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Tumor Registries of the American Urological Association1
I
TUMOR REGISTRIES OF THE AMERICAN UROLOGICAL ASSOCIATION 1 CoL. J. E. AsH From the Army Institute of Pathology, Washington, D. C.
The war is over and this presentation is an attempt to revive your interest in your three Registries. Those of you who were not on active duty have been too busy to register your cases, but the Registries have not been inaotive. Because of the enormous increase in work at the Institute during the war, h_owever, and out of deference to the busy times that you were all having, we suspended followups. We resumed them the beginning of this year. These have already reached some of you, no doubt, and we would appreciate their completion and return to us as soon as possible. There are now over 5,000 cases in the Bladder Tumor Registry and almost 800 in the Kidney Tumor Registry and over 150 prostatic carcinomas. Since we last met we have been authorized to change the name of the Army Medical Museum to the Army Institute of Pathology, which more truly connotes our expanded activities. The Army Directives, issued several years before the war, provided for centralization of Army pathology at the Institute. During mobilization; when the Army increased from 125,000 to 1,000,000, it became obvious that some decentralization would be necessary, so 18 histopathologic centers were established- usually in General Hospitals. In these centers we could concentrate what professional talent we had and provide an effective service for the smaller hospitals in the neighborhood. These centers forwarded pathologic material to the Institute after screening out the minor surgical cases. When war was declared, therefore, we had the mechanism all established for t he pathologic service in the Army and it was only necessary to expand the facilities and establish centers in our foreign theatres to provide effectively for the salvaging of almost literally all of the significant pathology arising in the Army. As a result, for several years we were receiving at the Institute an average of over 50 autopsies a day and as many significant surgical specimens. These were reviewed critically by a very conscientious and efficient staff of pathologists at the Institute, coded and put into the files. The U. S. Army is the only armed force in the world that had this centralization of its pathology and it has resulted in the largest single accumulation of material in the history of medicine. It is particularly valuable because it has given us the opportunity t o study not only the pathology incident to warfare but also pathology arising from the varied environments to which our soldiers were subjected, stretching from the Arctics to the Tropics. It has given us the first opportunity to study the pathology incidental to this supposedly healthy military-age group which we have arbitrarily placed between 18 and 38. As examples, we have almost 1,000 coronary deaths, a considerable percentage of them below 30 years of age; 1
Read at annual meeting, American Urological Association, Cincinnati, 0., July 25,
1946.
1202
TUMOR REGISTRIES OF AMERICAN UROLOGICAL ASSOCIATION
1203
an unexpectedly high incidence of carcinoma of the colon; hundreds of carcinomas of the lip; 800 carcinomas of the lung; a large group of brain tumors, and so forth. These are all the subjects of definitive studies, not only by the members of the staff of the Institute, but also by our civilian consultants who served with us during the war. The Registries, of course, have profited greatly by the acquisition of this large amount of material. It includes, for example, over 1,000 enucleated eyes, 200 temporal bones from aviators who were killed in flight, and also a large amount of genito-urinary pathology, the 1000 tumors of the testis that you are hearing about on this program; adenomatoid tumors of the genital tract; over 800 autopsies showing the lower nephron nephrosis; and the comprehensive collection of specific granulomas of the genitals, just to mention some of the conditions represented. During the war, the activities of the Institute were overshadowed by the more spectacular phases of war activities, but as these latter faded out, the importance of and responsibility connected with the possession of such an enormous amount of material led to the planning of a greatly expanded Institute of Pathology that would include all of the facilities for research. In this planning, we had the help and advice of the Advisory Committee on Pathology of the National Research Council, and the Secretary of your Registry Committee has been furnished a copy of the report and recommendations of this Committee. The plan has been approved and the new building recommended by the War Department which will form the nucleus of a Center for Army Medical Research and Training. Of interest and importance to you is the establishment in this new Institute as a major division the American Registry of Pathology. This will be in charge of a civilian scientific director, full time and on a permanent status, enabling him to concentrate on the development to their fullest, the possibilities in the fourteen Registries already organized, and on the establishment of Registries in other fields. A new Registry Committee has been appointed by the National Research Council which will act in an advisory capacity to the Director on administrative and scientific