A Pulitzer Prize winning play by Margaret Edson, entitled W;t, begins with an exchange
between an oncologist, Dr Harvey Kelekian, and his patient, a John Donne scholar and
professor of English named Vivian Bearing. He is in the process of informing her that
she has stage 4 ovarian cancer:
kelekian: You have cancer … you have advanced, metastatic ovarian cancer.
vivian: Go on …
kelekian: You present with a growth that, unfortunately, went undetected in stages
one, two and three. Now it is an insidious adenocarcinoma, which has spread from the
primary adnexal mass—
vivian: “Insidious”?
kelekian: “Insidous” means undetectable at an—
vivian: “Insidious” means treacherous.
kelekian: Shall I continue?
vivian: By all means.
Vivian then ponders what he has just said: “Insidious. Hmm. Curious choice of word.”1
Edson’s opening scene focuses attention on the meanings of words which are used to
describe ovarian cancer. On the one hand, the physician understands himself to be
using the word “insidious” as it has become part of clinical language, to refer to
a gradual, undetectable and harmful physical process of the sort associated with ovarian
cancer. His patient, on the other hand, recognizes that the word is being used metaphorically.
As the Oxford English Dictionary defines it, “insidious” does mean “treacherous”,
or “full of wiles or plots, lying in wait to entrap or ensnare”, and is derived from
the Latin insidiae, meaning “ambush”, and insidiosus, meaning “cunning” or “deceitful”.2
The purpose of this article is to examine the history and implications of ovarian
cancer’s association with metaphorical language. For most of the twentieth century,
the metaphor of the “silent killer”, often linked with the word “insidious”, was a
common feature of ovarian cancer discourse, and this article explores the reasons
why that image became dominant and considers the role it played in both reflecting
and confirming established understandings of the disease. While the term “silent killer”
has sometimes been used to describe other cancers and is also applied to such illnesses
as hypertension and diabetes, its longstanding and very widespread use in defining
ovarian cancer is striking and deserves analysis, as does the process whereby its
use was challenged.
Some basic knowledge of the characteristics of ovarian cancer is useful when considering
the language which has been used to describe the disease. While it is sometimes still
described as a rare disease, ovarian cancer affects as many as one in fifty-five women
in the United States.3 It is now the second most commonly occurring gynaecological
cancer (after endometrial cancer) and, as a cause of cancer deaths in women, it ranks
fourth after lung, breast, and colorectal cancers.4 There are many kinds of ovarian
cancer; as one recent text explains, the ovary “produces more varieties of tumors
than any other organ”.5 Ovarian neoplasms are categorized according to three main
types: epithelial (accounting for over 90 per cent of malignant tumours); germ cell,
which includes the teratomas, as discussed in Jackie Stacey’s Teratologies: a cultural
study of cancer; and sex cord and stromal, which includes the granulosa cell tumour
briefly mentioned below.6 The different kinds of ovarian cancer affect women at different
stages of life, with germ cell tumours most often occurring in women in their twenties
and thirties, while the median age for the diagnosis of epithelial carcinoma is around
sixty.7 Current medical literature discusses several possible aetiological factors,
most of them speculative, but authors tend to agree that continuous or “incessant”
ovulation, uninterrupted by pregnancy or oral contraceptive use, has the strongest
correlation with the disease.8 Like breast cancer, a portion of epithelial ovarian
cancers (estimated at around 10 per cent) have a genetic link.9 As yet, there is no
accepted general screening test for ovarian cancer, and diagnosis is often delayed
due to a lack of specific symptoms or a poor understanding on the part of patients
or physicians of the signs of ovarian cancer. When the disease is suspected, pelvic
examination, sonography, and a blood test known as CA-125 play a role in diagnosis.10
Surgery confirms the presence of the disease and the stage to which it has progressed.
Ovarian cancer is staged according to whether it is confined to the ovary (stage 1)
or has extended beyond. In stage 2, the disease has spread to the uterus, fallopian
tube, or to other tissues in the pelvis; in stage 3, it has metastasized to the abdominal
cavity; and in stage 4, it has spread elsewhere in the body.11 A recent text reports
that, when diagnosed at stage 1, the five-year survival rate for epithelial ovarian
cancer is as high as 93 per cent, but, in over 70 per cent of patients, the cancer
has spread outside the pelvis by the time of diagnosis.12 Aggressive surgery and chemotherapy
are employed to halt the disease, but at stage 3, the five-year survival rate is 23
to 41 per cent, while at stage 4 it is only 5 to 11 per cent.13 For much of the past
century, the deadly nature of advanced ovarian cancer, combined with the apparently
intractable difficulties associated with timely diagnosis, gave rise to the metaphor
of “the silent killer”, which, in turn, helped to shape understandings of the disease.
The significance of metaphor in medical language is the subject of an ongoing debate
which often refers back to Susan Sontag’s Illness as metaphor. In this work, first
published in 1978, Sontag made her now famous case against the mystification of illness
through the use of metaphor.14 More recent writers, including the ovarian cancer patient
and sociologist Jackie Stacey, have criticized Sontag’s methodology and her basic
premise that metaphorical thinking and language can be avoided in medical discourse.15
James F Childress suggests that, partly because illness very often is mysterious,
medicine needs “the vision provided by metaphors, analogies, and symbols”, but he
agrees with Sontag that metaphors are not just evocative figures of speech; they have
the power to shape our understanding. Far from being “merely ornamental or affective”,
he writes, metaphors “can be and often are cognitively significant”.16 In Medicine
as culture, Deborah Lupton supports this view by pointing out that, in medical discourse,
as in many kinds of communication, metaphor is “an epistemological device, serving
to conceptualize the world, define notions of reality and construct subjectivity”.17
Other writers have shown that medical metaphors are deeply embedded in historical
contexts. Emily Martin points out that the dominant metaphor in early scientific medicine
was “the metaphor of the body as machine and the doctor as mechanic”.18 With the rise
of bacteriology, metaphors of invasion and battle became commonplace, as “bacteria
were identified as agents of disease that threaten the body and its defenses”.19 During
the twentieth century, military metaphors came to dominate medical language, and this
was especially true in relation to cancer, as governments, especially in the US, declared
a “war on cancer” in the wake of the First World War.20 Barron Lerner has shown that
the American Society for the Control of Cancer chose to use military metaphors for
very specific reasons, partly because they suited the mood of the inter-war years,
but also because they harnessed public fears and the willingness to fight a disease
which, by its very name, suggested an entity (the crab) “growing out of control and
eating away at the body’s organs”.21 Decades later, Sontag was highly critical of
the way that cancer continued to be personified as an “evil, invincible predator”,
and maintained that metaphors of invasion, battle, and defeat contribute to the stigma
endured by cancer patients.22 But others have emphasized that military metaphors have
positive uses, not only in motivating social groups to fight disease but in supporting
patients’ private struggles to recover.23 More recently, patients’ movements have
explored alternatives to the military metaphor, such as the image of cancer “as a
journey”, while some practitioners have wondered, more generally, whether a greater
openness to new metaphors might play a part in the re-conceptualization of medical
problems.24
Metaphors do not come into common usage unless, on some level, they work. Throughout
much of the twentieth century, both medical professionals and laypeople applied military
metaphors to cancer because they seemed both apt and useful. Cancer was, as it is
now, a disease the public feared above most others. Anti-cancer campaigns focused
on detecting the enemy early; patients and physicians fought diseases such as breast
and uterine cancer with all the heroic methods at their disposal; and survivors celebrated
their victories over the adversary. How did ovarian cancer fit into this picture?
