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From the “Silent Killer” to the “Whispering Disease”: Ovarian Cancer and the Uses of Metaphor

Published online by Cambridge University Press:  17 May 2012

Patricia Jasen
Affiliation:
Patricia Jasen, Department of History, Lakehead University, 955 Oliver Road, ThunderBay, Ontario, Canada P7B 5E1; e-mail: pjasen@lakeheadu.ca
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Abstract

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Type
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Copyright
Copyright © The Author(s) 2009. Published by Cambridge University Press

References

1 Margaret Edson, W;t, New York, Faber and Faber, 1999, pp. 7–8. An HBO film of the same name stars Emma Thompson as Vivian Bearing. I thank Rob Gray for bringing this work to my attention.

2 Oxford English Dictionary, http://dictionary.oed.com/

3 Ivan K Strausz, You don’t need a hysterectomy: new and effective ways of avoiding major surgery, Cambridge, MA, Perseus, 2001, p. 302.

4 Alexander F Burnett, Clinical obstetrics and gynecology: a problem-based approach, Malden, MA, and Oxford, Blackwell Science, 2001, p. 374.

5 Ibid., p. 375.

6 Kathleen M Brennan, Vicki V Baker and Oliver Dorigo, ‘Premalignant and malignant disorders of the ovaries and oviducts’, in Alan J DeCherney, Lauren Nathan, T Murphy Goodwin and Neri Laufer (eds), Current diagnosis and treatment: obstetrics and gynecology, New York, McGraw-Hill, 2007, pp. 872–77; Jackie Stacey, Teratologies: a cultural study of cancer, London, Routledge, 1997.

7 Brennan, et al., op. cit., note 6 above, p. 875; Tamara L Callahan, Aaron B Caughey, and Linda J Heffner, Blueprints: obstetrics and gynecology, Malden, MA, Blackwell, 2003, p. 258.

8 Katherine Y Look, ‘Epidemiology, etiology, and screening of ovarian cancer’, in Stephen C Rubin and Gregory P Sutton (eds), Ovarian cancer, Philadelphia, Lippincott, Williams and Wilkins, 2001, pp. 168–74; Burnett, op. cit., note 4 above, p. 374; Callahan, et al., op. cit., note 7 above, p. 258.

9 Brennan, et al., op. cit., note 6 above, p. 871.

10 Ibid., pp. 877–8.

11 Burnett, op. cit., note 4 above, p. 379.

12 Brennan, et al., op. cit., note 6 above, pp. 883, 880.

13 Ibid., p. 883.

14 Susan Sontag, Illness as metaphor, New York, Farrar, Straus and Giroux, 1978.

15 Stacey, op. cit., note 6 above, pp. 44–8; Barbara Clow, ‘Who’s afraid of Susan Sontag? Or, the myths and metaphors of cancer reconsidered’, Soc. Hist. Med., 2001, 14: 293–312.

16 James F Childress, Practical reasoning in bioethics, Bloomington, Indiana University Press, 1997, p. 4.

17 Deborah Lupton, Medicine as culture, London, Sage, 2003, p. 59.

18 Emily Martin, The woman in the body: a cultural analysis of reproduction, Boston, Beacon Press, 2001, pp. 54–7.

19 Childress, op. cit., note 16 above, p. 6.

20 On inter-war cancer awareness campaigns in the US, see Kirsten E Gardner, Early detection: women, cancer, and awareness campaigns in the twentieth-century United States, Chapel Hill, University of North Carolina Press, 2006, pp. 17–92. On the later response in Great Britain, see Elizabeth Toon, ‘“Cancer as the general population knows it”: knowledge, fear, and lay education in 1950s Britain’, Bull. Hist. Med., 2007, 81: 116–38.

21 Barron H Lerner, The breast cancer wars: fear, hope, and the pursuit of a cure in twentieth-century America, New York, Oxford University Press, 2001, pp. 44–5. On public fear of cancer, see James T Patterson, The dread disease: cancer and modern American culture, Cambridge, Harvard University Press, 1987.

22 Sontag, op. cit., note 14 above, p. 7.

23 Devra Davis, The secret history of the war on cancer, New York, Basic Books, 2007, p. 16; Childress, op. cit., note 16 above, p. 6.

