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Cancer and the public health authorities
PUBIJC HEAI.TH, October, 1951 It w o u l d appear inevitable that the tuberculosis service is b o u n d to falter if its components are, as is largely now the case, dispersed most vicariously among a multiplicity of m a n a g e m e n t committees. It is in such circumstances, surely ingenuous to imagine, that a co-ordinated plan is possible at present or, if drafted now, capable of implementation. T h e d e v e l o p m e n t of two or three units within a Region of the kind now in operation in the immediate B i r m i n g h a m area, although difficult--and this largely because of Health A u t h o r i t y boundaries and responsibilities--would give purpose to the work of a central committee such as that so rightly proposed by Prof. F. G. R. Heaf, and it would re-establish the clinic in the hierarchy of the chest service. T h e general arrangements for the unit n o w briefly described are illustrated in the diagram (Fig. 1). T h e opinions expressed in this statement are not, of course, necessarily those of the Regional Hospital Board, but the keen interest of I)r. Scurlock, the Senior A d m i n i s trative Medical Officer, in the tuberculosis problem, is very w a r m l y acknowledged. CANCER
AND
THE
PUBLIC
HEALTH
AUTHORITIES* By MALCOLM DONALDSON, F.R.C.S., F.R.C.O.G.,
Lately Director of the Cancer Unit, St. Bartholomew's Hospital. INTRODUCTI ON
In 1949 there were registercd in England and Wales over 80,000 deaths due to cancer, but it may be asked, why should this be the concern of the Medical Officers of Health w h o have nothing to do with the diagnosis or treatm e n t of the disease? Moreover, it is neither infectious nor contagious, and is not even notifiable. All this is u n d o u b t e d l y true, but at least one-third of this mortality is due to fear and ignorance on the part of the public, which prevents patients f r o m seeking advice while the disease is often still c u r a b l e ; m u c h of this mortality is therefore preventable by educating the public. T h e onus for educating the public in medical matters rests with the Local Authorities, as laid d o w n by the Public Health and National Health Service Acts. In this lecture I shall endeavour to prove (1) that the greatest factor contributing to the cure of a patient suffering f r o m cancer is early diagnosis; (2) that the present delay in diagnosis is due in nearly every case to the delay in the patient seeking advice f r o m her doctor. T h i s will be followed by suggestions for a scheme to carry out the education of the public in cancer.
Benefit ol Early Diagnosis It is not difficult to prove that the possibility of curing a patient suffering from cancer depends m o r e on the stage to which the disease has advanced at the time of treatment than any other factor. As examples may be quoted, cancer of the cervix and cancer of the breasts. Cancer of the Cervix Uteri. In a recent international report (1948) on 30,299 cases of cancer in this site treated during or before 1941 (in 24 different institutions in eight different countries), 3,856 ( = 12.7%) were in Stage I, that is to say, the disease w a s confined to the cervix. O f these 3,856 patients, 2,299 have survived five years or m o r e and m a y be spoken of as " c u r e d . " T h i s equals 59.6%. I n m a n y of the institutions the figures were even m o r e favourable, in one case a m o u n t i n g to 77-1%. In Stage I I there were 10,033 ( = 33.1%), and of these 4,129 ( = 41.2%) patients have survived m o r e than five years. I n Stage I I I , 11,542 patients were treated, of w h o m 2,644 ( = 22-9%) have survived more than five years. I n Stage IV, 4,864 patients were treated and only 303 ( : 6 . 2 % ) have survived five years or more. # An address to the Midland Branch, Society of Medical Officers of Health.
