It is rare that an ABC movie of the week endures. Buzz Kulick’s 1971 Brian’s Song is the notable exception. IMDB describes the movie as a “beloved tearjerker,” which portrays the friendship between Chicago Bears teammates Gale Sayers and Brian Piccolo in the mid-1960s. Central to the plot is not only the race-based prejudice that existed in professional football at the time but also the public depiction of cancer in early 1970s America.
In one dramatic scene, a dying Piccolo holds his wife’s hand while breathlessly repeating, “Who’d believe it, Joy — who’d ever believe it?” His wife remembered Piccolo’s real death as pure torture, her husband writhing in agony and slipping in and out of consciousness. But the painful suffering Piccolo endured would not have fit into Hollywood’s narrative of a good death. Brian’s Song joined other early 1970s movies including Love Story and Bang the Drum Slowly, which centered the secrecy around a cancer diagnosis and a heroic progression towards certain death. According to the American Cancer Society, these unrealistic representations of cancer were not only acceptable but necessary. “If you portray cancer on the screen with all its degradation and pain, you haven’t a prayer,” an ACS spokesman lamented to Esquire magazine in 1973, “If they ever walked into a cancer ward, they’d run away so fast. And we want [the public] to stop running away from this goddamn disease.”
This duality of cancer was familiar to the American public, particularly women diagnosed with breast cancer. “Cancer” and “breast” were whispered in worried tones, not broadcast to the world. As depicted by Mary Tyler Moore in the biopic First You Cry, women suspected of having breast cancer underwent brutal radical mastectomies and then hid their resulting disabilities and pain behind brave faces. Cancer was still seen by some as contagious, and employers cited frequent absenteeism as a reason to pass over survivors who were otherwise qualified. Many employers would not hire a woman who revealed her diagnosis until five years had passed since her last treatment. Employers’ concerns were not completely unfounded. In 1974, breast cancer was deadly. Of the 90,000 women diagnosed with breast cancer that year, over a third would die — many after miserable suffering due to metastatic disease or after a painful and disfiguring surgery. “Our current means of cancer control are very crude and very physical,” concluded Dr. Albert Owens, a Johns Hopkins oncologist, in the same 1973 Esquire article titled “King Cancer.” Dr. Owens continued, “You can talk only about parts of the body which you can sacrifice.”
Into this scene waltzed a lithe dancer from Grand Rapids, Michigan: Elizabeth “Betty” Ford. The eighteen months leading up to the last weekend in September 1974 had been a blur of drama that ended with her husband being sworn in as the 38th president of the United States. Absent a normal transition period, the Fords, including their teenage daughter, Susan, started their new life as the First Family from their modest home in Alexandria, Virginia. After Ford’s appointment to the vice-presidency, the family planned to move into the newly renovated Naval Observatory but never got the chance. Thus, on his first day as president, Gerald Ford appeared on his doorstep in baby-blue pajamas looking for the morning paper and went back inside to fix his own breakfast — orange juice and an English muffin. Afterwards, like a typical American businessman, the president kissed his wife goodbye at the front door before walking down the sidewalk, briefcase in hand, to a waiting motorcade.
The grace period for the non-elected president was short lived. Just weeks after being sworn in, President Ford pardoned the disgraced former president Nixon and watched his approval ratings drop thirty points overnight. Meanwhile, inflation climbed to 11 percent, and gas prices skyrocketed. Congressional Republicans, anxious about the impact of the Watergate scandal on the upcoming midterms, clamored for Ford to campaign in their districts.
The First Lady, therefore, had plenty on her mind as she waited in a cold exam room at the National Naval Medical Center in Bethesda (later renamed Walter Reed National Military Medical Center). When she agreed to accompany her assistant for an annual physical just six weeks into her new job as First Lady, Betty’s intent was not to stop women from “running away from this goddamn disease.” In fact, like many women, Betty contemplated skipping the visit to address the mountain of work accumulating on her desk.
After an initial examination, the physician returned with another doctor who repeated the breast exam. Betty thought nothing of it as she had always had lumpy breasts. After the two men left the room, the First Lady dressed and returned to work. Later that afternoon, the White House physician called Betty and asked her to come by his office.
