October - Breast Cancer Awareness Month: Dr Janet-Lane Claypon and Diahann Carroll
It is hard to imagine that once upon a time, we believed illnesses happen randomly. Our ancestors believed that bad luck and mystical powers were the culprits and that people sometimes just fell ill without any explanation. Thanks to advancements in science and medicine we know understand that pathogens, genetics and environment are the different factors that cause ailments and illnesses. One of the main fields that contribute to this understanding is epidemiology. Epidemiology examines the distributions, patterns and determinants of diseases in a specific population. Epidemiology is used for many things—to find a source of infection and to understand the relationship between risk factors (age, gender, occupations) and occurrences of illnesses, as well as to produce data and statistics to predict future cases.
In the beginning, the field of epidemiology was similar to detective work. By following a subject, a detective learns to recognise certain patterns of behaviour. After familiarising themselves with these patterns, a detective can eventually, to a certain extent, predict their subject’s future behaviour or recognise unusual events. The power of epidemiology was greatly improved in the early 20th century when scientists started applying mathematical methods to analyse their observations.
One of the first scientists to develop this modern epidemiology was Dr Janet Lane-Claypon, a British medical doctor and scientist interested in female reproduction and health. In 1926 she published the ground-breaking epidemiological study on breast cancer, a study that produced a comprehensive list of risk factors we still use almost a century later. It was the first-ever “retrospective cohort” study as well as the first-ever “case-control” study, where she looked at 500 cases of women (cohort) with a history (retrospective) of breast cancers (cases) and compared them to 500 non-affected women (controls) in the UK. She was careful to select women of similar ages and social backgrounds. She discovered that the younger they married, the more children they had and the longer they breastfed the less likely they were to develop breast cancer. All of these findings indicate correlations and not causations, but they gave scientists direction on what to investigate next.
This study was outstanding for many reasons. Dr Claypon recruited a great number of cases and considered a great number of factors – far in excess of what contemporary studies would include. Dr Claypon was also critically aware of limitations to the study. To start with, the subjects of the study had to answer a 50-question survey – and some of them couldn’t remember exact details such as dates. Another discrepancy was that disease cases were surveyed via letters while the controls were surveyed in person. This might have introduced biases in reporting as the in-person reporting was done in a shorter time (relying on memory on the time of interview) as well as the possibility of false reporting from interacting with the interviewer (observation bias). The study inspired a group of US scientists to replicate it in 1931 to learn about breast cancer cases in their country. In 2010, a study revisited and reanalysed these historical studies and confirmed they were done with remarkable details and accuracy. This affirmed that Dr Claypon was a pioneer who was ahead of her time and her study was an important milestone in breast cancer history.
Dr Claypon was prolific as a scientist and as a medical doctor. She received private education as a child and joined London School of Medicine for Women (now part of University College London) in 1898. She was awarded a first-class honours degree in 1902, a doctorate in 1905 and an MD in 1910. She found a position in Lister Institute of Preventative Medicine in London, being one of only two women there between 1907-1912. Despite being a woman of her time, she was able to achieve high-ranking positions. She was the Dean of the Household and Social Sciences Department at King’s College for Women in 1917-1923 and afterwards joined the Ministry of Health where she undertook the breast cancer study and extended her research into mouth and skin cancers. Her career was cut short when she decided to marry Sir Edward Rodolph Forber in 1929 at the age of 52. As married women were forbidden to work in the civil service at that time, Dr Claypon had to give up her career and retired.
Breast cancer is the most common cancer to affect women worldwide, with approximately 1 in 8 women receiving a diagnosis during their lifetime. In rare cases, breast cancer can also affect men. Men have significantly less breast tissue, though this also complicates symptoms detection and diagnoses. The symptoms are similar between men and women—the presence of a lump, changes in size or shape of breast/nipple, unusual discharges, dimpling on the skin, as well as a rash on or around the nipple. Counterintuitively, breast pain is not usually a symptom of breast cancer.
Breast cancer affects mostly women over 50, though younger women with a family history can develop it earlier. The exact causes of breast cancer are unknown, but we now know that there are many risk factors to consider: sexual health history, age, family history, being tall or obese, alcohol consumption and history of hormone-altering treatment such as Hormone Replacement Therapy or the contraceptive pill. Detecting breast cancer can be tricky so consulting a GP when you notice changes in your breast and going for regular screening is crucial. Early detection and treatment can prevent cancer from spreading to other parts of the body. Treatments include surgery, radiotherapy and chemotherapy.
