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The cancer specialist or oncologist
Copyright, 1943 by The Amencan Journal of Surgery, Inc.
A
PRACTICAL
NEW SERIES VOL. LIX
JOURNAL
BUILT
MARCH,
1943
ON
MERIT NUMBER THREE
THE CANCER SPECIALIST OR ONCOLOGIST URING the past three or four decades the complexion of deathdealing diseases has passed through important changes. As everyone knows the improvement in genera1 pubhc hygiene and the controI of communicabIe disease have greatIy reduced the death rate under twenty-five years. In other words, a Iesser number of peopIe are dying in the first haIf of Iife. To this may be added the advances in diagnostic methods and medical and surgical therapeutics. SocioIogists teI1 us that in the United States the control of emigration and birth contro1 are other factors tending to make this country a country of old people. Whereas at the turn of the century the average duration of Iife in the United States was thirty-five, it is now close to sixty years. AI1 of this means that the probIem of controhing diseases has entered a new phase. Most of the deaths that occur today are from diseases developing after middle Iife. Foremost among these are cardiovascuIar diseases and second is These facts force the medica cancer. profession to devote more attention to the diagnosis and treatment of these deathdeaIing scourges. We hear much nowadays-and rightIy so-about the control of infantile paralysis. This is needed, for every year this dreaded disease Ieaves thousands of children crippIed for life. It is astonishing, however, that
D
cancer causes more deaths in chiIdhood than does infantiIe paraIysis.* Another we11 recognized fact about medica progress is that medicine and surgery are rapidIy becoming much more compIicated arts and sciences than in the previous generation. Our increasing knowIedge of the human body, its structures, functions and iIIs, requires a much more comphcated system of diagnostic aids and gadgets and therapeutic weapons. AI1 of this progress necessitates a much Ionger preparation for the practice of medicine and surgery, with emphasis upon speciaIization after a broad genera1 foundation. Along with this increase in the complications of medicine, the diagnosis and treatment of cancer has likewise advanced. In bygone days, interna cancer was aIways fata1. The treatment of externa1 cancer was a crude surgica1 or cautery procedure which perchance ended fairIy happily if the disease was taken earIy. CountIess numbers died of internal cancer without proper In recent years, surgery has diagnosis. made tremendous advances. Tumors &inthe brain, lungs, abdomen are now more frequently diagnosed and treated satisfactoriIy in the earIy stages. Operations for these serious conditions “have been made reIa-
459
* Read, CIifton R. Annual Report of the American Society for the Control of Cancer, zz: 9, December, ‘940.
460
Amencan
Journal
of Surgery
EditoriaI
tiveIy safe for the patient and the patient is being made safe for the operation.” The cautery, aIways a prominent part of the surgeon’s armamentarium from time immemoria1, is in many pIaces being repIaced by the refined apparatuses and technic of eIectrosurgery. The advent of radium and x-ray therapy are great boons to the cancer sufferer, not onIy in increasing the percentage of five-year saIvages, but aIso in reIieving the advanced cases. He who attempts to treat cancer today must have cognizance of a11 these therapeutic agents. One of my seniors once said, “Cancer is first to be treated by surgery and if this faiIs, then by x-ray or radium.” This man Iived to change this philosophy radicaIIy. Today each patient with cancer must be studied as an individua1 probIem and the therapeutic agent or agents chosen which are best suited for him. To be abIe to make a carefuI seIection of one or a combination of more than one of these therapeutic agents requires Iong and comphcated training. GraduaIIy a group of “speciaIists ” have grown up who are cognizant of the intricate probIems of cancer diagnosis and the eIaborate methods of treatment. The genera1 trend of speciahzation must be carefuIIy baIanced by fundamenta1, comprehensive training. Too narrow Iimitations Iead to many pitfalIs through short-sightedness. On the other hand, it is impossible for any one man to master a11 fields. A happy medium must be worked out with time and experience. This is especiaIIy true in the reaIm of cancer therapy; no one man can be proficient in the diagnosis and treatment of a11 neopIasms widely distributed throughout the body. A prominent surgeon put it bIuntIy by saying, “No one can remove every kind of a tumor from the brain to the toenaiIs!” OnIy the fooIish wouId attempt such an inclusive “speciaIty.” However, I can conceive of a type of speciaIist who is suffIcientIy we11 versed in the fundamenta1 principIes of neopIastic growth, its diagnosis and treatment, to be heIpfu1 in any cIinic or Iarge institution in soIving many of the therapeutic probIems.
