Chapter XXIV.
CANCER.
With the cooperation of Samuel C. Harvey, Professor of
Surgery, Yale School of Medicine.
1. Significance of Problem. The health problems so far considered (with the exception of pneumonia) are all in a fair way of solution. Our problem is merely to accelerate and complete the successful campaigns waged during the past twenty years. With cancer we begin to consider a far less encouraging picture. This disease, as will be indicated in detail in a later chapter on Vital Statistics, has, on the face of the returns shown a tendency to increase rather than to decrease in importance as a cause of death. Fifty years ago (in 1877) the recorded death-rate from this cause was 57 per 100,000; in 1887 and 1897 it was about the same (rates, 63 and 62 respectively). In 1907 it rose to 86; in 1917 to 108. During the past five years the rate has varied between 105 and 131 and has averaged 117. Thus we get the picture of a rate stationary at a low level from 1877 to about 1900 but mounting rapidly from 1900 to 1915 and then maintaining a new fairly stationary level.
These crude death rates are somewhat fallacious for three different reasons. In the first place the proportion of deaths of non-residents occurring in New Haven has greatly increased with the development of our hospitals. Of the cancer deaths in the three years 1924-1926, 19 per cent were deaths of non-residents.
In the second place improvements in diagnosis account for a large part of the increase in reported cancer. In the three years 1877-79 ill-defined and unspecified causes of death accounted for an average death rate of 46 per 100,000 while for 1925-1927 this figure had fallen to 2 per 100,000. A part of these deaths, once ill-defined, are now recorded as due to cancer.
Finally, a part of the actual increase in cancer mortality is due to the fact that with progress in the elimination of such diseases as typhoid fever, diphtheria and tuberculosis (diseases of youth) a larger proportion of the population lives on into the later age periods when cancer is likely to occur. Mr. E. E. Walker and Miss M. E. Farris in a study now under way in the Department of Public Health of the Medical School have analyzed the data for the past forty years by age and the results are tabulated below.
MORTALITY FROM CANCER BY AGE PERIODS.
DEATHS PER 100,000.
| Age Period | Under 20 | 20-39 | 40-49 | 50-59 | 60-69 | 70+ |
| 1888-1892 | 3 | 13 | 89 | 160 | 320 | 437 |
| 1893-1897 | 1 | 17 | 104 | 195 | 362 | 448 |
| 1898-1902 | 2 | 22 | 130 | 271 | 434 | 456 |
| 1903-1907 | 1 | 20 | 119 | 314 | 483 | 538 |
| 1908-1912 | 4 | 21 | 104 | 328 | 572 | 786 |
| 1913-1917 | 3 | 21 | 147 | 311 | 573 | 954 |
| 1918-1922 | 4 | 22 | 122 | 333 | 678 | 1070 |
| 1923-1926 | 3 | 25 | 122 | 354 | 722 | 1069 |
Apparently change in age distribution has had little to do with the increase in cancer mortality in New Haven. During the last 40 years the death rate from this cause has doubled and the rate has increased in about the same proportion at each age period, - beyond fifty years of age. The fact that the decade 40-49 shows a decrease since 1913-1917 and that between the ages of 20 and 49 there has been no increase since 1898-1902, may possibly be significant of some progress in the direction of postponing the average age at death from this disease by surgical treatment; but the picture as a whole is by no means an encouraging one.
Whether cancer has actually increased or merely been discovered, the fact remains that 200 people die every year of this disease in New Haven. For the past 40 years, cancer has consistently stood third or fourth as a cause of death, exceeded by heart disease and pneumonia and running neck and neck with apoplexy.
Along with pneumonia and the circulatory diseases, cancer confronts us as one of the three major health problems of the future. Furthermore the recorded rate for New Haven is much higher than that for the Registration Area as a whole (for the five years 1920-24, New Haven's cancer death rate averaged 117 and that for the Registration Area, 87). This high apparent rate is, however, in some considerable measure due to nonresident deaths in hospital which make up nearly 20 per cent of all cancer deaths in New Haven.
2. The Control of Cancer. It has been said that cancer is as controllable as tuberculosis; but this is an overstatement. Cancer of the esophagus, for example, and many forms of internal cancer can almost never be diagnosed sufficiently early to make operation successful. On the other hand, cancer of the skin and of the lip need never be fatal if diagnosed and treated promptly. The major factors in the cancer death rate, - cancer of the stomach and liver, of the peritoneum, intestines and rectum, of the female generative organs and of the female breast occupy an intermediate position, - with promise of successful surgical treatment in a substantial proportion of cases. It is estimated that from one third to one half of all true cancers are preceded by precancerous conditions or chronic irritations whose removal would have presumably prevented the development of the cancer. It is probably safe to estimate that one half of the deaths now due to cancer could be avoided by skillful diagnosis and prompt surgical treatment of cancerous or precancerous conditions.
The following analysis of 347 cases of cancer observed in the New Haven Hospital from 1921 to 1928 gives a picture of the possibilities. It would appear from this table that with reasonably early diagnosis 12 per cent of cases of cancer offer an excellent prospect of cure and 50 per cent a good prospect of cure while in 38 per cent there is relatively little hope of success.