matters. The Academy of Science will act as fiscal agent for the receipt and administration of Registry funds. These funds are from two main sources: (1) the appropriations from the societies sponsoring the individual Registries and (2) gifts, grants, etc., from foundations and other sources. A copy of the minutes of the first meeting of this Committee has also been furnished the Secretary of your Registry Committee. This meeting was concerned with the qualifications and duties of the Scientific Director of the Registry, the acquisition of new Registries and the sources of funds. Several of the national foundations are being solicited for funds that will meet the much expanded budget of the Registry, but the Committee also expressed the opinion that all scientific societies sponsoring a Registry should contribute to the funds for the support of the American Registry of Pathology. We have experienced difficulty i:n convincing some of the members of the participating societies of the importance of their co-operation in this activity and the necessity for their making a proportionate contribution to its upkeep. The society supporting a Registry
1204
J. E. ASH
is the representative one of tha.t specialty, and although the results may be more or less intangible, it is the responsibility of the society to take a part in any activity that is working for the advancement of the professional standard in that specialty. The individual member profits from the Registry by having his cases thoroughly reviewed, not only by the staff of the Institute, but also by the civilian consultants, and he can share in the educational features made possible by the material in the Registries. This material, in the shape of loan sets of slides, illustrated atlases and syllabuses, lantern slides, illustrative material for his articles and teaching programs, is readly available because of the Registry. We had a strange query just recently from one of the sponsoring societies: What happens if our Society does not contribute to the Registry fund? Our answer is that the Registry will go on by the contributions of more appreciative societies and by sheer momentum. As a matter of fact, simply on the basis of popular demand we have prepared study material in several specialties that have Certifying Boards and are not supporting Registries with us. The important consideration is: Does the parent society of a specialty wish to take a part in this facility that is bound to have an important influence on the scientific progress of the specialty, even if it may not, for the moment, ring the cash register. Motivation of these ambitious plans is already underway. "\Ve are now building up a faculty of civilian pathologists that will insure continuity of professional activities not heretofore possible with Army officers. A Department of Statistics, headed by an expert statistician, is already functioning, as is the new coding system, using a mechanical card system. Incidentally, the Institute is now officially the center for pathology of the Veterans Administration as well as for the Army. This will insure a maintenance at a high level of the receipt of significant pathology when that from the Army begins to recede. These increased facilities are already bearing fruit in your own field. We now have all the bladder tumors carded and the statistician is well along in an analysis of the material. Some interesting results are already in prospect. With this new era, the possibilities of the Registries are, of course, greatly expanded. These can be indicated by the following list: 1. Assist the larger clinics in the preparation of their material for registration. 2. More active follow-up of Registry cases. 3. Enlarge the formal loan study material, that is, slide collections, atlases and syllabuses. 4. Foster definitive studies on the material in the Registries. 5. Enlarge opportunities for post-graduate study for a. General pathologists b. Clinicians preparing for certification in the specialties. 6. Establish fellowships in special and general pathology. This last item has an especial appeal. The American Dental Association has already established a fellowship at the Institute for Dental and Oral Pathology. There is scarcely a time when we do not have at least one candidate for the Ophthalmologic Board with us and we are hoping that either through special
TUMOR REGISTRIES OF AMERICAN UROLOGICAL ASSOCIATION
1205
grants or by the action of the sponsoring societies, fellowships in other specialties will be available. In this way, it would be possible for a fellow in urology to come to the Institute for several months of his fellowship and concentrate on the pathology of his specialty. We have changed our attitude a bit toward the special pathology. Our concern up to now has been to assist the candidate in p11ssing his Board examinations. Our desire from now on is to make it possible for that candidate to acquire a more thorough grounding in the pathology of his specialty so that it will be an integral part of his professional background and not just a fleeting expedient to pass an examination. The success of the new program will be, to a large degree, dependent upon the co-operation and interest of the participating societies, and it is earnestly hoped that this Society, one of the pioneers in the Registry activity, will renew its interest and become a leader in this revival. You will help not only urology, but also American medicine.