He need not be a combination of brain surgeon, thoracic surgeon, gastrointestinal surgeon, uroIogist, gynecologist and radiologist. If, on the other hand, his training has been suffIcientIy broad by way of genera1 medicine, genera1 surgery, pathoIogy and radiotherapeutics, he can be of value as a consuItant in these fieIds and limit his own therapeutic efforts to a we11 defined and estabIished speciaIty. For example: A we11 trained genera1 surgeon who has studied pathoIogy thoroughIy and has had a year or two in radiotherapeutics, can continue as a genera1 surgeon with special emphasis upon the treatment of neopIasms, deveIop skilIed technic in his own fieId and be of inestimabIe vaIue in co-operating with his confreres in other domains. In recent years medica and surgica1 investigators have deIved into physioIogica1 probIems with far reaching discoveries. Cancer research has foIIowed suit, increasing our knowIedge of the behavior of ceI1 growth and its reIation to the cancer problem. The inffuence of hormones on cancer growth in the Iaboratory anima1 and patient has been studied with benefit. Just where this will Iead is specuIative. However, it means that the cancer therapist must keep abreast of these deveIopments and be abIe to co-ordinate the resuIts of Iaboratory investigation with cIinica1 findings and make cIinica1 appIications of new discoveries when pertinent. AIthough the “OncoIogist” may not be temperamentaIIy abIe to or by training capabIe of carrying on highIy technical laboratory, bioIogica1 and physioIogica1 experiments, yet by keeping himseIf familiar with the advances in scientific research he can assist in correIating the work of the investigator and the clinician. In this manner a great service wiI1 be rendered the group or institution with whom he works. It is obvious then that in the Iarger institutions at Ieast the whole cancer probIem cannot be settled by one man aIone, but the cancer speciaIist wiI1 be on hand to cooperate with a group of workers, incIuding
NEW SERIES
Vcx.LIX.No.3
Editorial
the Iaboratory investigator, the pathoIogist, surgica1 specialists, readioIogists, and at times the internist. In smaIIer communities, the cancer speciaIist perhaps has a greater pIace to fiI1. He may be the only one in a smaI1 city serving a Iarge surrounding territory, who has had besides his general medical foundation, training in pathoIogy, surgery and radiation therapeutics. It is aIso important that in these communities, there be a we11 trained physician who can bring together a11 efforts, professional and civic, in estabIishing a program of cancer contro1, incIuding education of the profession and Iay and furnishing diagnostic public aIike, facilities and therapeutic opportunities. After this genera1 discussion, it seems appropriate to make a few suggestions for the education of such persons. I wiI1 outline the training for a genera1 surgica1 oncoIogist, bearing in mind that in Iarger cancer hospitaIs and other institutions, one or more individuaIs in each department may become especiaIIy quaIified to manage the patients with cancer in the gynecoIogica1, urologica or other departments. In several hospitals in this country departmenta cancer cIinics have aheady been established and directed by a well trained physician. Suggestions for General Surgical Oncologist. (The term “oncoIogist” is herein used for Iack of a better one. It aIso obviates the somewhat distastefu1 titIe of “cancer speciaIist.“) First year, genera1 internship, incIuding medicine and surgica1 speciaIties. Second year, pathology. PathoIogicaI training couId be Iimited to six months, with the other six months devoted to a clinica speciaIty, thus increasing the general internship to eighteen months. Third, fourth and fifth years-surgica1 assistant residency and resiinternship, dency, respectiveIy. Three years in surgery prepares the trainee for the American Board of Surgery, if he wishes to certify in that Board.