24 Childress, op. cit., note 16 above, p. 6; George J Annas, ‘Reframing the debate on health care reform by replacing our metaphors’, New Engl. J. Med., 1995, 332: 744–47.

25 Gardner makes only one reference to ovarian cancer in Early detection, op. cit., note 20 above, p. 209. She posits that “one reason that activists may have directed little attention to ovarian cancer is that early detection rhetoric had little resonance for this cancer”.

26 ‘Ovarian cancer has early symptoms’, ACS News Center, 14 June 2007, http://www.cancer.org/ docroot/NWS/content/NWS_1_x_Ovarian_Cancer_ Symptoms_The_Silence_Is_Broken.asp (accessed 14/6/2009).

27 T Spencer Wells, Diseases of the ovaries: their diagnosis and treatment, New York, D Appleton, 1873, pp. 59–60.

28 Walter Hayle Walshe, The nature and treatment of cancer, London, Taylor and Walton, 1846, pp. 344–5.

29 Charles A L Reed, A text-book of gynecology, New York, Appleton, 1901, p. 632.

30 Ann Dally, Women under the knife: a history of surgery, New York, Routledge, 1992, pp. 13–15.

31 Ibid., p. 135.

32 Ibid., 15–19, 135. On McDowell’s pioneering surgery, also see Deborah Kuhn McGregor, From midwives to medicine: the birth of American gynecology, New Brunswick, NJ, Rutgers University Press, 1998, p. 160.

33 Ornella Moscucci, The science of woman: gynaecology and gender in England, 1800–1929, Cambridge University Press, 1990, p. 137.

34 Fleetwood Churchill, Outlines of the principal diseases of females, Dublin, Martin Keene and Son, 1838, p. 391.

35 Wells, op. cit., note 27 above, p. 117.

36 Moscucci, op. cit., note 33 above, pp. 156–60; Lawrence D Longo, ‘The rise and fall of Battey’s operation: a fashion in surgery’, Bull. Hist. Med., 1979, 53: 244–57.

37 Moscucci, op. cit., note 33 above, pp. 152–6.

38 Dally, op. cit., note 30 above, p. 139.

39 Wells, op. cit., note 27 above, p. 58.

40 Reed, op. cit., note 29 above, p. 633.

41 George Ernest Herman, Diseases of women: a clinical guide to their diagnosis and treatment, London, Cassell, 1913, p. 746.

42 R Olshausen, Diseases of the ovaries, ed. Egbert H Grandin, New York, William Wood, 1887, p. 384.

43 Charles B Penrose, A text-book of diseases of women, Philadelphia, W B Saunders, 1904, pp. 392–3.

44 John G Gruhn, ‘A selective historical survey of ovarian pathology emphasizing neoplasm’, in Lawrence M Roth and Bernard Czernobilsky (eds), Tumors and tumorlike conditions of the ovary, New York, Churchill Livingstone, 1985, pp. 269–85, on p. 276.

45 Fred L Adair (ed.), Obstetrics and gynecology, 2 vols, Philadelphia, Lea and Febiger, 1940, vol. 2, p. 324.

46 E Novak and J N Brawner, ‘Granulosa cell tumors of ovary: clinical and pathological study of 36 cases’, Am. J. Obstet. Gynecol., 1934, 28: 637–49, p. 637, quoted in Johannes Dietl, ‘Thomas Mann’s last novella “The black swan”: the tragic story of a post-menopausal woman’, Eur. J. Obstet. Gynecol. Reprod. Biol., 2004, 113: 255–7, http://www.sciencedirect.com (accessed 2/6/2009). Another view is that Mann was writing about a victim of uterine cancer; see Karen Nolte,‘Carcinoma uteri and “sexual debauchery”—morality, cancer and gender in the nineteenth century’, Soc. Hist. Med., 2008, 21: 31–46. Dietl’s interpretation seems most apt, however, as the protagonist not only resumed her menstrual period but “bloomed” again.

