Part 5

It has not, I think, been established beyond a doubt that chronic irritation is the sole exciting cause of cancer――this in the nature of things would be very difficult to prove――but it has been shewn that its presence strongly predisposes to new growth formation.

The problem which now arises is that of how we are going to put this knowledge we have gained to practical use in the prevention of cancer. In order to solve this we will consider in some detail the three commonest cancers met with, namely cancer of the breast, the womb and the stomach, and we will see how the problem applies to them.

Now in cancer of the breast we have this outstanding fact that, almost all the cases show for some years beforehand obvious signs of chronic inflammation of the breast, and in nearly all of them this precancerous stage can be seen, when they are examined microscopically.

Obviously this is the time to deal with the disease; and the way to do so is systematically to examine microscopically (by a procedure in itself devoid of all risk, except the very small one due to the administration of a general anaesthetic), every doubtfully malignant breast, afflicted by chronic inflammation. This may seem a revolutionary thing to say; but if we set ourselves to deal with this plague in the logical manner that we employ when we sit down to deal with any other pest, and, if we follow all the facts known to their inevitable conclusion, we are driven to it, and we shall see that there is no other course open to us but to deal in a wholesale manner with the precancerous condition. To do this we shall have to undertake a long campaign of education. One of the leading authorities on breast cancer in America, did undertake such a campaign in his own district, with the result that, from the enthusiastic propaganda of one man, the proportion of precancerous to fully developed malignant lesions which appeared at his clinic rose in six years by thirteen per cent. In twenty years the proportion of fully developed cancer to pre-malignant lesions dropped from ninety to seventy-eight per cent.

I am quite sure of the fact that the adoption of this proposal would mean operations upon a number of breasts which would never become cancerous, but, so far as I can see, we cannot help this, any more than we can help vaccinating a large number of people who will never have small-pox, or, when we isolate diphtheria contacts, can we help disturbing also a large number of people who will never get diphtheria. The public have been educated to regard these precautions as natural and proper, and as a rule raise no objections to their being carried out. Dr Bloodgood, to whose educational work I have just referred, states that if any woman could be kept under sufficiently close observation, she could be practically assured against death from cancer. I think every other surgeon of experience would agree with him.

So much for prevention and the precancerous lesions. Let us come to the question of the cure. Here we find that the chances of cure in any particular case simply depend on the stage at which the case appears for treatment. We can for convenience divide cases into two groups; those which have glands involved and those which have not. By this I mean those which have glands so grossly involved that they are appreciable to the touch. Again quoting Dr Bloodgood, it is found that of those cases with gland involvement, twenty-three per cent. only are cured after seven years but, of those without gland involvement, sixty-five per cent.

Now, here is the fact which ought to rouse us to action: the average duration of the disease in these cured cases was nine months――nine precious months in which that remaining thirty, or forty, per cent. might have been cured if they had only been treated earlier. Or, if they had been properly examined still earlier by a trained person, the disease could have been dealt with earlier with a still better chance of ultimate cure, and it is Dr C. H. Mayo who has said that there is no reason on earth why about ninety-five per cent. of all cases of cancer of the breast cannot be permanently cured.

So far we have spoken in detail of cancer of the breast but, when we come to deal with cancer of the uterus, we shall find that the facts are almost exactly analogous, only that the results of indecision and delay are even more deplorable. We find that, by the time they come for treatment, about half the cases are quite incurable, and those which are operable are as a rule a great deal further advanced than those of cancer of the breast. In spite of this we find that out of two hundred consecutive cases no less than forty per cent. were cured; that is to say, had no recurrence within seven years. All the cases which were operated on had had quite definite symptoms for six months. In other words, the patient herself should have come for examination six months before she did, and if she had been examined in the course of a proper routine, the disease could have been discovered far earlier than was the case.

Quite recently, a report of a series of cases has been published by Professor Faure, a distinguished French gynæcologist, which so exactly illustrates my views that perhaps I may be forgiven for making use of it. Faure cut ninety-six cases of cancer of the uterus and has divided them into good cases, mediocre cases and bad cases. It is significant that there were only twenty-one “good” cases, thirty-five “mediocre” cases and forty “bad” cases. The good cases are what I have called early cases, the mediocre cases correspond to moderately advanced cancer, and the bad cases to those which are on the border line between operability and non-operability. His total results approximate very nearly to most other published lists but their analysis is very significant. Of the good cases there was one operative death; of the remainder seventy-five per cent. were cured and twenty-five per cent. recurred.

Of the mediocre cases there was an operative mortality of 8.57%. Of those surviving the operation 62.5% were cured and 37.5% recurred. In the bad cases there was a post-operative mortality of 22.5%: only six were cured and twenty-five recurred. That is to say, respectively, 19.35% were cured and 80.65% recurred. These figures tell their own tale.

With this hopeless condition of affairs it is no use saying that the results of surgery are bad. They are; but it is not the fault of doctors, or the methods at their disposal; it is the misfortune of the patient that her lack of proper education must bear the blame.

Cancer of the uterus is in many cases preceded by precancerous lesions, all amenable to various kinds of treatment. Again, the only way to deal with it is not to wait and see whether a woman has got cancer but to look and see that she has not. Until this is our attitude, the results are not likely to be much better, whatever the means at our disposal for its cure.

Finally, turning to another great group of cancers which make up thirty per cent. of all in men (and in women too, if we exclude the two previously mentioned types), we find exactly the same condition of affairs.

In two out of every three cases of cancer of the stomach there is evidence that it has arisen in an old ulcer, and Dr Mayo has suggested that eating hot food may account for the remaining third. It is moreover the experience of all surgeons who systematically submit all gastric ulcers upon which they operate to microscopic examination, that about twenty per cent. of them all are malignant.

