Hayes Martin, M.D.

Pliny the Elder (23-79 AD) is reported to have found the following epitaph on a Roman tombstone: “¿�Hediedby reason of the confusion of the doctors.― While such an epitaph mightnever be inscribed and seldom justifiedtoday, it can hardly be denied that somesemantic confusion by the doctors isnevertheless still with us in medicalparlance and writing.

The human factors in the art of healing are so many and varied as to preclude medicine from ever becoming anexact science to the same degree asmathematics, chemistry, or physics.

There is no good reason, however, whymedical nomenclature and terminologyshould not be so exact that the readeror the listener might know literallywhat is meant, and what is intended tobe included as well as what is to be excluded. Medical editors might well insist that authors say precisely whatthey mean in terms understood by all,rather than a somewhat irresponsibleresort to a Humpty-Dumpty policy:“¿�WhenI use a word, it means exactlywhat I choose it to mean, neither morenor less―(Alice in Wonderland).

During the past quarter centurythere has been a steady increase in interest and activities in the cancer problem by both the layman and the physician. This specific interest has come tosurpass the general concern regardingtuberculosis and poliomyelitis, whichat one time were major preoccupationsof public health. The latter diseases arenow amenable to almost complete control, while cancer, next to atomic war,remains the “¿�bêtenoire― of survival.

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21(15' los'k (‘ito,

1?u'psiuuted fronu Au-chives of Surgery 87: 534-537,106,3.

Scientific knowledge may be definedas the accumulation, coordination, andapplication of proven facts. As suchknowledge concerning cancer grows,one may confidently expect increasinglyrapid progress in the form of new andbetter methods of treatment and theeventual discovery of the cause andspecific method of cure. If such progress is to be made with the greatest possible speed, a prime requisite is anorderly and exact recording and reporting of clinical and laboratory observations or, in other words—facts. Suchreporting is not possible without aliteral and uniform nomenclature andterminology. Unfortunately, medicalreports and even dictionaries (including the medical variety) are often inconsistent, contradictory, and confusing. But, after all, the compilers of dictionaries have little recourse other thancommon usage, which would naturallybe authoritative provided that it belogical, consistent, and uniform. It iswith this purpose in mind that the following glossary of cancer is proposed.

GlossaryCANCER

A long-accepted inclusive term for allforms of malignant neoplasia, eg, “¿�carcinoma,― “¿�epithelioma,― “¿�sarcoma,―“¿�lymphoma,―“¿�leukemia,―“¿�malignantmelanoma,― “¿�endothelioma,― “¿�mesothelioma.― All of these basic root terms(except melanoma) designate the tissuefrom which the cancer arises. In orderto avoid tiresome alliteration, there area number of acceptable synonyms forcancer, such as malignant tumor(growth, neoplasm), or where the antecedent is plain, simply tumor, growth,lesion, disease, etc. With the latterusage, the inclusion of the adjective ma

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A Proposed Glossary of Cancer

lignant to the terms lesion or disease isredundant,

The term cancer is perfectly respectable. The public accepts and uses it. Itis in no sense a “¿�dirtyword.― Someotherwise forthright medical writersand even speakers before medical audiences nevertheless appear to find theterm too crude and inelegant for politeusage and, therefore, resort to ostensibly more refined and erudite euphemisms, such as a malignancy or malignant disease.

CARCINOMA (NEVER A SYNONYM FORCANCER) AND SARCOMA

These as well as the other basic rootterms had best seldom if ever be employed without a specific qualifyingprefix (e.g., “¿�squamous carcinoma,―“¿�adenocarcinoma,― “¿�basalcell carcinoma,― “¿�papillary carcinoma,― “¿�lymphosarcoma,― “¿�reticulumcell sarcoma,―“¿�neurosarcoma,―“¿�periostealosteogenicsarcoma―). There would rarely be anyjustification for such titles as “¿�Carcinoma of the Breast― or “¿�Carcinomaofthe Tongue,― where there is no intentor purpose to exclude from the reportall other possible forms of malignantneoplasms of the respective organs.Properly the title should have readsimply, “¿�Cancerof the Breast― or “¿�Cancei' of the Tongue.― Later in the textunder a section on pathology, the author would find ample occasion to discuss the exclusive (if any) occurrenceof the epithelial cancers and their specific subvarieties.

