The History of Women’s Health with Dr. Elizabeth Comen

How breast cancer patients today grapple with long-embedded biases across all aspects of health and how we’re turning the tide

Earlier this month, BCRF investigator Dr. Elizabeth Comen joined BCRF staffer and breast cancer thriver Sadia Zapp for an Instagram live about the history of women’s health and how breast cancer patients experience care today. A student of medical history, medical oncologist at Memorial Sloan Kettering Cancer Center, and BCRF-funded investigator since 2011, Dr. Comen provides a unique point of view on women’s health then and now.  

Breast cancer, Dr. Comen noted, stands out in many ways in the history of women’s medicine. “We have dramatically changed the landscape of survival for breast cancer patients,” she said. “It’s an area that has gotten a lot of funding—but that doesn’t mean it doesn’t need more. It always needs more.”

Watch the interview below or read an edited excerpt of their conversation.

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Breast cancer is a full-body experience. Treatment affects us from our head to our toes. Let’s start with the heart, especially since patients like me who have had chemo and radiation are at a higher risk for heart disease. What has informed the care of heart disease and how have things improved?

In general, women’s heart disease has been neglected in the history of medicine. One of the founding fathers of cardiology and of our residency system was a man named Sir William Osler. He did amazing things, but he also didn’t believe that women died from heart disease. And today, it’s the number one killer of women. I really wanted to unpack where this came from. There was one famous treatise that he had on cardiovascular disease, and he talks about the white-haired executive clutching his chest—being so overworked that he collapses and has a heart attack. But when it came to women, he said they had neurotic angina, hysterical angina, and he wrote that these women don’t die. And that’s it. Hundreds of years later, too many women are dying of heart disease worldwide.

There’s a lot of work being done right now to understand how chemotherapy, radiation, and hormone treatment may affect the heart. This is certainly an area that researchers are working on to try to uncover gaps and fill them in with research and data and clinical attention.

Can you talk to us about the genesis of plastic surgery and breast implants. What surprised you?

It’s really, really interesting for me, because here I am. I examine women all the time. We talk about implants. We talk about reconstruction. We talk about body image. And I had no idea about who developed breast implants and why. They were not developed because surgeons were trying to help women with their body image after breast cancer. I’ll leave it in the book, but a lot of it came from concepts of male gaze, what they thought would look good for women, and pathologizing.

The flip side is that there were some incredible people and advances, especially against radical mastectomy. We know that Dr. Bernard Fisher did [seminal] work to show that you could do [less-invasive] lumpectomy and radiation, and it was as effective as mastectomy. But throughout history, there were some doctors in the breast cancer space that just felt that breasts were useless appendages, and it would not be scarring for women to lose them.

That really struck a chord with me because obviously for breast cancer patients, body image is so integral to our experience.

There is this idea that women’s beauty is of value culturally. I think that vanity has its role and can be important for some women. The purpose of writing that chapter was to show the nuance there. For cancer patients, it is very important for some of them to address their needs in terms of how they feel about themselves. For others, maybe less so. What we really need to do is make sure that we’re talking to women about who they are and what actually matters to them. Do they want an aesthetic flat closure? Do they do they want implants? Do they want like to look a certain way? We need to meet the needs of the patient in front of us and not impose what we think is best for them based on our perceptions.

There’s a lot of talk about weight loss and BMI right now. Can you talk a little bit about BMI and what it means for patients.

The BMI is not how we should be measuring women’s fitness or their overall health. It is a gateway to determining if someone is morbidly obese. We know that we have an obesity epidemic in this country. But when we’re talking drilling down to look at a healthy woman, [it shouldn’t be done] through BMI. We need to have much better studies on women’s metabolic health and their muscle-to-fat ratio. We know from BCRF researcher Dr. Neil Iyengar that you can be what’s called “skinny fat” where you have a normal if not low BMI, but you have more fat than muscle. You can’t lift your groceries but you’re fitting in your size 2 jeans. Or maybe you’re on Ozempic but you’re not lifting weights, so you’re losing muscles and your bones are weak. We really, really, really need to move to a model of women’s health that it’s not just about being small—as we often message to women—but about being strong.

How has breast cancer research stood out in the history of women’s health?

Yes, not everything is bad about the history of women’s medicine. Breast cancer is a shining example, particularly in terms of research. It’s an area that has gotten a lot of funding—but that doesn’t mean it doesn’t need more. It always needs more.

But we have dramatically changed the landscape of survival for breast cancer patients, thanks in part to BCRF, which was founded by Evelyn Lauder and my mentor, Dr. Larry Norton. There are incredible examples, but I think as with anything, we can always do better. We need to address not just how women survive, but how they thrive, which is something BCRF is doing. I’m thrilled to be a BCRF grantee.