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Health Education—Cancer
II,~.
PUBLIC HEALTH, April,, 1954 HEALTH
"FABLE I
EDUCATION---CANCER*
THREE-YEAR SURVIVAL FIGURES
By R. N. CURNOW, M.B., B.S., D . P . P I . -
County Medical Q~cer of Health, Cornwall
Length of history No. of cases Less than six months... 26 Six months to two years 22 Over two years ... 24
No. alive 2 8 13
Percentage 7.7 36.4 54.2
P r o p a g a n d a in f a v o u r of the early t r e a t m e n t of cancer d e p e n d s u p o n the t h e o r y t h a t p a t i e n t s w h o a t t e n d early for t r e a t m e n t are in s u c h a n early stage of t h e disease t h a t t r e a t m e n t offers a v e r y good p r o s p e c t of cure. " Life S a v i n g , " says a p ~ n p h l e t 1 q u o t e d w i t h a p p r o v a l b y M a l c o l m D o n a l d s o n - - " S t u d y these facts in c a n c e r of t h e breast. E i g h t y o u t of 100 c a n b e c u r e d w h e n the p a t i e n t s are treated whilst t h e disease is in an early stage ; w h e n i n the late stage, only 12 out of 100. I t is p e r h a p s a little d e p r e s s i n g to see t h a t t h e r e is a m o r t a l i t y rate of 2 0 % in spite of o u r p r o m i s e to those w h o come early for t r e a t m e n t . The differences in t h e t w o m o r t a l i t y rates are n o d o u b t sufficient justification for our p r o p a g a n d a . I t is obvious t h a t p a t i e n t s w h o come for t r e a t m e n t in Stage IV of t h e disease m u s t at some t i m e have b e e n in Stage I, so t h a t t h e t h e o r y u n d e r l y i n g this p r o p a g a n d a d e p e n d s u p o n a simple syllogism : - - ' ThQse w h o come early for t r e a t m e n t are in an early stage of t h e disease. T h o s e in a n early stage of t h e disease can b e cured. T h e r e f o r e t h o s e w h o come early for t r e a t m e n t can b e cured. I f this is t r u e , it s h o u l d b e possible to s h o w t h a t t h e l e n g t h of h i s t o r y of s y m p t o m s before seeking t r e a t m e n t varies directly w i t h t h e m o r t a l i t y r a t e - - t h e longer the history, t h e greater t h e n u m b e r of deaths w i t h i n , say, a five-year period. I n o t h e r words, it s h o u l d b e possible t o cut out all reference to t h e stage of t h e disease a n d relate t h e l e n g t h of history to t h e m o r t a l i t y rate. A considerable a m o u n t of i n f o r m a t i o n o n this is available in H a r n e t t ' s " S u r v e y of C a n c e r i n L o n d o n "z w h i c h reviews t h e h i s t o r y of some 15,000 cases of cancer of various sites. O n page 495 you will find a section dealing w i t h cancer of t h e breast, s h o w i n g t h e five-year results of radical m a s t e c tomy, classified according to t h e d u r a t i o n of s y m p t o m s . I t shows t h a t t h o s e t r e a t e d b y radical m a s t e c t o m y , a n d h a v i n g less t h a n six m o n t h s ' s y m p t o m s before t r e a t m e n t , h a d a survival rate of 5 0 % , whereas those w i t h over six m o n t h s ' h i s t o r y h a d a survival rate of 3'6%. T h e difference in percentage is said to b e statistically significant, b u t I m u s t say t h a t it is n o t very striking evidence of t h e value of early t r e a t m e n t . I n t h e case of those w i t h radical m a s t e c t o m y a n d radiotherapy, t h e c o r r e s p o n d i n g p e r c e n t a g e survival figures are 4 1 % a n d 45"6%. T h e difference in p e r c e n t a g e is said to b e n o t statistically significant, b u t t h e figures are, nevertheless, s u r p r i s i n g i n t h a t t h e r e is clearly n o a d v a n t a g e s h o w n to those w h o came u n d e r t r e a t m e n t in t h e s h o r t e r period. I n t h e case of o t h e r f o r m s of accessible cancer, t h e position is e v e n m o r e d i s a p p o i n t i n g . I n c a n c e r of t h e lip (page 166), t h e m o u t h (page 189), the t o n g u e (page 214), t h e cervix uteri (page 543), a n d t h e skin (page 626), t h e r e is n o statistical significance b e t w e e n t h e survival rate of those w h o came for t r e a t m e n t w i t h less t h a n six m o n t h s ' history of s y m p t o m s a n d t h o s e w i t h a longer history. O t h e r r e c e n t p u b l i c a t i o n s show t h e same lack of favourable r e l a t i o n s h i p b e t w e e n s h o r t n e s s of history a n d survival rate. Swynnerton and Truelove 8 published the surprising Table I i n c o n n e c t i o n w i t h t h e t h r e e - y e a r survival rate of patients w i t h c a r c i n o m a of t h e stomach. D o u g l a s H a r m e r 4 p u b l i s h e d T a b l e I I s h o w i n g the relationship b e t w e e n t h e l e n g t h of h i s t o r y a n d t h e 3-year survival rate of cancer of t h e larynx. S o m e t h i n g seems to have gone w r o n g w i t h o u r simple syllogism a n d it is neqessary to examine it again. T h e r e is n o d o u b t t h a t those c o m i n g for t r e a t m e n t in an early stage of t h e disease have a b e t t e r prognosis t h a n those c o m i n g in t h e later stages, a n d to t h a t e x t e n t t h e second premise is valid. I t is, I t h i n k , going a little too far to say t h a t those c o m i n g for t r e a t m e n t in t h e early stage c a n i n d e e d
1 to 3 months ...... 3 to 6 . . . . . . . . 6 to 12 . . . . . . . . Over 12 . . . . . . . .