If Stages I and II are added, the five years' survival rate is 45.8%. Calculated on these figures, 7,546 more w o m e n would probably have been saved if all the patients had been treated in Stages I and II, and the five-year survival rate for all cases would have been 46.1% instead of 30.9%. Cancer of the Breasts. T h e figures for breast cancer tell the same story2 Stage I five-year survival rate = 56-5% Stage I I I . . . . = 19.0°,~ " First Symptom to Doctor Interval " T h e next point to be discussed i s : W h y do patients present themselves for treatment when the growth is so far advanced ? Some consultants blame the general practitioners for this delay. T h i s is perhaps because they rem e m b e r one or two blatant cases of neglect or ignorance. In m y opinion, such an idea is quite unjustifiable, and if the same consultant would take the trouble to ask every patient w h e n she first noticed the symptoms and w h e n she first went to the doctor, they might alter their opinion. T h i s " F i r s t S y m p t o m to D o c t o r interval" has been recorded in several institutions in Jchis country, and the results in the individual institutions are very similar. T h e average " First S y m p t o m to D o c t o r i n t e r v a l " for carcinoma of the cervix is 5.1 months and for cancer of the breast six months. Why, then, do patients delay ? I know of no survey to prove that it is due to fear or ignorance, but every consultant who has given thought to the matter will agree on this point. T h e n u m b e r of times in the course of years that I have heard the remarks " It did not give m e any pain and so I thought that it could not be serious " ; or " I thought it was only the change " ; or " I didn't come before because I thought it might be cancer " has convinced m e that fear and ignorance are the two things that m u s t be fought and overcome. Alas, as no real attempt has been carried out in this country, it is necessary to turn to America, which I visited lately, for figures. T h e public health authorities in Boston have published figures which prove that the " First S y m p t o m to D o c t o r interval " in Massachusetts has fallen from 6.2 m o n t h s to 3.9 months between 1935 and 1948, due to cancer education. T h e mortality has also fallen, but m a n y other factors besides education may enter into that question, such as better treatment.
American Methods Cancer education in U.S.A. is carried out by the American Cancer Society, in close co-operation with the public health authorities and the hospitals. T h e Society has its headquarters in N e w York and collects over £4,000,000 a year, which is spent mostly on education of the public and fellowships to doctors, but also in supporting cancer clinics, etc. Each State has its own branch, and each branch organises a committee in every large town. T h e s e committees organise lectures with films, discussion groups, and distribute literature. Articles are written in magazines and the daily Press, and the " wireless " makes frequent references to cancer. It is not j u s t one effort, it is continuous all the year round. I do not approve of all their literature or films, but t h e y have succeeded in getting rid of all " t a b o o s " on the subject. Can This be Done in England ? Undoubtedly, and here is an outline of a scheme. M o s t counties, I understand, have a Health Education Medical Officer, but it would seem to me necessary that he should set up a voluntary Cancer Education Committee. His first step should be to approach the m a y o r of the town in order to call a meeting which should include representatives of T o w n s w o m e n ' s Guilds, W o m e n ' s Institutes, the Red Cross, W.V.S., I n n e r Wheel, the Churches, etc. T h e duties of the local committee would b e : (1) to organise public l e c t u r e s ; (2) to distribute literature.
PUBIJC HEALTH, October, 1951
Various Methods of Instrueti0n Pamphlets. A l t h o u g h it is p r o b a b l e t h a t a lecture, w i t h questions a n d a leaflet to take h o m e , is t h e best m e t h o d of instruction, only a v e r y few people can b e dealt w i t h b y this m e t h o d , a n d therefore t h e w r i t t e n w o r d m u s t b e relied u p o n to reach t h e mass of t h e people. T h e r e is n o difficulty in w r i t i n g s u c h p a m p h l e t s a n d t h e n u m b e r is only limited b y t h e cost. T h e s e p a m p h l e t s can, of course, b e sent b y post, b u t it is suggested t h a t a m o r e efficient a n d c h e a p e r way is to have t h e m d i s t r i b u t e d b y v o l u n t e e r s w h o w o u l d say, " D o read this ; it is really i m p o r t a n t f r o m t h e p o i n t of view of y o u r h e a l t h , " or some s u c h words. T h i s will be discussed later u n d e r V o l u n t a r y H e l p .
