SURGICAL SELF-SCRUTINY

1308

graphy alone. The two methods both detected disease an equally early stage. Mammography is reported contribute

at to

cancer deteotion most in postmenopausal in those older than 50 years,1,6,8,9 a point of some importance in view of Shapiro’s finding that screening was of greatest benefit in this age-group. The newer procedure of thermography seems less effective than mammography in detecting disease in the general

women

to

or

population."-"

accurate diagnosis of those positive on screening would be required 1° On present evidence it would seem wise to await these further developments before considering the introduction of mass screening for breast cancer.

I thank all members of the Department of Community Medicine, St. Thomas’s Hospital Medical School, who gave me their advice and criticism

With all methods the false-positive rate is high, resulting in about 5 patients requiring biopsy for each cancer case eventually detected.1,6,7 Thermography results in considerably more false positives than the other techniques.l6-14 Even using a combination of clinical palpation and mammography, breast cancer is detected on average only 20 months earlier than if women are left to present of their own accord 15 Thus screening must be repeated frequently to be effective. However, even with annual repeat screening almost a third as many cases are detected by women themselves during the intervening year as are detected at the screening sessionS.16 ’

Will Women Accept Screening? The response-rate of women invited to attend for breastcancer screening varies widely. A rate of 81 % has been reported from a study carried out in a Swedish town.17 However, in Britain only 38% of women invited by their general practitioner attended for screening.18 It is uncertain whether those who do not attend represent a high-risk group whose absence is therefore especially important. In the H.I.P. study, non-participants had a slightly lower risk of dying of breast cancer than controls, while " reluctant participants had at least as high a case-detection rate as those participating at the first invitation.3.19 Even those who initially attend show a progressively decreasing attendance at rescreening. And almost 20% of women refuse to have further investigation or biopsy when this is advised on the basis of screening results.2.20 "

How Much Does Screening Cost?? The cost of screening by combined palpation and mammography was estimated in 1968.21 At today’s prices, the estimates would correspond to E2.70 per examination or, at the expected detection-rate of between 1 and 2 per 1000, about U800 per cancer detected. Assuming that the H.I.P. result of a one-third reduction in 5-year deathrate is applicable,3 the cost of each additional case surviving up to 5 years would be in the region of 3400. Apart from financial considerations, the requirements for annual screening by mammography on a national scale would far exceed available manpower and equipment in Britain 21 Clinical palpation alone would be much less costly, especially since it could be more easily introduced within the present framework of services. Annual palpation would probably result in at least some reduction in deathrate,3,23 though this has not been adequately evaluated. In either event, some biopsy procedure would be required in 5-10 of every 1000 women screened. 80% of these This is women would be found to have benign disease. costly, not least in terms of personal anxiety.

Screening Worthwhile ? Early detection of breast cancer probably improves prognosis. However, our present screening methods are costly, and, in order to be effective, require frequent repetition. Better, cheaper screening by new methods or the use of present ones restricted to highrisk " groups is a prerequisite for the success of early-detection programmes."-14--21 Ideally, new tests should have a lower false-positive rate than those now available. Failing this, methods for the rapid and Is

"

on

this paper.

REFERENCES 1. Office of Population Censuses and Surveys. The Registrar General’s Statistical Review of England and Wales for the year 1972: part I, tables, medical. H.M. Stationery Office, 1974. 2. Shapiro, S., Strax, P., Venet, L. J. Am. med. Ass. 1971, 215, 1777. 3. Shapiro, S., Strax, P., Venet, L., Venet, M. in Proceedings of the Seventh National Cancer Conference; p. 663. Philadelphia, 1973. 4. Kelley, J. L., Thieme, E. T. Cancer, 1967, 20, 260. 5. Gershon-Cohen, J., Ingleby, H., Berger, S. M., Forman, M., Curcio, B. M. Radiology, 1967, 88, 663. 6. Griesbach, W. A., Eads, W. S. Cancer, 1966, 19, 1548. 7. Stevens, G. M., Weigen, J. F. ibid. p. 51. 8. Witten, D. M., Thurber, D. L. Am. J. Roentgenol. 1964, 92, 14. 9. Wolfe, J. N. Radiology, 1965, 84, 703.

10. Bjurstam, N., Hedberg, K., Hultborn, K., Johansson, N., Johnsén, C. Progr. Surg. 1974, 13, 1. 11. Hitchcock, C. R., Hickok, D. F., Soucheray, J., Moulton, T., Baker, R. C. J. Am. med. Ass. 1968, 204, 419. 12. Hoffman, R. L. Am. J. Obstet. Gynec. 1967, 98, 681. 13. Isard, H. J., Becker, W., Shilo, R., Ostrum, B. J. Am. J. Roentgenol. 1972, 115, 811. 14. Wallace, J. D., Dodd, G. D. Radiology, 1968, 91, 679. 15. Hutchison, G. B., Shapiro, S. J. nat. Cancer Inst. 1968, 41, 665. 16. Venet, L., Strax, P., Venet, W., Shapiro, S. Cancer, 1969, 24, 1187. 17. Langeland, P. Acta radiol. 1970, suppl. no. 297. 18. Barnes, S., Berry, W. H. C., Williams, M. J., Baum, M., Mackay, W. D., Howe, C. T., Murray, J. G. Lancet, 1968, i, 1417. 19. Fink, R., Shapiro, S., Roester, R. Am. J. publ. Hlth, 1972, 62, 328. 20. Pedersen, E. Proc. R. Soc. Med. 1966, 59, 1189. 21. Lowe, C. R. in Screening in Medical Care; p. 33. London, 1968. 22. Office of Population Censuses and Surveys. The Registrar General’s Statistical Review of England and Wales for the 2 years 1966 and 1967: supplement on cancer. H.M. Stationery Office, 1972. 23. Gilbertsen, V. A. Cancer, 1969, 24, 1192. 24. Bulbrook, R. D., Hayward, J. L., Spicer, C. C. Lancet, 1971, i, 395. 25. Macmahon, B., Cole, P., Brown, J. J. natn. Cancer Inst. 1973, 50, 21. 26. 27.