47 Dietl, op. cit., note 46 above.

48 Brooke M Anspach, Gynecology, Philadelphia, Lippincott, 1927, p. 395.

49 H S Crossen, ‘The menace of “silent” ovarian cancer’, JAMA, 1942, 119: 1485–9, pp. 1486–7.

50 Ibid., p. 1489.

51 Archibald Donald Campbell and Mabel A Shannon, Gynecology for nurses, Philadelphia, F A Davis, 1946, p. 144; Stanley Way, Malignant disease of the female genital tract, London, J and A Churchill, 1951, p. 182.

52 Estimates ranged from 15 per cent in Arthur Hale Curtis, A textbook of gynecology, Philadelphia, W B Saunders, 1946, p. 391; to 25 per cent in Aleck W Bourne and Leslie H Williams, Recent advances in obstetrics and gynecology, Philadelphia, Blakiston, 1945, p. 290; to 35 per cent in Campbell and Shannon, op. cit., note 51 above, p. 144.

53 C Jeff Miller, An introduction to gynaecology, St Louis, C V Mosby, 1934, p. 274.

54 Ibid, p. 17; Malcolm S Allan and Arthur T Hartig, ‘Carcinoma of the ovary’, Am. J. Obstet. Gynecol., 1949, 58: 640–53, p. 642.

55 Crossen, op. cit., note 49 above, pp. 1486–7.

56 J M Munro Kerr, Combined text-book of obstetrics and gynaecology for students and medical practitioners, Edinburgh, E & S Livingstone, 1933, p. 889; Zeph J R Hollenbeck, ‘Ovarian cancer—prophylactic oophorectomy’, Am. Surg., 1955, 21: 442–6, p. 443.

57 Clyde L Randall, ‘Ovarian carcinoma: risk of preserving the ovary’, Obstet. Gynecol., 1954, 5: 491–7, p. 496. On the continuing controversy, see Laman A Gray and Malcolm L Barnes, ‘Carcinoma of the ovary: a report of 106 cases’, Am. Surg., 1964, 159: 279–90, p. 289; Daniel Winston Beacham and Woodard Davis Beacham, Synopsis of gynecology, Saint Louis, C V Mosby, 1972, p. 291; Seymour L Romney, et al., Gynecology and obstetrics: the health care of women, New York, McGraw-Hill, 1975, p. 1067.

58 Crossen, op. cit., note 49 above, p. 1489; See John B Montgomery, ‘Malignant tumors of the ovary’, Am. J. Obstet. Gynecol., 1948, 55: 201–17, p. 215; Gray and Barnes, op. cit., note 57 above, p. 288; Andrew A Marchetti, ‘Tumors of the ovary’, in Robert A Kimbrough (ed.), Gynecology, Philadelphia, Lippincott, 1965, p. 370.

59 John Osborn Polak, A manual of gynecology, Philadelphia, Lea & Febiger, 1922, p. 348; Howard A Kelly, et al., Gynecology, New York, D Appleton, 1928, pp. 769–71; Miller, op. cit., note 53 above, p. 274; Curtis, op. cit., note 52 above, pp. 394–9.

60 Anspach, op. cit., note 48 above, p. 395; Hollenbeck, op. cit., note 56 above, p. 442.

61 Crossen, op. cit., note 49 above, p. 1486.

62 Gardner, op. cit., note 20 above, pp. 8, 30–8. In Britain, as well, the campaign was aimed at “accessible cancers”, primarily breast and cervical cancer. Toon, op. cit., note 20 above, p. 119.

63 Miriam Lincoln, Woman: her change of life, London, Williams and Norgate, 1951, pp. 75–6; Lena Levine and Beka Doherty, The menopause, New York, Random House, 1952, pp. 168–9; Emerson Day, ‘A specialist talks about cancer’, Women’s Home Companion, June, 1955, pp. 28–9; Isabel Hutton, Woman’s change of life, London, William Heinenann Medical Books, 1958, pp. 54, 169; M E Landau, Women of forty, New York, Philosophical Library, 1964, p. 29.

