Cancer: Its Cause and Treatment, Volume 2 (of 2)

by Lucius Duncan Bulkley

Third, the class of cases operated on affects surgical statistics very greatly. While epithelioma of the face, and even of the lip, when well removed, may yield most favorable statistics, cancer of the breast, uterus, stomach, intestines, gall bladder, etc., yield increasingly unfavorable statistics, as will be presently seen.

Fourth, the duration of observation after operation affects very seriously the validity of statistics. Not long ago three years’ freedom from disease was considered the time to regard a cancer as permanently cured; but this time has been lengthened more and more, by the observation of any number of cases where the disease has recurred even long afterwards, and reliable observers are now very chary in expressing an opinion as to the final cure of a cancer. This will be more fully considered in another lecture.

Finally, the optimism of the reporter seems often to have something to do with the reliability of surgical statistics. This need hardly be discussed. The older and more experienced the surgeon the less confident he is of having actually cured cancer with the knife. At a discussion in the New York Academy of Medicine, some years ago, Dr. Robert F. Weir said that the late Dr. Agnew, a celebrated surgeon of Philadelphia, had remarked, just before his death, that he doubted if he had ever been justified in an operation upon cancer, and he, Dr. Weir, stated that he could almost say the same.

Turning now to the actual statistics of operative surgery on cancer, we will find that the percentage of reported cures varies very greatly, in accordance with the points just stated. It is understood, of course, that no accurate statements can be made from statistics in reference to the actual mortality of cancer in any location, partly owing to the paucity of figures, and partly because the stages and extent of the disease differ so greatly, and the results vary with the previous duration of the lesion and the period of observation after the operation.

Cancer of the skin presents the best operative statistics of any region, and the claim is made that all cases are curable if operated on early enough and rightly. While this is not wholly true, it is certain that if all lesions which one chooses to call “pre-cancerous” are thoroughly extirpated very early, and included in the statistics, the percentage of cures can be reported as very high. So that it may be said that, taking all statistics together, including very small as well as large lesions, the favorable results, that is permanent cures of lesions which can be truly called cutaneous epithelioma, may run as high as 75 per cent. But against this is to be set the fact that a very large share of these cases, taken early and by competent persons, are equally amenable to cure by lighter measures, without the horrible disfigurement which one sometimes sees after purely surgical procedures.

Cancer of the lip, when taken early and treated radically, including gland extirpation, also yields a fairly satisfactory result, depending, of course, on the stage of the disease, or amount of involvement of tissue and glands, and the completeness of the operation. But while some operators have claimed 75 per cent of cures, Hertzler makes the percentage of permanent cures not much over 25 per cent. And here again, if taken very early and treated correctly, many of these cases yield without the knife, whereas very late cases may be practically inoperable.

When, however, we come to cancer within the mouth, the tongue, etc., it is quite a different story, and the end results of surgery are commonly unsatisfactory. Certain European surgeons have reported an operative mortality in cancer of the tongue as high as 36 per cent, while recurrences are the rule, and really permanent cures the very great exception.

As before stated, it is extremely difficult to give any true and accurate estimate of the real end results from operative surgery as ordinarily performed in cancer affecting various regions. The obvious reason of this is that most of our statistics are from those who are especially occupied with the disease under most favorable hospital facilities, and also certain statistics may be from selected cases; moreover, operators are naturally inclined to report mainly satisfactory results, while the other aspect of the case is seldom presented. Aside, then, from superficial epitheliomata, about the only locations in which there is even a fair chance for the patient under the knife are the breast, uterus, and rectum, and for these large statistics are available; but again these are unsatisfactory, as they vary so greatly.

The reported statistics of cancer of the breast are very provoking. Individual operators have claimed as high as 50 and even 70 per cent of cures (Rodman). Murphy, on the other hand, on a basis of end results states that the plump woman invariably succumbs, and that Paget’s disease ends fatally in 90 per cent of cases. Hildebrand mentions 606 operations in which the percentage of permanent cures varied from 15 to 23 per cent; late recurrence is not uncommon in cancer of the breast. He thinks that 35 per cent is the maximum possibility for permanent cures. He would be very suspicious of any higher figure. Judd reports that of 266 cases of carcinoma of the breast in the Mayo Clinic, which could be traced, 39.8 per cent were reported as alive at the end of five years, although there was recurrence in 6 cases.

Lubhardy, in an article on recurrence, in 1902, states that 1,321 recurrences were known to have occurred after 2,107 operations, or nearly 63 per cent, 4 per cent of which were late recurrences; he does not mention the number “cured” nor the number of patients untraced. Unfavorable results in breast cancer are seldom published. Dr. H. C. Coe in a discussion quotes the experience of a friend who had operated on between 200 and 300 cases of cancer of the breast with exactly 13 recoveries.