We have before us the plain fact that from ten to twenty per cent. of all chronic ulcers which have come for surgical treatment are already malignant and can only be cured by a complete removal. Another fact also requires taking into the most serious consideration, and this is, that it is the considered opinion of by far the large majority of experienced surgeons that exploration and some form of operation is the best treatment for every case of chronic gastric ulcer which has recurred once, or at least twice, after a thorough course of medical treatment. (The term “chronic gastric ulcer” is here used in its strictest scientific sense, and by it is meant an ulcer whose diameter in any one direction is more than a centimeter, and whose edges are hard and thickened). In spite of this, a distinguished surgeon recently put on record that every case of gastric ulcer upon which he operated had on an average been “cured” nine times. Why is this? The reason is clear. In nearly every case the symptoms of gastric ulcer (and, remember! twenty per cent. are already cancerous) can be relieved for a time by palliative treatment, when once again the deluded patient thinks he is cured.

There is no need for me to point the lesson from this. I have put forward the facts, and every one can draw his own conclusions. There is only one gleam of hope that I can see on the horizon, and that is, in dealing with the disease in an early stage by radical measures, and, in twenty per cent. of the cases, thus combining prevention with cure.

Again, we must alter our attitude. We must look and see, not merely “dope” and see! Once symptoms of this disease have recurred after efficient treatment, there is only one good reason for not looking and making certain, and that is when the risks of looking exceed those of the lesion being malignant――that is to say, somewhere between ten and twenty per cent. At present, the risks of looking are about one in a thousand, and the risks of removal of a cancer about three per cent., taking all cases, most of which are at an advanced stage. The operative risks of earlier cases are less than this, and to this must be added about a two per cent. risk of a further operation being necessary――in all, not exceeding five per cent.

I realise that the adoption of this policy will mean a certain number of otherwise avoidable operations. I know that it will mean operating on a few cases that would otherwise get better by themselves, or by other means. But until it is adopted, there is, as far as I can see, no prospect of reducing the death-rate from cancer of the stomach. For so long as indiscriminate medicine-taking has precedence over exact methods of investigation and treatment, so long will cancer of the stomach continue to make up thirty per cent. of all cancers. Again the question is largely out of the hands of the doctors. As long as patients come to a doctor wanting “a bottle of medicine, doctor, just to help me carry on”, so long will they get it, as the doctor finds it hard to refuse. For he knows the patient will go from doctor to doctor till he gets what he wants.

I have dealt in some detail with the three commonest types of cancer, but the same arguments apply to all. The problem is not so much how to cure cancer――so much can, and is being constantly done by one method or another――but how to educate people so that we can get hold of cancer early. The problem is one of diagnosis, and is therefore to be solved by education and courage, not by hesitation and fear.

No statement of the cancer problem would be complete without some mention of two methods of treatment which have recently come much to the fore: namely, the use of X-rays and of radium.

To give any really useful account of these is very difficult, as no really satisfactory groups of cases have been published, and one can only speak from one’s own experience and that of colleagues who have been working with them.

The action of both these methods of treatment is in essence the same. It has been found that X-rays and radium have the power of destroying living tissue when such is exposed to their action for varying lengths of time. Fortunately, cancerous tissue is destroyed before normal healthy tissue, and it is the aim of the treatment to expose the growth to that dosage of rays which will kill the malignant tissue but just fall short of doing harm to the normal tissue. Sometimes this is more easily done with X-rays and sometimes with radium; it all depends on the position of the growth. This all sounds very attractive, and one would think that, on the surface of things, with such a weapon at our disposal, every case could easily be efficiently dealt with. But, like many other superficially attractive things, it is found on further examination to have its drawbacks. Although a proper dose of X-rays will kill cancer tissue, a smaller dose will stimulate it to further action. Further, these rays have, comparatively speaking, a very low penetrating power. They are absorbed and rendered inactive by thin layers of metal, of skin or of other tissue.

Now, as has already been explained, a malignant growth, as well as extending superficially, tends to spread very deeply and also to involve neighbouring structures, and when X-rays or radium are applied to it, we find that in some cases it will deal with the more superficial parts of the growth but leave the deeper parts untouched, or even more active than before. All kinds of methods have been tried to get over this, such as burying radium in the substance of the growth, and using very big doses, applied to various aspects of the growth, but, so far, although there have been some very encouraging results, the problem has not been solved.

As has been said, it is extremely difficult to estimate the exact value of this treatment, as no figures are of any value till seven years at least have elapsed after treatment, and no such figures have been published. There can be no doubt, however, that an occasional case has been cured, but it is the experience of all that the results of radium treatment do not approximate in any way to the percentage of cures obtained by surgery, even in those types of cancer which react best to X-rays or radium.

Dr Knox, of the Cancer Hospital, London, who has had much experience of high tension X-rays, says that the treatment of malignant disease by X-rays has not yet reached that stage where it ought to be given to any operable case instead of an operation. I think this opinion may be regarded as an authoritative statement of the situation as it is at present.

This is not all, however; X-rays and radium have a very important place in the treatment of cancer, and as far as we can see at present, the future hope lies in a judicious combination of one or the other of these with surgery, for early operable cases, and their prolonged and intensive use in those advanced cases which cannot be removed by other means. A few advanced cases have even been rendered operable by this means.

In combination with surgery this method has its very greatest use in the prevention of superficial recurrences. In every operation, in spite of the greatest care, it is impossible to avoid the setting free into the tissues of a few cancer cells which may grow later into a recurrence. Post-operative radiation bids fair to abolish this type of recurrence, which formerly accounted for a good percentage of all recurrences.

From time to time many methods have been brought forward which have for a little while promised well, but so far none of them has produced results in any way comparable with those obtained by complete removal of the growth by surgical means.