(I was asked to make three short videos on the history of cancer, for the excellent liberal arts college, Gustavus Adolphus, where I spent a year. The theme of their annual Nobel Conference for 2020 was Cancer in the Age of Biotechnology. The videos are available here but if you prefer to read things, here is the script for the second one.)
What do we know about historical patients?
In the last piece, I talked about how we want a disease to have a history, and cancer’s no exception to that. Having a history is reassuring for medical practitioners, who can see themselves as part of a long tradition of progress, and also for patients, who realise they are not the first to suffer in this way.
Let’s think a bit more about patients; both ancient and more recent. We have to bear in mind again that point I made in the first video, that we can’t know a case described in the past was definitely cancer, because we just don’t have the sort of evidence that would make a diagnosis possible. But that hasn’t stopped historians and medics creating stories!
In this video I’ll again be concentrating on breast cancer. There are various lists online of famous women who had breast cancer, presumably supposed to be reassuring if you have it today. One of the earliest women who features on such lists is the Persian Queen Atossa.
Today, there’s even a clinical trial being run in Australia which uses her name: the company involved is Atossa Therapeutics. The trial tests hormone therapy, using oral (Z)-Endoxifen, in patients with invasive breast cancer who are about to have mastectomy or lumpectomy. As of May 2020, the results were looking encouraging and trials moved to the next stage.
So, what’s the story? Who was Atossa and what happened to her?
Our evidence comes from the Greek historian Herodotus, Book 3, chapter 133. You can read this story online here and use the forward and back arrows above the chapter number (133) to see the rest of it. It’s set in around 520 BCE.
A short time after this, something else occurred; there was a swelling on the breast of Atossa, the daughter of Cyrus and wife of Darius, which broke and spread further. As long as it was small, she hid it out of shame and told no one; but when it got bad, she sent for Democedes and showed it to him. He said he would cure her, but made her swear that she would repay him by granting whatever he asked of her, and said that he would ask nothing shameful.
He treated her (it doesn’t say how) and he cured her.
Who is Atossa? Daughter of one King of Persia, and wife of another. It’s interesting that her first response to whatever is happening in her breast is ‘shame’, αἰσχυνομένη from a verb which can have the sense of dishonour, make ugly. There are many, many examples from history of women not getting the treatment they need because they are ashamed to mention it to male caregivers.
Who is Democedes? A Greek doctor at the Persian court, who has already successfully treated king Darius for a badly dislocated foot; Herodotus tells us that Doctor Democedes ‘applied Greek remedies and used gentleness instead of the Egyptians’ violence’. So there’s a subtext here, in this history book written by a Greek – that Greek medicine is a lot better than everyone else’s!
And what is Democedes’ reward; what does he ask for in return? He gets Atossa to intervene with her husband and persuade him to invade Greece, with Democedes as his personal advisor. Stage one of the invasion plan sees 15 Persians and Democedes sailing to Greece to check out the coast, and in the process, cunning Democedes escapes and goes home!
What about that ‘swelling’? In the first of these videos we saw that some of the claims made about the earliest history of cancer are based on translating ancient texts to talk about ‘tumours’ when the original Greek or Latin could just be a more neutral ‘swelling’. In the original ancient Greek, here the word is phyma. Literally just a ‘growth’, but other translators use the words boil, ulcer, abscess, or tumour. This swelling bursts and spreads. It’s not clear what Democedes does to cure it. Remember, he is famous for ‘gentleness’ in his treatments, so it’s unlikely he used surgery. Atossa lived on for many years and has four sons and has no recurrence.
Yet those writing about it in modern times read all sorts of things into this very short story. Some say Atossa was terrified it might be cancer, that she was terrified that her status and her wealth would not protect her from this disease… that’s all fantasy! Here’s Siddhartha Mukherjee, oncologist and writer, in his 2011-Pulitzer-Prize-Winning book The Emperor of All Maladies: A biography of cancer, for whom Atossa is an important case, referred to several times in the book.
The first reference to Atossa in the book compares her with one of Mukherjee’s actual cases:
The isolation and rage of a thirty-six-year-old woman with stage III breast cancer had ancient echoes in Atossa, the Persian queen who swaddled her diseased breast in cloth to hide it and then, in a fit of nihilistic and prescient fury, possibly had a slave cut it off with a knife (p.5).
But the original text doesn’t tell us what treatment Democedes used – considering he was known for gentle remedies, mastectomy seems unlikely.
The second reference goes like this:
In the middle of her reign, Atossa noticed a bleeding lump in her breast that may have arisen from a particularly malevolent form of breast cancer labeled inflammatory… If Atossa had desired it, an entire retinue of physicians from Babylonia to Greece would have flocked to her bedside to treat her. Instead, she descended into a fierce and impenetrable loneliness. She wrapped herself in sheets, in a self-imposed quarantine. Darius’ doctors may have tried to treat her, but to no avail. Ultimately, a Greek slave named Democedes persuaded her to allow him to excise the tumor (p.41).
So while the first reference talked of her ‘fury’, the second attributes ‘loneliness’ to Atossa. Again the treatment is assumed to be surgical, but here it is excision of the tumour not the whole breast.
The third reference treats Atossa as a traveller through time, exploring what treatment she would have been offered from century to century over history. This includes
In 500 BC, in her own court, Atossa self-prescribes the most primitive form of a mastectomy, which is performed by her Greek slave (p.463).
In the second reference, Democedes ‘persuades’ Atossa to have surgery: in the third reference, she prescribes it herself.
What is going on here? You’ve read the original story – how did it become distorted into this? It seems to be impossible NOT to read things into this story: we assume we know how Atossa felt about this swelling, and we assume we know what the treatment was. All this is inevitably influenced by our own knowledge, but also by other stories of breast cancer. Among them, there is the extraordinary letter written in 1812 by the novelist and diarist Fanny Burney, describing to her sister the surgery she underwent in 1811. It has been digitized by the British Library so you can read it online here (click on ‘Transcript’ for the letter itself).
She describes cancer as ‘this dreadfullest of maladies’, and vividly describes the horror of seeing all the bandages and dressings prepared for the surgery, followed by the extreme pain of a mastectomy without anaesthesia. She lived for 29 years after this surgery. The message, as another survivor – the British broadcaster Jenni Murray – wrote, is that ‘though the diagnosis is awful and the surgery, even with a full anaesthetic, isn’t pleasant, breast cancer can be survived – and a long and productive life lived after it. For this, she deserves her place among the greatest women.’
The difference between Atossa and Fanny Burney is not just over a millennia and a half of time. Atossa lived in an era where cancer was not understood: Burney knows all too well what is going on. But also, we read Atossa only through the words of Herodotus, whose subtext is that Greek doctors are the best. For Burney, we have her own words, although written six months on from the events described. Both women, however, give hope to survivors and help them to make sense of their own experiences.
In the next and final piece in this series, I’ll be looking at changing theories of what cancer is. See you then!
Mistaking histories 