As a less common form of cancer, it posed less of a public threat than breast or uterine
cancers and therefore attracted far less attention. It was also harder to detect,
as it was often without symptoms in its early stages, or was characterized by non-specific
gastro-intestinal complaints rather than typical warning signs such as a lump or irregular
bleeding. As a result, it had usually spread throughout the abdomen by the time it
was diagnosed and therefore had a very poor prognosis. For all of these reasons, it
was a poor target in the “war” on cancer, which depended upon an optimistic message
to promote the promise of early detection and effective treatment.25 Ovarian cancer
was not exempt from military metaphors, but the medical profession portrayed it as
an enemy which kills silently, progressing undetected until its victory is secure.
Lack of success in the search for early detection strategies allowed the image of
the “silent killer” to remain the dominant metaphor until the end of the twentieth
century. By that point, however, an alternative metaphor was gaining ground, as ovarian
cancer activists, convinced that earlier detection was possible with closer attention
to early symptoms, promoted the image of a disease that “whispers” and can be “heard”
if one knows what to listen for.
The “silent killer” metaphor was challenged because, in the view of some patients
and practitioners, it had become inaccurate and dangerously misleading. A growing
body of medical evidence supported the hypothesis that an awareness of “early” symptoms
might hasten diagnosis and, with improvements in treatment, timely diagnosis became
a major factor in long-term survival. In June 2007, the American Cancer Society publicly
disassociated itself from the term “silent killer”—“a catchy phrase, but it is wrong”,
announced the ACS website.26 The ACS and other agencies identified a list of common
symptoms which might be present even in early stage cancer, including bloating, frequent
urination, pain, and eating or digestive problems. These non-specific symptoms had,
in fact, been noted for decades, but new guidelines confirmed that if they were new,
persistent, and worsening, women should see a gynaecologist. Further tests would then
determine whether the risk involved in laparoscopic surgery was justified.
Before examining the uses of metaphor in relation to ovarian cancer in the twentieth
century, this article takes a brief look at how the disease was envisioned in the
nineteenth century in order to provide some historical context. It then analyses the
reasons why the “silent killer” metaphor became so prominent during the inter-war
years, discusses some of the means by which physicians attempted to control the disease,
and notes that, by mid-century, a small number of researchers were already questioning
whether earlier attention to symptoms might have an effect on ovarian cancer diagnosis.
The “silent killer” metaphor persisted, however, and, during the post-war decades,
researchers focused on efforts to improve treatment and, somewhat belatedly, the identification
of risk factors such as family history. They also searched for a technological solution
to the problem of early detection but, by the end of the century, it was clear that
no viable means of mass screening had emerged. The final section of the article traces
the efforts of increasingly vocal patients and those physicians and researchers who
questioned the “silence” of ovarian cancer.
“Uncertain Sounds”: Interpreting Ovarian Growths in the Nineteenth Century
Ovarian cancer, while a relatively rare condition compared with breast or uterine
cancers, was certainly not unknown to nineteenth-century physicians. They considered
it to be an invariably fatal disease, but found it was often impossible to distinguish
from non-cancerous growths unless it was very advanced. While the suspicion of breast
or uterine cancer was commonly aroused by the presence of a breast lump or unexplained
bleeding, the vague symptoms of ovarian cancer were usually recognized in retrospect
and were only occasionally mentioned in medical literature. The British surgeon Thomas
Spencer Wells, for example, looked back on the case history of one patient whose tumour
had caused “incontinence of urine” for three years before her admission to the Samaritan
Hospital, where she soon died.27 The non-specific symptoms of the disease were also
noted by the cancer expert Walter Hayle Walshe, who remarked that the patient might
first report sensations that were “merely uneasy”, and that she might direct attention
to the ovary itself as the source of early pain.28 The gynaecologist Charles Reed
concurred that the “symptomatology of ovarian neoplasms is sometimes very obscure”,
but acknowledged that there might be “a vague sense of discomfort in the pelvis”.29
Even if symptoms had been noted more systematically in the nineteenth century, earlier
diagnosis would have been very unlikely to save women’s lives. Despite the poor prognosis
for ovarian cancer patients, ovarian growths of all sorts were of great interest to
nineteenth-century physicians. In good part, this was because the more common, non-cancerous
cysts could become debilitating and even deadly if they grew large enough, and there
was good reason to seek new means of treatment.30 Early in the century, ovarian growths
were treated by a wide variety of techniques, including drugs, bleeding, purging,
“blistering, electricity, friction, and abdominal pressure”, and by tapping, or the
removal of fluid.31 The first successful ovariotomy (the term then used for removal
of the ovaries) was performed in 1809 by the Kentucky surgeon Ephraim McDowell, who
removed a 22 ½ pound ovarian cyst. Other surgeons attempted similar operations, and
the first ovariotomy in Britain was performed in 1824.32
The dangers involved in abdominal surgery, however, brought the procedure into disrepute.