Betty arrived at 7 p.m. The White House physician, Dr. William Lukash, introduced her to a surgeon from George Washington University. Betty put on a gown, and both men examined her breasts. When she came out of the dressing room, she was surprised to find her husband waiting for her. Dr. Lukash told the president and First Lady that the doctors found a lump in her right breast and suspected breast cancer. Their recommendation was to operate immediately. They suggested surgery just two days later — Saturday, September 28, 1974. After spending Friday night in the hospital, she would be placed under general anesthesia, and the surgeon would perform a biopsy of her breast. If the lump was malignant, the surgeon would continue with a Halsted radical mastectomy while she was still under anesthesia. This was the standard practice. There were no other options.
The Fords took the elevator upstairs, processing the news. As the family sat down to dinner, Betty could tell her teenage daughter Susan had been crying. Susan admitted that she had stopped by the White House physician’s office earlier, and he revealed that he suspected her mother had cancer. The president’s mother had undergone a radical mastectomy for breast cancer many years earlier, and Susan remembered seeing the horrific scars that peeked out around her grandmother’s corset.
Betty pushed her own feelings aside as she comforted her family, and they discussed whether to share the news publicly. In the aftermath of Watergate and Vice President Spiro Agnew’s corruption scandal, President Ford promised the country complete transparency. Betty was already known around Washington for her forthright approach. In her mind, there was no question. “She was adamant about going public with it,” White House photographer David Kennerly recalled. “And women didn’t do that — not in 1974. And not only that, but President Ford agreed, and he stood by her. It had nothing to do with politics, and it had everything to do with the love and support for his wife.”
Accustomed to Pat Nixon’s frosty nature, Betty Ford was a breath of fresh air to the White House press corps. She spoke candidly in favor of abortion (“It is time to bring abortion out of the backwoods and put it in the hospitals where it belongs”) and mused that it was likely her children had smoked pot. A reporter for The Washington Post described the First Lady this way: “She’ll tell you plainly what she thinks about anything, without a moment’s hesitation and without any sense of fear.” Pot and politics were one thing. Breast cancer, however, was another matter. As the Ford family processed Betty’s news, a separate debate was happening that would change the treatment of breast cancer forever.
For months, word had been leaking out about the results of two important breast cancer studies. Organized by Dr. Bernard Fisher, a brash surgeon from Pittsburgh, one study showed that women who underwent a radical mastectomy (the standard treatment for breast cancer in 1974) weren’t living any longer than women who received less aggressive surgery. In addition, there were whispers that Fisher’s other trial showed that, for the first time, women with breast cancer who took a chemotherapy pill called L-PAM were living longer.
Pressure was mounting for Fisher to share his interim results. Dr. Nathaniel Berlin, an NCI official, recalled in an interview, “I wanted to break this data out because… if we waited for five years or ten years or whatever it is, until the data was absolutely solid, in that interval of time a lot of women would have been denied a good treatment.” Plodding and deliberate, Fisher resisted. The first randomized trials in breast cancer would be done correctly. The data wasn’t ready yet. Desperate to announce these earth-shattering results, Berlin offered the recalcitrant Fisher a compromise. The NCI hosted regular insider-only meetings where scientists receiving grants from the NCI presented their findings and discussed their results. Would Fisher agree to present his preliminary data to these colleagues only? Berlin promised there would be no press and no publicity.
Fisher considered Berlin’s proposal.
On the one hand, the surgical results were clear — women who received a “modified” radical mastectomy lived as long as women who received the disfiguring and painful radical mastectomy. Fisher was uncertain, however, about the L-PAM data. If the current trends continued, it appeared that women who took chemotherapy would live longer. Fisher, however, had been watching each participant’s progress on the magnetic boards in his office like a hawk. He knew that cancer returned in some women just a few years after stopping the drug. Watching the results in real time, he wasn’t yet convinced that L-PAM would cure more women. It might, he suspected, just delay cancer recurrence. It was too early, Fisher told Berlin. More follow-up was needed.
Berlin prevailed, and a small conference entitled “A Report to the Profession from the Breast Cancer Task Force” was scheduled at the NIH for the first Monday in September 1974. Fisher’s preliminary results would be presented to a few dozen experts. Months of careful planning went into the meeting. “The program was a broadly-based program. Every one of those five groups within the task force reported in the whole day’s meeting. But the hidden agenda was to break this out [the Fisher data],” recalled Berlin later.