* Presidential Address to the County Medical Officers of Health Group Society of M.O.H. (and Association of County Medical Officers in England and Wales).
T h i s s e e m s to b e a r out the low m a l i g n a n c y of t h e Stage I p a t i e n t s w i t h over 12 m o n t h s ' h i s t o r y of s y m p t o m s , a n d t h e
TABLE II LENGTH OF ]~{ISTORY
Months 3
No. of cases 2 Three-year survivals 0
Years 10 15
3
6
9
1
2
3
4
5
7
19
15
11
I1
16
6
4
1
2
1
I
11
6
5
5
7
2
2
0
0
0
1
be cured, b u t t h e i r outlook is u n d o u b t e d l y b e t t e r t h a n those c o m i n g in t h e later stages. T h e fallacy seems to lie p r i n c i p a l l y i n the first p r e m i s e - - t h a t t h o s e w h o come early for t r e a t m e n t are in a n early stage of t h e disease. Russ 6 has p r o d u c e d a n i n t e r e s t i n g analysis of 695 cases of c a n c e r of t h e cervix uteri, f r o m w h i c h h e derives T a b l e I I I . TABLE I I I
Duration of symptoms Stage I Stage I I Stage III Stage IV before treatment Alive Dead Alive Dead Alive Dead Alive Dead 1 to 3 months 3 to 6 ,, 6 to 12 ,, Over 12 ,, Not known Totals
32 14 12 8 6
42 12 10 5 8
46 15 14 8 5
82 46 31 23 17
19 5 5 1 -
69 41 26 25 9
2 1 1 -
25 14 5 10 1
72
77
88
199
30
170
4
55
Five-year survivals 48"3~
30"5%
15~
7%
T h i s table shows i m m e d i a t e l y w h e r e we have gone w r o n g . T h e wise p a t i e n t s w h o came for t r e a t m e n t w i t h i n t h r e e m o n t h s of t h e o n s e t of s y m p t o m s were b y n o m e a n s all in Stage I of t h e disease ; in fact, only a m i n o r i t y of t h e m were i n Stage I - - f a r greater n u m b e r s h a v i n g already progressed to Stages I I a n d I I I . L o o k i n g at it in a n o t h e r way, it is o b v i o u s t h a t t h e p a t i e n t s i n Stage I of t h e disease were n o t only those w i t h a v e r y s h o r t history, b u t i n c l u d e d a n u m b e r of foolish p a t i e n t s w h o h a d delayed over 12 m o n t h s before seeking t r e a t m e n t , b u t w h o were still f o r t u n a t e e n o u g h to b e in Stage I in spite of t h e delay. T h o s e 13 p a t i e n t s w i t h a h i s t o r y of over 12 m o n t h s , b u t still in Stage I of t h e disease, m u s t surely have h a d a c a n c e r of very low m a l i g n a n c y ; t h e 27 wise p a t i e n t s w h o h a d s o u g h t t r e a t m e n t w i t h i n t h r e e m o n t h s b u t n e v e r t h e l e s s were already i n Stage I V of t h e disease, m u s t have h a d cancers of u n u s u a l l y h i g h m a l i g n a n c y . By c o n v e r t i n g t h e five-year survival rate at each stage at each l e n g t h of history into percentage rates, T a b l e I V is obtained. TABLe IV PERCENTAGE ALIVE AFTER FIVE YEARS Stages Duration of symptoms before treatment
I
II
II1
43 54 55 62
36 25 31 26
22
IV 7
11
0
16 4
17 9
PUBI, IC HEALTH, April, ~954 h i g h m a l i g n a n c y of the Stage IV patients w i t h a history of less t h a n t h r e e m o n t h s . T w o i m p o r t a n t points i m m e d i a t e l y e m e r g e f r o m a consideration of R u s s ' s table : - (1) I t is w r o n g to regard the t e r m s " Stage I o f the disease " and " S h o r t history of s y m p t o m s " as b e i n g s y n o n y m o u s , j u s t as it is w r o n g to regard the t e r m s " Stage I V of the disease " and " Delay in seeking t r e a t m e n t " as being s y n o n y m o u s . (2) T h e essential malignancy of the cancer seems to exercise an o v e r w h e l m i n g effect on t h e p r o g n o s i s - - s o overw h e l m i n g , in fact, that it cannot be reversed b y any m o d e r n treatment. T h e effect is so striking that the prognosis in those w h o have delayed m o r e t h a n 12 m o n t h s in seeking t