Not only was there a very high death rate, estimated at close to 50 per cent at mid-century,
but surgeries were performed on women who turned out not to have ovarian disease at
all or had cancerous tumours adhering to other abdominal structures, which made effective
surgery impossible.33 Such a horrific procedure was not even recommended for women
who were thought to have ovarian cancer and were expected to die anyway. In his Outlines
of the principal diseases of females, Fleetwood Churchill declared in 1838 that surgery
was “never advisable, for at the advanced period, at which alone so formidable an
operation would be justifiable, the patient’s whole constitution is contaminated by
the cancerous diathesis”.34 Many also questioned whether any woman who might survive
for some years without surgery should be exposed to such pain and danger. Wells would
eventually make his reputation as a leading ovariotomist, but he recalled that in
the early days “Surgeons stood and trembled on the brink of ovarian waters… . Could
we know beforehand that the circumstances would admit of such treatment? The difficulty
was in the diagnosis. There was a thick surgical darkness over the abdomen, and it
gave out only uncertain sounds.”35
Although surgery was in disfavour at mid-century, within a few years the ovariotomy
would become an established, if still controversial, procedure.36 The growing use
of anaesthetics increased the demand for and the acceptability of surgery, and, by
the 1870s, the introduction of antisepsis (or the new emphasis on general surgical
cleanliness, in the case of Listerism’s opponents), reduced the risk of infection
and death. Wells worked to perfect his technique by performing hundreds of ovariotomies
at charity hospitals such as the Samaritan Hospital for Women during the 1860s and
1870s, and he claimed to have reduced the fatality rate in his cases from 50 per cent
to 11 per cent.37 Other prominent surgeons, including James Young Simpson and Robert
Lawson Tait, also became advocates, and ovariotomy, says Ann Dally, became “the operation
by which a surgeon’s skill and worth were assessed”.38
Rising confidence in the safety of surgery, combined with a growing awareness of the
changeability of ovarian growths, caused some physicians to believe that the development
of life-threateningly large and even cancerous ovarian growths might be prevented
if surgery was undertaken sooner rather than later—that the risk of delay might outweigh
the risk of surgery. Benign tumours were increasingly recognized as being very prone
to cancerous changes; Wells’s extensive experience led him to observe that all ovarian
cysts had the potential to degenerate into “the worst forms of epithelial cancer”.39
This warning grew louder by the end of the century and became the primary argument
for immediate surgical intervention. In his textbook of gynaecology, Charles Reed,
president of the American Medical Association, advised that all growths needed to
be investigated because of the risk of “malignant degeneration”.40
But the call for immediate action should not be taken to mean that surgeons expected
to save the lives of women in whom malignant ovarian growths had already developed.
As one London surgeon explained, it was more a matter that one should not assume a
tumour to be cancerous and therefore hopeless when surgery might prove that the diagnosis
was mistaken.41 Ovarian cancer was still regarded as “absolutely fatal”, for, as another
advised, even when the tumour is completely removed and “no metastases can be discovered,
a rapid return appears to be the invariable rule”.42 In contrast with breast cancer,
for which radical surgery was being promoted as a potential cure, the fatal nature
of ovarian cancer drew frequent and despairing comment in turn-of-the-century medical
texts.43
The “Silent Menace” and Early-Twentieth-Century Gynaecology
Throughout the early decades of the twentieth century, the fatalism surrounding ovarian
cancer stood in contrast to the rhetoric of optimism applied to some of the more common
cancers in women. Cancer awareness campaigns, which emphasized the promise of early
detection, portrayed both breast and uterine cancers as enemies which could be conquered
through due vigilance on the part of patients and their physicians. Ovarian cancer,
on the other hand, was increasingly envisaged as a “silent killer” which would secure
its deadly victory before it was even discovered.
One factor which may have enhanced the image of ovarian cancer as a particularly deceptive
disease was the growing fascination with the hormone-producing granulosa cell tumour,
even though it was a much less common form of the disease.44 For researchers, especially
those in the new field of endocrinology, this was an intriguing example of pathological
hormonal change. These oestrogen-producing tumours, only some of which were cancerous,
could cause early puberty and menstruation when they occurred in children, but much
more often they affected post-menopausal women who might briefly and unwittingly welcome
their “feminizing” effects.45 “At the beginning”, wrote gynaecologists Emil Novak
and J N Brawner in 1934, “there are only symptoms of hyperestrogenism and the patient
appears surprisingly and pleasantly to bloom again. However, this cruel deception
is not kept up for long, the disease soon destroying both this tragic illusion and
the body itself.” 46 The novelist Thomas Mann was so fascinated by this expression
of “the cruel demonic side of nature” that he wrote a novella, entitled The black
swan, about a woman who dies from ovarian cancer after rejoicing in the return of
her youth. He sought to create, he said, “A story of deception, of a deadly hoax played
by Nature on its own good child.”47
In the inter-war period and beyond, medical literature increasingly framed ovarian
cancer of all types as a cruel trick of nature, a disease which grew stealthily until
it was too late. The adjective “insidious” came into use; “Carcinoma of the ovary
is the most insidious disease of the generative tract” explained one text in 1927.48
The renowned gynaecologist Harry Sturgeon Crossen vividly evoked the “silent killer”
metaphor when he reminded colleagues of the “symptomless onset and symptomless progress”
of this “creeping death which defies early discovery”.49 Despite the relatively low
incidence of the disease, he and others pointed out that it was a greater threat than
some might think. Crossen suggested that one could “get some idea of the magnitude
and importance of this ‘silent menace’” by considering the many cases which each and
every gynaecologist had encountered in recent years, and by also adding the many other
patients, vaguely diagnosed with “abdominal” cancer, who might also have been victims
of ovarian malignancies.50 By mid-century, it was not unusual for medical texts to
refer to ovarian cancer as a “relatively common” disease, but not one which offered
much hope of a cure.51
In spite of their general pessimism about treating ovarian cancer and the still very
real dangers of surgery, many surgeons during the inter-war years continued to advise
an aggressive approach to dealing with all ovarian masses in the hope of reducing
the risk of cancerous changes developing in benign cysts. Although there was a great
variation in opinion regarding the percentage of growths which would prove to be malignant,
there was a growing consensus by the 1930s that all were potentially deadly and that
all must be investigated as soon as they were detected.52 “The division into malignant
and non-malignant tumors is important from the clinical aspect”, advised an Introduction
to gynecology, “but as a matter of fact practically all ovarian tumors possess potentialities
for malignant change.”53 A very few gynaecologists even toyed with the hope that the
lives of at least some patients with ovarian cancer could be saved through timely
surgery, though reported rates of long-term survival remained extremely low.54
Because ovarian cancer was so difficult to detect and treat, some surgeons advocated
prophylactic oophorectomy as a means of reducing the risk of ovarian cancer in post-menopausal
women. The removal of healthy ovaries was still a controversial procedure and, as
the frequency of hysterectomy increased during the early twentieth century, the practice
of performing oophorectomy at the same time caused divisions within the medical profession.
