Hq gu TIONAL LIBRARY OF MEDICINE "READER'S REQUEST _ 2. Please print clearly. 3. Keep last copy. at one time is limited. 5. Allow 30 minutes for delivery. INSTRUCTIONS: Today's Date v 1. Use one slip for each item requested. 4. Number of requests accepted Ain ba Pel Call Number AMP fice, TS° Ss 7 2x > FOR JOURNAL REQUESTS, complete this section Journal Title 7 wae _ Ael a ‘ file ll Cel Phils case ah tei eo r * i / . a if ‘ . : wo . yt See eit i EL pes Leg L Year/Month Zz. | Volume | Issue / ~/ | Pages > FOR BOOK OR AV REQUESTS, complete this section « REPLY TO READER . 1 (TEM IS NOT AVAILABLE... (1 NLM does not own item C1 Net on shelf (C1 Item is on loan Ci ttem is at bindery (1 Other: ‘| Author Title (with edition) Pp Name (Please Print) | SNin 1866-1 (Rev. 11/89) JANUARY 1965 a Ww < & z we z x 2 2 z fx) @ z oO 9 2 z a a U) we 7 oT \ Re pi : ye Prt Paro /; a f He HM 3] ES Rit sy y > z « . © * 0 ua aa -. Zz 3 x 3 « y oo } . 5 s ’ e i 2 2 i u 7 G : HW y i 3 my 3 = i 4 oe } : ! x a --. i < f Hi wot p a i) Q er i—_— « . my 9 3 t x 5 a 3 ies Nexson A. ROCKEFELLER Governor Houuis S. Incranam, M.D. Commissioner of Health EDITOR James J. Quinlivan, M.D. ADMINISTRATIVE EDITOR Irving Weinstein MANAGING EDITOR Lillian S. Harrell PHOTOGRAPHIC STAFF Monroe Dixson Adolph Scherer H. F. McGaughan STAFF ARTISTS Gerard E. Mealy Earl C. Strickland Health News published monthly by the New York State Department of Health, Albany, New ‘York 12208. Second class postage paid at Albany, New York. VOL. 42, NO. 1 CONTENTS EDITORIAL—Wedical Audit—The Quest for Quality: 3 A technique for continuing excellence in the practice of medicine. Services and Facilities Available to The Private Practitioner for His Cancer Patient —-.-----—----- 4 Services and resources to facilitate the effective detection, diagnosis, treatment, and rehabilitation of the cancer patient. Activities of The New York State Health 16 Department in Chronic Respiratory Disease 2... Objectives, proposed services and research studies. The Cover The illustration on the front cover shows New York State coverage by tumor clinics. Fighty- eight per cent of the upstate population lives within 25 miles of one of these clinics. The radius of each circle represents 25 miles. Credits Pages 9 and 14-courtesy prints. Other photos by staff photographer. wa EDITORIAL Medical Audit---The Quest for Quality Tue medical audit bill passed in 1963 staked out a major research frontier for public and private medicine in New York State. This pioneering legislation, backed by both the State Medical Society and the State Health Department, au- thorizes research and studies “which have for their pur- pose the reduction of morbidity and mortality and the improvement of medical care through the conduction of medical audits.” For a year and more the State Medical Society, medi- cal schools and the Department have worked together to develop a mutually acceptable, meaningful method- ology for gauging the quality of medical care. The first audit research project gets underway this year. The project goals are positive, its approach voluntary. Twenty-nine hospitals in the Rochester area have agreed to take part in a study of perinatal care to be carried out by the Empire State Medical, Scientific and Educational Foundation, research arm of the State Medical Society. The State Health Department is cooperating closely in development of the project. Practicing obstetricians and pediatricians from out- side the study area will review and evaluate hospital records of perinatal care provided. These reviewers, Sé- lected by medical school faculties and the State Medical Society, will concern themselves only with identifying problems and evaluating care. Patients and attending physicians will be identified by code number only, and in keeping with the law, information obtained will re- main confidential. The practicing physician can justly ask what profes- sional benefit he gains from this project and any subse- quent studies of his performance. For one thing, the audit technique contains the in- gredient essential to rigorous judgment—objectivity. Granting the desirability and value of devices such as hospital tissue committees, these internal audits where Heartit News, January 1965, workaday colleagues review one another have some practical limits. Medical audit also offers the opportunity to dramatize situations. For example, the effect on the quality of care caused by a doctor shortage in a rural area may be spot- lighted by a medical audit which can spur more vigorous recruitment of new physicians. Nonmedical groups like insurance companies, union health programs and consumer groups are increasingly asking pointed questions about the quality of care they pay for. But the physician would prefer to consider these questions when they are posed in studies spon- sored by medical confreres—his medical society, medi- cal schools and public health agencies. The dominant value of the medical audit is its poten- tial as a powerful teaching tool. Auditing makes pos- sible the deliberative, thorough, unhurried review of cases that the conscientious physicians would like to make for themselves, if only time permitted. Medical audit takes the time to find out for hard-working physi- cians the present quality of care provided and how that care can be made even better. The Society, the Department and cooperating schools will advance the desire for professional improvement by jointly developing training programs in areas where studies suggest that care can be strengthened. In the medical audit we have perhaps the greatest in- strument for refreshing and enriching the physician’s skills outside the halls of formal medical education. In- deed, we might look upon the three stages of these studies—review, evaluation and improvement—as a kind of postgraduate institution where the subject pur- sued is continuing excellence in the practice of medicine. Yotls 8 groban: MP Services For The P hysician