r e a t m e n t and are still in Stage I is b e t t e r t h a n in t h o s e in Stage I w h o h a v e ~sought t r e a t m e n t w i t h i n three m o n t h s of the onset of symptoms. T h e r e is no evidence here w h i c h will justify our p r o m i s i n g cure to those w h o seek t r e a t m e n t early, and d e a t h to t h o s e w h o delay. I n Russ's figures, in S w y n n e r t o n and T i u e l o v e ' s figures, in H a r n e t t ' s figures, and in Douglas H a r m e r ' s figures, the only explanation lies in the o v e r w h e l m i n g effect of the essential malignancy of the t u m o u r , u n a l t e r e d by the results of treatment. T h i s u n f o r t u n a t e l y begins to t h r o w d o u b t on the value o f t r e a t m e n t as a m e a n s o f p r o l o n g i n g life in cases o f cancer. Williams, M u r l e y a n d C u r w e n s p u b l i s h e d a very revealing analysis of the results of conservative and redical s u r g e r y in carcinoma of the female breast. H a l f the cases subjected to simple surgery w e r e treated b y simple excision of the t u m o u r . It is a little d i s t u r b i n g to see thot the results o f simple s u r g e r y are as good as t h o s e of radical surgery. T h e y say, " all the m a i n t r e a t m e n t m e t h o d s analysed seem to have b e e n equally effective in Stages I and II. It m u s t , however, be frankly recognised that all m e t h o d s of t r e a t m e n t m a y have b e e n equally ineffective in p r o l o n g i n g life." H e d l e y Atkins: is q u o t e d as w a r n i n g the Association of S u r g e o n s that the claims of rival schools o f t h e r a p y in the t r e a t m e n t of carcinoma of the breast were unlikely to differ very m u c h . H e p o i n t e d out that a large p r o p o r t i o n o f patients w i t h this disease w o u l d be d e a d w i t h i n t h r e e years, w h a t e v e r was done. A n o t h e r large g r o u p w o u l d survive five years or m o r e in the absence of all t r e a t m e n t . It was only in a small fraction that, in t e r m s o f survival, it m a t t e r e d w h a t k i n d of t r e a t m e n t was given. I f our syllogism breaks d o w n in the first p r e m i s e ; if even in the cases of accessible cancers t h e r e is no d e m o n s t r a b l e relationship b e t w e e n t h e length of history a n d the survival rate ; if H e d l e y Atkins is right in d e n y i n g the life-saving quality o f m o d e r n t r e a t m e n t in all b u t a small fraction o f cases ; if Williams, M u r l e y and C u r w e n are right in suggesting that all m e t h o d s of t r e a t m e n t m a y be equally ineffective in p r o l o n g i n g life, w h a t is the basis for our p r o m i s e to cancer sufferers that if t h e y come early for t r e a t m e n t , t h e y will be cured ? Are our transatlantic colleagues, w i t h their passion for brevity and clarity, right in saying, " T o no small e x t e n t the d o c t r i n e of s y n o n y m y of ' early ' t r e a t m e n t and curability should be recognised for the s h i b b o l e t h w h i c h it is ,,?8 REFERENCES
1 DONALDSON, M. (1953.) Med. Offr. 9o, 201. 2 Surveyof Cancer in London, 1952. W. L. tlarnett. Brit. Emp. Cancer Campaign. aBrit. M e d . ~ . (1952.) x, 287. 4 _ _ (1953.) 2, 735. s _ _ (1953.) I, 581. - (1953.) % 792. ~--. (1953.) 2, 817. a MAcDoNALD, IAN. (1942.) Surg. Gyn. Obstet. 74, 75-82. Dr. G. Clark Trotter and Mr. A. R. Horsham (R.I.P.H. & H.), Dr. G. F. McCleary and Miss I. V. Evelyn (Nat. Assoc. for Maternal and Child Welfare), Dr. J. Harley Williams (N.A.P.T.), Mr. Victor Howard (Erhpire Rheumatism Council), Mr. Arnold Marsh (N.S.A.S.), Dr. G. A. Noble (Cremation Society) and Miss Amy Sayle (Women Public Health Officers Associatlo~).