T h e A m e r i c a n s have d o n e a s u r v e y w h i c h shows t h a t p a m p h l e t s a n d m a g a z i n e articles are t h e m a i n source of t h e p u b l i c ' s k n o w l e d g e c o n c e r n i n g cancer. Leaflets. Leaflets given o u t at t h e t i m e of a lecture are of great value, b u t t h e r e is a risk in d i s t r i b u t i n g t h e m alone, because it is difficult to write facts a b o u t cancer in a few words w h i c h c a n n o t be m i s u n d e r s t o o d a n d create a p p r e hension. Lectures. T h e difficulty is t h a t t h e r e are n o t n e a r l y e n o u g h medical lecturers, a n d t h e r e is at p r e s e n t a v e r y s t r o n g p r e j u d i c e against lay lecturers. T h i s is, of course, quite illogical, since t h e R e d Cross t r a i n lay p e o p l e to diagnose injuries a n d to t r e a t t h e patient, w h i c h is far m o r e d a n g e r o u s t h a n to teach a lay person, w h o n e v e r comes in contact w i t h a patient, m e r e l y to r e p e a t a lecture. T h e o n l y way to get these lectures given is to ask general practitioners to give t h e m (after h a v i n g b e e n briefed) a n d to receive a n o m i n a l fee for d o i n g it. T h i s is also one of the best ways o f m a k i n g t h e G . P . " cancer c o n s c i o u s . " Recorded Lectures. L e c t u r e s can n o w b e r e c o r d e d o n g r a m o p h o n e records, one side of a disc lasting 25 m i n u t e s . T h e s e can be u s e d w i t h film strips. A s o u n d film is a m o r e efficient m e t h o d a n d could b e sent r o u n d in a van. T h i s would, in m y opinion, b e of t h e very greatest value, b u t t h e initial cost w o u l d be high. I suggest this s h o u l d be a cartoon w i t h a slight tinge of h u m o u r . W e m u s t get rid of the idea that it is necessary to p u t on black cr~pe w h e n speaking of cancer. Discussion Groups. T h e s e m i g h t b e organised b y the midwives, h e a l t h visitors, R e d Cross, W.V.S., I n n e r W h e e l , w o m e n ' s institutes. (See V o l u n t a r y H e l p later.) Exhibition. T h e initial cost w o u l d p r o b a b l y b e £ 1 0 0 for a p h o t o g r a p h e x h i b i t i o n NOT p o r t r a y i n g cases of c a n c e r b u t general subjects s u c h as pathology, laboratories, r a d i u m a n d x-ray d e p a r t m e n t s , o p e r a t i n g theatres, etc. These would b e in folding frames for t r a n s p o r t . Local Newspapers. T h e s e can b e of t h e greatest help a n d are extensively u s e d in America, b u t in m y experience E n g l i s h p a p e r s are n o t always v e r y co-operative. It is m o s t i m p o r t a n t t h a t surveys s h o u l d be carried out f r o m t i m e to t i m e in o r d e r to j u d g e progress. T h e science of surveys is very specialised, a n d o n e of the first steps in t h e s c h e m e w o u l d b e to call in t h e aid of the M e d i c a l Research Council or t h e C e n t r a l Office of I n f o r m a t i o n , b o t h of w h i c h b o d i e s I believe h a v e specialised in this field. H a v i n g ascertained w h a t data w o u l d be required, a n a p p r o a c h m u s t b e m a d e to the hospitals to o b t a i n these data. T h e o v e r - w o r k e d general p r a c t i t i o n e r s h o u l d b e m o l e s t e d as little as possible, b u t a distinctive c a r d to be sent w i t h t h e p a t i e n t s in all cases of suspected m a l i g n a n t disease w o u l d b e of great value in ascertaining t h e " alive-. n e s s " of t h e G.P. to c a n c e r diagnosis, a n d t h e n u m b e r of patients visiting h i m w i t h s y m p t o m s . It w o u l d also help t h e hospitals. O n e of t h e m o s t difficult surveys to carry out is to estim a t e the fall or increase i n t h e a m o u n t of cancer a p p r e h e n sion. People w h o have n o t g i v e n real t h o u g h t to the m a t t e r are i n c l i n e d to say, " I f we talk a b o u t cancer it will increase fear." A n y psychologist will tell you t h a t t h e exact
