In June 2020, I was seeing consults in the damp, windowless basement of a community hospital in North Carolina.
As the pandemic wore on and social tensions continued to rise, I thought about stories older physicians told me about the violent animosity Bernie Fisher faced as he promoted less mutilating operations for breast cancer in the 1980s. I wondered what wisdom this contrarian, pugnacious surgeon might be offering about COVID.
When I searched his name online, I was saddened to find his New York Times obituary from 2019.1
As I skimmed pages of professional tributes, I learned that except for a few years at the University of Pennsylvania, Fisher spent his entire life in Pittsburgh.2 Remaining within blocks of his childhood home, Fisher changed the world’s approach to breast cancer treatment forever.
I had heard of Bernie Fisher in my radiation oncology residency. Now, I went into what might be called a Bernie Fisher obsession, which gradually led to determination to write a book about this curmudgeon with a scratchy voice and surgical personality who changed the way we think about cancer.
I knew the basics, of course. Fisher’s second landmark trial, NSABP B-06, established the surgical treatment of early-stage breast cancer. Women had a choice in what surgery they wished to undergo because of Bernie Fisher, and most chose to conserve their breasts with a lumpectomy and radiation.
By cementing organ preservation into the foundation of the most common cancer in women, Fisher gave radiation oncologists like me a steady job. I would later learn all his other contributions—prevention of breast cancer in high-risk women, the role of neoadjuvant chemotherapy in downstaging inoperable tumors, and even sphincter preservation trials in patients with rectal cancer.
As I progressed in my career, I noticed that no one talked to breast cancer patients about Bernie Fisher. This omission, I felt, left women oblivious to the science behind their care. So, I began to tell newly diagnosed patients who passed through my practice the story of Bernie Fisher.
The arc of Fisher’s research put my recommendations and their choices in the context of dozens of clinical trials engineered to provide an approach to breast cancer that is both personalized and evidence-based.
Through the fall of 2020, I spent more time learning about Fisher. For the first time, I read about the scandal that engulfed him near the end of his career.
Targeted by a powerful congressman, a determined reporter, and a furious NCI director, Fisher resigned from his position of chair of the NSABP on March 31, 1994.
As I drilled deeper into the story, I could see how leaving the group he had founded and led for almost forty years destroyed Fisher. The sudden loss of identity, complicated by the betrayal of NCI leaders and administrators at the University of Pittsburgh, left this elderly lion broken and depressed.
After his accusers moved on, I learned, Fisher spent the remaining years of his life picking up the pieces.
Twenty years into my career, I was not shocked by the behavior displayed by the powerful during the political maelstrom that has become known as the NSABP Scandal. The scandal was overblown—most of it was hot air—and Fisher was never culpable of any wrongdoing. Throughout the story, he stood stooped yet unbending, surprised and disappointed by the blowing winds.
That such a heroic story should end with such an unhappy ending elicited only knowing recognition. On a smaller scale, decisions informed by professional expediency have shaped my own career and those around me. But the larger-than-life Fisher was one of the foundational characters in our field.
How had his story ended like this? Fisher lived in a time when giants of cancer care really did walk the Earth, and he was one of them. And yet, when I asked our residents about him, few knew his name. How could that be?
I mulled the answers to these questions throughout the pandemic. I watched every video of Fisher that I could find. Once it reopened to visitors, I made an appointment at the National Archives and spent hours picking through dusty boxes of documents.
I took a week of vacation and drove to Pittsburgh. There, I was disappointed to learn that most of his archives are not yet publicly available and the University of Pittsburgh archives contain little information about his groundbreaking work.
I scoured past issues of The Cancer Letter, The Pittsburgh Post-Gazette, The New York Times, and The Washington Post. I joined the Squirrel Hill Historical Society and learned more about Pittsburgh’s Jewish community. I even submitted a FOIA request to the FBI for any records on Fisher. (There were none).
Close associates of Fisher spoke to me anonymously or declined to talk to me at all out of concern over upsetting his family. Finally, I asked every physician of a certain age as well as any I met if they knew Fisher. Even if they wouldn’t say it on the record, everyone, it seemed, had a story to tell about the time they met Bernie.
Dr. Vincent DeVita agreed to share his memories about working with Fisher on the record. When we finally met on Zoom, I asked him about a story I read in his biography, “The Death of Cancer.” He agreed to tell it again.