CARCINOGEN(IC) (ESIS) ANDCANCERIGEN(IC) (ESIS)

Although the meaning of these respective terms should be plain to all,one often hears or reads of a cancer researcher referring to a “¿�carcinogen―as producing some form of “¿�sarcoma.―It should be obvious that a carcinogencaa call3e only carcinoma, while the responsible agent in the causation of a

sarcoma, if it need be specifically defined, requires some other term. Theetymologically sound term “¿�cancerigen,― which has the additional authority of long though possibly notcommon usage, would not only beproper but an entirely adequate substitute for the tiresome, repetitious “¿�carcinogen,― where no such restriction isintended. If there were actually anygreat need for the term “¿�carcinogen,―then logically there should be an equalneed for collateral terms such as “¿�sarcomagen,― “¿�lymphomagen,―“¿�leukemogen,― or even “¿�melanomagen.―

MALIGNANT, MALIGNANT DISEASE,MALIGNANT LESION

From Webster's New InternationalDictionary of the English Language(second edition, 1943):

Malignant (adj.) . , . 1. Rebelliousagainst God oi- against a government.2. Having a fateful influence . . . 3.Poisonous; deletei'ious . . . 4. Disposedto do harm . . . 5. (Med.) tending orthreatening to produce death. Curiously enough, there is no referenceeither in the 1927 or 1943 editions tomalignant disease as a synonym forcancer.

If one relies on the foregoing, theterm malignant has many applicationsin medicine as well as in human behavior, animals, plants, forces of nature, etc. In medicine, any disease“¿�tending or threatening to producedeath― therefore may be rightly termedmalignant. Diseases of the heart (thenumber one cause of death), such ascoronary occlusion, valvular insufficiency, et al, are consequently more malignant than cancer. Moreover, sincethere is a definite percentage of recovery and cure both in heart diseaseand cancer, the distinction of being themost malignant must go to such lethaldiseases as tetanus and rabies, practically always fatal within a few days,or to such lingering, invariably fatal

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afflictions as multiple sclerosis, Parkinson's disease, and lupus erythematosus,for which there are no remedies todate. By contrast, basal cell carcinoma(a form of cancer and therefore logically included in the malignant diseasecategory) is seldom a cause of deathand certainly less malignant than hemophilia. Other diseases ordinarilyconsidered to be benign, such as perforated gastric ulcer or perforated appendiceal abscess (actually highly malignant lesions), are certainly muchmore malignant than let us say papillary carcinoma of the thyroid.

In the case of Pope John XXIII, is itnot a curious commentary that up untilthe day of his death, some newspapersshould continue to report that the Vatican authorities had not as yet disclosedwhether the Holy Father's disease was“¿�malignantor benign―?

MALIGNANT TUMOR ORMALIGNANT NEOPLASM

From the practical standpoint theseterms had probably best be accepted asproper synonyms for cancer, althoughstrictly speaking, such “¿�benign―neoplasms as bulky adenomas of the thyroid or hypertrophy of the prostate arecertainly malignant if they progress toa fatal issue.

MALIGNANT BIOPSY OR MALIGNANTBIOPSY SPECIMEN

These common solecisms are at leasta minor offense to good literary taste.Surely a biopsy is always made for ahumane purpose and in itself can hardlybe termed a “¿�malignant―act. The specimen which is even bacteriologicallysterile after immersion in formalin oralcohol is certainly among the mostinnocuous objects on earth. It would beproper to speak of a biopsy of a suspected malignant tumor, but (horrors!)hardly of a “¿�malignantbiopsy.―

MALIGNANCY

When used as a synonym for cancer,

this malapropism is inexcusable, andhere one must take issue with Webster's New International Dictionary ofthe English Language (second edition,1943) which has come under the malign influence of some modern medicalwriters.

Malignancy. 1. state or quality ofbeing nialignant . . . 2. (a) virulence

(b) the state of having a malignanttumor... (c) a malignant tumor; as amalignancy of the breast.

Actually, except in the medical definition, the term is defined by Webster'sas being an abstraction, expressing aquality or characteristic of an action,an object, a plant, a person, a disease,or a neoplasm. As an abstraction it cannot properly be used to define a concrete object. When used in reference toa neoplasm, malignancy is of course byfar the most significant characteristic.along with its other less significantproperties such as size, shape, color,microscopic appearance, etc. One maycorrectly speak only of the malignancyof a tumor, or of any other disease, orof an act of human behavior. Howridiculous it would be to speak of the“¿�American Malignancy Society,― the“¿�AmericanSociety for Malignancy Research,― or the “¿�National MalignantDisease Society.―

OPERABLE AND INOPERABLE

These malapropisms are among themost objectionable because they sooften serve as a convenient excuse forinaction in those cancer cases in which,despite their advanced state, there maybe an excellent chance of cure byprompt and competent surgery, whichmay nevertheless be of a more radicalnature than a timid, less experienced,or less competent surgeon cares toundertake. In such cases the chance ofcure is often lost, and “¿�palliative―treatment in the form of radiation is given.More often than not such treatment is

*Susch a rlefiuuifiosu apperis-s- lucre for flue first time.

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more palliative to the bad conscience ofthe incompetent or timid surgeon thanto the sufferings of the patient.

Actually, any disease case is operableif a surgeon is willing to make the attempt and the patient gives consent.The question of operability (if thatterm of doubtful propriety were to beused) should be determined only by thepatient's best interests and by a competent surgeon. The only truly inoperablecases are those in which the patientsrefuse to give consent, where facilitiesfor adequate surgery are lacking, orwhen no competent surgeon is available. The alternatives for these termsare discussed in the following section.