Crossen advocated the removal of the ovaries when abdominal surgery was done for any
reason in women past their childbearing years, which he set at forty-two. He cited
several cases from his own experience of women for whom he had performed hysterectomies
who later developed ovarian cancer. The lesson he had learned, he confessed, was that
he should never have left the ovaries intact: “I thought then that it was advisable”,
he wrote, “but I know better now.” He went on to explain that although the ovaries
“have a halo about them” they are of only temporary value. By the time a woman is
in her early forties, he wrote, they are “no longer an important part of the economy
but vestigal structures which carry a special tendency toward cancer—and toward a
particularly dangerous form of cancer, in that it develops to an incurable stage without
warning symptoms”.55 Some other practitioners opposed the procedure because the sudden
hormonal change could render “the patient a physical and nervous wreck”, which they
saw as an unjustifiable outcome given the odds against a malignancy ever developing.56
Admitting that ovarian cancer was “a wholly unsolved problem”, Clyde Randall of the
University of Buffalo weighed the pros and cons of the procedure and concluded that
perhaps “the all too apparent futility of our present treatment may have cowed us
to illogical extremes”.57
As a second front in the struggle for ovarian cancer control, some gynaecologists
also advocated increased surveillance of middle-aged patients through regular pelvic
examinations. The growing acceptance of this procedure as a normal part of health
care was a side effect of the campaign to control uterine cancer, which encouraged
apparently healthy women to seek regular checkups. Crossen was adamant that examinations
for “silent” ovarian cancer should occur every six months, and there were a few gynaecologists
who attempted to follow his lead. They noted, however, that the procedure, including
a rectal examination, must be conducted by physicians with considerable expertise,
and they acknowledged that this level of surveillance was impossible to establish
and maintain in entire populations.58
Thus, as concern over ovarian cancer grew, emphasis was placed upon preventive surgery
and on signs which could be detected by the physician, rather than on sensations which
might be reported by the patient. The “silent killer” image was now firmly associated
with the disease, and some standard textbooks said nothing at all about its symptoms
at any stage, thus leaving medical students and practitioners without a basis for
recognizing possible signs of ovarian cancer experienced by their patients. Other
texts mentioned only the symptoms of very advanced disease, while stressing that ovarian
tumours were “silent” until they were large and incurable.59 Because most patients
presented with pronounced swelling or pain prior to diagnosis, many physicians concluded
that those must, in fact, be the first symptoms, even though “careful questioning”
might reveal that the patient had experienced more subtle discomforts for a much longer
period of time.60 These were the non-specific sensations of “unease”, along with urinary
and gastro-intestinal complaints, which had been remarked upon in nineteenth-century
texts. Physicians occasionally noted such complaints retrospectively; Crossen, for
example, chose twelve of his case histories to illustrate the “symptomless progress”
of ovarian cancer, including that of “Mrs. M.”, of whom he observed that, prior to
her diagnosis, she had no symptoms at all—merely “constipation for the past year and
considerable bloating”.61
Given its neglect in medical literature, it not surprising that ovarian cancer symptomatology
was seldom discussed in cancer awareness campaigns aimed at the wider public. The
rhetoric of early detection focused on breast and uterine cancers, which were diseases
with a high incidence, specific (though not necessarily “early”) symptoms, and, it
was claimed, a good prognosis if found soon enough.62 Articles in women’s magazines
and advice manuals intended for the middle-aged woman confined themselves to identifying
breast lumps and several varieties of irregular bleeding as the danger signs which
must not be ignored.63 For example, in a popular work entitled The woman asks the
doctor (1944), the leading American gynaecologist Emil Novak included an entire chapter
entitled ‘Cancer, The Arch-Enemy of Women’ which focused exclusively on breast and
uterine cancers and made no mention of ovarian cancer at all.64
Even though the rhetoric of early detection seemed not to apply to ovarian cancer,
an interest in pursuing a more nuanced understanding of its non-specific symptoms
did emerge within a very small minority of medical researchers on both sides of the
Atlantic. Through retrospective studies, they began, as early as the 1930s, to take
note of the wider pattern of their patients’ complaints and to tabulate symptoms in
order of frequency for more systematic analysis.65 Most importantly, they began to
record the occurrence of mild but persistent gastro-intestinal complaints and to consider
their relevance in relation to ovarian cancer detection. The British gynaecologist
Beckwith Whitehouse paid a good deal of attention to “the complex subject of symptomatology”,
and in 1931 reported that, in a series of 200 cases of ovarian disease, digestive
symptoms “occurred in 29% of my simple cases and 41% of the malignant”.66 John Montgomery
of the Jefferson Medical College Hospital repeated the usual refrain about the silence
of ovarian cancer, but none the less reported that 37 per cent of his patients “had
abdominal symptoms, mostly referable to the gastrointestinal tract for six months
to several years before a pelvic examination was made. One patient, the sister of
a physician, was given ‘samples’ for ‘indigestion’ for three years before her abdomen
began to swell.”67
At mid-century, another prominent British gynaecologist, Stanley Way, made a concerted
effort to draw colleagues’ attention to this very issue. He did not deny that of “all
the aspects of ovarian cancer, the symptomatology is the least satisfactory”, but
he proposed that abdominal discomfort and persistent digestive problems were likely
the earliest symptoms of the disease in a great many cases. Relying, as had others,
on case histories of cancer patients to illustrate the problem, he recounted the death
of a 52-year-old woman who succumbed shortly after exploratory surgery was performed.
Two years before she died, “[S]he had been investigated in a London teaching hospital
for vague abdominal pain thought to be due to pyelitis, and six months after this
she had again been investigated in the medical department of a large provincial hospital
for ‘indigestion’ thought to be due to a gastric ulcer.” He insisted that because
“vague digestive disturbances” were so common in ovarian cancer patients they must
be considered to be “of diagnostic importance”. Lamenting that the number of ovarian
cancers which “have been nurtured in a sea of bicarbonate of soda and potassium citrate
by the practitioners of the world” was beyond calculation, he insisted that all women
over forty who complained of such symptoms should be fully examined.68
Old Metaphors and New Strategies
Way’s advice seems to have had little impact, and few researchers in the post-war
decades challenged the image of the “silent killer”. The illness attracted growing
attention, however, partly because its incidence appeared to be on the rise. In 1954,
one gynaecologist reported a “startling increase of 40 per cent” in the ovarian cancer
death rate in New York State over the previous twenty years, and researchers in both
North America and Great Britain reported upward trends over the following decades.69
The risk of developing the disease, reported to be 1 in 100 in 1965, had risen to
1 in 70 by the 1980s and was reported to be as high as 1 in 55 by the mid-1990s, although
the reasons underlying this apparent increase were obscure.70 Rising incidence combined
with poor survival rates meant that it was a growing threat compared with other gynaecological
cancers. In 1979, one American researcher pointed out that “more women die as a result
of the ravages of this insidious … neoplasm … than succumb to cervical and endometrial
cancer combined”, and another reported in 1983 that “one woman dies from ovarian cancer
every 50 minutes in this country”.71
In the face of such discouraging facts, researchers sought new means of gaining control
over the disease. Important advances in surgery and chemotherapy were made, but their
long-term impact was limited by the fact that a majority of cases were not diagnosed
until metastasis had occurred.72 By the 1980s, more concerted attention was finally
given to the long-neglected epidemiology of ovarian cancer, and some progress was
made in identifying women at increased risk who might benefit from increased surveillance.73
Much effort was devoted, as well, to development of mass screening techniques which
might make earlier diagnosis possible for all patients, but results on that front
were disappointing.