TUMOR REGISTRIES OF THE AMERICAN UROLOGICAL ASSOCIATION 1 CoL. J. E. AsH From the Army Institute of Pathology, Washington, D. C.
The war is over and this presentation is an attempt to revive your interest in your three Registries. Those of you who were not on active duty have been too busy to register your cases, but the Registries have not been inaotive. Because of the enormous increase in work at the Institute during the war, h_owever, and out of deference to the busy times that you were all having, we suspended followups. We resumed them the beginning of this year. These have already reached some of you, no doubt, and we would appreciate their completion and return to us as soon as possible. There are now over 5,000 cases in the Bladder Tumor Registry and almost 800 in the Kidney Tumor Registry and over 150 prostatic carcinomas. Since we last met we have been authorized to change the name of the Army Medical Museum to the Army Institute of Pathology, which more truly connotes our expanded activities. The Army Directives, issued several years before the war, provided for centralization of Army pathology at the Institute. During mobilization; when the Army increased from 125,000 to 1,000,000, it became obvious that some decentralization would be necessary, so 18 histopathologic centers were established- usually in General Hospitals. In these centers we could concentrate what professional talent we had and provide an effective service for the smaller hospitals in the neighborhood. These centers forwarded pathologic material to the Institute after screening out the minor surgical cases. When war was declared, therefore, we had the mechanism all established for t he pathologic service in the Army and it was only necessary to expand the facilities and establish centers in our foreign theatres to provide effectively for the salvaging of almost literally all of the significant pathology arising in the Army. As a result, for several years we were receiving at the Institute an average of over 50 autopsies a day and as many significant surgical specimens. These were reviewed critically by a very conscientious and efficient staff of pathologists at the Institute, coded and put into the files. The U. S. Army is the only armed force in the world that had this centralization of its pathology and it has resulted in the largest single accumulation of material in the history of medicine. It is particularly valuable because it has given us the opportunity t o study not only the pathology incident to warfare but also pathology arising from the varied environments to which our soldiers were subjected, stretching from the Arctics to the Tropics. It has given us the first opportunity to study the pathology incidental to this supposedly healthy military-age group which we have arbitrarily placed between 18 and 38. As examples, we have almost 1,000 coronary deaths, a considerable percentage of them below 30 years of age; 1
Read at annual meeting, American Urological Association, Cincinnati, 0., July 25,
1946.
1202
TUMOR REGISTRIES OF AMERICAN UROLOGICAL ASSOCIATION
1203
an unexpectedly high incidence of carcinoma of the colon; hundreds of carcinomas of the lip; 800 carcinomas of the lung; a large group of brain tumors, and so forth. These are all the subjects of definitive studies, not only by the members of the staff of the Institute, but also by our civilian consultants who served with us during the war. The Registries, of course, have profited greatly by the acquisition of this large amount of material. It includes, for example, over 1,000 enucleated eyes, 200 temporal bones from aviators who were killed in flight, and also a large amount of genito-urinary pathology, the 1000 tumors of the testis that you are hearing about on this program; adenomatoid tumors of the genital tract; over 800 autopsies showing the lower nephron nephrosis; and the comprehensive collection of specific granulomas of the genitals, just to mention some of the conditions represented. During the war, the activities of the Institute were overshadowed by the more spectacular phases of war activities, but as these latter faded out, the importance of and responsibility connected with the possession of such an enormous amount of material led to the planning of a greatly expanded Institute of Pathology that would include all of the facilities for research. In this planning, we had the help and advice of the Advisory Committee on Pathology of the National Research Council, and the Secretary of your Registry Committee has been furnished a copy of the report and recommendations of this Committee. The plan has been approved and the new building recommended by the War Department which will form the nucleus of a Center for Army Medical Research and Training. Of interest and importance to you is the establishment in this new Institute as a major division the American Registry of Pathology. This will be in charge of a civilian scientific director, full time and on a permanent status, enabling him to concentrate on the development to their fullest, the possibilities in the fourteen Registries already organized, and on the establishment of Registries in other fields. A new Registry Committee has been appointed by the National Research Council which will act in an advisory capacity to the Director on administrative and scientific matters. The Academy of Science will act as fiscal agent