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Special Articles.THE SURGICAL TREATMENT OF CANCER

OF THE BREAST.THIRD MEMORANDUM OF DEPARTMENTAL COMMITTEE

OF MINISTRY OF HEALTH.

THE third of the series of reviews summarisingthe position of modern knowledge and practice inregard to different aspects of cancer, now being issuedby the Departmental Committee on Cancer of the I

Ministry of Health, relates to cancer of the breastand the results of surgical operation in connexionwith this condition. One of the first undertakings ofthe Committee was to arrange an exhaustive study ofexisting surgical literature, home and foreign, whichbears on this subject. This considerable task, whichhas involved the analysis of records of upwards of20,000 cases, has been undertaken for the Committeeby Dr. Janet Lane-CIaypon. The presentment ofthis analysis requires some little time, but meanwhilesome important conclusions to be deduced from italready stand out clearly, and have confirmed theCommittee in their belief that public advantage willbe gained by the issue of the present memorandum.

Facts which should be Recognised.The memorandum reviews the general position at

which surgery has arrived in the case of this form ofcancer, and states certain facts which the publicshould recognise if operative treatment is to yield thesuccess which in favourable circumstances and undermodern conditions it is capable of yielding.The first section deals with immediate operation

m.ortality past and present, and with the durationof convalescence. It is stated that deaths directlyattributable to the operation, if performed by skilfulsurgeons and in well-equipped institutions, have beenreduced in breast operations to a fraction of 1 per cent.At the present time even more extensive operationsheal, as a rule, without any suppuration and the patientis out of bed in about a fortnight.

In the second section on the natural course of cancerof the breast, the well-known symptoms-age incidenceand course of the disease-are set out. There isreason to believe that the upper and outer quarter is ithe commonest situation in which cancer appears,while the nipple is the rarest, the other portionsoccupying intermediate positions in this respect.The matter is important because the severity of thedisease bears a relation to the portion of the breastaffected. The fact that in its early stages cancer isusually unattended by pain is again emphasised.For many reasons the natural duration of cancer

of the breast is difficult to state with precision. Thus(1) the onset frequently cannot be fixed with anydegree of accuracy ; (2) amongst cases of cancer, evenin women of the same age and of the same habit ofbody, some run an acute, others a chronic, course ;and (3) the age at which the patient becomes affectedappears to exert an important influence upon thenatural course of the disease : cancer takes, on thewhole, a more rapid course in the young person thanin the old. If cancer of the breast supervenes duringpregnancy or lactation the course of the disease maybe abnormally rapid. While subject to these varia-tions, the average natural duration of a case of cancerof the breast appears to be a little over three years.The close relation between cancer and antecedent

chronic innammatory disease of the breast is discussedin the third section ; this relation, coupled with thefact that a non-malignant tumour of the breast mayremain so for a long period of years and ultimatelypass into undoubted cancer, must have a bearing onthe advisability or otherwise of operation in diseasedconditions of the breast other than cancer.

1 Cancer.—iii. Circular 496. Ministry of Health, 1924. H.M.Stationery Office. 1d. The two preceding pamphlets were dealtwith in THE LANCET, 1923, ii., 479 ; and 1924, i., 770.

On treatment of cancer of the breast, which is thesubject next dealt with, it is stated as being beyondquestion that, at the present time, early surgicaloperation affords the one chance for a patient sufferingfrom cancer of the breast. Cases of cancer treatedonly with internal medicines, or external applications,or by dietetic methods are not being effectuallytreated. This does not mean that such agents asradium and X-rays cannot be usefully employed asaids to surgery, or in cases in which surgical operationis impossible. Unfortunately, with improvement insurgical technique there has been no correspondingincrease in the proportion of cases which reach thesurgeon at a stage of the disease when such treatmentoffers the greatest advantage, and this fact has to beremembered in assessing the results of surgicaltreatment. As to varieties of operation, it is indubit-able that the better results obtained at the presenttime by operation in cancer of the breast mainlydepend upon the completeness with which the outlyingportions of the cancer are removed. It is satisfactoryto note that the modern " complete

"

operation doesnot add in any significant degree to the risk of theoperation itself, nor to subsequent disability, so faras the patient is concerned. A modern extension ofthe operation lies in the addition of such advantagesas are afforded by radium and X rays, to the" complete operation." The object of this radiationtreatment subsequent to operation is to deal withmicroscopical foci of living cancer cells that may liebeyond the limits of the operation, so as to preventtheir development.