The first risk factor to be systematically examined was low parity, although there
was much disagreement over why it might predispose women to ovarian cancer. The debate
centred on the question of whether “poor reproductive performance”, optional or otherwise,
was in itself a source of risk, or whether low parity was to be interpreted as a sign
of poor ovarian health which might lead to malignancy.74 The New York ovarian cancer
expert Hugh Barber declared in 1978 that: “Women at high risk usually have a long
history of ovarian imbalance or dysfunction, including … a tendency for spontaneous
abortion, infertility, and nulliparity, as well as an early menopause. The ovary is
like a cam running off center.”75 At the same time, other researchers emphasized that
the protection afforded by pregnancy was probably the key factor, because unmarried
and childless married women both had a higher incidence of the disease.76 More studies
followed and yet the question remained open, complicated by the fact that the known
causes of infertility were so diverse.77
Attention was also turned to another hypothesis, first put forward in 1971, that uninterrupted
or “incessant” ovulation might be an important factor in the aetiology of ovarian
cancer.78 This theory was compatible with studies suggesting that the contraceptive
pill, which prevented ovulation, had a very significant protective effect. The U.S.
Center for Disease Control, for example, estimated that “oral contraceptive use alone
may have prevented up to 1700 cases of ovarian cancer” in 1982.79 Some years later,
the theory that frequent ovulation might predispose women to the disease provided
an explanation for an emerging association between ovarian cancer and the use of fertility
drugs. As women became more vocal about their right to know about potential risks
associated with drugs and medical treatments, some cancer patients would charge that
fertility clinics were negligent in not providing this information.80
The question of a hereditary factor was also given serious consideration in 1980s.
Instances of individual families with a high incidence of the disease had been mentioned
in the late nineteenth century, and, from the 1930s onwards, studies of affected families
grew slowly in number. One such study, published in 1950 by Amour Fiscus Liber, concerned
‘Ovarian cancer in mother and five daughters’. At the time, Liber was a lone voice
calling for radical action based on his assumption of a genetic link. Although, in
his words, he stopped short of advocating “eugenic limitation of breeding”, he recommended
prophylactic oophorectomy for women in families thus affected, close monitoring from
an early age, and the creation of agencies to keep records of all cases—even suggesting
that, if possible, autopsies be performed not only on patients but on all relatives,
including males, in case “there is a recognizable phenotype of male carriers”.81 During
the 1950s and 1960s, the importance of a genetic link was widely dismissed, but by
the 1970s the number of families on record was increasing rapidly, and there was speculation
that the incidence of familial disease was actually growing.82 In 1981, the first
Familial Ovarian Cancer Registry in the US was established at Roswell Park Memorial
Institute in Buffalo. Its goal was not merely to study the “mode of inheritance” but
to examine relationships with breast and other cancers, as well as inter-connections
with other suspected risk factors, including asbestos exposure.83 That same year,
a widely cited study reported that women with a mother or sister with the disease
had an alarming eighteen-fold increase in risk, and during the 1980s there was much
speculation upon the nature of the familial link, whether screening procedures should
be introduced for high-risk women, and whether prophylactic oophorectomy should be
recommended.84 In the early 1990s, the BRCA1 and BRCA2 genes associated with both
breast and ovarian cancer were localized, removing all doubt that women in certain
families faced an extremely high level of hereditary risk.85
Because the incidence of ovarian cancer was much higher in western industrialized
countries than elsewhere, researchers also investigated cultural and environmental
factors. One of these was a possible association with asbestos exposure in the workplace
and the use of talc (contaminated by asbestos until at least the mid-1970s) in personal
hygiene. A 1960 study had suggested that women with asbestosis had a higher rate of
ovarian cancer, and another published in 1971 directed attention towards the possible
link with talc by reporting that, in the set of ovarian tumours which they examined,
75 per cent contained talc particles.86 That study and others proposed that this factor
might actually help to account for the rising incidence of ovarian cancer in the post-war
decades.87 Further investigations demonstrated that talc applied to the genital area
could make its way very rapidly into the peritoneal cavity, and a case control study
published in 1982 found that 42.8 per cent of the women with ovarian cancer had used
talc regularly, compared with 28.4 per cent of the controls.88 The association between
asbestos exposure, talc use and ovarian cancer remained controversial, however, because
researchers continued to produce conflicting results.89
In addition to the examination of potential risk factors, a second approach to the
growing incidence of ovarian cancer was the search for a means of effectively screening
asymptomatic women—either entire populations, or only those deemed to be high risk.
By the mid-1980s, three main screening techniques were available; these were the manual
pelvic examination, the ultrasound technology which had been developed during the
previous decades, and the recently devised CA-125 blood test, which measured the level
of a cancer antigen associated with ovarian cancer.90 As already mentioned, many physicians
viewed regular pelvic examinations as an important means of detecting potential cancers
in asymptomatic women, but others increasingly opposed this strategy, arguing that
pelvic examination was limited in sensitivity and did not yield “the desired percentage
of early diagnoses”. Ovarian cancer was found in only about one in 10,000 such procedures,
while, at the same time, about one examination in 125 revealed some sort of mass which,
they pointed out, resulted in unnecessary anxiety and potentially hazardous surgery.91
Ultrasound technology, meanwhile, held out the hope that masses not felt during examination
could be detected through imaging, and also that manually locating a mass would be
“safer” if it could then be assessed without surgery.92 Ultrasound offered a step
forward but was found to be too inaccurate, and too costly, for general screening,
while the CA-125 blood test was neither specific nor sensitive enough for regular
use in asymptomatic women (though both came into use for monitoring women considered
high risk).93 Despite efforts to develop an early detection programme which paralleled
mammography and the Pap smear, no viable strategy emerged for ovarian cancer.94
Meanwhile, during the second half of the twentieth century, medical literature of
various kinds re-confirmed the image of the “silent killer”. “Ovarian cancer, is unfortunately,
very insidious and ‘silent’ in terms of signs and symptoms”, reiterated Novak’s authoritative
text in 1988, and similar language appeared in many other works.95 But, as the prospect
of mass screening for ovarian cancer proved elusive, some voices were raised in favour
of giving more attention to the non-specific symptoms which women could detect themselves,
and of questioning the very use of the term “silent killer”. “Evidence that current
screening techniques reduce mortality is lacking”, wrote one team. “Therefore, symptom
recognition is important in the detection of ovarian cancer.”96 Due to “problems with
sensitivity and specificity”, decided another, “we have to rely on the woman and her
initiative in order to achieve an early diagnosis.”97
From the “Silent Killer” to the “Whispering Disease”
Increasing attention to ovarian cancer symptoms coincided with a much wider women’s
health movement in the 1980s and 1990s. Its objectives were many, but a central goal
was to transform the clinical encounter through the legitimization of patients’ own
experiences of health and illness. For the nascent ovarian cancer movement, much of
the focus was on reducing the risk of wrong or delayed diagnosis through educating
both physicians and the public about the common symptoms of “the disease that whispers”.