DISTRIBUTION OF 338 CASES OF CANCER ACCORDING TO
SITE (9 OTHERS WERE CLASSED AS MISCELLANEOUS).
|
Probability of cure with reasonably early diagnosis |
Excellent | Good | Poor | |||
| Site | No. Cases | Site | No. Cases | Site | No. Cases | |
| Skin | 20 | Mouth | 14 | Esophagus | 13 | |
| Lip | 21 | Stomach | 46 | Antrum | 3 | |
| Intestine | 24 | Lung | 6 | |||
| Rectum | 12 | Prostate | 6 | |||
| Larynx | 4 | Testicle | 2 | |||
| Bladder | 18 | Lymph Nodes | 6 | |||
| Breast | 52 | Pancreas | 9 | |||
| Thyroid | 2 | |||||
| Uterus | 80 | |||||
| Total | 41 | 170 | 127 | |||
Of a total of 282 cases of cancer actually treated in the New Haven Hospital between 1921 and 1928 (88 per cent of them by operation) 53 per cent are known to be dead, and 35 per cent are still living, while 12 per cent of the cases have been lost sight of.
3. An Ideal Community Program for the Control of Cancer. If we seriously wish to control cancer, as we are controlling tuberculosis, we must set up essentially the following type of community machinery.
4. The Present Situation in New Haven. New Haven possesses admirable facilities for the hospital treatment of cancer, its hospitals enjoying the service of an unusual proportion of surgeons specially skilled in dealing with this disease. During the year 1926, 129 cases of cancer were admitted at St. Raphael's Hospital, 71 at Grace Hospital and 92 at New Haven Hospital.* The total of nearly 300 cases a year treated in the New Haven hospitals is a high one and testifies to the excellent quality of the surgical services of the city.
The Visiting Nurse Association admitted 43 cancer cases in 1926 and discharged 40, a figure which could profitably be much enlarged if a definite community program were organized.
Aside from these two factors, New Haven has almost nothing in the way of a cancer control program. There is no one in the Health Department to make an intensive statistical study of the problem. Deaths are tabulated by age and sex but not by organ affected. (It is a curious fact that this tabulation was actually made in the Health Department reports up to 1897 - and then abandoned!)
The Department of Pathology of the New Haven Hospital does furnish free pathological diagnostic service, but there is no special Cancer Clinic and no consulting service available. Nursing service under these circumstances is necessarily mainly confined to actual bedside care rather than to the securing of early diagnosis. There is no systematic educational campaign whatever. During the past two years not a single article has appeared in the Bulletin of the Department of Health in regard to cancer.
* This last figure is from 1927 not 1926
5. Conclusions and Recommendations. Cancer is the fourth cause of death in New Haven, contributing some 200 deaths a year to the total mortality. It is a disease which could in very large measure be controlled by prompt surgical treatment of cancerous and pre-cancerous conditions. New Haven has unusual surgical skill available for the treatment of this disease but this skill is now generally applied too late to be of the most substantial value, for the lack of effective community machinery for promoting early diagnosis.
There are two steps which seem obviously necessary in order to develop a cancer program for New Haven.
The first is the setting up of machinery in the city health department for continuing statistical study of the local cancer problem and for the development of an intensive campaign of popular education in regard to the importance of early treatment. Such a step need not involve great expense. It would not be necessary in this case to employ a surgical specialist since expert knowledge of this kind is amply available at the dispensary and hospitals. The educational work could be carried on by the Director of Health Education whose appointment is suggested in a succeeding chapter. The statistical work could be performed without any additional expense by a properly organized Bureau of Vital Statistics under the Health Department, such as has been already recommended. Pending such an arrangement, a special statistical assistant should be employed to perform this work and the allied work on the statistics of acute communicable diseases, tuberculosis and heart disease which is now undone or done at unnecessary cost, by medical men whose time is too valuable for such a purpose.
The second essential now lacking in New Haven is a specially organized Cancer Clinic. The fact that cancer cases can be seen at the general surgical clinics does not at all meet the situation, since effective propaganda by the Health Department must necessarily focus on the provision of a special expert service designed to facilitate the early diagnosis of this particular disease. With 200 deaths a year, we may presume that there are at a given time 400 cases of cancer in the city and some 300 of these should ideally be in contact with such a clinic. The Surgical Department of the Dispensary should be able to provide the medical service necessary for a cancer clinic if clerical assistance were available for the record-keeping and correspondence necessary. Actual home follow up should be provided through the Visiting Nurse Association, ultimately of course necessitating an increase of staff in that organization.
Our four recommendations in regard to the development of a cancer control program in New Haven would therefore be as follows:
Recommendation 88. That, unless a transfer of the whole work of vital statistics registration to the Health Department can be effected, the Board of Health provide for a special statistical assistant to make a continuing study of the statistical aspects of the cancer problem in New Haven (and of allied topics to be discussed in the following chapter).
Recommendation 89. That the Board of Health through the medium of a special Bureau of Health Education (to be later discussed) organize, with the cooperation of local physicians and surgeons, an intensive campaign of education among the members of the medical profession and the public in regard to the importance of the early diagnosis and prompt surgical treatment of cancer.
Recommendation 90. That a special Cancer Clinic for the early diagnosis of this disease be opened at the New Haven Dispensary and that free consultation service in respect to this problem be offered to the private physicians of the city; and that provision be made in the Dispensary budget for clerical assistance to keep the records and carry on the correspondence of the Cancer Clinic.
Recommendation 91. That, if, and when, the last two steps are taken, the Visiting Nurse Association staff should be increased to provide for more intensive follow-up of suspected cancer cases, of cases diagnosed but not yet operated upon and of post-hospital cases.
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