for the receipt and administration of Registry funds. These funds are from two main sources: (1) the appropriations from the societies sponsoring the individual Registries and (2) gifts, grants, etc., from foundations and other sources. A copy of the minutes of the first meeting of this Committee has also been furnished the Secretary of your Registry Committee. This meeting was concerned with the qualifications and duties of the Scientific Director of the Registry, the acquisition of new Registries and the sources of funds. Several of the national foundations are being solicited for funds that will meet the much expanded budget of the Registry, but the Committee also expressed the opinion that all scientific societies sponsoring a Registry should contribute to the funds for the support of the American Registry of Pathology. We have experienced difficulty i:n convincing some of the members of the participating societies of the importance of their co-operation in this activity and the necessity for their making a proportionate contribution to its upkeep. The society supporting a Registry
1204
J. E. ASH
is the representative one of tha.t specialty, and although the results may be more or less intangible, it is the responsibility of the society to take a part in any activity that is working for the advancement of the professional standard in that specialty. The individual member profits from the Registry by having his cases thoroughly reviewed, not only by the staff of the Institute, but also by the civilian consultants, and he can share in the educational features made possible by the material in the Registries. This material, in the shape of loan sets of slides, illustrated atlases and syllabuses, lantern slides, illustrative material for his articles and teaching programs, is readly available because of the Registry. We had a strange query just recently from one of the sponsoring societies: What happens if our Society does not contribute to the Registry fund? Our answer is that the Registry will go on by the contributions of more appreciative societies and by sheer momentum. As a matter of fact, simply on the basis of popular demand we have prepared study material in several specialties that have Certifying Boards and are not supporting Registries with us. The important consideration is: Does the parent society of a specialty wish to take a part in this facility that is bound to have an important influence on the scientific progress of the specialty, even if it may not, for the moment, ring the cash register. Motivation of these ambitious plans is already underway. "\Ve are now building up a faculty of civilian pathologists that will insure continuity of professional activities not heretofore possible with Army officers. A Department of Statistics, headed by an expert statistician, is already functioning, as is the new coding system, using a mechanical card system. Incidentally, the Institute is now officially the center for pathology of the Veterans Administration as well as for the Army. This will insure a maintenance at a high level of the receipt of significant pathology when that from the Army begins to recede. These increased facilities are already bearing fruit in your own field. We now have all the bladder tumors carded and the statistician is well along in an analysis of the material. Some interesting results are already in prospect. With this new era, the possibilities of the Registries are, of course, greatly expanded. These can be indicated by the following list: 1. Assist the larger clinics in the preparation of their material for registration. 2. More active follow-up of Registry cases. 3. Enlarge the formal loan study material, that is, slide collections, atlases and syllabuses. 4. Foster definitive studies on the material in the Registries. 5. Enlarge opportunities for post-graduate study for a. General pathologists b. Clinicians preparing for certification in the specialties. 6. Establish fellowships in special and general pathology. This last item has an especial appeal. The American Dental Association has already established a fellowship at the Institute for Dental and Oral Pathology. There is scarcely a time when we do not have at least one candidate for the Ophthalmologic Board with us and we are hoping that either through special
TUMOR REGISTRIES OF AMERICAN UROLOGICAL ASSOCIATION
1205
grants or by the action of the sponsoring societies, fellowships in other specialties will be available. In this way, it would be possible for a fellow in urology to come to the Institute for several months of his fellowship and concentrate on the pathology of his specialty. We have changed our attitude a bit toward the special pathology. Our concern up to now has been to assist the candidate in p11ssing his Board examinations. Our desire from now on is to make it possible for that candidate to acquire a more thorough grounding in the pathology of his specialty so that it will be an integral part of his professional background and not just a fleeting expedient to pass an examination. The success of the new program will be, to a large degree, dependent upon the co-operation and interest of the participating societies, and it is earnestly hoped that this Society, one of the pioneers in the Registry activity, will renew its interest and become a leader in this revival. You will help not only urology, but also American medicine.