In the late 1970s, DeVita attended a meeting at Rockefeller University. A group of prominent physicians gathered to hear Fisher give a talk on the surgical treatment of breast cancer.3
He began his talk by reviewing the data he collected during what he referred to as his “Promethean period.” Using radiolabeled cells injected into animals, Fisher’s experiments demonstrated how cancer cells readily traversed lymph nodes, entered the bloodstream and spread to other organs. These results suggested that cancer was a systemic disease from almost the moment it formed.
Fisher’s rusted hinge of a voice tinged, by his signature Pittsburgh accent, reverberated around the packed auditorium, but the audience didn’t believe a word he was saying.
Any surgeon worth his scalpel knew that local lymph nodes, aka Virchow’s filters, trapped cancer cells. Cancer spread locally by contamination of a careless surgeon’s knife rather than through the blood. Extensive, technically complex and physically deforming surgeries were necessary to remove every cancer cell. Halsted’s radical mastectomy had been surgical dogma for almost a century. What Fisher was suggesting was completely bonkers.
Ignoring the murmurs of disbelief in the crowd, Fisher proceeded to discuss the results of NSABP B-04, the first clinical trial to evaluate how much surgery was necessary to cure breast cancer.1 Hundreds of women had been randomly assigned to either the “standard” Halsted radical mastectomy, a “modified” radical mastectomy with radiation or a “modified” radical mastectomy alone. The results of B-04 were clear: less aggressive surgery cured just as many women as the barbaric Halsted radical mastectomy. In fact, Fisher suggested, a partial mastectomy or “lumpectomy” that preserved the breast might be just as effective as removing it. Either way, the radical mastectomy, Fisher declared, was dead.
The words were barely out of his mouth when Dr. Jerome Urban, chief of breast surgery at Memorial Hospital, jumped to his feet and began screaming at Fisher. The audience held their breaths as the legendary New York surgeon, whose clientele included Second Lady Happy Rockefeller, berated Fisher. “You’re a traitor to your own profession,” Urban spewed. The pack of surgeons around Urban howled in agreement, shaking their fists and hurling insults at the burly Fisher who waited patiently.
His calm confidence only fueled their rage. Eventually, the surgeons returned to their seats, still fuming. Fisher motioned for his last slide.
On the screen, a graph appeared with two overlapping lines—an upward curve labeled “CR” and a downward curve labeled “PR.” These were familiar terms to the oncologists in the room, usually denoting “complete response” or “partial response” of a leukemia patient’s bone marrow to treatment with chemotherapy.
There was no established role for chemotherapy in breast cancer in the 1970s and this was a surgical presentation. The men shifted uncomfortably in their seats. What was Fisher suggesting now?
Fisher paused and pointed to the first curve. “Here is the problem with my critics,” he said, tracing the up-sloping curve. “Increasing cerebral rigidity,” he sang out amid furious whispers, “is matched by,” moving the pointer along the downward sloping line, “decreasing penile rigidity.” The crowd erupted as the most respected surgeons in the country again rose to their feet in anger.
Fisher yelled over the clamor that his critics’ inability to accept the results of randomized trials revealed their age and ineptitude. Dr. Urban and half the audience stormed out.
After speaking with DeVita, I searched online for interviews of Urban. To my surprise, I found national news footage of Urban unabashedly dismissing Fisher’s ideas. In written editorials, Urban declared that any doctor who performed less than a radical mastectomy was playing Russian roulette with a patient’s life.
Another Fisher critic, Columbia University surgeon Cushman Haagensen, wrote that doctors would suffer “ruination of the soul” if they changed their practices and followed Fisher.
These men had refused to participate in Fisher’s trials and yet castigated his results. To defend their outdated approach, each published retrospective reports of selected patients.
Surgical conferences evinced a Jerry Springer vibe as debates between Fisher, Urban, and Haagensen sometimes ended in physical violence. Verbally, and less often physically, beating up on Bernie Fisher became a sport. At one point, the hulking 6’3” Fisher confided to DeVita that he feared for his life.
These sloppy articles, Urban and Haagensen argued, showed that radical or even supra-radical approaches were necessary to cure breast cancer. Acting as anonymous reviewers at prestigious journals, these same establishment surgeons criticized Fisher’s well-reasoned manuscripts for lack of follow up and refused to publish them.