Stark, A. M., Way, S. Lancet, 1970, ii, Wynder, E. Cancer, 1969, 24, 1235.

407.

Hospital Practice SURGICAL SELF-SCRUTINY R. Y. CALNE

University Department of Surgery, Addenbrooke’s Hospital, Cambridge CB2 2QQ THE conscientious surgeon embarking on a riskv operation will certainly be under a strain which pends not solely on the risks but also on his attitude towards the patient. The tradition of not opera::ng on one’s own family has become firmly established: a surgeon may be equally disturbed in removing an appendix from his son as in resecting an aneurysm from a patient to whom he is unrelated. The principles of surgical practice are taught by apprenticeship; but it is surprising how often the traditional code of surgical practice can be usurped, usually unintentionally, by attributes of the surgeon’s personality that can be detrimental to patient care. The consultant’s security of tenure is in general laud-

1309

able ; but it is anomalous that the day

a man ceases

be a senior registrar on his appointment as a consultant marks the beginning of a period, extending to retirement age, in which professional criticism from his colleagues is most unlikely, unless his malpractice is so blatant as to involve a suit for damages. Such immunity from criticism is unusual in other profesFirst-class and very bad sions and occupations. to be known tend surgeons by their colleagues, their staff. Yet a surgeon may junior particularly his whole life spend making poor judgments and with an operating badly unacceptably high morbidity and mortality, and remain unaware that his work is If no-one else will criticise our work below par. then we must judge ourselves and attempt objectively, to correct recognisable faults. to

Decision

Operate Whenever operation is considered, the surgeon must not divorce the surgical procedure from the patient as an individual. He should balance the points for and against operation: he must consider the patient’s future without surgery (for instance, the danger of his dying and the likelihood of his suffering discomfort and unhappiness), and compare this with the prognosis following surgery. He must appraise the fear of the operation itself, the risks of death and of postoperative discomfort and morbidity. The patient’s own approach to his illness, his age, his family, and his social background will be relevant and sometimes all-important. If, after a full explanation, the patient refuses operation, a surgeon will usually be wise to abstain from persuading him to change his mind. to

Surgical Pride and the Clock Pride in one’s work, if based on a realistic appraisal, is a worthy attribute. Unfortunately, misplaced surgical pride is the commonest and most dangerous personality defect in surgeons. A consultant surgeon who is never criticised by his colleagues can all too easily feel that he can do any operation, not only well but quickly. I wonder how many common bileducts have been cut simply because the surgeon presumed that he could always remove a gallbladder in less than half an hour. This feat being expected of him by his junior staff and theatre nurses, he may not be prepared to take more care and more time in a case where the anatomy is difficult to see. Operating against the clock can be due to factors other than misplaced pride. The surgeon may have to travel to operate in another hospital; he may be expected to attend one of the new committees or subcommittees that are proliferating like cancer cells, to the detriment of the National Health Service; or he may be expected to finish by a certain time so that another consultant can occupy the theatre. I feel that work in the hospital should be structured so that there is never any pressure on a surgeon to operate more quickly than he considers to be safe for his patient. There must be provision for him to extend the time of the operation even though this may slow the vacuous progress of the " Cogwheel ". A surgeon should not have to operate when he is tired, for his judgment and technical abilities will be impaired.

Misplaced Individualism Surgeons seem to have a built-in reluctance to refer It is regrettably common cases to their colleagues. for a surgeon to struggle with an operation that he has never seen performed when a nearby hospital, or even his own institution, contains an expert who has specialised in this technique. This is perhaps a hangover

ted

from the 19th century when

a

surgeon

was

expec-

was often practise every surgical procedure isolated so either he that physically operated or the was not operation performed. Operating in contemBritain is not the same as practising as a porary doctor in the Congo. If one’s own capamissionary bilities are not suitable, a good test is to ask oneself the question " If a member of my family were suffering from this condition, who would I have to operate? and then to act accordingly. To request the advice of a colleague is a sign of surgical strength, not personal

and

to

"

weakness

or

failure.

MAJOR DISASTERS DAVID CARO Accident and St. Bartholomeu’s

Emergency Department, Hospital, London EClA 7BE

WITH the proliferation of -bomb incidents in the United Kingdom, much thought has been given to plans for coping with major disasters 1 The police, who are usually in charge of the organisation of disaster relief, have defined, after consultation with the ambulance service and the hospitals, a major disaster as one producing more than fifty casualties needing treatment in hospital either as inpatients or

outpatients. POLICE AND FIRE SERVICES

The police and the fire services have well thoughtand thoroughly rehearsed major-disaster schemes. ""’They should both be notified and called to the accident from the very beginning, and usually the chief police officer or the chief fire officer will be in charge of the relief work. The first person of responsible level to arrive at the accident site must make a rapid but brief survey of the situation and call up the assistance he thinks necessary. With the arrival of supporting services, a more precise assessment of the casualty numbers will be possible, but it will be some time before thorough search of the area reveals the actual number of casualties. An assessment must, therefore, be made on the minimum of information, and on occasion a major accident will be declared unnecessarily. The presence of the police is essential for the control of crowds and traffic and for the clearing of routes for the arrival of fire-fighting equipment and ambulances. Once a major accident has been declared the ambulance service will designate a hospital to receive the first of the casualties. The responsible hospital is notified by telephone. The hospital must then mobilise its resources to cope with the casualties. Complex plans of- notification have been made by out