mesitias OJ <pC?’6tf<0.The most important point of all, from the

patient’s aspect, is the measure of the success ofsurgical treatment, and this is very difficult to assess.The average duration of life in patients whose diseasehas followed a natural course is estimated at littlemore than three years. No precisely comparablefigure for patients who have been operated upon canbe given owing to the difficulty of keeping in touchwith them for perhaps 10, 15, or more years afteroperation. A majority of surgeons have been obligedto content themselves with reporting the percentagesof their patients who have survived three years fromthe date of operation.The aggregate results, based on the experience of

many surgeons in different countries, are as follows :-When the old and now generally superseded incom-plete operation was performed, about 25 per cent. ofthe patients were known to be alive at the end ofthree years after operation. When the more completeoperation of modern times was performed, twice asmany, some 50 per cent., survived three years, and33 per cent. survived five years after operation.These statistics, however, relate to patients who atthe time of operation were in various stages of thedisease, some in a condition such that, although thesurgeon could be reasonably sure that operationwould afford relief, and might eradicate the diseasealtogether, he could have little confidence that thedisease would not recur. On the other hand, statisticsexist of the results when the disease at the time thepatient came to the surgeon appeared to be in anearly stage and limited to the breast only. In thisearly condition it is certain that 60 per cent., andhighly probable that 75 per cent., of the patientswere alive and well three years after operation.Indeed, some experienced surgeons have thought thatthe percentage of cured patients might, in thesecircumstances, be stated to reach 75 per cent.

Prolongation of Life.lTpon the basis of all these statistics it is possible

to reach an average figure of the duration of life afteroperation which can be set against the average ofsome three and a half years in the unoperated cases,but this can only be done by means of assumptions,to state which would require a technical and detailedaccount unsuited to this memorandum. It may,however, be stated that, even under the unsatisfactoryconditions imposed by the late stage at which many

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cases come under surgical observation, which gravelylowers the average success recorded in the massedstatistics, the mean duration of life is prolongedseveral years. In the special circumstances of opera-tion at the most favourable-that is, the earliest-moment after recognition of a lump in the breast,there is an average prolongation of life amounting tomany years. The Committee have advisedly refrainedfrom adopting the word " cure " and have only spokenof the prolongation of life. It is, however, certainthat cure, in the widest popular sense of the word,has frequently been effected by early operation-i.e., that patients have lived 10, 15, 20, or more

years and died ultimately of some other disease.The surgeon cannot promise this, however early theoperation, but he is entitled to assert that in a greatmajority of cases life will be considerably prolongedand in a still greater majority rendered more accept-able, freer from pain, and more capable of activeenjoyment. On the other hand, the after-history ofpatients not operated upon, or operated upon whenthe disease has spread beyond its first point of attack,can be foretold with equal certainty and is a sad one :it will not often exceed three or four years. Theteaching of surgical statistics is, then, that the resultsof early and complete operation justify not a certain,but a highly favourable, prognosis.

A Demand for Local 7’H<yMe.s.The considerations set out in the memorandum

suggest that local inquiries may be useful to ascertainthe extent to which, in a given area, cancer of thebreast is now being allowed to continue to a fataltermination without appropriate surgical treatment.It is suggested that local authorities, in conjunctionwith local representative bodies of the medicalprofession in suitable areas, might periodicallyundertake a review of such questions as this as wellas of the facilities given locally (1) for clinical con-sultations and for pathological examinations, and (2)for the treatment, especially operative treatment, ofcases of cancer.

IMPERIAL SOCIAL HYGIENE CONGRESSAT WEMBLEY, MAY 12TH-16TH.

(Concluded from p. 1024.)

THE proceedings of this congress, the first day ofwhich was reported in our columns last week, demon-strated the many-sidedness of the problem and theexistence of a large body of men and women, lay andmedical, keenly interested in its solution. Importantpapers were read on a number of more or less closelyrelated topics. It may be useful to summarise heresome of the points in the control of venereal diseases onwhich there appear to be general agreement and alsothose which give rise to controversy.

Education. .