Surgical conferences evinced a Jerry Springer vibe as debates between Fisher, Urban, and Haagensen sometimes ended in physical violence. Verbally, and less often physically, beating up on Bernie Fisher became a sport. At one point, the hulking 6’3” Fisher confided to DeVita that he feared for his life.
Confident in his quest, the pugnacious Fisher ignored the establishment and instead recruited general surgeons across the country to join his efforts.
Acting as salesman, researcher, and surgeon, Fisher promised aspiring surgeons at lesser-known institutions national recognition in what was sure to be practice-changing research.
Fisher’s enthusiasm attracted young, bright surgeons like Norman Wolmark, Armando Giuliano, and Terry Mamounas. He even convinced the NCI to pay Canadian hospitals to enroll patients on his trials. Never had so many surgeons in so many locations been involved in clinical research.
With few established protocols for conducting clinical research, Fisher and his talented team made them up as they went along. The NSABP created best practices for centralized pathology review, patient consent, and data collection. The complexity of this undertaking in the 1970s boggles the mind.
Through decades of carefully plotted clinical trials, each building on the findings of the last, Fisher forced surgeons to examine the shaky foundation on which their tightly held beliefs rested—the opinion of a long-dead surgeon and his successors.
The establishment squirmed under pointed questioning of their lack of intellectual curiosity and the possibility that their beliefs were wrong. Accustomed to fawning adulation, these men were incredulous that another surgeon, particularly one from a place like Pittsburgh, would dare to challenge their experience and ability.
“While we take for granted the clinical trial mechanism today,” Fisher said in an interview, “when I began my clinical trials, it was difficult for me to get women and physicians to take part in them. When the radical mastectomy was being evaluated, the idea of performing less extensive operations was considered, in some institutions, to be equivalent to malpractice.” Undaunted by this fierce opposition, Fisher followed the data and demanded that others do the same.
Sometimes I wonder how Bernie would have regarded me and my book obsession.
After all, he did not set out on a feminist quest to dismantle the surgical patriarchy. He was a “man’s man” by all accounts. What he could not tolerate, however, was decision-making based on instinct, personal experience, or historical anecdotes. Thus, his most famous quote: “In God we trust, all others must bring data.”
The societal upheaval of the 1970s provided fertile ground upon which to test Fisher’s hypotheses. The rise of feminism prompted women to demand a louder voice in their medical care about the same time as Fisher opened B-04.
Noting this interplay, I tracked down a yellowed copy of Rose Kushner’s book, “The Breast Cancer Controversy.” I read about Shirley Temple Black and finished Betty Ford’s autobiography on a family beach trip. On YouTube, I watched Mary Tyler Moore play journalist Betty Rollins in “First You Cry.”
I bought a copy of the June 1973 Esquire magazine on eBay to read Philip Nobel’s epic profile, King Cancer. In it, Urban admitted that he probably did more surgery than was needed and referred to anything less than a radical mastectomy as “all that small crappy stuff.”
Nobel interviewed breast cancer survivor and journalist Rosamond Campion. After a biopsy revealed cancer, Campion refused a radical mastectomy. She instead flew to Cleveland where the lone breast conservationist at the time, Dr. George Crile, Jr., performed a lumpectomy and sent her on her way.
Campion wrote a book, “The Invisible Worm,” about her experience, encouraging other patients to practice self-advocacy. Women, including Rosmond, Rollins, Kushner, and others began to speak. Armed with Fisher’s data, they also forced their doctors to listen.2
By the mid-1980s, women with early-stage breast cancer had a choice, based on Fisher’s work and the women’s advocacy, to not have their breasts removed at all.
After all this time spent in his world, I wondered: should I write a book about Bernie Fisher?
This question was on my mind after the loss of my longtime mentor and boss, Dr. William Blackstock. I had never known a career without him, and his unexpected death unmoored me.
My CV contained a modest number of publications, but I was not a prolific author. I’m a great radiation oncologist and love seeing patients, but I had no formal writing training. I do like a side job, however, and with the project Dr. Blackstock and I worked on together hanging in the balance, I wondered if writing a book about Fisher could be my next challenge.
While contemplating my professional future, my husband and I planned a trip to New York City to visit our daughter in the fall of 2023. After leaving her apartment one afternoon, we found ourselves walking past Rockefeller University, the site of Dr. Fisher’s presentation fifty years earlier.
