WHY CANCER IS NOT RECOGNIZED EARLY'

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1 WHY CANCER IS NOT RECOGNIZED EARLY' WILLIAM CARPENTER MAcCARTY, M.D. (Diviswn on Surgical Pathology, The Mayo Clinic, Rochester, Ninnesota) That cancer is not recognized in its early stage by the medical profession as a whole is quite obvious from the following facts: 1. Thirty to 50 per cent of the cancers of the breast (Harrington), 42 per cent of the cancers of the large intestine (Rankin), and 75 per cent of the cancers of the stomach (Balfour) are inoperable when first seen in The Mayo Clinic. 2. Sixty-two per cent of the operable cancers of the breast, 38 per cent of the cancers of the large intestine, and 53.5 per cent of the cancers of the stomach have metastasized to regional lymph nodes when seen. 3. The average size of operable cancers of the breast is 3.2 cm. in diameter, of those of the large intestine 6.4 cm., and of those of the stomach 6.1 em. (5). 4. Only 29 per cent of the operable cancers of the breast are smaller than a quarter of a dollar (2.5 em.), and this is true of only 2.2 per cent of the cancers of the large intestine and only 6 per cent of cancers of the stomach (4). That cancers do occur and are sometimes found as very small lesions is also quite obvious from the fact that in a series of 7,179 specimens of surgically removed cancers, the smallest found in the breast was 2 mm. in diameter, in the large intestine 9 mm., and in the stomach 5mm. (5). There must be some reason, or reasons, for these results of medical practice, aiid it is my purpose frankly, critically, and, I' hope, constructively, to state what I believe to be these reasons. Progress has rarely been made in any field of human activity without frank constructive criticism. I shall begin by reviewing briefly the profession's historical approach to the handling of cancer of the stomach, since that is the most frequent form of cancer. In 1827, Bright published his Memoirs o'y1 Abdokd Tumom. In this classic work he described 112 cases (15 hydatid cysts, 26 ovarian cysts, 26 splenic tumors, 12 renal tumors, and 33 miscellaneous conditions). All of these tumors were large, the patients were in the last stages of the disease, treatment was purely palliative, none of the tumors was described as cancer of the stomach, and none was treated surgically. Most of them came to necropsy, where the real nature of the disease was first positively discovered. This was, of course, in 1827, when there was no science of bacteriology, no asepsis, and no operative abdominal technic. In 1894, sixty-seven years later and forty years ago, Osler wrote 1 Hcad bcforo the American Association for Cancer ReReareh, Toronto, Ontario, March 28, For discussion, scc Am. J. Cancer 22: 667, Nov

2 832 WILLIAM CARPENTER MAOOARTP a report on abdominal tumors. In that report he recorded 24 cases of tumor of the stomach. All the tumors were large; all the patients were in the last stages of the disease and all were treated palliatively; only one was submitted to surgery, and that one died. In 1900, Osler and McCrae reported on 150 cancers of the stomach, all large; all the patients were in the late stages of the disease, and all of them were treated palliatively. Only 9 patients were operated upon. Six of the 9 were explored and the condition found to be inoperable; three of these died, and the fate of the other three is not mentioned. One of the remaining three underwent gastro-enterostomy and died, one underwent gastrostomy and died, and from the other a growth waa removed but the patient died. Up to the time of this last report, at the beginning of the present century, no one had seen, or at least described, an early cancer of the stomach, not even Hauser in his epoch-making work. The only possible chance to see a growth in the early stage depends, of necessity, upon early clinical recognition by the physician, early exploration by the surgeon, or visualization by roentgen rays, none of which was to be expected in Patients with early cancer of the stomach do not die except perhaps by some rare accident and consequently the condition was not described post mortem, despite the fact that cancer and ulcer of the stomach, in their fatal stages, have been known to pathologists for centuries. The opportunity for the pathologirt to see small cancers could not and did not come until operative and explorative surgery had passed the experimental stages and been frequently practised, until immediate and end-results were reported, and conservative clinicians were educated to the value of operative surgery. This did not occur until well into the first and second decades of the twentieth century. Even now the education of physicians has not been completed. In The Mayo Clinic, before 1907, only 150 stomachs had been partially resected, despite the fact that 851 gastric and duodenal operations had been performed. Since 1907, 4,129 stomachs have been partially resected for gastric cancer. It is this new opportunity, not available to Bright and Osler, that I wish to emphasize. 1 have selected at random 100 cancers of the stomach removed surgically. All were the size of a quarter of a dollar (2.5 cm.) or smaller. All were approximately a third of the average size (6.1 em.) of the operable 25 per cent of all cancers of the stomach seen in our clinic (Figs. 1, 2, 3 and 4). Although this is not primarily a clinical paper, it becomes necessary to state how these cancers were discovered as such small lesions in order to answer the question implicit in the title of this presentation. Throughout the 100 clinical histories one finds such terms or expressions as pain (dull or sharp, sudden or burning), weakness, tired feeling, nausea, vomiting, flatulence, bloating, sour eructations, feeling of fullness, indigestion, stomach trouble, and periodicity of symptoms. Reports of the physical examination, contrary to the classic descrip-