64 Emil Novak, The woman asks the doctor, Baltimore, Williams and Wilkins, 1944, pp. 113–23.

65 Carl Henry Davis (ed.), Gynecology and obstetrics, 3 vols, Hagerstown, MD, W F Prior, 1935, vol. 2, p. 16.

66 Beckwith Whitehouse, ‘The clinical aspects of ovarian tumours’, J. Obstet. Gynaecol. Br. Emp., 1931, 38: 264–79, pp. 266–7.

67 Montgomery, op. cit., note 58 above, p. 214.

68 Way, op. cit., note 51 above, pp. 183–7.

69 Muriel L Newhouse, R M Pearson, J M Fullerton, E A Boesen and H S Shannon, ‘A case control study of carcinoma of the ovary,’ Br. J. Prev. Soc. Med., 1977, 31: 148–53, p. 148; M Steven Piver, Joseph J Barlow and Diane M Sawyer, ‘Familial ovarian cancer: increasing in frequency?’, Obstet. Gynecol., 1982, 60: 397–400, p. 399; Ralph C Benson, Handbook of obstetrics and gynecology, Los Altos, CA, Lange Medical Publications, 1983, p. 641; V Beral and M Booth, ‘Occurrence and etiology’, in Norman M Bleehen (ed.), Ovarian cancer, Berlin, NY, Springer Verlag, 1985, pp. 14–22, on p. 14.

70 Marchetti, op. cit., note 58 above, p. 370; M Steven Piver, ‘Epidemiology of ovarian cancer’, in M Steven Piver (ed.), Ovarian malignancies: diagnostic and therapeutic advances, Edinburgh, Churchill Livingstone, 1987, pp. 1–11, on p. 1; M Steven Piver with Gene Wilder, Gilda’s disease: sharing personal experiences and a medical perspective on ovarian cancer, Amherst, NY, Prometheus, 1996, p. 35.

71 J D Woodruff, ‘The pathogenesis of ovarian neoplasia’, Johns Hopkins Med. J., 1979, 144: 117–20, p. 117; William M Rich, ‘Benign and malignant ovarian neoplasms’, in Ralph W Hale and John A Krieger (eds), A concise textbook of gynecology, Hyde Park, NY, Medical Examination Publishing, 1983, p. 297.

72 Rich, op. cit., note 71 above.

73 Margaret Booth and Valerie Beral, ‘The epidemiology of ovarian cancer’, in C N Hudson (ed.), Ovarian cancer, Oxford University Press, 1985, pp. 22–44, on p. 22.

74 J Donald Woodruff, ‘Premalignant and malignant disorders of the ovaries and oviducts’, in Martin L Pernoll (ed.), Current obstetric and gynecologic diagnosis and treatment, Norwalk, CT, Appleton and Lange, 1991, p. 974; Beral and Booth, op. cit., note 69 above, p. 17; Booth and Beral, op. cit., note 73 above, pp. 27–8.

75 Hugh R K Barber, Ovarian carcinoma: etiology, diagnosis, and treatment, New York, Masson, 1978, p. 98.

76 Newhouse, et al., op. cit., note 69 above, pp. 152–3.

77 Susan Harlap, ‘The epidemiology of ovarian cancer’, in Maurie Markman and William J Hoskins (eds), Cancer of the ovary, New York, Raven Press, 1993, p. 83.

78 Booth and Beral, op. cit., note 73 above, p. 29.

79 Lloyd H Smith and Richard H Ol, ‘Detection of malignant ovarian neoplasms: a review of the literature. I. Detection of the patient at risk; clinical, radiological and cytological detection’, Obstet. Gynecol. Surv., 1984, 39: 313–28, p. 314; Harlap, op. cit., note 77 above, p. 83.

80 Piver with Wilder, op. cit., note 70 above, pp. 42–4. For a patient’s account of the controversy over fertility drugs in the 1990s, see Liz Tilberis, No time to die, Boston, Little, Brown, 1998, pp. 40–5, 246–54.

81 Amour Fiscus Liber, ‘Ovarian cancer in mother and five daugthers’, Arch. Pathol., 1950, 49: 280–90, pp. 289–90. Liber cites cases from 1877 onwards.