And His Cancer Patient by Vincent H. Hanpy, M.D. Director, Bureau of Cancer Control New York State Department of Health Mucx has been written describing the advances made in cancer therapy during the last decade due to more radical surgery, perfusion techniques, radioisotopes, supervoltage radiation, and newer drugs. But too often one is inclined to forget that before the patient reaches the treatment stage, some selective process has taken place to identify him. This is usually the result of a dif- ferential diagnosis by the patient’s physician. Whatever can be done to accelerate the process of identifying the cancer patient is worthwhile since treatment cannot start . until the patient is diagnosed. There are several ways in which the Bureau of Cancer Control of the New York State Department of Health can assist the private practitioner in his work. Public Education The most important single characteristic of cancer is that during its early course, when it is most curable, it is least apt to affect the general health or to cause symp- toms sufficiently severe to alarm the patient and impel him to seek medical care. During the early or most curable stage of cancer, the natural spurs of disability and pain which lead to action are absent and must be replaced by incentives produced by education, publicity, and demonstration. The Bureau of Cancer Control, in cooperation with the Office of Public Health Education, has produced the © following education material which can assist the physi- cian not only in his daily patient contacts but also in group cancer education meetings in which he might become involved: The Truth About Cancer -A basic cancer leaflet. 4 A Monthly Check Pays Dividends A leaflet which explains breast self-examination and is intended primarily for adult women. Yes, Children Get Cancer Too A leaflet for the general public describing leukemia and other malignancies of children. Leukemia A leaflet for the general public describing leukemia both in adults and children. Memo to Adults About Cigarette Smoking A leaflet for adults describing some of the evidence link- ing cigarette smoking and lung cancer. Smoking—It’s Up to You A leaflet for teenagers describing some of the evidence - linking cigarette smoking and lung cancer. Action Against Cancer A booklet for special groups which have a particular interest in cancer in New York State. It Takes Two to Beat Oral Cancer A leaflet for adults which describes oral cancer and the use of oral cytology. In addition, the following films on cancer are avail- ‘ able for the general public from the State Health De- partment to assist physicians in group meetings. These films are more fully described in the Department’s Film Catalogue. Challenge: Science Against Cancer ‘Points up the meaning of new achievements in biology, physics, chemistry and genetics. Its principal objective is to help answer the widespread demand for information about progress in cancer research. A film for all audiences, particularly high school and college. (30 minutes) The Doctor Speaks His Mind Designed to pave the way for the professional speaker qualified to discuss the medical and scientific aspects of cancer which are not included in film. Theme centers around a general practitioner deeply concerned because so many of his patients come to him when it is too late to be of help. His subsequent observation and reminiscences take the form of pictorial soliloquy which ends on a strong note of hope. (22 minutes) Enemy X Film opens with murder mystery technique to obtain audience interest. Story then goes into subject of cancer with “surprise punch” to retain interest and get across the message forcefully. For high school and adult groups. (15 minutes) From One Cell Designed to supply instructors with material. Presents the subject of cancer in an educational manner rather than a disease problem of concern primarily to adults. Planned to meet requests from biology teachers for a film which presents cancer from the student point of view. Intended for biology classroom use. It is not recommended for showing in general school assembly. (14 minutes) Man Alive A general purpose film on cancer. Designed to influence the attitude of the layman by showing the lack of good sense in fearing a cancer checkup. Presented in animated, cartoon style. Suitable for showing before any lay audience. 112 minutes} A Question In Time Asks and answers those questions about cancer which are most commonly addressed to doctor-speakers by lay audiences. Built around the theme that adults, as well as children, can let their imaginations lead them astray. Demonstrates how fear can be dispelled with proper knowl- edge, (22 minutes) Time Is Life Emphasizes the importance of seeking early medical advice when a danger signal of cancer appears; a discus- Some of the leaflets and booklets published by the New York State Health Department which deal with cancer and which can assist the physician. Copies of Department publications may be obtained with- out charge from city, county or district health offices and from the Office of Public Health Education, New York State Health Depart- ment, 84 Holland Avenue, Albany, \.Y. 12208. sion of such danger signals, methods of treatment. and the hope of cure. (19 minutes! The Traitor Within By means of animation, this highly constructive film. in a light and entertaining manner. tells the story of cancer. the cell growth, the lawless multiplication of gangster cells. the spreading of cancer hy lymph nodes and the possibili- ties of curing the disease through the use of surgery, N-ray and radium. For all types of audiences such as high school groups. women’s clubs, PTA’s. men’s organizations and others. (11 minutes) The Web of Life Stresses known facts concerning cancer. early symptoms, diagnosis and methods of treatment. Suit- Describes the able for general audiences. (25 minutes} You Are the Switchman Emphasizes the importance of seeking early competent medical advice in the treatment of cancer and the dangers in delay, quackery, proprietary medicine and any other unrecognized treatments. Also emphasizes the hope of cure. the three modes of treatment, and the importance of recog: nizing the early danger signals. (15 minutes) Breast Self-Examination Designed for adult women in women’s clubs. parent- teacher associations, church societies and social organiza- tions. A live model is used to explain the steps women can follow in. breast examination. Emphasizes that if breast cancer were suspected earlier hy women themselves. 