American
Journal
of Surgery
461
Sixth and seventh year-radiation therapeutics. This, of course, shouId incIude radium and x-ray therapy. With two years in radiation therapeutics and a foundation in pathoIogy, the trainee would be eIigibIe to appIy for certification in the American Board of RadioIogy in radiation therapeutics. Inasmuch as there is no Board of OncoIogy, an attempt has been made in the above outhne for the trainee to emphasize either surgery or radiation therapeutics, so that he may certify in one of the estabIished Boards. He cannot certify in more than one Board and therefore must choose his preference. It remains to be seen, as time goes on, and experience accumuIates, whether an American Board of Oncology is reaIIy advisable. A criticism of the above scheme might be raised as to the Iength of the training period. However, if one is to understand the cancer probIem thoroughly and prepare himseIf to treat cancer patients in some one of the accepted speciaIties, six or seven years are certainIy not too many. In recapituIation then, one might say that the cancer speciaIist, or oncologist, is a practitioner of medicine, who has first of a11 a we11 founded knowIedge of medicine. FoIlowing this he shouId have sufficient training in pathoIogy, surgery and radiation therapeutics to understand the fundamenta1 probIems in cancer diagnosis and therapy. He cannot be expected to master a11 procedures for the treatment of a11 neopIasms wherever they may occur in the body. However, after a wide general cancer training he can specialize in some fIeId to his liking and at the same time be of valuabIe consuItatory aid to his confreres. In Iarge genera1 institutions, he can head up the group which operates the cancer clinic. In speciaIized cancer hospitaIs, he naturaIIy wouId faI1 into a narrower fieId of one of the aIready accepted speciaIties. In smaIIer communities, as in a genera1 hospita1, he can be the Ieader in the cancer program. GRANT
E. WARD,M.D.
A
PRACTICAL
NEW SERIES VOL. LIX
JOURNAL
BUILT
MARCH,
1943
ON
MERIT NUMBER THREE
THE CANCER SPECIALIST OR ONCOLOGIST URING the past three or four decades the complexion of deathdealing diseases has passed through important changes. As everyone knows the improvement in genera1 pubhc hygiene and the controI of communicabIe disease have greatIy reduced the death rate under twenty-five years. In other words, a Iesser number of peopIe are dying in the first haIf of Iife. To this may be added the advances in diagnostic methods and medical and surgical therapeutics. SocioIogists teI1 us that in the United States the control of emigration and birth contro1 are other factors tending to make this country a country of old people. Whereas at the turn of the century the average duration of Iife in the United States was thirty-five, it is now close to sixty years. AI1 of this means that the probIem of controhing diseases has entered a new phase. Most of the deaths that occur today are from diseases developing after middle Iife. Foremost among these are cardiovascuIar diseases and second is These facts force the medica cancer. profession to devote more attention to the diagnosis and treatment of these deathdeaIing scourges. We hear much nowadays-and rightIy so-about the control of infantile paralysis. This is needed, for every year this dreaded disease Ieaves thousands of children crippIed for life. It is astonishing, however, that
D
cancer causes more deaths in chiIdhood than does infantiIe paraIysis.* Another we11 recognized fact about medica progress is that medicine and surgery are rapidIy becoming much more compIicated arts and sciences than in the previous generation. Our increasing knowIedge of the human body, its structures, functions and iIIs, requires a much more comphcated system of diagnostic aids and gadgets and therapeutic weapons. AI1 of this progress necessitates a much Ionger preparation for the practice of medicine and surgery, with emphasis upon speciaIization after a broad genera1 foundation. Along with this increase in the complications of medicine, the diagnosis and treatment of cancer has likewise advanced. In bygone days, interna cancer was aIways fata1. The treatment of externa1 cancer was a crude surgica1 or cautery procedure which perchance ended fairIy happily if the disease was taken earIy. CountIess numbers died of internal cancer without proper In recent years, surgery has diagnosis. made tremendous advances. Tumors &inthe brain, lungs, abdomen are now more frequently diagnosed and treated satisfactoriIy in the earIy stages. Operations for these serious conditions “have been made reIa-
459
* Read, CIifton R. Annual Report of the American Society for the Control of Cancer, zz: 9, December, ‘940.
