody has been diagnosed
with breast cancer, to better visualize the tumor and to
monitor progress during treatment.
Speaker 1 (32:59):
In more recent years, there have also been recommendations for
mammography to be paired with automated whole breast ultrasound in
people with dense breasts, and at this point it's usually
recommended in addition to not instead of a mammogram. But
there's also an overall higher false positive rate for breast ultrasounds,
including automated whole breast ultrasound, than there is for mammograms.
(33:23):
Some of the concerns about mimmography that were raised in
the wake of the Hip study continue to be debated today.
Like the Hip study had shown clear evidence that routine
breast cancer screening could reduce the number of deaths from
breast cancer in people over the age of fifty, but
there wasn't clear evidence for women between the ages of
forty and fifty. Screening mammograms really didn't seem to make
(33:46):
much of a difference in this age group. If you're
in that age bracket, which I am, and you've gotten
a mammogram, you may have gotten results describing your breasts
as dense. Basically, younger bread guests contain a lot more
connective tissue and other structures that show up on a mammogram,
and that can make it harder to spot small tumors,
(34:08):
but older breasts usually have less connective tissue and more fat,
so tumors stand out more on a mammogram. In general,
breast cancer risk also increases with age, So what's the
right age for a person to start having mammograms? Guidance
on this has changed repeatedly since the years of the
(34:29):
Hip study, including an incredibly controversial recommendation by the US
Preventative Services Task Force in two thousand and nine. That
recommendation was that women between the ages of forty and
forty nine not be routinely screened. There is still so
much debate about the age at which people should start
getting mammograms and how often they should get them after
(34:51):
that point, and there's often a lack of consensus among
different organizations and governing bodies about what those recommendations should be.
Recommendations for transgender and non binary people are even more
scattered in contradictory and are based on just really limited data.
I read through these and I found them very confusing.
(35:12):
And this is for a community of people. Trans and
non binary people already often having a really high bar
to getting compassionate medical care at all, just making it
more complicated and based on limited data A cynical way
to look at this debate about when and how often
(35:33):
people should get mammograms, especially in places like the United
States where we don't have universal health care, is that
this is all about money and what insurance companies are
willing to pay for, especially when it comes to people
under the age of fifty. There definitely are arguments about
whether routine mammograms are the cost effective way to detect
(35:53):
signs of breast cancer. I read some of those papers.
I found them irritating. To the National Cancer Institute, more
than seventy five percent of women in the US between
the ages of fifty and seventy four have had a
mammogram within the last two years, but more than half
of breast cancers are discovered by the patients themselves or
(36:16):
their partners, not from a mammogram. So that's like a
question of like, wouldn't it be cheaper to just make
sure everybody's getting regular physical exams.
Speaker 2 (36:27):
I find that I'm like, this is it cheaper? I
find that to be a frustrating way to look at it.
Speaker 1 (36:33):
I have a question about that that we can table
till an so frietay, sure, yes, But beyond all of that,
there are real questions about the efficacy of mimography as
a screening tool, especially in people under the age of fifty.
As we said earlier, it's not just about the fact
that a higher breast density can make small tumors harder
(36:54):
to see. There are also questions around the risks of
false positive and overtreatment. As we're result of earlier annual mammograms.
It's estimated that over the course of ten screenings, roughly
half of patients in the US will experience a false
positive and roughly twenty percent of patients in Europe. And
there are still lingering questions about overtreatment and whether very
(37:17):
small growth seen on mammograms need to be treated or
would ever jeopardize the patient's life in any way.
Speaker 2 (37:24):
So we can't speak from experience about other parts of
the world. Holly and I live in the United States,
but here there are huge disparities and who has access
to screening mammograms, including who has access to the newer
technologies like three D mimography, and these disparities are often
compounded in every step of the process. So a person
(37:45):
who can't get an appointment, or can't get an appointment
at a place that has the most up to date
equipment or can't afford a mammogram at all, or feels
unwelcome at the doctor due to factors like medical racism
and fat phobia and trans phobia. They're gonna have these
same exact issues again when it comes to follow ups
(38:05):
if additional imaging is needed. Treatment can also be incredibly
expensive for breast cancer, even in people who have insurance,
and so all of this contributes to racial and economic
disparities in breast cancer detection rates and survival rates for
breast cancer, with black women in the US in particular
being a lot just disproportionately more likely to die from
(38:29):
the disease. I know that is a kind of dire
place to leave off the episode.