In just twenty-four hours, however, the stakes of the conference had been raised substantially. A quiet report to the profession turned into a media circus. Across the street from the NIH where the small conference was set to take place, dozens of news vans now stood parked outside the Naval Hospital. A gaggle of reporters kept their eyes on the front doors and their searchlights shining into the windows of the First Lady’s hospital suite. Jerry Boyd, editor and founder of The Cancer Letter, commented dryly, “Any chance that the report would be limited to the profession with little public awareness disappeared with Betty Ford’s illness.”
Two days after Betty Ford’s mastectomy, the largest meeting ever held at the NIH convened. When word leaked out of the groundbreaking research being presented across the street, reporters covering Mrs. Ford rushed over. The Cancer Letter noted the discomfort on the faces of buttoned-up surgeons sitting next to long-haired journalists. According to Boyd, philanthropist Mary Lasker attended, and breast cancer activist Rose Kushner was in the audience.
The crowd was so large that a closed-circuit TV had to be set up in a conference room on a different floor to accommodate the overflow. In addition to Fisher’s two studies, the agenda included presentations on advanced methods to detect estrogen receptors on the outside of cancer cells and the possibility of finding cancer markers in blood. The only female scientist presented on the virology of breast cancer in mice. Not a single speaker mentioned the psychological effects of breast cancer treatment.
As planned, Fisher presented the dramatic success of L-PAM. The 250 premenopausal women who had taken the drug had far fewer cancer recurrences than those who had taken a placebo pill. The results were so spectacular, Fisher announced, that this part of the study would stop, and all premenopausal women would now receive chemotherapy. The news shocked doctors and reporters alike.
Today it seems like a miraculous cancer drug is discovered every week, but in 1974 no one expected any change in the dismal prognosis of patients with breast cancer. Giving chemotherapy to otherwise healthy women on the supposition that she MIGHT develop metastases was, as Fisher described it, “a revolutionary departure from prior treatment strategies.”
The other study Dr. Fisher presented on that fall weekend in 1974 would have an even greater impact. The trial Fisher called the “Rosetta Stone” of cancer, NSABP B-04, showed that a modified radical mastectomy was equal to radical mastectomy in the treatment of breast cancer. Between 1971 and 1974, over 1,600 patients were randomly assigned to one of three arms of the study: radical mastectomy, modified radical mastectomy, or modified radical mastectomy with radiation. After two and a half years of follow-up, the data showed that the radical mastectomy was no more effective than a modified radical mastectomy with a 15 percent recurrence rate in both arms.
Breast cancer, according to Fisher, was now undeniably a systemic disease, and future research efforts should move in that direction. Increasingly radical surgery, as many prominent surgeons including Dr. Jerry Urban and Dr. Cushman Haagensen championed, would not cure more women. The Breast Cancer Task Force Report released after the conference suggested that “less than radical surgery is acceptable for the treatment of primary breast cancer.”
News of Fisher’s findings quickly made its way across the street. At a press conference, journalists questioned the First Lady’s physicians about their recommendation for a radical mastectomy. Would a lesser procedure have been just as effective? Overnight, Betty Ford brought breast cancer out from the shadows and into public view. Drawings of breasts were published in national newspapers along with instructions on how to perform a breast exam. Thirty-five thousand people sent heartfelt letters to Betty Ford and thousands more to the president. Many included stories of their own cancer diagnosis or that of their loved one.
Inside her hospital room, Mrs. Ford performed a “spider walk” with her fingers up the wall to increase her arm motion and celebrated when she could lift a teacup for the first time. Her husband brought a signed football from the Washington Redskins–Denver Broncos match-up that weekend as a gift from the Redskins coach. To the shock of her husband and surgeon, Betty spontaneously drew her arm back and threw a pass to her husband, much to the delight of the press who captured the moment on film.
The First Lady was discharged two weeks after her surgery, and despite involvement of her lymph nodes, her doctor noted in a press release, “Mrs. Ford’s progress to date has been excellent and her outlook for prolonged good health is extremely favorable.” Fisher and others recommended she take L-PAM for two years, which she did.