82 Romney, et al., op. cit., note 57 above, p. 1065; Piver, et al., op. cit., note 69 above, p. 398.

83 Piver, et al., op. cit., note 69 above, pp. 399–400; Piver with Wilder, op. cit., note 70 above, p. 46.

84 The study often referred to was G Hildreth, Jennifer L Kelsey, Virginia A Livolsi, Diana B Fischer, et al., ‘An epidemiologic study of epithelial carcinoma of the ovary’, Am. J. Epidemiol., 1981, 114: 398–405. And see Smith and Ol, op. cit., note 79 above, pp. 316–17; Booth and Beral, op. cit., note 73 above, pp. 30–1.

85 Barnaby D Rufford and Ian J Jacobs, ‘Identification and management of familial ovarian cancer’, in Henry C Kitchener, Jonathan A Ledermann and Andrew Miles (eds), Effective management of ovarian cancer, London, Aesculapius Medical Press, 2001, pp. 128–38. On the patient experience of hereditary risk and delays in its recognition, see Nina Hallowell, ‘Varieties of suffering: living with the risk of ovarian cancer’, Health, risk and society, 2006, 8: 9–26.

86 W J Henderson, C A F Joslin, K Griffiths and A C Turnbull, ‘Talc and carcinoma of the ovary and cervix’, J. Obstet. Gynaecol. Br. Commonw., 1971, 78: 266–72.

87 Ibid., p. 271; Woodruff, op. cit., note 71 above, p. 120.

88 Howard C Jones III, Anne Colston Wentz and Lonnie S Burnett, Novak’s textbook of gynecology, 11th ed., Baltimore, Williams and Wilkins, 1988, p. 793; Daniel W Cramer, William R Welch, Robert E Scully and Carol A Wojciechowski, ‘Ovarian cancer and talc: a case-control study’, Cancer, 1982, 50: 372–6.

89 Mark S Shahin and Joel I Sorosky, ‘Prevention and early diagnosis of ovarian cancer’, in Alberto Manetta (ed.), Cancer prevention and early diagnosis in women, Philadelphia, Mosby, 2004, pp. 249–66, on pp. 254–5.

90 On the development of ultrasound, see S Levi, ‘The history of ultrasound in gynecology 1950–1980’, Ultrasound Med. Biol., 1997, 23: 481–552.

91 Walter J Burdette, Cancer: etiology, diagnosis, treatment, New York, McGraw-Hill, 1998, p. 166; Rich, op. cit., note 71 above, p. 297.

92 Smith and Ol, op. cit., note 79 above, p. 322.

93 Burdette, op. cit., note 91 above, p. 166; Marilyn F Vine, Roberta B Ness, Brian Calingaert, Joellen M Schildkraut and Andrew Berchuck, ‘Types and duration of symptoms prior to diagnosis of invasive or borderline ovarian tumor’, Gynecol. Oncol., 2001, 83: 466–71, p. 466; Clare Bankhead and Joan Austoker, ‘Women’s cancer screening: cervical, breast, and ovarian screening’, in Deborah Waller and Ann McPherson (eds), Women’s health, Oxford University Press, 2003, p. 484; Barbara A Goff, Lynn S Mandel, Cindy H Melancon and Howard G Muntz, ‘Frequency of symptoms of ovarian cancer in women presenting to primary care clinics’, JAMA, 2004, 291: 2705–12, p. 2710. On a patient’s experience with the unreliability of ultrasound, see Barbara R Van Billiard, A feather in my wig: ovarian cancer cured, Portsmouth, NH, Peter E Randall, 1998, pp. 1–4.

