Part 3

London, 1925

THE CONQUEST OF CANCER

The cure of cancer is now ceasing to become a purely medical problem, to be solved by biologists, pathologists and surgeons, and is becoming a problem in psychology, and education, to be solved by publicists, schoolmasters, and perhaps, when enough people are alive to the facts of the situation, by legislators and statesmen.

This may sound a bold thing to say, but I hope to be able to bring forward evidence proving that it is at present possible to cure seventy-five per cent. of cancer cases with a mortality of under five per cent.

Possibly the response to this essay will be that of one of the most enlightened persons of my acquaintance who, on seeing my title, said, “Of course this is perfectly absurd”, but it was a favourite saying of Dr Maguire, a great American surgeon of the nineteenth century, that the most useful thing one man can do for his fellows is to see a thing clearly, and to say it plainly.

Here is a plain statement, susceptible of the fullest proof. Out of every hundred people in our community, ten will in all probability die of cancer; and, of those ten, seven or eight could be cured, or their disease prevented with the present methods at our disposal. All that is required is an intelligent facing of the facts concerning this disease, and efficient medical attention.

The average annual deaths during the last eleven years in the United Kingdom were 466,000,――nearly half a million people. Of these, 43,000 were due to cancer; 19,000 males and 24,000 females. Moreover, although taken altogether ten per cent. of the population die of cancer, a greater proportion of adults so die. I say again that a large proportion of these cases is either preventable or curable.

The Executive Committee of the British Empire Cancer Campaign have recently published a statement based on the last census. They say that, during the year 1921, in Great Britain, of persons over 30 years of age, one out of every seven died of cancer.

These figures make it plain that the question is not merely one of interest to doctors and scientists; it is of concern to every one of us, and to one person in every ten it has direct and very personal interest.

Surgery and medicine have very little further to advance along technical lines, so far as the type of case we see at present is concerned. It is nearly impossible to make operations more extensive and thorough than they are at present; and it is unlikely that the operative mortality in the average good risk will fall much lower than its present very small figure. Other methods of curing cancer do not at the moment show promise of producing anything so good as the present surgical results. We have therefore to resort to an educational campaign for its victims before we can get much further on.

This brings me to the first point to be brought home before any more is said――that early cancer and late cancer are, so far as results and cures are concerned, two entirely different diseases. A well-known English authority, speaking of cancer of the tongue, says: “An early superficial cancer on the free part of the tongue should be, and is, curable in practically all cases. The general conviction of the incurability of cancer is founded on the results of operation on the average fairly advanced case and, until this conviction is shaken, I fear the public will remain relatively indifferent and pessimistic as to the advantages of early treatment. Every surgeon of any experience is aware that, as regards its accessibility to treatment, early cancer is a totally different disease from even moderately advanced cancer, but I am very doubtful as to whether we shall be able to enforce the fact by direct statement so long as the treatment of advanced cases furnishes the public with so many terrible object lessons in the apparent intractability of the disease.”

The problem we have before us, then, is that of changing the whole attitude, not only of the physician, but of the patient, to cancer. Here is an example of the present point of view:――I have frequently heard it said that such and such a patient has a lump, or some disquieting symptom or other, but she won’t go to the doctor as she is afraid he will say it is cancer. What we have to do is to strip this disease of its fear-complex and bring all the facts about it into the open. We have to change the attitude of the patient, and often, unfortunately, of his doctor, from one of “wait and see” to one of “look and see.” Then, and only then, shall we be on the way to curing cancer.

The results of the present-day and popular point of view are appalling. Somewhere about half the cases of cancer are far too advanced for us to think about curing them at the time the patients appear. Of the remaining half, approximately two-thirds have about a thirty per cent. chance of cure, and the remainder about a sixty per cent. chance. These figures are rough estimates based on impressions formed in hospital out-patient work, but they will not be found far wrong. The heart-breaking part of it is that it is all the result of fear, carelessness and crooked thinking, which could be avoided in a large percentage of the cases.

Yet there are signs that we are entering on a new phase, and that a realisation of the importance of early diagnosis is slowly permeating through the medical profession. In America we see an increasing insistence on the use of detailed and specialised laboratory methods for exact diagnosis; and in Great Britain there is in existence, at St. Andrew’s University, a complete medical unit, under the supervision of Sir James Mackenzie, for the investigation of the early symptoms of disease. The establishment of this institute is, I think, one of the most important advances that medicine has made in the last twenty-five years, for it is a milestone on the road to progress, a concrete and tangible expression of a changed point of view.

Let us for the moment leave generalities and give some few minutes to more detailed consideration of the disease; first in outline, and then in respect of some particular cases.

Cancer is a degeneration. It most often occurs at that period of life when our biological work is done, and, as far as Nature is concerned, we are of no use. From her point of view we are on this planet to reproduce our kind and, when we are past doing that, our tissues begin to lose their firm hold on their appointed form, and stray from their former habit of exactly reproducing their kind when attempting to recover from any kind of injury. Cancer is commonest in those organs which have soonest finished their work――the reproductive organs of women; and, after these, it appears most often in that organ so much more abused than any other――the stomach.

The greatest number of cases appears at or after fifty, and therefore at that age it behoves us, not to wait and see whether we shall get it or not, but to look and see that we have not got it, for of people who survive till the age of fifty, a great many more than ten per cent. die of cancer.

From the biological point of view cancer presents another interesting feature. It used to be generally stated by biologists that acquired characteristics cannot be transmitted. In cancer we see a cell taking on foreign characteristics in response to some environmental stimulus and transmitting these to its offspring until the organism from which it sprang is destroyed.