What he could not tolerate, however, was decision-making based on instinct, personal experience, or historical anecdotes. Thus, his most famous quote: ‘In God we trust, all others must bring data.
Imposing fences surrounded the leafy campus, and a stern security guard declined my request for a quick peek inside. Heading back towards our hotel, we crossed over Broadway and into Rockefeller Center.
Overseeing the long lines of sweaty families waiting in line to get into the LEGO store stood the recognizable statue of the Greek titan Prometheus. His muscular figure sits atop circles of gold, in one hand, a ball of fire. This is allegedly the most photographed statue in New York City, and I obligingly raised my phone to capture the moment.
According to Greek mythology, Prometheus stole fire from Zeus and gave it to humankind. Using Prometheus’ gift, humans evolved from their animal-like existence to civilized life. Zeus punished Prometheus’ betrayal by chaining him to a mountain for eternity, tortured by a liver-eating eagle.
As Prometheus’s body floated in front of me and the leafy Rockefeller University courtyard was fresh in my mind, I thought back to Fisher’s defiant presentation here in New York.
“Women in the U.S. should erect a statue to Bernie Fisher,” DeVita told me in our interview. “He changed breast cancer surgery from the horrendous Halsted operation…to a more compassionate procedure resulting in far less morbidity.”
Prometheus’s statue stands in one of the most prominent places in the United States, representing science, knowledge, and stories. Dr. Fisher is present in the room of every woman diagnosed with breast cancer.
Yet no statue stands in his honor and no book has told his story.
- “The Emperor of All Maladies” dedicates almost fifty pages to William Stewart Halsted and less than ten to Bernie Fisher.
- “The Cambridge Illustrated History of Surgery” tells the story of Halsted over a dozen pages and does not mention Fisher at all.
- The most recent cancer book of cancer history, “From Whispers to Shouts: The Ways We Talk About Cancer” contains zero references to how Fisher broke the chains of surgery once and for all.
By the mid-1980s, women with early-stage breast cancer had a choice, based on Fisher’s work and the women’s advocacy, to not have their breasts removed at all.
Fisher bestowed knowledge to human society and civilized the process of cancer research. The foundation he laid informs the treatment plan of every newly diagnosed patient we meet and provides the answer that every survivor asks, “Did I do enough?”
Fisher worked well into his nineties, pondering the future and synthesizing the lessons of the past. In his later writings, he challenged us to pick up his sword and continue the quest towards more personalized and less radical treatments for breast cancer. As we march forward toward that exciting future, it is time to celebrate Bernie Fisher’s contributions to science, to us and to patients.
Acknowledging that Bernie’s achievements warrant a statue, I must acknowledge also that I don’t work in bronze and granite.
Instead, I am telling his story in its full human grandeur, portraying him as he was.
The first episode of “Less Radical,” a podcast about the life of Bernie Fisher, will be released on Sept. 25. Listen to the trailer and subscribe on Cancer Culture.
Endnotes
- Gellene, Denise. Dr. Bernard Fisher, Who Revolutionized Breast Cancer Treatment, Dies at 101.The New York Times, Oct. 19, 2019. https://www.nytimes.com/2019/10/19/science/dr-bernard-fisher-dead.html
- Barker, Clyde F. HUP Resident Bernard Fisher 1918-2019. Penn Surgery Society News, Winter 2020. https://www.pennmedicine.org/-/media/academic%20departments/surgery/pdfs/pss_newsletters/pss_winter_2020.ashx
- DeVita, Vincent T., and DeVita-Raeburn, Elizabeth. The Death of Cancer: After Fifty Years on the Front Lines of Medicine, a Pioneering Oncologist Reveals Why the War on Cancer Is Winnable—and How We Can Get There. United States: Farrar, Straus and Giroux, 2015.
- Fisher B, Jeong JH, Anderson S, Bryant J, Fisher ER, Wolmark N. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002 Aug 22;347(8):567-75. doi: 10.1056/NEJMoa020128. PMID: 12192016.
- Lerner B. The Breast Cancer Wars: Fear, Hope, and the Pursuit of a Cure in Twentieth Century America. Oxford: Oxford Press, Inc, 2001.
Stacy Wentworth will be joining the Department of Radiation Oncology at Duke Health in the fall.
