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The Diary of a Breast 
by Elisa Segrave.
Faber, 287 pp., £9.99, April 1995, 0 571 17446 9
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Cancer must sell almost as many books as cookery: not just old-fashioned self-help guides to detection or prevention, tips on how to survive the chemotherapy or colostomy (now lavishly illustrated with the kinds of photograph that were once allowed only in medical textbooks), but also a vast range of new-style ‘cancer journals’. These are first-person accounts – diaries, memoirs or letters – that chart the progress of ‘me and my cancer’ from the moment of discovery, through diagnosis and treatment, to life again on the other side. They range in tone from something close to Gothic horror to naive optimism.

For sheer terror, one of the earliest precursors of this particular genre has never been beaten. Fanny Burney was diagnosed with breast cancer in 1810, and wrote a long account to her sister (only published years later), detailing her illness, treatment and recovery. She was operated on at home without anaesthetic, apparently fully conscious through most of the procedures. It was not, she wrote, until she was on the makeshift operating-table and heard the surgeon ask, ‘Who will hold the breast for me?’, then glimpsed him make practice strokes with his knife in the air, that she realised that he intended to remove her whole breast. From the moment of the first incision, she screamed ‘unremittingly’, while the doctor (who went on to amputate 200 limbs in 24 hours after the Battle of Borodino) changed the knife from hand to hand, in his effort to get through the stubborn flesh. When finally she thought it was all over, she found him attacking her once more, scraping over her breastbone to ensure that every bit of the disease was gone.

In fact, several modern accounts of undergoing chemotherapy are not far behind Burney in capturing the pain and torture of the ‘cure’. Some cancer journals dwell insistently, almost with relish, on the baldness, the mouth sores, the continual vomiting and diarrhoea inflicted on the innocent, and already suffering, body of the patient. And even without all those details, they read as documents of the utter wilfulness of our faith in chemotherapy, the contemporary equivalent of the 18th-century leech and of the prevailing view that illness in general, and cancer in particular, is ‘the enemy’, to be nuked and bombarded, notwithstanding the death toll on the harmless civilian cells round about.

At the opposite end of the spectrum, some writers treat their cancers as the best present they could ever have received. It is not just that they tolerate the nastier aspects of the treatment, on the principle of ‘doctor knows best’ (though there is quite a lot of such self-effacement in the more dutiful journals): they positively embrace the disease, and the painful, rocky path to remission or cure, as a new entry into humanity, granting fresh insights into the human condition, life, the world and everything. Part of this is founded on the shadiest of New Age philosophies, in which personal growth is seen (implausibly) to be fostered by the conquest of the cancerous growth within the body. But some of it is implausible in a much more down-to-earth way. It is honestly hard to believe many of the claims that sex is better after a radical mastectomy; or – for that matter – that the stoma of a colostomy can be one of the most erotic sites known to man. It is even harder to decide whether the enthusiasm with which the cancer is welcomed in these books is a tribute to the mind’s collusion with the body – or simply an example of the sad gullibility of the very sick.

Perched somewhere between these extremes of agony and pleasure, there is a peculiar sub-set of what might be called ‘designer cancer’ journals. Designer cancer (commonly of the breast, but occasionally the ovaries) tends, it seems, to afflict unattached women writers and journalists in their early forties. It is ridden with conflicts: conflicts with doctors, who more often than not turn out to be insulting, when they are not incompetent or falsely reassuring (‘I’m sure it’s nothing to worry about’); conflicts with nurses, who patronise; but most of all conflicts between cancer and career, social life, parties, holidays and sex. How, in other words, do you fit your chemotherapy in, when you’ve got a book to finish and want to go to Florida next week? The designer cancer sufferer is typically torn between two men. On the one hand, there is the loyal ex-lover (or ex-husband) of a decade or so ago, who devotedly drives her miles each week to keep the radiotherapy appointments – but remains the wimp he always was. On the other, the unreliable object of her current passions, callously unconcerned with her present illness and liable to come out with such lines as ‘I can’t imagine why you’re afraid of dying under the anaesthetic. It’s always seemed to me one of the best ways to go.’ In a sense, designer cancer journals are not about cancer at all. They are about being female and forty, and about men behaving badly.

Elisa Segrave’s Diary of a Breast – the story of ‘a nine-month struggle against cancer’ – is one of the more engaging examples of this genre. Designer cancer always seems to bring with it a compulsion to write of the illness with a certain detached amusement; but Segrave is more successfully and sustainedly funny than most. Her best humour is at her own expense, as she documents her struggle to keep up her two favourite occupations (partygoing and literary self-promotion) despite feeling absolutely lousy from the treatment she was undergoing. She puts in a heroic appearance at the Booker Prize dinner only the day after being released from her second stay in hospital (‘a further part of my lump taken out ... my lymph nodes removed’). And just a couple of months later, one course of chemotherapy down the road, she drags herself along, semi-invited, to a New Year’s Eve party at the Skidelskys (‘Robert ... is a brilliant historian who was made a lord this summer’).