To sum up, the tissues from which cancer grows, in their normal process of repair tend to reproduce themselves more or less exactly, or if the injury is too gross, they are replaced by scar tissue; but when we reach the age at which their biological work is done, there is a tendency to atypical reproduction, in which an atypical cell continues to reproduce itself atypically and grows at the expense of the organism, eating into or eroding it as it enlarges, till it finally kills the host on which it preys.

This will serve as a general definition, but, if we wish to be a little more concrete, we must plunge for a while into the realms of pathology, in order to get a clearer idea of what cancer means.

Our body is made up of three layers of tissues; each of these has its separate function, and, within small limits, its own way of reacting to long continued injury. Early in our prenatal development, these three layers can be distinguished, and each of these later produces its own type of tissue, and under appropriate conditions, its own type of malignant tumour. From the outer and inner layers develop the cells which actually touch the outside world, that is to say, which cover the exterior of our body and provide our inner lining, or mucous membranes. From the inner layer is developed glands which are, so to speak, ingrowths from this layer, and it is the tumours arising from this latter tissue layer which mostly concern us now, and which are the cause of so much human suffering.

These Carcinomata, as they are called, all have something in common, alike from the point of view of their recognition, pathology and onset. They begin in some tissue which has previously been the seat of disease, usually some chronic inflammatory process which has been present for years, and which may have healed up and broken down many times. When this occurs on open surfaces, such as the tongue, intestinal mucous membrane, or lip, we can watch the gradual transformation of the disease from a simple chronic inflammatory process to that of a malignant growth.

Let us take, for instance, the case of cancer of the lip. We see an old man who for years has been smoking a clay pipe. The stem of the pipe gets shorter as the years go by, and consequently, as he smokes it, hotter and hotter. One day he notices that his lip is cracked, the crack being just on that part with which he habitually holds his pipe. If we were to look at this under the microscope we should just see that the mucous membrane was broken at this point. Perhaps he stops smoking for a day or two till his lip has healed, and then continues to smoke again. Soon, from force of habit, the pipe returns to its old comfortable spot; and again the lip cracks. This time it is not so painful, and takes longer to heal. This cracked lip may be present for years, and if, after some time, we were to look at it again under the microscope, we should see a very different kind of thing. All round the crack would be congregated thousands of white blood cells, trying vainly to assist the sore to heal, but, as well as this, we should notice that, in their efforts to bridge the gap of broken mucous membrane, the delicate epithelial cells which line our lips had increased in number and thickness. We might also see that they had a tendency to grow down to the deeper layers of the lip.

If we were to persuade our friend to give up his clay pipe and indulge in some other form of smoking, or even to have a few teeth extracted so that his pipe was more comfortable in some other position, the small ulcer would, given time and a little attention, heal up quite satisfactorily. But, with all the perversity of human nature, he will not; he only has a small sore: it doesn’t hurt him, or anyone else, so why should he worry?

We pass on another few years, and our friend reappears. This time his sore has a more permanent appearance about it. It is hard, and somehow looks as if it goes deep, and has a tendency to bleed. We look at it and tell him that he ought to let us cut out that small sore, but as a rule he won’t allow this procedure; he wants medicine to take for it, an ointment to put on it. If we were again to have a microscopical section at our disposal we should see a very different state of things. Those epithelial cells which before were just thickened, and a little angry looking, have at last wakened up and begun to grow. They have branched out and grown deeper into the lip; there is nothing to check them since they have thrown aside all the restraints imposed by the necessity of keeping to their original form, and have, so to speak, got out of the control of the usual mechanisms which the body possesses for keeping cells in their proper place. The only thing we can do for the patient is either to find some means to kill them――an end which has not yet been achieved, as what will kill them will also kill the patient――or to cut away the tissue in which they have grown, leaving a wide margin around the farthest palpable edge of the ulcer. If this is done, the patient can be assured of a permanent cure. But if he will not believe you, as he often will not, possibly because you are not willing to stake your reputation on the ulcer being malignant, or the certainty of its cure by surgery, he will go away for another year or so. One day he appears again because his ulcer has been showing a tendency to bleed and has got a bit bigger lately; also he has noticed, while shaving, a small hard lump in his neck which he feels as the razor goes over it. He still has no pain and no discomfort whatever. We look at this and tell him that he has to undergo an operation, both on his lip and on his neck, and that he has got cancer. We remove the ulcer and every gland that we can find in a large area around, but we can only assure him that he has a one in five or three chance of a permanent cure whereas, if he had taken our previous advice, we could have promised him a permanent cure in between ninety and one hundred per cent. of chances, according to the age of the disease.

If we now use our microscope, we see that the undisciplined epithelial cells have penetrated the lymphatic capillaries which are present in all our tissues, and have followed them until they reach their destination, the nearest glands. What will happen next depends on time. The growth may spread to more glands, or even outside the glands, and the only course we have open to us is to remove the primary growth, again with a wide margin, irrespective of what disfigurement may result, together with its corresponding lymphatic glands, trusting to radium or X-rays to kill any stray cells that may be set free or missed during the operation. The chances of cure simply depend on whether it is possible to remove the disease completely or not.

The figures I have given are taken from a recent analysis of more than five hundred cases of cancer of the lip carefully followed up. Of cases in which there were no glands involved, ninety-one per cent. were cured: of those with glands only eighteen per cent. were cured. Now here is the point I want to emphasize. The average duration of all these cases was two and a half years before operation. It is impossible to devise any more radical operation, with a much lower death-rate than we at present obtain, and there is no other method which as yet produces better results than I have just quoted, but it is possible to do away with that two and a half years of waiting and medicine. There is no reason for it but ignorance, neglect, stupidity, self-deception and fear.

The example which I have just quoted is not an unusual one, nor, as I hope to show you later on, do the figures materially differ for cancer arising in other parts of the body. Cancer of the lip merely happens to be a convenient, and easily understood, peg upon which to hang my text.