Speaker 1 (38:37):
The Grim de new mal of the episode.
Speaker 2 (38:40):
Yeah, I didn't feel like I could just leave that out.
Speaker 1 (38:43):
Do you have less Grim listener mail?
Speaker 2 (38:45):
Do I have much less Grim listener mail? Fabuloush The
clistener mail came from Dave and Dave's subject line is
just Assassin's Creed origins. Dave wrote, Hi, Holly and Tracy,
I guess I have a PhD in the show. Since
I've been listening to the podcast from the very start,
I've loved the many evolutions of the show over the years,
and I'm grateful for all the hard work you put
(39:07):
into it. Naturally, I've been tempted to write several times,
especially since my hometown of Saint Catherine's, Ontario has appeared
in a number of episodes, but I never felt I
had something worth sharing, well, at least until you talked
about Assassin's Creed. During the Banu Musa episode. You touched
upon how ubsoft tries to add some level of historical
(39:27):
accuracy to the backgrounds in the game. What you may
not realize is that historians and museums have taken note
of that. I volunteer at the Nilson Atkins Museum in
Kansas City. It's a world class museum and I love
giving tours and interacting with guests. Before the pandemic, we
had an episode on Nefertari was an amazing collaboration with
the museum, Egzo and for In Italy. Featured prominently in
(39:51):
the exhibit were animated outtakes from an educational version of
Assassin's Creed origins. You can find these online at Ubusov's
website and there's a link to that. Needless to say,
it was very cool to have these recreated sites next
to actual artifacts, and people love it. So I hope
you enjoy that tidbit and don't get stuck in the
rabbit hole of these Assassin's Creed discovery tours. Here's my
(40:12):
pet tax. What follows is an adorable black kitty cat
asleep on a cream colored carpet. Cricket is a Manx.
This breed typically do not have tails. She's got a
lot of personality and wants a lot of attention. Although
she refuses to be a lap cat. She wants her
tribute on her terms. Keep up the great work, sincerely, Dave.
(40:34):
I love this kitty cat.
Speaker 1 (40:35):
I used to have a Manx and I loved him desperately,
and it was like living with a really fabulous drag queen.
Speaker 2 (40:43):
Oh.
Speaker 1 (40:43):
It would look you up and down and be like
you're wearing that today? Like chess?
Speaker 2 (40:47):
Yeah, the goofiest, sweetest but also slightly attitudinous. Yeah. So
I knew that these discovery tours existed in the Assassin's
Creed games. I have never actually checked any of them
out on my games. I see them there in the menu,
I see that there are achievements for doing them. I
have not actually done any of them. I did not
(41:08):
know though, that they were also used in museums and
educational centers to like add another element to the educational stuff.
I think that is pretty cool. So thanks so much
for this email day. If you'd like to write to us,
we're History podcast at iHeartRadio dot com. We are on
(41:30):
social media at Missing History. That's where you'll find our
Facebook Twitter. It's not even called Twitter anymore. I don't
know why even say it is.
Speaker 1 (41:38):
To me.
Speaker 2 (41:38):
I think it's always Twitter in my heart.
Speaker 1 (41:40):
I refuse to acknowledge.
Speaker 2 (41:44):
And you can subscribe to our show on the iHeartRadio
app or wherever else you like to get your podcasts.
Stuff you Missed in History Class is a production of iHeartRadio.
For more podcasts from iHeartRadio, visit the iHeartRadio app, Apple Podcasts,
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Stuff You Missed in History Class News
Hosts And Creators
Tracy V. Wilson
Holly Frey
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