Title: Trial and Error
Description: Between the mid-1940s and the mid-1970s oncology turned from a marginalized experimental field into one of the most dominant medical specialties in the United States. Cancer chemotherapy, once a controversial practice, became a standard therapy alongside surgery and radiation. The success of cancer chemotherapy, however, is not so simple to explain. Cancer chemotherapy was adopted despite broad and evident dissatisfaction with its limited clinical achievements, common among patients and doctors alike. To explain the success of cancer chemotherapy, this dissertation examines the social processes that allowed for the emergence and stabilization of a new therapeutic field. I show that common sociological approaches for studying medical experts, such as the sociology of the professions and medicalization theories, fail to provide a convincing explanation for the emergence of chemotherapy because they assume the existence of professional entities or a set of tasks and problems as pre-given facts.

Alternatively, I build on these approaches to show that oncology itself, as well as the tasks and problems of cancer medicine, evolved with the invention of the new therapeutic technologies of cancer chemotherapy. I argue that when cancer chemotherapists, a nascent professional group, failed to deliver on their promise for a cancer cure in the 1940s, they began exploring what cancer chemotherapy might become. During the following decades, they gradually reinvented the diagnostic categories, clinical methods and therapeutic objectives of oncology, thus establishing a new mode of therapeutic intervention. The dissertation further examines the tactics and resources that contributed to the success of these efforts and to the stabilization of the new therapy. I trace how oncologists leveraged limited clinical achievements to (a) legitimate their practices and frame experimental outcomes as therapeutic objectives and (b) assemble the infrastructure and alliances needed to expand the enterprise and improve on existing clinical practices and results.

The first paper ‘Adequate Trials: How the Search for a Cure Shaped Leukemia Diagnosis?’ addresses the rewriting of the diagnosis of leukemia, to demonstrate that the success of chemotherapy depended on the ability to transform the categories used to classify cancers and patients. Mobilizing bureaucratic capacities and redefining their ethical commitments, oncologists managed to allocate the ‘right patients’ to the ‘right trials,’ reshuffling existing diagnostic classifications, so that the conditions under which drugs could ‘work’ might be created. The second paper ‘From Bullets to Cocktails: The Invention of New Therapeutic Methods in Cancer Chemotherapy’ explains how oncologists sheltered themselves from the external demands of patients and regulators to secure space for experimentation with controversial procedures of combination therapy. The paper traces the epistemic, institutional and ethical resources mobilized by oncologists to articulate their research agendas as problems for basic science, thus establishing alliances within the National Institute of Health.

The third paper, ‘How Means Turn to Ends: A Pragmatist Account of the Rise of Oncology’ addresses the normative legitimation of the objectives of chemotherapy to demonstrate that the framing of new experimental categories in terms of community-based clinical care was a key to the success of oncology. Together, the three papers demonstrate that to make medical drugs ‘work’ (i.e., produce predictable effects that are commonly seen as therapeutically valuable), oncologists had to restructure the practices, institutions, classifications, objectives, and roles in cancer research and clinical care. The dissertation thus suggests that an analytical focus on the invention of new modes of therapeutic intervention would provide valuable insights into questions central to a wide range of sociological investigations. The invention of therapeutic technologies offers a lens for exploring the transformation of the institutions and practices of the medical profession, biomedical research, drug regulation and healthcare.