This campaign would eventually lead to collaboration between patient activists and
members of the research community and, by the early twenty-first century, to official
recognition of a pattern of what would now be termed “early” symptoms, accompanied
by a widening critique of the “silent killer” metaphor.
A start was made in 1978 when Hugh Barber revived Stanley Way’s plea of nearly three
decades before, declaring it was time “to change the generally accepted notion that
there are no early symptoms” of ovarian cancer. Like Way, Barber observed that women’s
complaints of increased girth and gastro-intestinal problems were routinely dismissed
or wrongly diagnosed. “All too often”, he wrote, “the patient is considered a middle-aged
crock who goes to too many cocktail parties and eats too many hors d’oeuvres.”98 A
year later, the South Dakota physician Brooks Ranney used patients’ records to tabulate
the symptoms they had experienced and confirmed that most patients, including women
with stage 1 and 2 disease, who therefore had a much better prognosis, had noticed
symptoms over a period of two weeks to ten years.99 In 1985, an Iowa team collected
information from patients rather than from clinical records, and found that “[i]n
sharp contrast to clinical perceptions and previous research … three fourths of women
with locally staged tumors of the ovary” had symptoms ranging from swelling to fatigue,
pain, problems with urination, indigestion, irregular bleeding, shortness of breath,
and bowel changes. Nearly half of the women had dismissed these discomforts as “not
serious”, especially those under forty and over fifty. They concluded that localized
cancer did have symptoms, and that helping women to recognize them was an important
public health priority.100 Physicians, as well, needed to know what they were, and
a Swedish team pointed out that, “[h]owever vague the symptoms, there are some that
should alert the clinician to the possibility of ovarian cancer”.101
That call was repeated at intervals during the 1990s. Researchers continued to observe
the long delays that separated the onset of symptoms from correct diagnosis and the
challenge of finding a doctor “who is familiar with the symptoms of ovarian cancer”.102
Their efforts attracted less attention than they might have hoped, and physicians’
uneven knowledge of the disease was the subject of a pair of studies conducted in
1999. The first surveyed primary care physicians and achieved a response rate of just
over one half. Within this group, the researchers reported a good deal of variation
in respondents’ ability to identify risk factors correctly, while the accurate identification
of symptoms ranged from 60 per cent for weight gain to 94 per cent for ascites (abdominal
fluid).103 An odd feature of this first study was that the authors’ list of six symptoms
omitted any reference to the common signs of indigestion, bloating, and changes in
bowel habits. The second study, however, which measured gynaecologists’ perceptions,
did include abdominal bloating and altered bowel function (but excluded indigestion),
and a strong majority of respondents recognized these symptoms. Only 62 per cent identified
the use of fertility drugs as a potential risk factor, however, and 71 per cent identified
a previous history of breast cancer.104
The contrast between physicians’ sometimes limited knowledge and their seemingly unlimited
authority was of major importance to women’s health activists in the 1980s and 1990s.
This growing movement questioned the assumption that lay knowledge was necessarily
inferior to biomedical knowledge and protested the dismissal of women’s intimate experience
of their bodies. Activists sought to recover “the voice of the subject” and to recognize
the role of intuition in relation to health and illness, despite the difficulties
inherent in defining that concept.105 These concerns would have particular resonance
for the ovarian cancer movement, which—while hampered by the fact that many potential
activists did not survive many years after treatment began—was intensely motivated
by the need to improve the possibility of earlier diagnosis.
Like many other aspects of the women’s health movement, ovarian cancer activism was
strongly influenced by what Laura Potts described in her study of breast cancer narratives
as “a dominant culture of revelation, disclosure, and the making of testimony”.106
The disease story is an old genre, but during the late twentieth century it became
a powerful means of giving voice to the personal experience of cancer and of furthering
the goals of the women’s health movement.107 This sense of purpose was shared by writers
of ovarian cancer narratives and, as was the case with breast cancer, the process
began with the publication of testimonies written by well-known women such as the
NBC correspondent Betty Rollin (who wrote about her mother’s illness and death from
ovarian cancer), the comedian and actress Gilda Radner, Cosmopolitan editor Barbara
Creaturo, and Liz Tilberis, editor-in-chief of Harper’s Bazaar.108
Radner revealed that she unknowingly had most of the risk factors for ovarian cancer,
including a strong family history and the use of fertility drugs. She did not recognize
her own symptoms (“my stomach felt bloated and hard”), was diagnosed with stomach
problems by her gynaecologist and gastroenterologist, and spent months seeking an
explanation for her increasing painful condition before finally being told she had
ovarian cancer, stage 4. Her physician and family friend Steven Piver recalled that,
at the time of her death in the spring of 1989, he assumed that the publicity surrounding
her ordeal would mean that “the days of no newspaper or magazine articles or television
specials on ovarian cancer were over”.109 Radner’s death was certainly a turning point,
with both Piver and her husband, Gene Wilder, taking up the cause of early detection,
but the struggle for public awareness would continue.
Many women who were not in the public eye were also motivated to publicize their experiences,
whether in books, newspaper articles, or online. By the turn of the century, ovarian
cancer patients by the hundreds were telling their stories on the internet where,
as for many diseases, websites were being created which provided ordinary people with
a forum for sharing their perspectives on the experience of cancer. On these sites,
entries could be very brief and still serve some of the same purposes as other cancer
narratives. As Shani Orgad writes in Storytelling online, the process of writing “allows
the author to make sense of her experience; to organize people, events, and information
that she encountered, into a coherent framework of meaning”.110 Using such narratives
as historical sources obviously has limitations; as Potts says, disease stories tend
to have “an aura of authenticity” when in reality they are one person’s version of
events, possibly related in a time of crisis.111 As a means of entry into that experience
of crisis, however, they are a valuable resource.