94 Goff, et al., op., cit., note 93 above, p. 2710; Shahin and Sorosky, op. cit., note 89 above, p. 259.

95 Jones III, et al., op. cit., note 88 above, p. 793. For other examples during the post-war decades, see Robert James Crossen and Ann Jones Campbell, Gynecologic nursing, St Louis, C V Mosby, 1956, pp. 136–7; Elizabeth Parker, The seven ages of woman, Baltimore, Johns Hopkins Press, 1960, p. 554; Marchetti, op. cit., note 58 above, p. 369; Beacham and Beacham, op. cit., note 57 above, p. 291; Romney, et al., op. cit., note 57 above, p. 1067; Woodruff, op. cit., note 71 above, p. 117; Sandra L Tyler and Gail M Woodall, Female health and gynecology across the lifespan, Gowie, MD, Robert J Brady, 1982, p. 226; Benson, op. cit., note 69 above, pp. 640–1; Mary Daly and G Iris Obrams, ‘Epidemiology and risk assessment for ovarian cancer’, Semin. oncol., 1998, 25: 255; Jo Ann Rosenfeld, ‘Ovarian cancer and ovarian masses’, in Jo Ann Rosenfeld (ed.), Handbook of women’s health: an evidence-based approach, Cambridge University Press, 2001, pp. 333–48, on p. 334.

96 Vine, et al., op. cit., note 93 above.

97 C Wikborn, F Pettersson and P J Moberg, ‘Delay in diagnosis of epithelial ovarian cancer’, Int. J. Gynecol. Obstet., 1996, 52: 263–7, p. 266.

98 Barber, op. cit., note 75 above, p. 97. Barber may well have inspired other researchers to turn their attention to this issue for, according to his obituary, he was “internationally renowned for his seminal work in ovarian cancer”. The New York Times, 29 Dec. 2006, http://query.nytimes.com/gst/fullpage.html (accessed 2/6/2009).

99 Brooks Ranney and M I Ahmad, ‘Early identification, differentiation, and treatment of ovarian neoplasia’, Int. J. Obstet. Gynecol., 1979, 17: 209–19.

100 Elaine M Smith and Barrie Anderson, ‘The effects of symptoms and delay in seeking diagnosis on stage of disease at diagnosis among women with cancer of the ovary’, Cancer, 1985, 56: 2727–32.

101 Folke Flam, Nina Einhorn and Kerstin Syovall, ‘Symptomatology of ovarian cancer’, Eur. J. Obstet. Gynecol. Reprod. Biol., 1988, 27: 53–7, p. 53.

102 Gamal H Eltabbakh, Pramila R Yadev and Ann Morgan, ‘Clinical picture of women with early stage ovarian cancer’, Gynecol Onccol., 1999, 75: 476–9, p. 479; Wikborn, et al., op. cit., note 97 above, p. 266.

103 Ross E Gray, P Chart, J C Carroll, M I Fitch and D Cloutier-Fisher, ‘Family physicians’ perspectives on ovarian cancer’, Cancer Prev. Control, 1999, 3: 61–7, pp. 62, 64.

104 Margaret I Fitch, R E Gray, A Covens, Thomas G Franssen, et al., ‘Gynecologists’ perspectives regarding ovarian cancer’, Cancer Prev. Control, 1999, 3: 68–76, pp. 71–2.

105 Laura K Potts, ‘Introduction: ‘Why ideologies of breast cancer? Why feminist perspectives?’ in Laura K Potts (ed.), Ideologies of breast cancer: feminist perspectives, London, Macmillan, 2000, pp. 1–11, on pp. 2–3; Jennifer Fosket, ‘Problematizing biomedicine: women’s contruction of breast cancer knowledge’, in ibid., pp. 15–36; Sara M Morris, ‘Lumps in the breast: negotiating risks after a cancer diagnosis’, Health, Risk and Society, 1999, 1: 179–94, pp. 184–5.

106 Laura K Potts, ‘Publishing the personal: autobiographical narratives of breast cancer and the self’, in Potts (ed.), op. cit., note 105 above, pp. 98–127, on p. 98.

107 Ibid., pp. 99–103.

108 Betty Rollin, Last wish, New York, Linden Press, 1985; Gilda Radner, It’s always something, New York, Simon and Schuster, 1989; Barbara Creaturo, Courage: the testimony of a cancer patient, New York, Pantheon, 1991; Tilberis, op. cit., note 80 above.

109 Radner, op. cit., note 108 above, pp. 53, 58, 72; Piver with Wilder, op. cit., note 70 above, pp. 27–9, 42, 67–9, 20.