t 13 THE
LATE
SIR
GEORGE
ELLISTON
A distinguished senior Fellow of the Society, who wishes to remain anonymous, has sent us the following interesting recollections of his old friend : - " The death of George Elliston eight years beyond the allotted span closes the last chapter in the history of the Society of Medical Officers of Health, About 40 years ago the Society was run by a barrister, Lawton by name, who had a salary, house and other emoluments in Upper Montague Street. I-Ie had six or seven cronies, medical officers of health, compo ring a General Purposes Committee ; he himself used to cook a delectable meal for them after Council Meetings. All the important business of the Council was referred to this Committee witb power to act. Away back about 1912 I was an assistant M.O.II ; my chief went off to Egypt holding the hand of a parson brother, in whose parish a lady had the urge to pack him off, expenses paid, for a rest cure. The Public Health Committee decided to send me as deputy to the York Congress of the R.S.I., and there I met Elliston. I was watching a display of gymnastics by girls of a chocolate company when a tall, distinguished, soldierly man with a monocle standing next to me said : ' That's well worth coming all the way to York to see.' We were friends for 40 years and more. " Some of us, Joseph of Warrington, Kerr of Newcastle, Lyster of Hampshire, Buchan of Willesden and Wheatley of Shropshire, made up our minds that Lawton must go, together with his fancy cooking, but who was to succeed him ? I t h o u g h t Elliston was the man ; he ran the Medical Qfficer most efficiently, a paper which was kindly to the assistant M.O.H. and other bottom dogs. So he was delicately approached and seemed cautiously interested, particularly with the idea that the Medical ()./ricer should become the weekly journal of the M.O.tI. Society. " Then, after careful preparation, we moved. Lawton, breathing threats of legal action, was evicted and the General Purposes Committee was clipped in the wing. The Society of Medical Officers of Health was reconstituted on a reasonable foundation to the surprise and misgiving of some of the old m e m b e r s - - H o p e of Liverpool, Niven of Manchester, the brothers Hill (Bostock of Warwick, Eustace of Durham), ttowarth of London and the Willoughbys. A salary campaign began and achieved a large measure of success. Woe is me that the Society handed the reins to the B.M.A., but that is long ago and far away. " George Elliston, who was above all else a keen business man, made a great success of his stewardship, well liked by all. When be advanced into politics and City affairs his son ably gathered up the mantle and, fortunately for the Society, still wears it in a true Ellistonian manner.* " Sir George Elliston was a superb strategist, a good fighter and a firm friend. Having decided where he was going, he most thoroughly explored the ground, prepared means of escape, carefully briefed his troops and at the appropriatesecond advanced ; he was rarely beaten. May his ashes lie for ever undisturbed." ----SENEX.
A memorial service to Sir George was held at St. l)unstan-inthe-West, Fleet Street, on Friday, March 19th, 1954, Prebendary A. J. Macdonald, D.D., officiating. Amongst those present were : Lady Elliston, Mr. and Mrs. G. I.. (7. Elliston and other members of the family and relatives. Mr. W. G. Boston (representing the Rt. Hon. the l.ord Mayor of London) and other representatives of the City Corporation and officers including Dr. Charles F. White, M.O.H. Sir Cosmo Parkinson, Sir Archibald Gray, Prof. A. Bradford Hill, Dr. G. M. Frizelle, Miss Kathleen Shaw and Mr. I.. W. Blandford (London School of Hygiene and Tropical Medicine). The President of the Society (l)r. Metcalfe Brown) was represented by Mr. S. R. Bragg and other members present were Drs. A. Anderson (Home Counties Branch), F. A. Belam, George F. Buchan, Sir John Charles (Chief Medical Off• I-{. M. Cohen and Kenneth Cowan, Sir Allen l)aley, Dr. F. M. Day (Metropolitan Branch), J. Duncan Dewar (Borough Medical Officers Committee), Margaret Emslie, T. P. Evans, James Fenton, A. V. Kelynack (also B.M.A.), Vv'. R. Martine (Midland Branch), M. Mitman (Fever IIospital Group), George North (Registrar-General and Honorary Fellow, S.M.O.H.), J. A. Scott, W. G. Senior, r.D.s., A. J. Shinnie, A. B. Stewart, T. Standring and Ann Mower White (Maternity and Child Welfare Group) and Miss B. A. Seotchford (formerly on the Staff of the Society), Dr. G. S. "Wilson (M.R.C.) and l)r. ]Z_ Ashwortb Underwood (Wellcome Historical Medical Musemn). (Co,zcluded at f o o t o f left-ha~ld c,,lumu) Actually, the mantle has been assumed by Dr. Frederick ttall as from April 1st, 1954.--Editor.