Ovarian cancer narratives are both similar to and different from most other types
of cancer stories. A shared feature is the motif of “the enterprising self”, as Orgad
calls it, through which the patient is cast as the protagonist embarking on a challenging
journey.112 In ovarian cancer narratives, however, the theme of “the enterprising
self” often emerges most powerfully during the quest for a diagnosis, when the obstacle
to be overcome, through courage and persistence, is not yet the disease itself but
medical professionals who do not recognize the symptoms of ovarian cancer or seem
unwilling to listen to patients’ complaints. All such accounts are necessarily retrospective;
they look back, after a diagnosis has been made, to the symptoms which preceded it
and the false starts which were made in identifying the disease.
In writing such narratives, some patients recalled that they were not aware that ovarian
cancer was called the “silent killer” until after their disease was recognized, but
they later identified the term as a factor in their delayed or incorrect diagnoses.
One such story was that of Ayala Miron, the editor of a book titled Ovarian cancer
journeys. She was diagnosed in 2000 after several years of reporting symptoms to her
doctors and two trips to the emergency ward, where she was diagnosed with a gallbladder
attack on the first visit and diverticulitis on the second.113 “As it turned out”,
wrote Miron,
my health care providers had completely misdiagnosed my symptoms. They didn’t know
enough about ovarian cancer and did not suspect that my complaints were serious. After
my ovarian cancer diagnosis, I realized that this disease caused the symptoms I felt.
I also learned that many health care providers mistakenly consider ovarian cancer
“a silent disease”. My symptoms, over a number of years, taught me differently.114
Miron attributed health care professionals’ apparent lack of awareness to the influence
of the “silent disease” image but also suggested that she, herself, failed to identify
the symptoms she was experiencing because she was uninformed.
The Johns Hopkins Pathology Ovarian Cancer Website provided a forum for women to write
about their personal experiences with ovarian cancer in the early twenty-first century,
and it became a particularly rich source of patient perceptions regarding the process
of diagnosis. Stories of long delay were legion, and a repeated theme was that both
physicians and patients must be made aware of the symptoms which may signal ovarian
cancer. For example, Amy Chaiklin described “the laparoscopic discovery of ovarian
cancer after 13 years of suffering”, while Becky Bennett recalled experiencing swelling
and discomfort in the early 1990s, noticed a “lop-sided” abdominal enlargement by
1994, began to have problems with urination in 1999, and was diagnosed with a ten-pound
tumour in 2001.115 A woman signing herself as “Barbara”, in a testimony reminiscent
of Stanley Way’s warning fifty years earlier, wrote of “popping Tum’s [sic] and over-the-counter
gas medications like crazy” and being diagnosed with acid reflux, while “Chris Y.”
wrote of being told for three years that she had endometriosis and was then treated
for a kidney infection before her diagnosis.116 Donna McNulty related that her swollen
stomach was attributed to peri-menopausal weight gain; her bloating and nausea were
treated as acid reflux; and her constant need to urinate was diagnosed as a bladder
infection—all common occurrences in women, but symptoms which, seen together, comprise
a pattern typical of ovarian cancer.117 Judy Lidgate experienced the usual symptoms
and was told she was suffering from depression, while Karen Leonard’s intense pain
was attributed to gallstones or a parasite.118 An especially common misdiagnosis was
irritable bowel syndrome, or IBS, and women sometimes blamed themselves for not questioning
their diagnosis. Augusta Gluck admitted, “I regret that I accepted the diagnosis of
irritable bowel syndrome and did not investigate further … But I had seen my internist,
my gynecologist, and a gastroenterologist. No one even mentioned that my symptoms
might have been ovarian cancer and my life threatened by it.”119
Often employing the term “whispering disease” brought into use by the ovarian cancer
movement, such testimonies addressed the relationship between the two principal metaphors
considered in this paper. They argued that ovarian cancer is not “silent” but that
women must “listen” to their bodies in order to recognize the signs of “the disease
that whispers”. They urged others to put aside their fears of disapproval, trust their
own perceptions and intuitions, and—shifting their use of the word “listen” to its
more literal sense—demand their doctors’ attention: “Don’t just listen to your body
(we all know or have heard that ovarian cancer whispers), make sure the doctor is
listening, too.”120 The notion of “the disease that whispers” itself came under criticism,
however, for it lacked resonance for women whose symptoms had become intense well
before they were diagnosed. As one woman declared in a newspaper interview, “It’s
such a whimpy, cop-out term. I hate it. It’s not a whispering disease. It’s a shouting
disease.”121 Another woman, a long-term survivor of stage 4 cancer, told of how by
the time a diagnosis was reached “the ‘disease that whispers’ was screaming out to
her”.122 The majority, none the less, focused on the need to heed the earlier, subtler
symptoms of ovarian cancer, and various permutations of “the whispering disease” metaphor
gained wide currency in the ovarian cancer movement.123
In spite of the efforts of the ovarian cancer movement, many women’s health manuals
and menopause guidebooks, written by women’s health advocates and physicians, were
slow to reflect need for more information about symptoms of the disease. In part,
this reticence may have reflected other priorities of the women’s health movement.
The prophylactic removal of healthy ovaries when hysterectomies were performed was
still common, and one way to counter that practice was to downplay the danger of ovarian
cancer. Lonnie Barbach’s The pause, for example, assured readers that ovarian cancer
is a sufficiently rare disease that the ovaries “should not be removed preventatively”.124
Even in the early twenty-first century, most health manuals aimed at middle-aged women
said little or nothing about ovarian cancer symptoms. In her Menopause and hormone
book, Dr Susan Love passed lightly over the complexities of ovarian cancer diagnosis
with the simple comment that there is “no good way to detect it early”, while Ivan
K Strausz’s You don’t need a hysterectomy described the early symptoms of the disease
as “entirely inconspicuous” and remained highly pessimistic about the prospect of
timely diagnosis.125 And yet, this neglect was far from uniform, for the Boston Women’s
Health Book Collective had already begun, as early as the 1984 edition of Our bodies
ourselves, to detail the “warning signs” of ovarian cancer which, they cautioned,
“are frequently dismissed merely as ‘stress’ or nerves’”. These symptoms included
“indigestion, gas, constipation or diarrhea, loss of appetite or weight, a feeling
of fullness, lower abdominal discomfort or pain, frequent urination, fatigue, backache,
nausea, vomiting, nonmenstrual vaginal bleeding, enlargement or bloating of the abdomen
or an unusual growth or lump”. Persistence of such symptoms, they advised, called
for “a thorough physical evaluation for ovarian cancer” by means of a symptom review,
family history, pelvic and rectal examination, CA-125 blood test, and ultrasound.126
This disparity within the popular women’s health literature shows that information
about symptoms and diagnostic procedures was available to the public, even if many
authors chose not to include it in their works.