110 Shani Orgad, Storytelling online: talking breast cancer on the internet, New York, Peter Lang, 2005, pp. 36–7.

111 Potts, op. cit., note 106 above, p. 99.

112 Orgad, op. cit., note 110 above, p. 62.

113 Ayala Miron, ‘Symptoms are opportunities’, in Ayala Miron (ed.), Ovarian cancer journeys, Lincoln, NE, iUniverse, 2004, pp. 11–17, on p. 14.

114 Miron, ‘Foreword’, in ibid., pp. xiii–xiv, on p. xiii.

115 Johns Hopkins Pathology, Ovarian Cancer, Community, Personal Stories, http://ovariancancer.jhmi.edu/menu_community.cfm, Amy Chaiklin, Becky Bennett (all stories accessed 2 June 2009).

116 Ibid., Barbara, Chris Y.

117 Ibid., Donna McNulty.

118 Ibid., Judy Lidgate, Karen Leonard.

119 Ibid., Augusta Gluck. And see Amy Chaiklin, Vanessa Marshall, Jan Witsoe, Kate “jemakri” beckman (sic).

120 Ibid., Beverley; and see Diane Paul, Diane McNulty.

121 Freda Ariella Muscovitch, quoted in Gabor Mate, ‘Ending the deadly silence’, Globe and Mail, 2 Oct. 2001, p. R5.

122 Marlene Eisner, ‘The disease that whispers’, http://thesuburban.com (accessed 1/6/2009).

123 Jane Brody, ‘The deadly whispers of ovarian cancer’, New York Times, 2 Oct. 2001, online. http://www.nytimes.com/2001/10/02/health/personal-health-the-deadly-whisper-of-ovarian-cancer.html (accessed 1/6/09).

124 Lonnie Barbach, The pause: positive approaches to menopause, New York, Penguin, 1995, p. 99.

125 Dr. Susan Love’s menopause and hormone book, New York, Three Rivers Press, 2003, p. 164; Strausz, op. cit., note 3 above, p. 303.

126 Boston Women’s Health Book Collective, Our bodies, ourselves, New York, Touchstone, 1984, p. 627.

127 Johns Hopkins Pathology website, op. cit., note 115 above, Cindy Melancon.

128 Barbara Goff, ‘Introduction’, in Miron (ed.), op. cit., note 113 above, pp. xv–xvii, on p. xv.

129 Barbara A Goff, L Mandel, H G Muntz and C H Melancon, ‘Ovarian carcinoma diagnosis: results of a national survey’, Cancer, 2000, 89: 2068–75.

130 Goff, et al., op. cit., note 93 above, pp. 2705–12.

131 ‘Ovarian cancer has early symptoms’, op. cit., note 26 above. Other studies included S H Olson, L Mignone, C Nakraseive, T A Caputo, et al., ‘Symptoms of ovarian cancer’, Obstet. Gynecol., 2001, 98: 212–17; Barbara P Yawn, Brigitte A Barrette and Peter C Wollan, ‘Ovarian cancer: the neglected diagnosis’, Mayo Clin. Proc., 2004, 79: 1277–82; Lloyd H Smith, C R Morris, S Yasmeen, A Parikh-Patel, et al., ‘Ovarian cancer: can we make the clinical diagnosis earlier?’, Cancer, 2005, 104: 1398–1407.

132 ‘Ovarian cancer has early symptoms’, op. cit., note 26 above.

133 Associated Press, ‘Doctors identify early symptoms of ovarian cancer’, FoxNews.com, 14 June 2007, http://www.foxnews.com/story/ 0,2933, 281653,00.html (accessed 1/6/2009).

134 ‘Doctors identify possible early signs of ovarian cancer’, 13 June 2007, http://www.pbs.org/newshour/bb/health/jan-june07/cancer_06–13.html (accessed 2/6/2009).

135 Denise Grady, ‘Symptoms found for early check on ovarian cancer’, New York Times, 13 June 2007, http://nytimes.com/2007/06/13cancer.html (accessed 2/6/2009).

136 Ibid.

137 Ibid.

138 Ibid.

139 B A Goff, L S Mandel, C W Drescher, N Urban, et al., ‘Development of an ovarian cancer symptom index’, Cancer, 2007, 109: 221–7.

140 Lupton, op. cit., note 17 above, p. 59.