RESECTABLE (IN TOTO) OR

NONRESECTABLE (IN TOTO)

On the Head and Neck Service atMemorial Hospital, the terms “¿�operable― and “¿�inoperable―are not used inconferences. A growth is either resectable or nonresectable, with the tacitmeaning of in toto. In many instances,although a growth is not resectable intoto, it may nevertheless be “¿�operable―in the sense that a subtotal resection ofa bulky, bleeding, infected, and painfultumor may give great relief for suchcomplications as dyspnea, dysphagia,hemorrhage, pain, etc., and therebyprolong life. Other cases certainly become “¿�operable―when ligation of arteries for hemostasis, tracheostomy, gastrotomy, esophagostomy, colostomy, cystostomy, or neurotomy are performedto relieve complications of cancer.

BIOPSY

This term defines the process of examining a portion of tissue removedfrom a living subject. It includes thetaking, or detachment, of the specimen,its immediate immersion in a fixativefluid (formalin in most cases), its submission with clinical data to a pathology laboratory for further processing,ending in the preparation of a stained

slide, and finally its interpretation bythe microscopist. Therefore, the surgeon does not “¿�takea biopsy.― Herather takes a specimen for a biopsy.From the practical standpoint, onemight say that he “¿�makesa biopsy,―although he actually only initiates theprocess by taking a specimen for thesubsequent longer process.

GLANDS

This term is one of the most likely toconfuse and mislead in discussions oncancer. The tendency for most forms ofcancer to disseminate widely moreoften through the lymphatics thanthrough the blood stream makes thelymph nodes the subject of prime importance in the discussions of the clinical aspects of cancer. The term“¿�glands―as applied to lymph nodesarose in English when the cervicallymph nodes (often affected by scrofulaor tuberculosis) were not differentiatedfrom the true cervical glands, seven innumber, i.e., the three paired salivaryglands and the thyroid and, if onewishes to pursue the point to absurdity,the sweat and sebaceous glands of theskin of the neck. The French have nosuch difficulty; lymph nodes are calledles ganglions in differentiation fromles glandes. The German Knoten orLymphknoten likewise differentiatesthe two forms of anatomic structures.In English and American medical literature, the misuse of the term hassometimes resulted in such ludicroussequences with a few sentences or paragraphs as “¿�aglandular cancer.. . of thethyroid gland . . . metastasized to thecervical glands.― Sometimes the term“¿�glands―is used as a synonym for “¿�metastases,―and an author may reportthat in such and such a percentage ofcases “¿�therewere no glands― or “¿�noglands were present―—m i/a bile dictmiand surely a most unusual anomaly.

The modern concept of the lymphnodes as the source of production of

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certain antibodies can hardly hold to bea justification for persisting in the ancient and confusing “¿�glands―or “¿�lymphglands― rather than “¿�nodes―or “¿�lymphnodes.―

SummaryThe following abridgement is in

tended for the convenience of and usageby those medical writers and medicaleditors who may find themselves inagreement with the logic of the foregoing discussion.

Cancer: An inclusive term for allforms of malignant neoplasia. Synonyms—malignant growth, malignanttumor or, where the antecedent is plain,simply growth, tumor, lesion. (“Malignancy,― “¿�malignantdisease,― and “¿�carcinoma― should not be used as synonyms for cancer.)

Carcinoma: (cf. sarcoma, lymphoma,

melanoma, et al.). A cancer arisingfrom epithelial tissues. This term alone,like its collaterals (sarcoma et al.),should seldom if ever be used withoutqualifying prefixes (e.g., squamouscarcinoma, neurosarcoma). In most instances where the term “¿�carcinoma―isused alone and nonspecifically, the allinclusive term cancer is to be preferred.

Malignancy: An abstraction, a property of many diseases, of which canceris one. It is ungrammatical and incorrect as a synonym for cancer.

Malignant Disease: Incorrect whenused as a synonym for cancer. Cancer isnot the only malignant disease, nor isit even the most malignant.

Biopsy: A long and somewhat involved process, beginning with the removal of tissue from a living subjectand ending with the microscopist's interpretation. A surgeon, therefore, doesnot take a biopsy. He simply initiatesthe process by taking a specimen forbiopsy.

Operable and Inoperable: The truedefinitions of these terms actually depend mainly on the patient's consent orlack of consent to an operation or theabsolute lack of facilities for surgery.It is too often used as a feeble excuseand face saver for inaction in advancedcases of cancer where there is a chanceof cure by competent surgery.

Resectable and Nonresectable (intoto): Wholly necessary descriptiveterms which are not in all cases synonymous with the conventional meanings of the terms operable and inoperable.

ERRATUM

In the interview with Doctor Dobson, “¿�TheTreatment of Recurrent or MetastaticBreast Cancer,―Ca 13 (September-October) pages 202-207, a photograph of Presbyterian Medical Center was erroneously captioned as Stanford University Schoolof Medicine. Photographs of the new Stanford University School of Medicine appearon pages 242-243 in this issue of Ca.

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