Needless to say, none of these occasions turns out quite as she would have wished. At the Booker dinner, she has a pretty uninspiring time next to Kingsley Amis (who deserts her for ‘more important literary friends’ as soon as the food is through), and finishes the evening at the runners-up party at the Groucho Club – all too aware that ‘the most important party’, for the winner, is happening on the floor below. At the Skidelskys, on the other hand, still nursing a very sore arm (to which she won’t admit), she finds herself ignominiously thrashed at knock-out ping-pong by the hosts’ nine-year-old daughter. Similar disappointments come from her large array of male escorts, friends and lovers – who fall pretty much into the predictable stereotypes of the designer cancer journal. There is Hal, for example, who flies in from France from time to time, protests (unconvincingly) undying love, and calls her – whether as a mark of affection, or in excruciatingly bad taste, or both – ‘Cancer Girl’. Against him, we read of the loyal Julian, who takes his turn at hospital visits and ferrying her to appointments, but never quite makes his sexual intentions clear. At the crucial moment, in fact, Segrave is unable to fathom whether his obscure anecdote over a cup of tea amounts to a recondite pass or a recondite rebuttal; and she makes no move. The message, it seems, is that flirtation at forty is just as baffling to its participants as it ever was when they were twenty.

Inevitably, the whole story is played out against a background of doctors’ surgeries, hospital clinics and an underfunded and failing NHS. Segrave (unwittingly) jumps the NHS queue by means of a single private appointment. But from then on, she is fully in the hands of public medicine, whose vagaries, charms and other patients she captures astutely. Many of her literary set-pieces depict confrontations with doctors. Again it is a story of repeated dissatisfaction. The lovely Dr Isaacs, whose breast examinations obviously have their pleasurable side (she regrets on one occasion not having put her make-up on before the appointment), does not even send a reply to her party invitation. The others constantly fail to come up to scratch in different ways: they keep her waiting; they don’t turn up when they say they will; they tell half-truths about her condition – notoriously failing to agree among themselves about whether or not chemotherapy is likely to accelerate her menopause. (Endearingly, Segrave herself sees that there might be some advantages in a decreased sexual libido – but insists that she would at least like to know.)

On one occasion her fury at the absence of both the consultant surgeon and the professor of oncology from an appointment arranged to set up her next course of treatment drives her to write a formal letter of complaint. Reading this emotional outburst, backed up as it is with all her newly-learnt, semi-scientific jargon, anyone is likely to feel a twinge of sympathy for the medical professions; especially when one reflects on the hundreds of other patients they must see in a year, each with different demands, different expectations and different levels of resilience. Who, after all, would want to be a doctor, caring for the likes of Segrave, threatened with limited life-expectancy? But then there is the other kind of cancer literature, written by and for doctors not patients: it is hard to read this and sustain much sympathy. Doctors, it seems, are actually taught to behave in almost all the ways patients hate.

Take this recorded exchange, from a recent book advising the medical profession on how best to discuss their illness with cancer patients.

Doctor: How did you feel when you heard you had cancer?

Patient: Terrified.

Doctor: In what way terrified?

Patient: I kept seeing myself in a coffin.

Doctor: That sounds awful for you.

Patient: It was. It was terrible.

Doctor: Why do you equate having cancer with being in a coffin?

Patient: My mother and elder sister both died of it.

Doctor: Are there any other reasons why you are so upset when you think of the coffin?

This is not, as you might imagine, an example of what not to do in this situation (ask a load of patronising questions and you will surely get something thrown at you). An apparently wilful refusal to recognise that, for most of us, cancer means coffins means dying is the recommended, empathetic, open-ended approach of the new radical, caring oncologist; and it deserves all the ridicule that Segrave and others can pour on it. In fact, one of Segrave’s friends, Miranda, does just that in a three-cornered exchange with a newly-qualified doctor in the hospital. It is shortly after the operation to remove the lymph nodes, but before the results of the biopsy have come through. The doctor walks in, and having learnt his medical school lessons asks: ‘Are you at all worried?’ ‘Of course she is, you wally,’ replies Miranda.

Doctors might, then, have a good deal to learn from cancer journals such as Diary of a Breast; at the very least, it ought to be useful for them to see how their clumsy clinical practice appears from the other side of the sheets. They might object, however, that these journals have little more to do with the somatic forms of the disease that they are trying to alleviate than 19th-century novels had to do with the clinical care of tuberculosis. It is not just that an extremely unpleasant disease (as unpleasant and terrifying for Segrave as for anyone else) is being converted into an upbeat commercial narrative. It is also a question of what kind of cancer, and whose, makes a good story. Presumably, it is no coincidence that (with the exception of Bob Champion) the cancers of the cancer journals are suffered by women, middle-aged or young, and start from the breast or ovary. For these are the late 20th-century versions of the old narrative of untimely death, and of women conquered (as always) by their own sexual organs.

Of course, we all must hope that, when our time comes, it is designer cancer that afflicts us – with its feisty conflicts, wry anecdotes and optimistic prognosis. But sadly cancer of the flesh is a very different disease from cancer on the page.

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Vol. 17 No. 14 · 20 July 1995

Mary Beard’s review of my book The Diary of a Breast (LRB, 6 July) is complimentary and thought-provoking and I thank her for this, but her phrase ‘designer cancer’ is demeaning. If my book had been published posthumously, would she have still used these words? A life-threatening illness is not about fashion. I have survived, but many other women, who started with the same symptoms as I had, have not. In the UK, 15,000 women a year die of breast cancer. Is my own experience to be belittled because I am still alive? Mary Beard makes a distinction between ‘cancer of the flesh’ and ‘cancer on the page’. I also had ‘cancer of the flesh’. Since I am a writer, I wrote about it and I naturally hope that my book will reach as wide an audience as possible. But I would not have chosen to undergo, first, the terror of my life ending halfway through, then the ever-present nagging fear of a recurrence, in order to perform a ‘fashionable’ literary exercise.

Elisa Segrave
London W8

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