opposite is true. " T o b o t t l e u p " worries increases t h e m . I a m c o n v i n c e d t h a t cancer education, if carried o u t properly, will d i m i n i s h fear. E v e r y p r a c t i t i o n e r has a considerable k n o w l e d g e of the s y m p t o m s of cancer a n d s h o u l d ask himself, " Does t h a t k n o w l e d g e m a k e m e w o r r y a b o u t cancer a n d b e c o m e a n e u r a s t h e n i c ? " I f the a n s w e r is " N o , " t h e n w h y on e a r t h s h o u l d he t h i n k it will have this effect on o t h e r people ? Voluntary Help. Officials in all services have l e a r n t b y b i t t e r experience the " snags " in o b t a i n i n g v o l u n t a r y help. E n t h u s i a s m is inclined to w a n e a n d in t h e e n d t h e d e p a r t m e n t has to do t h e work. I n spite of all this, I do feel t h a t if t h e p o p u l a t i o n of a large area is to be covered, say, in two years, it can only be d o n e b y c o - o p t i n g v o l u n t a r y help. T h e disadvantage of carrying o u t such e d u c a t i o n in a small way over m a n y years is, first, the difficulty of estimating a n y value it m a y have, a n d secondly, a factor comes in c o m p a r a b l e to W e b e r ' s Law, i.e., if a p e r s o n reads one article p e r year t h e result at t h e e n d of t e n years will be less t h a n if she reads ten articles in t h e first y e a r . I a m c o n v i n c e d that, unless the e n t h u s i a s m of the people is aroused, cancer e d u c a t i o n will b e v e r y difficult.
Arguments Against Education W h a t , t h e n , are t h e a r g u m e n t s against s u c h e d u c a t i o n ? First, t h e r e is the t i m e - h o n o u r e d b u t quite e r r o n e o u s idea t h a t b y talking a b o u t cancer fear a n d a p p r e h e n s i o n will b e increased. Since 80,000 people die in t h e i r o w n h o m e s each year a n d are looked after b y t h e i r friends a n d relations aggregating p e r h a p s h a l f a million people, it is o b v i ously impossible to keep c a n c e r a " h u s h - h u s h " disease. H a d a n y b o d y over t h e age of 25 not h e a r d of cancer ? Since all these friends a n d relations, a d d i n g u p to millions in t h e course of years, see t h e i r relations die, i n m a n y cases w i t h t e r r i b l e complications s u c h as i n c o n t i n e n c e , bleeding, etc., a n d realise t h a t n o t h i n g can b e done for t h e m , is it n o t n a t u r a l t h a t t h e y s h o u l d c o n s i d e r cancer as b e i n g always i n c u r a b l e ? T o w h o m can t h e y t u r n to ask questions if t h e y are b r a v e e n o u g h to do so ? N o t to t h e medical p r o fession, w h o only too often c o n s i d e r s u c h questions d e n o t e nervous eancerphobia and must be treated by "laughing it o u t of the p a t i e n t . " S u c h t r e a t m e n t generally p r e v e n t s t h e p a t i e n t f r o m ever again talking a b o u t c a n c e r ; but t h e y do go o n t h i n k i n g . Crowding the Surgery. It has b e e n suggested t h a t the general p r a c t i t i o n e r will b e s w a m p e d w i t h patients. If e d u c a t i o n is p r o p e r l y c o n d u c t e d it m a y h a v e the opposite effect. M y o w n experience over m a n y years convinces m e that many patients "live on their doctors' doorstep," saying t h a t " t h e y d o n ' t feel very well " because they w a n t to b e told " Y o u have no sign of c a n c e r , " a n d t h e y are too n e r v o u s to u t t e r t h e word cancer. L a c k of Beds and Facilities. T h i s is n o t an a r g u m e n t , unless it is h o p e d t h a t b y n o t d i a g n o s i n g cancer in the early stage t h e p a t i e n t will in t i m e b e c o m e " u n t r e a t a b l e " a n d will n o t n e e d to be t a k e n into hospital. C a n c e r is a progressive disease, a n d in t h e early stage will occupy a b e d for t r e a t m e n t for half t h e t i m e t h a t will b e r e q u i r e d if t r e a t e d at a later stage. T h e real reason w h y cancer e d u c a t i o n is n o t i n s t i t u t e d is t h a t people are too b u s y w i t h m a t t e r s that offer a quicker r e t u r n for t h e e x p e n d i t u r e of e n e r g y a n d m o n e y . T h e results of cancer e d u c a t i o n will n o t be seen for at least two years after a s c h e m e has b e e n started, a n d alas, t h e r e will b e n o fear of a s u d d e n rush, s u c h as some people envisage. I appeal to every Medical Officer of H e a l t h to do s o m e t h i n g now. " K n o w l e d g e is the a n t i d o t e to Fear."--EMERSON.