PUBLIC HEALTH, April,, 1954 HEALTH
"FABLE I
EDUCATION---CANCER*
THREE-YEAR SURVIVAL FIGURES
By R. N. CURNOW, M.B., B.S., D . P . P I . -
County Medical Q~cer of Health, Cornwall
Length of history No. of cases Less than six months... 26 Six months to two years 22 Over two years ... 24
No. alive 2 8 13
Percentage 7.7 36.4 54.2
P r o p a g a n d a in f a v o u r of the early t r e a t m e n t of cancer d e p e n d s u p o n the t h e o r y t h a t p a t i e n t s w h o a t t e n d early for t r e a t m e n t are in s u c h a n early stage of t h e disease t h a t t r e a t m e n t offers a v e r y good p r o s p e c t of cure. " Life S a v i n g , " says a p ~ n p h l e t 1 q u o t e d w i t h a p p r o v a l b y M a l c o l m D o n a l d s o n - - " S t u d y these facts in c a n c e r of t h e breast. E i g h t y o u t of 100 c a n b e c u r e d w h e n the p a t i e n t s are treated whilst t h e disease is in an early stage ; w h e n i n the late stage, only 12 out of 100. I t is p e r h a p s a little d e p r e s s i n g to see t h a t t h e r e is a m o r t a l i t y rate of 2 0 % in spite of o u r p r o m i s e to those w h o come early for t r e a t m e n t . The differences in t h e t w o m o r t a l i t y rates are n o d o u b t sufficient justification for our p r o p a g a n d a . I t is obvious t h a t p a t i e n t s w h o come for t r e a t m e n t in Stage IV of t h e disease m u s t at some t i m e have b e e n in Stage I, so t h a t t h e t h e o r y u n d e r l y i n g this p r o p a g a n d a d e p e n d s u p o n a simple syllogism : - - ' ThQse w h o come early for t r e a t m e n t are in an early stage of t h e disease. T h o s e in a n early stage of t h e disease can b e cured. T h e r e f o r e t h o s e w h o come early for t r e a t m e n t can b e cured. I f this is t r u e , it s h o u l d b e possible to s h o w t h a t t h e l e n g t h of h i s t o r y of s y m p t o m s before seeking t r e a t m e n t varies directly w i t h t h e m o r t a l i t y r a t e - - t h e longer the history, t h e greater t h e n u m b e r of deaths w i t h i n , say, a five-year period. I n o t h e r words, it s h o u l d b e possible t o cut out all reference to t h e stage of t h e disease a n d relate t h e l e n g t h of history to t h e m o r t a l i t y rate. A considerable a m o u n t of i n f o r m a t i o n o n this is available in H a r n e t t ' s " S u r v e y of C a n c e r i n L o n d o n "z w h i c h reviews t h e h i s t o r y of some 15,000 cases of cancer of various sites. O n page 495 you will find a section dealing w i t h cancer of t h e breast, s h o w i n g t h e five-year results of radical m a s t e c tomy, classified according to t h e d u r a t i o n of s y m p t o m s . I t shows t h a t t h o s e t r e a t e d b y radical m a s t e c t o m y , a n d h a v i n g less t h a n six m o n t h s ' s y m p t o m s before t r e a t m e n t , h a d a survival rate of 5 0 % , whereas those w i t h over six m o n t h s ' h i s t o r y h a d a survival rate of 3'6%. T h e difference in percentage is said to b e statistically significant, b u t I m u s t say t h a t it is n o t very striking evidence of t h e value of early t r e a t m e n t . I n t h e case of those w i t h radical m a s t e c t o m y a n d radiotherapy, t h e c o r r e s p o n d i n g p e r c e n t a g e survival figures are 4 1 % a n d 45"6%. T h e difference in p e r c e n t a g e is said to b e n o t statistically significant, b u t t h e figures are, nevertheless, s u r p r i s i n g i n t h a t t h e r e is clearly n o a d v a n t a g e s h o w n to those w h o came u n d e r t r e a t m e n t in t h e s h o r t e r period. I n t h e case of o t h e r f o r m s of accessible cancer, t h e position is e v e n m o r e d i s a p p o i n t i n g . I n c a n c e r of t h e lip (page 166), t h e m o u t h (page 189), the t o n g u e (page 214), t h e cervix uteri (page 543), a n d t h e skin (page 626), t h e r e is n o statistical significance b e t w e e n t h e survival rate of those w h o came for t r e a t m e n t w i t h less t h a n six m o n t h s ' history of s y m p t o m s a n d t h o s e w i t h a longer history. O t h e r r e c e n t p u b l i c a t i o n s show t h e same lack of favourable r e l a t i o n s h i p b e t w e e n s h o r t n e s s of history a n d survival rate. Swynnerton and Truelove 8 published the surprising Table I i n c o n n e c t i o n w i t h t h e t h r e e - y e a r survival rate of patients w i t h c a r c i n o m a of t h e stomach. D o u g l a s H a r m e r 4 p u b l i s h e d T a b l e I I s h o w i n g the relationship b e t w e e n t h e l e n g t h of h i s t o r y a n d t h e 3-year survival rate of cancer of t h e larynx. S o m e t h i n g seems to have gone w r o n g w i t h o u r simple syllogism a n d it is neqessary to examine it again. T h e r e is n o d o u b t t h a t those c o m i n g for t r e a t m e n t in an early stage of t h e disease have a b e t t e r prognosis t h a n those c o m i n g in t h e later stages, a n d to t h a t e x t e n t t h e second premise is valid. I t is, I t h i n k , going a little too far to say t h a t those c o m i n g for t r e a t m e n t in t h e early stage c a n i n d e e d
1 to 3 months ...... 3 to 6 . . . . . . . . 6 to 12 . . . . . . . . Over 12 . . . . . . . .