460
Amencan
Journal
of Surgery
EditoriaI
tiveIy safe for the patient and the patient is being made safe for the operation.” The cautery, aIways a prominent part of the surgeon’s armamentarium from time immemoria1, is in many pIaces being repIaced by the refined apparatuses and technic of eIectrosurgery. The advent of radium and x-ray therapy are great boons to the cancer sufferer, not onIy in increasing the percentage of five-year saIvages, but aIso in reIieving the advanced cases. He who attempts to treat cancer today must have cognizance of a11 these therapeutic agents. One of my seniors once said, “Cancer is first to be treated by surgery and if this faiIs, then by x-ray or radium.” This man Iived to change this philosophy radicaIIy. Today each patient with cancer must be studied as an individua1 probIem and the therapeutic agent or agents chosen which are best suited for him. To be abIe to make a carefuI seIection of one or a combination of more than one of these therapeutic agents requires Iong and comphcated training. GraduaIIy a group of “speciaIists ” have grown up who are cognizant of the intricate probIems of cancer diagnosis and the eIaborate methods of treatment. The genera1 trend of speciahzation must be carefuIIy baIanced by fundamenta1, comprehensive training. Too narrow Iimitations Iead to many pitfalIs through short-sightedness. On the other hand, it is impossible for any one man to master a11 fields. A happy medium must be worked out with time and experience. This is especiaIIy true in the reaIm of cancer therapy; no one man can be proficient in the diagnosis and treatment of a11 neopIasms widely distributed throughout the body. A prominent surgeon put it bIuntIy by saying, “No one can remove every kind of a tumor from the brain to the toenaiIs!” OnIy the fooIish wouId attempt such an inclusive “speciaIty.” However, I can conceive of a type of speciaIist who is suffIcientIy we11 versed in the fundamenta1 principIes of neopIastic growth, its diagnosis and treatment, to be heIpfu1 in any cIinic or Iarge institution in soIving many of the therapeutic probIems.
He need not be a combination of brain surgeon, thoracic surgeon, gastrointestinal surgeon, uroIogist, gynecologist and radiologist. If, on the other hand, his training has been suffIcientIy broad by way of genera1 medicine, genera1 surgery, pathoIogy and radiotherapeutics, he can be of value as a consuItant in these fieIds and limit his own therapeutic efforts to a we11 defined and estabIished speciaIty. For example: A we11 trained genera1 surgeon who has studied pathoIogy thoroughIy and has had a year or two in radiotherapeutics, can continue as a genera1 surgeon with special emphasis upon the treatment of neopIasms, deveIop skilIed technic in his own fieId and be of inestimabIe vaIue in co-operating with his confreres in other domains. In recent years medica and surgica1 investigators have deIved into physioIogica1 probIems with far reaching discoveries. Cancer research has foIIowed suit, increasing our knowIedge of the behavior of ceI1 growth and its reIation to the cancer problem. The inffuence of hormones on cancer growth in the Iaboratory anima1 and patient has been studied with benefit. Just where this will Iead is specuIative. However, it means that the cancer therapist must keep abreast of these deveIopments and be abIe to co-ordinate the resuIts of Iaboratory investigation with cIinica1 findings and make cIinica1 appIications of new discoveries when pertinent. AIthough the “OncoIogist” may not be temperamentaIIy abIe to or by training capabIe of carrying on highIy technical laboratory, bioIogica1 and physioIogica1 experiments, yet by keeping himseIf familiar with the advances in scientific research he can assist in correIating the work of the investigator and the clinician. In this manner a great service wiI1 be rendered the group or institution with whom he works. It is obvious then that in the Iarger institutions at Ieast the whole cancer probIem cannot be settled by one man aIone, but the cancer speciaIist wiI1 be on hand to cooperate with a group of workers, incIuding