There are different types of breast cancer depending on the part of the breast or tissue type affected. The two most common types are non-invasive breast cancer (carcinoma in situ) and invasive breast cancer. The former, sometimes also called a pre-cancer, is found in the duct of the breast and has yet to spread further. The latter type develops in the lining of the duct where it affects cells that are able to spread cancer outside the breast. Breast cancer occurrences have been associated with different ethnic groups or population—one study indicated that Asian-American women are more likely to develop breast cancer than Asian women and another study showed that compared to white British women, black British women develop a more aggressive type of cancer and at a younger age. While there is currently no genetic explanation to this, it is believed that external factors (such as diet, sexual history, or environment) are the main difference in the different populations. Many also believe that late diagnoses, from either lack of awareness or fear, play a big part in this phenomenon.
Actor and singer Diahann Carroll received a diagnosis of breast cancer in 1998 after her annual physical examination. The cancer was still under a centimetre and her doctor was very optimistic that this early diagnosis was beneficial to her recovery. With this in mind, she considered keeping the diagnosis away from the public eye. She didn’t want cancer to be the focal point of her life, to be the first word she was associated with when people thought of her. However, she quickly realised how selfish it would have been for her to keep it a secret. She wanted to share it with the many other women out there who had the same struggles and remind them that they are not alone. She became a breast cancer activist, discussing the importance of screening and treatment. She survived breast cancer the first time but suffered a recurrence two decades later and Carroll died from complications earlier this month on October 4. She was 84.
Diahann Carroll started her career in 1954 with a small part in Carmen Jones, an operatic movie starring the superstar Dorothy Dandridge. In the same year, she also debuted in a musical and started her life-long affair with theatre. However, she was subject to discrimination just like many black actors at the time, playing in only a handful of movies and plays for the first 8 years of her career. Despite this, in 1962, she won a Tony Award for the musical No Strings—the first black woman to ever win in the leading role category. Her most prominent role came in 1968 when she got the lead role in Julia, becoming the first black woman to star in her own television show as a character that is not a domestic helper. This portrayal won her a Golden Globe award and an Emmy Award nomination. In 1974 she starred in the movie Claudine and received a Golden Globe and an Academy Award nomination. She joined the prime time soap opera Dynasty in the 1980s and despite her breast cancer diagnosis, she continued making guest appearances in various shows until her death in 2019. On top of her acting, Carroll recorded various albums and continued doing theatres and musicals.
Carroll was a pioneer for many black actors in the movie industry. Her first movie, Carmen Jones, was deemed culturally significant for being a musical movie, a non-stereotypical genre, with an all-black cast. As a singer and musical actor, she was always dressed fashionably. This inspired the musical No Strings, a production especially written for her. Her portrayal of a fashion model in this musical won her a Tony Award. However, the glamorous persona almost cost her the role of Julia. The producer wasn’t convinced she would be convincing as a middle-class single mother. However, she proved to them she was a chameleon. Julia turned out to be a beloved tv show, introducing an unfamiliar figure. Her next role in Claudine was another single mother, one that relied on the welfare system. The movie is critically-acclaimed for highlighting the struggles of many black Americans at the time and the way they were treated by the government. Off-screen, she co-founded a charity that does addiction rehabilitation as well as being active in raising breast cancer awareness.
Dr Claypon and Carroll were forerunners in their fields. Despite being women (and Carroll being black) they rose to prominence with hard work and ingenuity. They dared to take risks and be different, and it paid off. Dr Claypon’s work contributed greatly to the research of breast cancer, while Carroll openly discussed her diagnosis to raise awareness of this disease especially in the black community. They used their roles and opportunities presented to them to benefit others, and we shall thank them.
Note: October is both Breast Cancer Awareness Month and Black History Month in the United Kingdom.
References and further reading:
· BBC. Diahann Carroll: Pioneering actress dies aged 84. BBC News 04/10/2019.
· Bowel RL, Duffy SW, Ryan DA, Hart IR, and Jones JL. Early onset of breast cancer in a group of British black women. Br J Cancer. 2008 Jan 29; 98(2): 277–281.
· Fox M. Diahann Carroll, Actress Who Broke Barriers With ‘Julia,’ Dies at 84. NY Times 04/10/2019.
· Gomez SL, Yao S, Kushi LH, and Kurian AW. Is Breast Cancer in Asian and Asian American Women a Different Disease? JNCI: Journal of the National Cancer Institute, djz091, https://doi.org/10.1093/jnci/djz091
· Nightingale K. Tales from the Century: Janet Lane-Claypon and epidemiology. MRC blog accessed 01/10/2019.
· Press DJ, Pharoah P. Risk factors for breast cancer: a reanalysis of two case-control studies from 1926 and 1931.Epidemiology. 2010 Jul;21(4):566-72. doi: 10.1097/EDE.0b013e3181e08eb3.
· Waggoner C. DIAHANN CARROLL (1935-2019). Black Past 23/05/2008.
· Winkelstein WJ. Janet Elizabeth Lane-Claypon: A Forgotten Epidemiologic Pioneer. Epidemiology. 2006;17(6):705