AND
THE
PUBLIC
HEALTH
AUTHORITIES* By MALCOLM DONALDSON, F.R.C.S., F.R.C.O.G.,
Lately Director of the Cancer Unit, St. Bartholomew's Hospital. INTRODUCTI ON
In 1949 there were registercd in England and Wales over 80,000 deaths due to cancer, but it may be asked, why should this be the concern of the Medical Officers of Health w h o have nothing to do with the diagnosis or treatm e n t of the disease? Moreover, it is neither infectious nor contagious, and is not even notifiable. All this is u n d o u b t e d l y true, but at least one-third of this mortality is due to fear and ignorance on the part of the public, which prevents patients f r o m seeking advice while the disease is often still c u r a b l e ; m u c h of this mortality is therefore preventable by educating the public. T h e onus for educating the public in medical matters rests with the Local Authorities, as laid d o w n by the Public Health and National Health Service Acts. In this lecture I shall endeavour to prove (1) that the greatest factor contributing to the cure of a patient suffering f r o m cancer is early diagnosis; (2) that the present delay in diagnosis is due in nearly every case to the delay in the patient seeking advice f r o m her doctor. T h i s will be followed by suggestions for a scheme to carry out the education of the public in cancer.
Benefit ol Early Diagnosis It is not difficult to prove that the possibility of curing a patient suffering from cancer depends m o r e on the stage to which the disease has advanced at the time of treatment than any other factor. As examples may be quoted, cancer of the cervix and cancer of the breasts. Cancer of the Cervix Uteri. In a recent international report (1948) on 30,299 cases of cancer in this site treated during or before 1941 (in 24 different institutions in eight different countries), 3,856 ( = 12.7%) were in Stage I, that is to say, the disease w a s confined to the cervix. O f these 3,856 patients, 2,299 have survived five years or m o r e and m a y be spoken of as " c u r e d . " T h i s equals 59.6%. I n m a n y of the institutions the figures were even m o r e favourable, in one case a m o u n t i n g to 77-1%. In Stage I I there were 10,033 ( = 33.1%), and of these 4,129 ( = 41.2%) patients have survived m o r e than five years. I n Stage I I I , 11,542 patients were treated, of w h o m 2,644 ( = 22-9%) have survived more than five years. I n Stage IV, 4,864 patients were treated and only 303 ( : 6 . 2 % ) have survived five years or more. # An address to the Midland Branch, Society of Medical Officers of Health.
If Stages I and II are added, the five years' survival rate is 45.8%. Calculated on these figures, 7,546 more w o m e n would probably have been saved if all the patients had been treated in Stages I and II, and the five-year survival rate for all cases would have been 46.1% instead of 30.9%. Cancer of the Breasts. T h e figures for breast cancer tell the same story2 Stage I five-year survival rate = 56-5% Stage I I I . . . . = 19.0°,~ " First Symptom to Doctor Interval " T h e next point to be discussed i s : W h y do patients present themselves for treatment when the growth is so far advanced ? Some consultants blame the general practitioners for this delay. T h i s is perhaps because they rem e m b e r one or two blatant cases of neglect or ignorance. In m y opinion, such an idea is quite unjustifiable, and if the same consultant would take the trouble to ask every patient w h e n she first noticed the symptoms and w h e n she first went to the doctor, they might alter their opinion. T h i s " F i r s t S y m p t o m to D o c t o r interval" has been recorded in several institutions in Jchis country, and the results in the individual institutions are very similar. T h e average " First S y m p t o m to D o c t o r i n t e r v a l " for carcinoma of the cervix is 5.1 months and for cancer of the breast six months. Why, then, do patients delay ? I know of no survey to prove that it is due to fear or ignorance, but every consultant who has given thought to the matter will agree on this point. T h e n u m b e r of times in the course of years that I have heard the remarks " It did not give m e any pain and so I thought that it could not be serious " ; or " I thought it was only the change " ; or " I didn't come before because I thought it might be cancer " has convinced m e that fear and ignorance are the two things that m u s t be fought and overcome. Alas, as no real attempt has been carried out in this country, it is necessary to turn to America, which I visited lately, for figures. T h e public health authorities in Boston have published figures which prove that the " First S y m p t o m to D o c t o r interval " in Massachusetts has fallen from 6.2 m o n t h s to 3.9 months between 1935 and 1948, due to cancer education. T h e mortality has also fallen, but m a n y other factors besides education may enter into that question, such as better treatment.