NEW SERIES
Vcx.LIX.No.3
Editorial
the Iaboratory investigator, the pathoIogist, surgica1 specialists, readioIogists, and at times the internist. In smaIIer communities, the cancer speciaIist perhaps has a greater pIace to fiI1. He may be the only one in a smaI1 city serving a Iarge surrounding territory, who has had besides his general medical foundation, training in pathoIogy, surgery and radiation therapeutics. It is aIso important that in these communities, there be a we11 trained physician who can bring together a11 efforts, professional and civic, in estabIishing a program of cancer contro1, incIuding education of the profession and Iay and furnishing diagnostic public aIike, facilities and therapeutic opportunities. After this genera1 discussion, it seems appropriate to make a few suggestions for the education of such persons. I wiI1 outline the training for a genera1 surgica1 oncoIogist, bearing in mind that in Iarger cancer hospitaIs and other institutions, one or more individuaIs in each department may become especiaIIy quaIified to manage the patients with cancer in the gynecoIogica1, urologica or other departments. In several hospitals in this country departmenta cancer cIinics have aheady been established and directed by a well trained physician. Suggestions for General Surgical Oncologist. (The term “oncoIogist” is herein used for Iack of a better one. It aIso obviates the somewhat distastefu1 titIe of “cancer speciaIist.“) First year, genera1 internship, incIuding medicine and surgica1 speciaIties. Second year, pathology. PathoIogicaI training couId be Iimited to six months, with the other six months devoted to a clinica speciaIty, thus increasing the general internship to eighteen months. Third, fourth and fifth years-surgica1 assistant residency and resiinternship, dency, respectiveIy. Three years in surgery prepares the trainee for the American Board of Surgery, if he wishes to certify in that Board.
American
Journal
of Surgery
461
Sixth and seventh year-radiation therapeutics. This, of course, shouId incIude radium and x-ray therapy. With two years in radiation therapeutics and a foundation in pathoIogy, the trainee would be eIigibIe to appIy for certification in the American Board of RadioIogy in radiation therapeutics. Inasmuch as there is no Board of OncoIogy, an attempt has been made in the above outhne for the trainee to emphasize either surgery or radiation therapeutics, so that he may certify in one of the estabIished Boards. He cannot certify in more than one Board and therefore must choose his preference. It remains to be seen, as time goes on, and experience accumuIates, whether an American Board of Oncology is reaIIy advisable. A criticism of the above scheme might be raised as to the Iength of the training period. However, if one is to understand the cancer probIem thoroughly and prepare himseIf to treat cancer patients in some one of the accepted speciaIties, six or seven years are certainIy not too many. In recapituIation then, one might say that the cancer speciaIist, or oncologist, is a practitioner of medicine, who has first of a11 a we11 founded knowIedge of medicine. FoIlowing this he shouId have sufficient training in pathoIogy, surgery and radiation therapeutics to understand the fundamenta1 probIems in cancer diagnosis and therapy. He cannot be expected to master a11 procedures for the treatment of a11 neopIasms wherever they may occur in the body. However, after a wide general cancer training he can specialize in some fIeId to his liking and at the same time be of valuabIe consuItatory aid to his confreres. In Iarge genera1 institutions, he can head up the group which operates the cancer clinic. In speciaIized cancer hospitaIs, he naturaIIy wouId faI1 into a narrower fieId of one of the aIready accepted speciaIties. In smaIIer communities, as in a genera1 hospita1, he can be the Ieader in the cancer program. GRANT
E. WARD,M.D.