3 FIG. 1. ADENOCARCINOXA AND COLLOID CARCINOMA OF THE STOHACE; ULCER 1.5 CM. IN DIAMETEB 833

4 PIQ. 2. ADENOCARCINOMA AND COLLOID CARCINOXA OF TEE STOadACH; ULCER 2 CM. IN DIAMETER 834

WHY CANCER IS NOT RECOGNIZED EARLY 835 tions in text-books, show absence of such features as emaciation, palpable tumor in the epigastrium, anasarca, accessory nodules, cachexia, pallor, edema of the

5 WHY CANCER IS NOT RECOGNIZED EARLY 835 tions in text-books, show absence of such features as emaciation, palpable tumor in the epigastrium, anasarca, accessory nodules, cachexia, pallor, edema of the legs, hematemesis, tarry stools, and loss of weight greater than might be explained by a restricted diet. Strangely, also, gastric acidity was high rather than low, and the hemoglobin records were iiormal in the great majority of cases. None of these signs, symptoms, or laboratory findings is pathognomonic of cancer. All may be found when no cancer is present, as in simple gastric ulcer, duodenal ulcer, and, frequently, in association with cholecystitis and FIG. 3. CARCINOMA OF THE STOMACH; ULCER 2.5 OM. IN DIAMETER even appendicitis. Such symptoms are common in any group of Americans, and certainly not all of these have cancer. It is fair to suspect, however, that some may have cancer, and this cannot be determined by signs and symptoms alone. Just as long as physicians continue to wait for the text-book picture of cancer we will continue to find a high percentage of cases hopeless when the correct diagnosis is made. The lessons which may be learned f porn this series are : 1. Cancer does occur as a small lesion. 2. As such, its signs and symptoms are not those described for cancer in the text-books of pathology and of the practice of medicine.

6 Fro. 4. UARCINOMA OF THE STOMACH; ULCER 2 CM. IN DIAMETER 836

WHY CANCER IS NOT RECOGNIZED EARLY 837 3. Advanced cancer of the stomach, described by post-mortem pathologists, is not the picture seen by the surgeon and the surgical pathologist. 4.

7 WHY CANCER IS NOT RECOGNIZED EARLY Advanced cancer of the stomach, described by post-mortem pathologists, is not the picture seen by the surgeon and the surgical pathologist. 4. As these 100 cases show, the recognition of a gastric lesion is best made by a trained roentgenologist, who knows that he cannot see small cancers but who can see a lesion, locate it in the stomach, and recognize pyloric obstruction in its incomplete stages, and who can suggest whether or not the lesion is operable. Cancers are not recognized early by the medical profession and never will be until it learns that there are no characteristic signs and symptoms for early cancer and that the only means of telling whether the condition is gastric, duodenal, appendiceal, or in the gallbladder is the roentgen ray. It makes little difference for the present whether pathologists believe cancer can be diagnosed from cells alone or not. There still are enough cancers easily recognizable, histologically, which are smaller than a quarter of a dollar, that will have to be removed if the cancer problem is ever to be settled. The risk of cancer is still greater than the risk of removing a few benign ulcers which may he cancer in so far as signs, symptoms, roentgenologic data, and grosfi appearance are concerned, BIBLIOGRAPHY 1. BALFOUR, D. C. : Personal coinmunication to the author. 2. BRIGHT, RICHARD : Clinical Memoirs on Abdominal Tumors in Tumescence, London, The New Sydenham Society, Pp HAUSER, GUSTAV : Das chronische Magengeschwiir sein Vernarbungsprocess und dessen Beziehungen zur Entwicklung des Magencarcinoms, Leipzig, F. C. W. Vogel, Pp HARRINGTON, S. W. : Personal communication to the author. 5. MACCARIT, W. C. : The size of operable cancers, Am. J. Cancer 17 : 25-33, OaLER, WILLIAM: Lectures on the Diagnosis of Abdominal Tumors, New York, D. Appleton & Co., Pp OaLm, WILLIAW, AND MCCRAE, THOWAS: Cancer of the Stomach, Philadelphia, P. Blakiston s Son & Co., Pp RANKIN, F. W.: Personal communication to the author.

LIFE EXPECTANCY AND INCIDENCE OF MALIGNANT DISEASE

LIFE EXPECTANCY AND INCIDENCE OF MALIGNANT DISEASE IRA T. NATHANSON,' M.S., M.D., AND CLAUDE E. WELCH,2 M.A., M.D. (From the Collis P. Huntington Memorial Hospital, Harvard University, Boston, Mass., and