Mrs. Ford recalled her reaction to the pills in her autobiography, The Times of My Life: “It was on a Sunday night that Dr. Lukash brought up a little brown bottle of pills for the first time. I was upset. I thought, every time I look at these pills it’s going to remind me of the fact that I’ve had cancer. Also, I’d heard so many dreadful tales about chemotherapy… Then I pulled myself together.” A journalist reported that L-PAM was “being given out like jellybeans at the White House.” The research championed, organized, and presented by the previously unknown Jewish surgeon from Pittsburgh changed treatment of the most famous breast cancer patient with one presentation that he’d been reluctant to give.
Fisher recalled that after the conference “we were flush with success… for twelve hours.” Attacks on Fisher that before were dismissive turned merciless and personal. How dare he, a surgeon, advocate for less surgery? Rumors began circulating that Fisher, the talented surgeon who cannulated the whisper-thin lymphatic channels of rodents in his lab “could not operate his way out of a paper bag.” Former National Cancer Institute director Dr. Vincent DeVita was shocked by the vitriol directed at Fisher, “The academic surgeons who worshiped Halsted were furious; to them, Bernie was attacking the sacred cow, and he became the most hated surgeon on the planet. I have never seen doctors treated as badly as he was. It was stunning.”
Just a few weeks after Fisher’s blockbuster presentation, the (all-male) breast cancer advisory committee of the American Cancer Society released a statement declaring that “recommendations for the treatment of breast cancer should be made by the physician.” The ACS warned women not to be “misled” into “lesser, unproven surgeries.” The statement made no mention of patient input or the possibility of shared decision-making. Breast cancer survivor and activist Rose Kushner was not surprised. “The ACS is a conservative organization that moves with the speed of a senile snail,” she remarked dryly in her book Why Me? What Every Woman Should Know About Breast Cancer to Save Her Life.
An anonymous physician lamented this new direction in an editorial in the Western Journal of Medicine:
Physicians also know that patients who are ill, in pain or fearful are often simply not capable of understanding… or of making sound decisions on their own behalf… It is for reasons such as these that physician dominance in health care came into being and should not be lightly cast aside… It is perilous to ignore the special role of a physician or to substitute the patient… in his role.
Fisher understood the reticence of his peers. He was one of them. “[The radical mastectomy] became a dogma,” he said, “and if a surgeon did something other than a radical mastectomy, he could be put off the staff. There was no thought of doing anything else.” Breast cancer survivor and surgeon Dr. Susan Love described the surgeons’ resistance to change as predominantly driven by fear, “They had put their whole life into this and to say they were wrong? I don’t think they could admit it. Even to themselves.” Rose Kushner agreed: “Too many surgeons would rather stonewall than switch.” The older surgeons could fight change, but thanks to Betty and Bernie, the new era of breast cancer treatment had arrived. And there was no going back.
In the weeks following that fall weekend in 1974, women across the country flooded breast cancer screening centers with phone calls. So many women got breast exams that the United States experienced a “Betty Blip” in 1974, a 15 percent increase in breast cancer diagnoses in the year after her announcement. Betty later commented on the power of the First Lady in her autobiography, The Times of My Life: “Lying in the hospital thinking of all those women going for cancer checkups because of me, I’d come to recognize more clearly the power of the position, a power which could be used to help.”
Exposed to daily headlines of Mrs. Ford’s diagnosis and emboldened by the research of Bernie Fisher, by the end of 1974, the American public became more comfortable with conversations about breast cancer. By 1977, breast cancer became so normalized that when the same physician who examined Mrs. Ford found a breast mass during First Lady Rosalynn Carter’s routine physical, a description of her procedure was buried on page 14 of The New York Times. The public shrugged and moved on.
By the end of 1974, the American public was more familiar with breast cancer, exposed through daily headlines on the diagnosis, treatment, and recovery process of Mrs. Ford. It had become so normalized that just three years later in April 1977, the same physician who examined Mrs. Ford found a breast mass during First Lady Rosalynn Carter’s routine physical. She was taken for an immediate surgical biopsy, and thankfully the mass was benign. A description of her procedure was buried on page 14 of The New York Times. The public shrugged and moved on.
Breast cancer would eventually make its way to NFL jerseys and freezer aisles. Co-opting the red ribbon of AIDS awareness, breast cancer advocates in the 1990s would soon raise their voices demanding more research into this deadly disease. It was Betty and Bernie, on a fall weekend in September 1974, however, who started the conversation.
Stacy Wentworth is a radiation oncologist.