American Methods Cancer education in U.S.A. is carried out by the American Cancer Society, in close co-operation with the public health authorities and the hospitals. T h e Society has its headquarters in N e w York and collects over £4,000,000 a year, which is spent mostly on education of the public and fellowships to doctors, but also in supporting cancer clinics, etc. Each State has its own branch, and each branch organises a committee in every large town. T h e s e committees organise lectures with films, discussion groups, and distribute literature. Articles are written in magazines and the daily Press, and the " wireless " makes frequent references to cancer. It is not j u s t one effort, it is continuous all the year round. I do not approve of all their literature or films, but t h e y have succeeded in getting rid of all " t a b o o s " on the subject. Can This be Done in England ? Undoubtedly, and here is an outline of a scheme. M o s t counties, I understand, have a Health Education Medical Officer, but it would seem to me necessary that he should set up a voluntary Cancer Education Committee. His first step should be to approach the m a y o r of the town in order to call a meeting which should include representatives of T o w n s w o m e n ' s Guilds, W o m e n ' s Institutes, the Red Cross, W.V.S., I n n e r Wheel, the Churches, etc. T h e duties of the local committee would b e : (1) to organise public l e c t u r e s ; (2) to distribute literature.
PUBIJC HEALTH, October, 1951
Various Methods of Instrueti0n Pamphlets. A l t h o u g h it is p r o b a b l e t h a t a lecture, w i t h questions a n d a leaflet to take h o m e , is t h e best m e t h o d of instruction, only a v e r y few people can b e dealt w i t h b y this m e t h o d , a n d therefore t h e w r i t t e n w o r d m u s t b e relied u p o n to reach t h e mass of t h e people. T h e r e is n o difficulty in w r i t i n g s u c h p a m p h l e t s a n d t h e n u m b e r is only limited b y t h e cost. T h e s e p a m p h l e t s can, of course, b e sent b y post, b u t it is suggested t h a t a m o r e efficient a n d c h e a p e r way is to have t h e m d i s t r i b u t e d b y v o l u n t e e r s w h o w o u l d say, " D o read this ; it is really i m p o r t a n t f r o m t h e p o i n t of view of y o u r h e a l t h , " or some s u c h words. T h i s will be discussed later u n d e r V o l u n t a r y H e l p .