Agreement was general that much more needs to bedone to educate the public as to the serious ravages ofthese diseases, that cure is a means of prevention, thatearly treatment is essential to cure, and that theattainment of a higher moral standard and theavoidance of promiscuous sexual intercourse shouldbe put in the forefront. Education of the young andadolescents in sex hygiene, it was pointed out, shouldbe founded on the teaching of self-control, beginningin infancy, and on education in biology and goodcitizenship from the elementary school periodonwards. Sir Frederick Mott’s interesting papershowed how necessary it is for elders to understandand allow for the varying effects of the critical periodof puberty on the adolescent of either sex. In somequarters it was contended that health authorities arenot sufficiently interested, owing to the fact that theyhave been, as it were, " contracted out" of theschemes, and have not that direct interest in thesuppression of this section of infectious diseases,which is, perhaps, more important than any other tothe health of the comnmnity . The old idea thatvenereal diseases are a just punishment for immorality

is evidently not dead, in spite of the well-known factthat a large proportion of the sufferers acquire thedisease innocently, and it was stated that someinstitutions still regard these patients as pariahs.Evidently the truth that, in these diseases particularly,adequate treatment is a measure of prevention of first-class importance, must be insisted upon day in andday out. The obvious corollary is that, in order to getthe sick treated, every facility and a sympatheticreception must be provided at all clinics and institu-tions engaged in the work.

Efficiency of the V.D. Clinic.It was made evident by the papers and discussion

on May 14th that the clinics at present fail to securethe attendance of a large proportion of those whoneed treatment, and that of those who do attend aconsiderable proportion default. Sir George Newmansuggested that the amount of default is exaggeratedby the high standard of cure adopted, and that inmany cases those not returned as cured have been,no doubt. rendered permanently non-infective or

greatly relieved. On the other hand, Mr. David Lees,of Edinburgh, and Colonel L. W. Harrison (Ministry ofHealth) were of opinion that the clinics with thehighest standard of cure showed the smallest propor-tion of defaulters. Mr. Lees considered that one of themain factors in reducing the failure to continuetreatment at the Edinburgh clinic from 40 per cent.four years ago to the present low figure of 14t per cent.had been the discouragement of self-treatment.Patients who are instructed to treat themselves areapt to cease attending. All patients at the Edinburghclinic are required to attend weekly or fortnightly, andtreatment is, as far as possible, administered at theclinic. Colonel Harrison emphasised the great advan-tage of clinics open all day (say from 8 A.M. till10 P.M.) over clinics open only at stated hours, andcompared the results of one all-and-every-day clinicwith a percentage of " ceased attendance " of 12-3for syphilis and 14-6 for gonorrhcea, with the results ofa clinic open at restricted hours with a percentage of" ceased attendance " of 33-2 for syphilis and 32-4for gonorrhoea. Colonel Harrison also insisted uponthe need for setting aside time for the systematic andthorough examinationof thecases of chronic gonorrhoea.If this were not done, and the treatment of such casesbecame merely routine, the patients would losehope and cease to attend. There was generalagreement that the tact and sympathy of the medicalofficer was a most powerful factor in reducing defaultto a minimum. Dr. F. N. Kay Menzies would like tohave the 28 London centres reduced in number tosix or eight thoroughly efficient all-day clinics. It isquite clear that a large number of the clinics do notapproach the high standard laid down by ColonelHarrison and Dr. Lees, and that apart from thequestion of patients ceasing to attend before cure iscompleted, a large number of cases do not come up fortreatment at all. More cases of gonorrhoea attendthan formerly, but a very large proportion of femalegonorrhoea goes untreated. Very little syphilis ofparturient women is treated. Hostels are needed toensure the successful treatment of single girls who arein domestic service or other employment. Specialsessions are needed for married women and children,although the all-day clinic minimises the objections tothe herding together of all types of patients in thecommon waiting-room. The looking-up of contactsand infecting cases is a difficult matter. ColonelHarrison pointed out how much could be done in thisrespect by tactful almoners, and would like to see analmoner attached to each clinic. Miss Frances Brown

(supervisor of the Venereal Disease Nursing Depart-ment of Public Health, Toronto, Canada) showed thatin Canada each V.D. clinic receiving a (Governmentgrant is required to employ a public health nurse,and that on this nurse devolve the duties of (1) securingthe regular attendance of patients ; (2) securing theexamination of other members of the family ; and(3) instructing the family as to home treatment. Itwas evident from the papers and discussion that little