Carsten Timmermann's monograph on the history of lung cancer follows several years' work concerning cancer and cancer patients. A History of Lung Cancer primarily covers the early development of treatment for lung cancer in the UK and, to an extent, the USA.
Timmermann begins his introduction with a case study from the 1840s, detailing the illness of a Mrs Benbow, who received treatment at Guy's Hospital, London. After her death, it was learned that Mrs Benbow had had lung cancer. A swift comparison of the experiences of mid-nineteenth-century lung cancer patients with those of the mid-twentieth century suggests that little had changed with regard to treatment or survival. Setting the scene for the book, Timmermann questions why this may be, particularly in light of so many other medical improvements in the twentieth century. What makes lung cancer so different? Why is it ‘recalcitrant’?
In order to help answer this question, Timmermann considers clinical research and treatment options, and the role of smoking in lung cancer history. Most chapters are framed with this first consideration in mind. The second chapter considers the first diagnoses of lung cancer during a period of improving pathology. The transition from tissue morphology to cell pathology is briefly considered in the context of lung cancer, suggesting that both old and new concepts were combined in developing nineteenth-century lung cancer diagnoses. The rise of epidemiology in the late nineteenth century initially indicated that there was an increasing incidence of cancers in the latter decades of the century, but many suggested that this was an increase in diagnosis as opposed to incidence.
Timmermann outlines the first primary treatment for lung cancer in his third chapter: surgery. In the first half of the twentieth century, surgery was the preferred option for physicians, sending their lung cancer patients to the surgeon. Not all patients were suitable for surgery, however; survival rates were poor; and, by the 1940s, the incidence of lung cancer was rising dramatically.
In an effort to maintain the chronological organization of the book, Timmermann's fifth chapter concerns lung cancer treatment from the 1950s to the 1970s. Despite better organization, research and data collection, the conclusion is that there were more people being diagnosed with lung cancer, with little improvement in treatment or survival rates. This dire state of affairs resulted in a push for more work on preventing, screening and treating lung cancer from the 1960s onwards: the topic of a sixth chapter. Again, the lack of successful outcomes is noted, despite more being learned about the disease. For instance, different types of lung cancer were now identifiable, and prognosis following surgical treatment was improving. However, radiotherapy was still considered to be a poor second option to surgery, and chemotherapy was thought to be of little use. So poor was the prognosis that many died without being told they had lung cancer (although no ethical considerations of this are mentioned).
Cancer working groups were set up to help improve prognosis, and, as generations of new practitioners were recruited to the group, newer therapy regimes were considered. As wider dissemination of ideas and results occurred through the Lung Cancer Working Group, and standardization of protocols and cancer staging were achieved, more was learned about lung cancer and about better courses of treatment for individual patients. This said, Timmermann suggests that lung cancer was still a neglected field; although he does not explicitly state it here, there are clear links to the fourth and seventh chapters: stigmatization.
The fourth chapter describes a link that has been synonymous with lung cancer in the latter half of the twentieth century: smoking. Convincingly, Timmermann shows that the link between smoking and lung cancer made this condition different to many other malignant diseases, succeeding in giving an informative history of the causal link between smoking and lung cancer in a concise manner.
In a useful seventh chapter, Timmerman carefully teases out how and why lung cancer in particular became so stigmatized, occasionally comparing the condition with tuberculosis and HIV (there is no mention, however, about how poor lifestyle choices have become stigmatized following research linking them with cancer in general). Guilt and stigmatization are shown to affect treatment requested and given for lung cancer, and lack of funding for this ‘self-inflicted’ disease continued. This said, smokers present themselves as knowing the health risks of smoking (and over-estimating their risk of lung cancer); however, Timmermann mentions no studies carried out asking why smokers continue. This would have made a relevant addition considering the emphasis on prevention of lung cancer in the latter half of the book.
There appears to be some confusion in the first few chapters about the audience for the book – for example, some technical terms are explained (more than once), whilst others are not. There is also an impression given that each chapter was written with a certain amount of segregation in mind, as though each was considered apart from the rest. This has resulted in some needless repetition, and occasionally missed links to other sections of the book that are relevant; this is particularly evident in the later chapters, where the story becomes more complex. This said, the predominant aims of the book are clear, and the chronology connects the chapters well.
Timmermann's account is somewhat shrouded in pessimism, with lung cancer shaded as an ‘avoidable’ cancer – a condition related to poor lifestyle choices, and even deviancy; the mood is not lifted with any account of more recent advances in lung cancer treatments, which have decreased mortality rates little in the past decade or so. This follows Timmermann's theme of recalcitrance throughout; lung cancer has such a label not only due to its biology, or the difficulty of its treatment, but because of its association with being self-inflicted by a stigmatized, marginalized section of society. Timmermann shows, however, that despite the recalcitrant nature of lung cancer, this has not translated into lack of interest; in fact, obstinate researchers, clinicians and patients respond to this recalcitrance the only way they can: by keeping on trying.