T h e A m e r i c a n s have d o n e a s u r v e y w h i c h shows t h a t p a m p h l e t s a n d m a g a z i n e articles are t h e m a i n source of t h e p u b l i c ' s k n o w l e d g e c o n c e r n i n g cancer. Leaflets. Leaflets given o u t at t h e t i m e of a lecture are of great value, b u t t h e r e is a risk in d i s t r i b u t i n g t h e m alone, because it is difficult to write facts a b o u t cancer in a few words w h i c h c a n n o t be m i s u n d e r s t o o d a n d create a p p r e hension. Lectures. T h e difficulty is t h a t t h e r e are n o t n e a r l y e n o u g h medical lecturers, a n d t h e r e is at p r e s e n t a v e r y s t r o n g p r e j u d i c e against lay lecturers. T h i s is, of course, quite illogical, since t h e R e d Cross t r a i n lay p e o p l e to diagnose injuries a n d to t r e a t t h e patient, w h i c h is far m o r e d a n g e r o u s t h a n to teach a lay person, w h o n e v e r comes in contact w i t h a patient, m e r e l y to r e p e a t a lecture. T h e o n l y way to get these lectures given is to ask general practitioners to give t h e m (after h a v i n g b e e n briefed) a n d to receive a n o m i n a l fee for d o i n g it. T h i s is also one of the best ways o f m a k i n g t h e G . P . " cancer c o n s c i o u s . " Recorded Lectures. L e c t u r e s can n o w b e r e c o r d e d o n g r a m o p h o n e records, one side of a disc lasting 25 m i n u t e s . T h e s e can be u s e d w i t h film strips. A s o u n d film is a m o r e efficient m e t h o d a n d could b e sent r o u n d in a van. T h i s would, in m y opinion, b e of t h e very greatest value, b u t t h e initial cost w o u l d be high. I suggest this s h o u l d be a cartoon w i t h a slight tinge of h u m o u r . W e m u s t get rid of the idea that it is necessary to p u t on black cr~pe w h e n speaking of cancer. Discussion Groups. T h e s e m i g h t b e organised b y the midwives, h e a l t h visitors, R e d Cross, W.V.S., I n n e r W h e e l , w o m e n ' s institutes. (See V o l u n t a r y H e l p later.) Exhibition. T h e initial cost w o u l d p r o b a b l y b e £ 1 0 0 for a p h o t o g r a p h e x h i b i t i o n NOT p o r t r a y i n g cases of c a n c e r b u t general subjects s u c h as pathology, laboratories, r a d i u m a n d x-ray d e p a r t m e n t s , o p e r a t i n g theatres, etc. These would b e in folding frames for t r a n s p o r t . Local Newspapers. T h e s e can b e of t h e greatest help a n d are extensively u s e d in America, b u t in m y experience E n g l i s h p a p e r s are n o t always v e r y co-operative. It is m o s t i m p o r t a n t t h a t surveys s h o u l d be carried out f r o m t i m e to t i m e in o r d e r to j u d g e progress. T h e science of surveys is very specialised, a n d o n e of the first steps in t h e s c h e m e w o u l d b e to call in t h e aid of the M e d i c a l Research Council or t h e C e n t r a l Office of I n f o r m a t i o n , b o t h of w h i c h b o d i e s I believe h a v e specialised in this field. H a v i n g ascertained w h a t data w o u l d be required, a n a p p r o a c h m u s t b e m a d e to the hospitals to o b t a i n these data. T h e o v e r - w o r k e d general p r a c t i t i o n e r s h o u l d b e m o l e s t e d as little as possible, b u t a distinctive c a r d to be sent w i t h t h e p a t i e n t s in all cases of suspected m a l i g n a n t disease w o u l d b e of great value in ascertaining t h e " alive-. n e s s " of t h e G.P. to c a n c e r diagnosis, a n d t h e n u m b e r of patients visiting h i m w i t h s y m p t o m s . It w o u l d also help t h e hospitals. O n e of t h e m o s t difficult surveys to carry out is to estim a t e the fall or increase i n t h e a m o u n t of cancer a p p r e h e n sion. People w h o have n o t g i v e n real t h o u g h t to the m a t t e r are i n c l i n e d to say, " I f we talk a b o u t cancer it will increase fear." A n y psychologist will tell you t h a t t h e exact
opposite is true. " T o b o t t l e u p " worries increases t h e m . I a m c o n v i n c e d t h a t cancer education, if carried o u t properly, will d i m i n i s h fear. E v e r y p r a c t i t i o n e r has a considerable k n o w l e d g e of the s y m p t o m s of cancer a n d s h o u l d ask himself, " Does t h a t k n o w l e d g e m a k e m e w o r r y a b o u t cancer a n d b e c o m e a n e u r a s t h e n i c ? " I f the a n s w e r is " N o , " t h e n w h y on e a r t h s h o u l d he t h i n k it will have this effect on o t h e r people ? Voluntary Help. Officials in all services have l e a r n t b y b i t t e r experience the " snags " in o b t a i n i n g v o l u n t a r y help. E n t h u s i a s m is inclined to w a n e a n d in t h e e n d t h e d e p a r t m e n t has to do t h e work. I n spite of all this, I do feel t h a t if t h e p o p u l a t i o n of a large area is to be covered, say, in two years, it can only be d o n e b y c o - o p t i n g v o l u n t a r y help. T h e disadvantage of carrying o u t such e d u c a t i o n in a small way over m a n y years is, first, the difficulty of estimating a n y value it m a y have, a n d secondly, a factor comes in c o m p a r a b l e to W e b e r ' s Law, i.e., if a p e r s o n reads one article p e r year t h e result at t h e e n d of t e n years will be less t h a n if she reads ten articles in t h e first y e a r . I a m c o n v i n c e d that, unless the e n t h u s i a s m of the people is aroused, cancer e d u c a t i o n will b e v e r y difficult.
