The cancer problem: a speculative review of the etiology, natural history, and treatment of cancer.

Abstract

THE CANCER PROBLEM: A SPECULATIVE REVIEW OF THE ETIOLOGY, NATURAL HISTORY, AND TREATMENT OF CANCER GEORGE CRILE, JR., M.D.* I. Evolution of Thought on the Natural History ofCancer A. FAILURB OP TREATMENT TO ALTER DEATH RATE Historically, it is surgeons who have been chiefly concerned with the treatment ofcancer, and since much ofsurgery is based upon mechanistic concepts, it is not surprising that the cancer problem has been approached mechanically. To detect a cancer when it is as smallaspossible and to excise it as widely as possible have been the surgical challenges ofthe twentieth century. Remarkable technical advances have been made in response to these challenges. Cancers have been diagnosed and treated earlier in their development , and more extensive operations have been performed with fewer postoperative deaths than ever before. Despitethese apparent advances, the death rate from most of the common types of cancer, age adjusted per 100,000 people, has not changed significantly (1). The incidence ofsome cancers—like those of the lung—has increased; the incidence of others— like cancer of the stomach—has decreased. The results of the treatment of some cancers—like those of the cervix and the mouth—have improved, and the death rate from these tumors is decreasing, partly because ofimprovement in their diagnosis and treatment and partly because of a decrease in their incidence. Aside from these exceptions, the death rates from most common cancers remain unchanged. For the last fifty years, despite the unchanged death rates, the reported rates ofcure ofmany types ofcancer have risen steadily (2). This paradox * Head, Department of General Surgery, The Cleveland Clinic Foundation; and The Frank E. Bunts Educational Institute, Cleveland, Ohio. 358 George Crile.Jr. · The Cancer Problem Perspectives in Biology and Medicine · Spring i960 can be explained by assuming that with better methods ofdiagnosis there has been included a higher proportion ofcases oflow malignancy (i). Perhaps , also, the rising rate of"cure" in the face ofan unchanged death rate is a reflection of the fallacy of using the "five-year cure" as a yardstick to measure the success of treatment (3). In any event, the failure of earlier diagnosis and more radical treatment to solve the problem of cancer has brought about a reappraisal oflong-accepted methods oftreatment. B. BIOLOGIC PRBDETERMINISM Although the term "biologic predeterminism" (4) is relatively new, it is a concept as old as clinical practice: that each cancer has its own natural history and each patient with cancer should be treated as having an individual problem. Certain types of cancer—like leukemias—have metastasized systemically by the time they are first recognized with our present methods ofdiagnosis and are incurable by our present methods oftreatment . Other types—like basal cell cancers ofthe skin—are ofthe lowest order ofmalignancy; treated or untreated, they are not apt to metastasize. Between these two extremes lies a middle group for which early and radical treatment may tip the scales in favor ofthe patient. "Predeterminism," in short, is the frank admission ofthe facts about cancer that every good clinician knows. When the principles ofbiologic predeterminism were first spoken out loud, an astonishing storm ofcontroversy arose. Those who upheld individualization oftreatment often were accused of "violating the principles of cancer surgery." Yet, out ofthis controversy came a re-evaluation of surgical results and a trend away from treatment ofcancer that was purely anatomic and mechanical. Gradually surgeons realized that no formula could be written to simplify the decision how a specific cancer should be treated; that the widest possible operation was not always the best treatment for the patient; and that in some types ofcancer a delay in treatment was less important than had formerly been supposed. One ofthe greatest contributions to this line of thought came from the rapidly developing field ofcancer cytology. Ever since the turn ofthe century, cancer cells have been demonstrated occasionally in the blood stream ofpatients with cancer; pathologists have called attention to the tendency ofcertain tumors to invade blood vessels; and the hematogenous spread of cancer is now clearly recognized. But 359 how frequently cancer cells can be demonstrated in the blood stream was not appreciated until 1955, when Fisher and Turnbull (5) reported finding cancer cells in the blood...