* Presidential Address to the County Medical Officers of Health Group Society of M.O.H. (and Association of County Medical Officers in England and Wales).
T h i s s e e m s to b e a r out the low m a l i g n a n c y of t h e Stage I p a t i e n t s w i t h over 12 m o n t h s ' h i s t o r y of s y m p t o m s , a n d t h e
TABLE II LENGTH OF ]~{ISTORY
Months 3
No. of cases 2 Three-year survivals 0
Years 10 15
3
6
9
1
2
3
4
5
7
19
15
11
I1
16
6
4
1
2
1
I
11
6
5
5
7
2
2
0
0
0
1
be cured, b u t t h e i r outlook is u n d o u b t e d l y b e t t e r t h a n those c o m i n g in t h e later stages. T h e fallacy seems to lie p r i n c i p a l l y i n the first p r e m i s e - - t h a t t h o s e w h o come early for t r e a t m e n t are in a n early stage of t h e disease. Russ 6 has p r o d u c e d a n i n t e r e s t i n g analysis of 695 cases of c a n c e r of t h e cervix uteri, f r o m w h i c h h e derives T a b l e I I I . TABLE I I I
Duration of symptoms Stage I Stage I I Stage III Stage IV before treatment Alive Dead Alive Dead Alive Dead Alive Dead 1 to 3 months 3 to 6 ,, 6 to 12 ,, Over 12 ,, Not known Totals
32 14 12 8 6
42 12 10 5 8
46 15 14 8 5
82 46 31 23 17
19 5 5 1 -
69 41 26 25 9
2 1 1 -
25 14 5 10 1
72
77
88
199
30
170
4
55
Five-year survivals 48"3~
30"5%
15~
7%
T h i s table shows i m m e d i a t e l y w h e r e we have gone w r o n g . T h e wise p a t i e n t s w h o came for t r e a t m e n t w i t h i n t h r e e m o n t h s of t h e o n s e t of s y m p t o m s were b y n o m e a n s all in Stage I of t h e disease ; in fact, only a m i n o r i t y of t h e m were i n Stage I - - f a r greater n u m b e r s h a v i n g already progressed to Stages I I a n d I I I . L o o k i n g at it in a n o t h e r way, it is o b v i o u s t h a t t h e p a t i e n t s i n Stage I of t h e disease were n o t only those w i t h a v e r y s h o r t history, b u t i n c l u d e d a n u m b e r of foolish p a t i e n t s w h o h a d delayed over 12 m o n t h s before seeking t r e a t m e n t , b u t w h o were still f o r t u n a t e e n o u g h to b e in Stage I in spite of t h e delay. T h o s e 13 p a t i e n t s w i t h a h i s t o r y of over 12 m o n t h s , b u t still in Stage I of t h e disease, m u s t surely have h a d a c a n c e r of very low m a l i g n a n c y ; t h e 27 wise p a t i e n t s w h o h a d s o u g h t t r e a t m e n t w i t h i n t h r e e m o n t h s b u t n e v e r t h e l e s s were already i n Stage I V of t h e disease, m u s t have h a d cancers of u n u s u a l l y h i g h m a l i g n a n c y . By c o n v e r t i n g t h e five-year survival rate at each stage at each l e n g t h of history into percentage rates, T a b l e I V is obtained. TABLe IV PERCENTAGE ALIVE AFTER FIVE YEARS Stages Duration of symptoms before treatment
I
II
II1
43 54 55 62
36 25 31 26
22
IV 7
11
0
16 4
17 9
PUBI, IC HEALTH, April, ~954 h i g h m a l i g n a n c y of the Stage IV patients w i t h a history of less t h a n t h r e e m o n t h s . T w o i m p o r t a n t points i m m e d i a t e l y e m e r g e f r o m a consideration of R u s s ' s table : - (1) I t is w r o n g to regard the t e r m s " Stage I o f the disease " and " S h o r t history of s y m p t o m s " as b e i n g s y n o n y m o u s , j u s t as it is w r o n g to regard the t e r m s " Stage I V of the disease " and " Delay in seeking t r e a t m e n t " as being s y n o n y m o u s . (2) T h e essential malignancy of the cancer seems to exercise an o v e r w h e l m i n g effect on t h e p r o g n o s i s - - s o overw h e l m i n g , in fact, that it cannot be reversed b y any m o d e r n treatment. T h e effect is so striking that the prognosis in those w h o have delayed m o r e t h a n 12 m o n t h s in seeking t