“Official” Recognition of Ovarian Cancer Symptoms
By the late 1990s, a growing body of research was providing more and more evidence
that there was, indeed, a pattern of early warning signs of ovarian cancer which should
be more widely publicized and acted upon. The growing ovarian cancer movement, meanwhile,
lobbied for further research initiatives, and, on occasion, worked with members of
the research community to document ovarian cancer symptom patterns. One leading activist
was Cindy Melancon, a registered nurse living in Amarillo, Texas, who was diagnosed
in 1992 and started a newsletter, Conversations, as a forum for women with ovarian
cancer and as a vehicle for disseminating information.127 A seminal moment in the
relationship between lay activists and professional researchers came in 1998, when
Barbara Goff, a gynaecologic oncologist from Seattle, Washington, met Melancon at
a conference for the lay public. As Goff described the meeting:
Cindy and other survivors challenged the notion that ovarian cancer is a silent disease.
After listening to these survivors’ exceptional stories, I decided to team up with
Cindy so that we could evaluate symptoms and early diagnosis in a scientific manner.
During medical school, residency, and even gynecologic oncology fellowship I had been
taught that ovarian cancer was a silent disease and so initially I was not optimistic
that our studies would yield new information.128
Although a number of researchers were already challenging the language long used to
describe ovarian cancer, the findings of Goff and her colleagues would eventually
prove to be a turning point. Their first study was published in the American Cancer
Society’s journal Cancer in 2000. It was a retrospective study based on information
collected from ovarian cancer patients through a survey sent to subscribers of Melancon’s
newsletter, and the authors concluded that the great majority of women diagnosed at
an early stage experienced symptoms. They analysed the reasons for delays in detecting
the disease, ranging from women’s own ignorance of symptoms to dismissive attitudes
on the part of some physicians and the failure to perform pelvic examinations or order
tests. While acknowledging the possibility of both selection bias (the women were
Melancon’s subscribers) and recall bias (they were recalling symptoms after receiving
their diagnoses), Goff’s team concluded that “women with ovarian carcinoma do have
symptoms in contrast to what is stated in most textbooks and taught in most medical
schools”.129 A second study responded to the problem of bias and also addressed a
concern voiced by primary care physicians, which was that the non-specific symptoms
of ovarian cancer are experienced by a great many women and can hardly be considered
a guide to early diagnosis. By tabulating symptoms experienced during the past year
by women about to undergo surgery for a pelvic mass compared with two control groups
attending primary care clinics, the team found that, while women commonly reported
at least one of the symptoms associated with ovarian cancer, those eventually diagnosed
with the disease had much more severe, frequent and varied symptoms, even compared
with women suffering from IBS. They concluded that their study “adds further evidence
that ovarian cancer is not a silent disease”.130
Other researchers pursued the same question, and their combined work eventually led
to a public statement released in June 2007 by the American Cancer Society, the Gynecologic
Cancer Foundation, and the Society of Gynecologic Oncologists announcing that, for
the first time, a “national consensus” had been reached in the US regarding early
signs of ovarian cancer.131 The signs were listed as “bloating, pelvic or abdominal
pain, trouble eating or feeling full quickly” and “urinary symptoms, such as urgent
or frequent feelings of needing to go”.132 The news media quickly spread the word,
and Goff was one of the main spokespeople called upon to interpret these findings
to the public. “There’s been this myth about ovarian cancer being silent and people
saying there’s nothing you can do about it”, Fox News reported her as saying, “well,
that’s simply not true anymore.”133 In an interview with Jim Lehrer on PBS, the American
public television network, Goff addressed the old problem of the non-specificity of
symptoms by explaining that “it’s not simply just having the symptom that is important”,
but that the symptom is new, persistent, and increases in severity.134 “The majority
of time”, she advised, such symptoms will not signify ovarian cancer, “but it’s just
something that should be considered.”135 She recommended that persistent symptoms,
when reported by patients, should lead to a pelvic examination, including “a recto-vaginal
exam so that the ovaries can be appropriately felt”, followed by ultrasound and a
CA-125 blood test, if warranted. If the ultrasound detected a mass and the blood test
revealed an elevation of a tumour marker that is common with ovarian cancer, the patient
should be referred to a specialist in gynaecologic cancers.136 Debbie Saslow, director
of breast and gynaecologic cancer at the American Cancer Society, was also widely
quoted, and spoke to the still relevant concern over causing more women to undergo
unnecessary and hazardous surgery. She revealed that the ACS still had reservations
about the recommendations, due to the fact that “[w]e don’t have any consensus about
what doctors should do once the women come to them”.137 None the less, leading members
of the cancer research community stood firmly behind the public statement. Columbia
University’s director of gynaecologic oncology, Thomas J Herzog, commented, that “By
no means do we want this to result in unnecessary surgery. But I would not expect
that to occur in the vast majority of cases.” He also saw a need for physicians to
reverse their old approach and discuss the existence of early symptoms with their
patients so that women might become “more pro-active” in recognizing them. The gynaecologic
oncologist Carol Brown, at Manhattan’s Memorial Sloan Kettering Cancer Center, agreed
that “[t]his is something that women themselves can do”.138 While the June 2007 announcement
did not suddenly produce a consensus within the medical community regarding the significance
of early symptoms, researchers would continue to investigate the role they might play
in improving ovarian cancer diagnosis.139
Conclusion
This article has examined ovarian cancer’s long association with the metaphor of the
“the silent killer” and has traced the process by which that metaphor, and the understanding
of ovarian cancer symptoms which it signified, were eventually challenged in the pages
of medical journals and through the voices of ovarian cancer activists. It has attempted
to show that, while the use of metaphorical language in medical discourse is inevitable,
metaphors arise within particular contexts and may outlive their utility in expressing
medical realities. In the early twentieth century, within the context of the “war”
on cancer, the adoption of the “silent killer” metaphor in medical texts reflected
the fact that the disease almost always progressed to an advanced stage before it
was diagnosed and was almost always fatal. These factors also supported its exclusion
from public information campaigns and popular medical literature aimed at women readers.
From mid-century onwards, a small number of physicians openly questioned the accuracy
of this metaphor and the medical assumptions which it signified, but only during recent
years were the existence of early symptoms and their possible role in diagnosis widely
and publicly addressed in both the lay and medical press. The association of the “silent
killer” metaphor with ovarian cancer was exceptionally tenacious, and it arguably
played a role in diverting attention away from systematic attention to symptoms which
were later deemed relevant by a growing number of researchers. This history provides
support for the conclusion that medical metaphors do have a role in defining “notions
of reality” and therefore deserve close scrutiny.140