Arguments Against Education W h a t , t h e n , are t h e a r g u m e n t s against s u c h e d u c a t i o n ? First, t h e r e is the t i m e - h o n o u r e d b u t quite e r r o n e o u s idea t h a t b y talking a b o u t cancer fear a n d a p p r e h e n s i o n will b e increased. Since 80,000 people die in t h e i r o w n h o m e s each year a n d are looked after b y t h e i r friends a n d relations aggregating p e r h a p s h a l f a million people, it is o b v i ously impossible to keep c a n c e r a " h u s h - h u s h " disease. H a d a n y b o d y over t h e age of 25 not h e a r d of cancer ? Since all these friends a n d relations, a d d i n g u p to millions in t h e course of years, see t h e i r relations die, i n m a n y cases w i t h t e r r i b l e complications s u c h as i n c o n t i n e n c e , bleeding, etc., a n d realise t h a t n o t h i n g can b e done for t h e m , is it n o t n a t u r a l t h a t t h e y s h o u l d c o n s i d e r cancer as b e i n g always i n c u r a b l e ? T o w h o m can t h e y t u r n to ask questions if t h e y are b r a v e e n o u g h to do so ? N o t to t h e medical p r o fession, w h o only too often c o n s i d e r s u c h questions d e n o t e nervous eancerphobia and must be treated by "laughing it o u t of the p a t i e n t . " S u c h t r e a t m e n t generally p r e v e n t s t h e p a t i e n t f r o m ever again talking a b o u t c a n c e r ; but t h e y do go o n t h i n k i n g . Crowding the Surgery. It has b e e n suggested t h a t the general p r a c t i t i o n e r will b e s w a m p e d w i t h patients. If e d u c a t i o n is p r o p e r l y c o n d u c t e d it m a y h a v e the opposite effect. M y o w n experience over m a n y years convinces m e that many patients "live on their doctors' doorstep," saying t h a t " t h e y d o n ' t feel very well " because they w a n t to b e told " Y o u have no sign of c a n c e r , " a n d t h e y are too n e r v o u s to u t t e r t h e word cancer. L a c k of Beds and Facilities. T h i s is n o t an a r g u m e n t , unless it is h o p e d t h a t b y n o t d i a g n o s i n g cancer in the early stage t h e p a t i e n t will in t i m e b e c o m e " u n t r e a t a b l e " a n d will n o t n e e d to be t a k e n into hospital. C a n c e r is a progressive disease, a n d in t h e early stage will occupy a b e d for t r e a t m e n t for half t h e t i m e t h a t will b e r e q u i r e d if t r e a t e d at a later stage. T h e real reason w h y cancer e d u c a t i o n is n o t i n s t i t u t e d is t h a t people are too b u s y w i t h m a t t e r s that offer a quicker r e t u r n for t h e e x p e n d i t u r e of e n e r g y a n d m o n e y . T h e results of cancer e d u c a t i o n will n o t be seen for at least two years after a s c h e m e has b e e n started, a n d alas, t h e r e will b e n o fear of a s u d d e n rush, s u c h as some people envisage. I appeal to every Medical Officer of H e a l t h to do s o m e t h i n g now. " K n o w l e d g e is the a n t i d o t e to Fear."--EMERSON.