r e a t m e n t and are still in Stage I is b e t t e r t h a n in t h o s e in Stage I w h o h a v e ~sought t r e a t m e n t w i t h i n three m o n t h s of the onset of symptoms. T h e r e is no evidence here w h i c h will justify our p r o m i s i n g cure to those w h o seek t r e a t m e n t early, and d e a t h to t h o s e w h o delay. I n Russ's figures, in S w y n n e r t o n and T i u e l o v e ' s figures, in H a r n e t t ' s figures, and in Douglas H a r m e r ' s figures, the only explanation lies in the o v e r w h e l m i n g effect of the essential malignancy of the t u m o u r , u n a l t e r e d by the results of treatment. T h i s u n f o r t u n a t e l y begins to t h r o w d o u b t on the value o f t r e a t m e n t as a m e a n s o f p r o l o n g i n g life in cases o f cancer. Williams, M u r l e y a n d C u r w e n s p u b l i s h e d a very revealing analysis of the results of conservative and redical s u r g e r y in carcinoma of the female breast. H a l f the cases subjected to simple surgery w e r e treated b y simple excision of the t u m o u r . It is a little d i s t u r b i n g to see thot the results o f simple s u r g e r y are as good as t h o s e of radical surgery. T h e y say, " all the m a i n t r e a t m e n t m e t h o d s analysed seem to have b e e n equally effective in Stages I and II. It m u s t , however, be frankly recognised that all m e t h o d s of t r e a t m e n t m a y have b e e n equally ineffective in p r o l o n g i n g life." H e d l e y Atkins: is q u o t e d as w a r n i n g the Association of S u r g e o n s that the claims of rival schools o f t h e r a p y in the t r e a t m e n t of carcinoma of the breast were unlikely to differ very m u c h . H e p o i n t e d out that a large p r o p o r t i o n o f patients w i t h this disease w o u l d be d e a d w i t h i n t h r e e years, w h a t e v e r was done. A n o t h e r large g r o u p w o u l d survive five years or m o r e in the absence of all t r e a t m e n t . It was only in a small fraction that, in t e r m s o f survival, it m a t t e r e d w h a t k i n d of t r e a t m e n t was given. I f our syllogism breaks d o w n in the first p r e m i s e ; if even in the cases of accessible cancers t h e r e is no d e m o n s t r a b l e relationship b e t w e e n t h e length of history a n d the survival rate ; if H e d l e y Atkins is right in d e n y i n g the life-saving quality o f m o d e r n t r e a t m e n t in all b u t a small fraction o f cases ; if Williams, M u r l e y and C u r w e n are right in suggesting that all m e t h o d s of t r e a t m e n t m a y be equally ineffective in p r o l o n g i n g life, w h a t is the basis for our p r o m i s e to cancer sufferers that if t h e y come early for t r e a t m e n t , t h e y will be cured ? Are our transatlantic colleagues, w i t h their passion for brevity and clarity, right in saying, " T o no small e x t e n t the d o c t r i n e of s y n o n y m y of ' early ' t r e a t m e n t and curability should be recognised for the s h i b b o l e t h w h i c h it is ,,?8 REFERENCES
1 DONALDSON, M. (1953.) Med. Offr. 9o, 201. 2 Surveyof Cancer in London, 1952. W. L. tlarnett. Brit. Emp. Cancer Campaign. aBrit. M e d . ~ . (1952.) x, 287. 4 _ _ (1953.) 2, 735. s _ _ (1953.) I, 581. - (1953.) % 792. ~--. (1953.) 2, 817. a MAcDoNALD, IAN. (1942.) Surg. Gyn. Obstet. 74, 75-82. Dr. G. Clark Trotter and Mr. A. R. Horsham (R.I.P.H. & H.), Dr. G. F. McCleary and Miss I. V. Evelyn (Nat. Assoc. for Maternal and Child Welfare), Dr. J. Harley Williams (N.A.P.T.), Mr. Victor Howard (Erhpire Rheumatism Council), Mr. Arnold Marsh (N.S.A.S.), Dr. G. A. Noble (Cremation Society) and Miss Amy Sayle (Women Public Health Officers Associatlo~).
