The rugged history of cervical cancer screening
17 February 2010
On World Cancer Day, Professor Tilli Tansey discusses the lessons and surprises revealed in her oral history of the development of treatment for cervical cancer.
Professor Tansey (UCL History of Medicine) has edited the Witness Seminar on the History of Cervical Cancer and the Role of the Human Papillomavirus, 1960-2000, which looks at the development of the study of cervical cancer cells, effective screening, and its ultimate success in reducing cervical cancer incidence and mortality - a story that has, until now, remained largely untold.
What is a witness seminar and why did you decide upon this approach?
A Witness Seminar is a specialised form of oral history, where several people associated with a particular set of circumstances or events are invited to meet to discuss, debate, and even disagree about their reminiscences.
The idea came to me when I organised a conventional seminar at which a medical historian spoke about the history of interferon. I'd invited some scientists who had worked in academic or industrial laboratories on interferon, and the discussion following the talk was incredibly revealing: many members of the audience contributed memories and recollections far beyond the immediate subject matter of the presentation and alerted the historian to people and sources he had not known about. The animated discussions convinced me that trying to record such eyewitness testimonies should be tried. I knew from my own historical practice that interviews were vital tools for a historian of the recent past, but one can be regaled with familiar stories, as frequently encountered in printed materials.
I also learned that political historians at the Institute of Contemporary British History had roundtable discussions they called Witness Seminars, and it seemed an apt name for what I was trying to do. We've now run over 50 such meetings. Each is recorded, transcribed and published, and all are freely available to download. Additionally all the original tapes, transcripts, correspondence and any other material donated to us by the participants, plus photographs we take on the day, are deposited in the Wellcome Library and in this way we are building up a considerable archive of late 20th-century biomedicine for present and future researchers.
What are the highlights that emerged from this research?
As Anne Johnson, Professor of population health at UCL, commented in her introduction to the cervical cancer volume, it was largely due to the 'dogged persistence' of clinicians, virologists, cytologists, epidemiologists and public health officials that Human Papilloma Virus (HPV) was recognised as the cause of cervical cancer, and established cervical screening as an effective tool to reduce cancer mortality'.
The stories of these pioneers revealed fascinating glimpses of the serendipity of much research, the importance of the early dedicated screening staff, and the importance of rugged individuals who pursued unpopular hypotheses, ultimately proved true, against received wisdom.
The predominance of the theory that cervical cancer was caused by HSV (Herpes simplex virus) delayed recognition that HPV (the Human Papillomavirus) was the causative agent, and once HPV had been identified, the laborious work to develop vaccines could be started in earnest.
Many of the early screeners were female doctors seeking part-time employment as they raised young children, and often working in ramshackle conditions. Professor Dulcie Coleman recalled that when she first started, the lab was in a private house, and she sat on a high stool with her feet in a fireplace, with her microscope on the mantelpiece!
What surprised you most when you conducted the seminars?
The most engaging point about these meetings is the way individuals fire off each others' memories, in ways that historians are rarely able to do, however well briefed they may be. A Witness Seminar can be seen as a form of open peer review, with all comments and opinions immediately susceptible to rejoinder, agreement or dispute, from others who were there at the time.
Those of us who do individual interviews are often struck by the frailty of memories, or that one is hearing a well rehearsed account. Participants at Witness Seminars can often prompt, challenge or supplement others' memories. That doesn't mean however that people necessarily agree - far from it. For example we held a meeting on the 'Committee on Safety of Drugs' during which we discussed the origin of the 'yellow card' system by which doctors report adverse drug reactions. We had four different accounts of why the card is yellow, from an accidental pile of paper in the copying machine, to a conscious attempt to suggest 'yellow peril'. All those offering explanations were astonished at others', and all stuck resolutely to their own explanation.
What are the key benefits of using seminars of this kind?
These meetings are more than just collections of anecdotes. We recognise that an inherent problem in oral history is bias and distortion, occasionally deliberate, more frequently unintentional, but that charge can be laid at the sometimes arbitrary way in which traditional written archives have survived and been collected. The Witness Seminars not only provide the traditional benefits of oral history, of revealing material not found in conventional documentary sources but they also help with the interpretation of events, personalities and documents.
Another particularly valuable benefit is the possibility we have to invite a wide range of people to contribute to each meeting. For example, we held a meeting on the development of platinum compounds as chemotherapeutic agents for solid state tumours, such as ovarian cancer, for which there was very little treatment before the 1970s. These drugs were effective but caused such serious vomiting and nausea that many patients gave up on the treatment. Pharmacologists became involved in trying to treat the sickness, developed a whole new range of compounds that were then used not only in treating platinum-induced vomiting, but also other forms of sickness associated with chemotherapy and radiotherapy.
We brought together the basic scientists, chemists who had started investigating the physical properties of platinum with no intention of discovering a cancer treatment, microbiologists and cell biologists who investigated the metal's effect on cell growth, oncologists and pharmacologists who devised the cancer treatments and the anti-emetic drugs, and also a former child patient and her mother who spoke movingly of the harrowing but eventually successful treatment of her eight-year old daughter's cancer with platinum therapy. The Witness Seminar format allows for unique interactions between different professional and related non-professional groups
Could these seminars be used as a model for best practice?
As a mechanism for recording historical testimony this technique has much to recommend it - the opportunity of hearing different voices, recorded together in open discussion is a valuable opportunity to not only extend the written documentary record, but in some cases to help create publications, archives, websites and other collections that can be used by a diverse range of people - not only scholars.
I am currently collaborating in a pilot project with policy analysts from the Wellcome Trust to use this technique to provide a qualitative evaluation of research outputs, which promises to extend and enhance the bibliometric methods largely in use by funding and evaluation bodies.
The Wellcome Trust Centre for the History of Medicine at UCL continues to build on its proud tradition of excellence in furthering the academic study of the history of medicine and an awareness of its importance. History counts, as anyone reading about current events recognises. The Centre remains committed to furthering the knowledge of medicine's past in order to offer analyses of the complexities and ambiguities, as well as the hard-won knowledge, surrounding health, diseases, and their treatment.