t 13 THE
LATE
SIR
GEORGE
ELLISTON
A distinguished senior Fellow of the Society, who wishes to remain anonymous, has sent us the following interesting recollections of his old friend : - " The death of George Elliston eight years beyond the allotted span closes the last chapter in the history of the Society of Medical Officers of Health, About 40 years ago the Society was run by a barrister, Lawton by name, who had a salary, house and other emoluments in Upper Montague Street. I-Ie had six or seven cronies, medical officers of health, compo ring a General Purposes Committee ; he himself used to cook a delectable meal for them after Council Meetings. All the important business of the Council was referred to this Committee witb power to act. Away back about 1912 I was an assistant M.O.II ; my chief went off to Egypt holding the hand of a parson brother, in whose parish a lady had the urge to pack him off, expenses paid, for a rest cure. The Public Health Committee decided to send me as deputy to the York Congress of the R.S.I., and there I met Elliston. I was watching a display of gymnastics by girls of a chocolate company when a tall, distinguished, soldierly man with a monocle standing next to me said : ' That's well worth coming all the way to York to see.' We were friends for 40 years and more. " Some of us, Joseph of Warrington, Kerr of Newcastle, Lyster of Hampshire, Buchan of Willesden and Wheatley of Shropshire, made up our minds that Lawton must go, together with his fancy cooking, but who was to succeed him ? I t h o u g h t Elliston was the man ; he ran the Medical Qfficer most efficiently, a paper which was kindly to the assistant M.O.H. and other bottom dogs. So he was delicately approached and seemed cautiously interested, particularly with the idea that the Medical ()./ricer should become the weekly journal of the M.O.tI. Society. " Then, after careful preparation, we moved. Lawton, breathing threats of legal action, was evicted and the General Purposes Committee was clipped in the wing. The Society of Medical Officers of Health was reconstituted on a reasonable foundation to the surprise and misgiving of some of the old m e m b e r s - - H o p e of Liverpool, Niven of Manchester, the brothers Hill (Bostock of Warwick, Eustace of Durham), ttowarth of London and the Willoughbys. A salary campaign began and achieved a large measure of success. Woe is me that the Society handed the reins to the B.M.A., but that is long ago and far away. " George Elliston, who was above all else a keen business man, made a great success of his stewardship, well liked by all. When be advanced into politics and City affairs his son ably gathered up the mantle and, fortunately for the Society, still wears it in a true Ellistonian manner.* " Sir George Elliston was a superb strategist, a good fighter and a firm friend. Having decided where he was going, he most thoroughly explored the ground, prepared means of escape, carefully briefed his troops and at the appropriatesecond advanced ; he was rarely beaten. May his ashes lie for ever undisturbed." ----SENEX.
A memorial service to Sir George was held at St. l)unstan-inthe-West, Fleet Street, on Friday, March 19th, 1954, Prebendary A. J. Macdonald, D.D., officiating. Amongst those present were : Lady Elliston, Mr. and Mrs. G. I.. (7. Elliston and other members of the family and relatives. Mr. W. G. Boston (representing the Rt. Hon. the l.ord Mayor of London) and other representatives of the City Corporation and officers including Dr. Charles F. White, M.O.H. Sir Cosmo Parkinson, Sir Archibald Gray, Prof. A. Bradford Hill, Dr. G. M. Frizelle, Miss Kathleen Shaw and Mr. I.. W. Blandford (London School of Hygiene and Tropical Medicine). The President of the Society (l)r. Metcalfe Brown) was represented by Mr. S. R. Bragg and other members present were Drs. A. Anderson (Home Counties Branch), F. A. Belam, George F. Buchan, Sir John Charles (Chief Medical Off• I-{. M. Cohen and Kenneth Cowan, Sir Allen l)aley, Dr. F. M. Day (Metropolitan Branch), J. Duncan Dewar (Borough Medical Officers Committee), Margaret Emslie, T. P. Evans, James Fenton, A. V. Kelynack (also B.M.A.), Vv'. R. Martine (Midland Branch), M. Mitman (Fever IIospital Group), George North (Registrar-General and Honorary Fellow, S.M.O.H.), J. A. Scott, W. G. Senior, r.D.s., A. J. Shinnie, A. B. Stewart, T. Standring and Ann Mower White (Maternity and Child Welfare Group) and Miss B. A. Seotchford (formerly on the Staff of the Society), Dr. G. S. "Wilson (M.R.C.) and l)r. ]Z_ Ashwortb Underwood (Wellcome Historical Medical Musemn). (Co,zcluded at f o o t o f left-ha~ld c,,lumu) Actually, the mantle has been assumed by Dr. Frederick ttall as from April 1st, 1954.--Editor.