80 per cent of the patients could be saved by surgery. It is recommended that a doctor be on hand at all showings to (16 answer questions and give a preliminary talk. minutes ) Living Insurance This colorful film tells how an isolated danger signal changed the lives of three generations of a eiven family. It points out in telling fashion what a thorough physical examination by a competent physician can mean in the con- trol of cancer. (15 minutes) The Warning Shadow This film is a dramatization of one of the first complete One sequence in animation shows cures of Jung cancer. ane 7 a The State Health Department’s Film Library has many lay an professional films available on cancer. Inquiries should be addressed to the Film Library Supervisor, New York State - Health Department, 84 Holland Avenue, Albany, N. Y. 12208 6 Physician imparts information on the incidence of breast cancer and the importance of early detection as part of a public education program. how lung cancer starts and how it spreads. Special emphasis is given to the importance of semi-annual chest X-ray examinations for men over 45, with the purpose of discover- ing any signs of possible lung cancer early enough for its complete cure. Suitable for showing before any adult audience interested in the prevention of lung cancer, includ- ing physicians, nurses, medical students and student nurses. (17 minutes) Horizons of Hope Cancer research is the theme of this motion picture. Skillfully combining live action and extremely clever cartoon animation, a clear, concise report is entertainingly presented of the progress researchers and medical scientists are making in the prevention and cure of cancer. It is not a “warning” film but rather one of encouragement and hope for the future. (18 minutes) 146 Thousand Could Live Dramatizes cancer’s seven danger signals and stresses the fact that cancer can be cured if diagnosed and treated in time. Five of the signals are represented by cured cancer patients, a sixth by a woman who lost her son to cancer, and the seventh by a man who noticed a danger signal in himself but upon being ‘examined found he did not have cancer, The film’s clear and powerful use of statistics and its direct simplicity, complete honesty and freedom from any false note of optimism on the one hand, or hysteria on the other, add to its dramatic interest. (28 minutes) Time and Two Women This film alerts women to the urgency of early detection of uterine cancer and explains the uterine cancer cell examination (the pap smear). It concludes with an appeal for them to go to their family physician once a year for pelvic examination even though they have no symptoms. The picture is recommended for showing to all women. (18 minutes) Hunt for a Cancer Killer This important motion picture details science’s deter- mined search for a cancer cure and the resulting dis- coveries which, although not providing the miraculous cure, nevertheless do impede the spread of the disease. It explores work now being done in the laboratory, hospital and in the field in an attempt to develop a chemical which will destroy cancer cells without harming healthy tissue. It also shows current work at the Brooklyn Botanical Garden aimed at finding a mold which may produce a cancer-killing chemical. (27 minutes) Sane Physicians register for Cancer Symposium to help keep informed of new developm ents. Life Story The film shows the importance of periodic medical examinations in preventing and discovering cancer. i emphasizes detection of cancer of the rectum and. colon. It is a satisfactory educational presentation quite suitable for any audience and is perhaps intended to allay the fears of lay persons who may seeit. (15 minutes) The Human Cell and the Cytotechnologist Animation sequences show how cells: behave and how an abnormal cell is a clue to cancer. A cytotechnologist in a pathology laboratory plays an important role in cancer detection as she screens slides of cells and works with the scientific team. Through her eyes, students interested in medical technology see an important and rewarding career. {22 minutes) Is Smoking Werth I? This film effectively contrasts scenes showing the iil effects of smoking with a discussion by four teenagers who think the possibilify of lung cancer is remote. It shows that by the time people begin to worry about lung cancer the smoking habit ig often so strongly entrenched that absten- tion is difficult. (19 minutes) The Million Club This is an excéllent film describing the seven danger ional cast. signals, and has been produced with a profe (29 minutes) Professional Education Postgraduate medical education is important for the private practitioner since he is the one person upon whose shoulders rests the greatest responsibility in re- gard to the cancer patient. Frequently, life and death >, depend upon his efforts to recognize precancerous le- sions, to diagnose cancer early, to render adequate trealment, and to secure competent consultation. Physicians are advised when special cancer courses are put on in their areas. Physicians interested in or- ganizing cancer leaching days for their county medical society usually plan them through their local health officer since funds for paying honoraria to speakers for these special programs can be arranged from the Bureau . of Cancer Control. The following films are available from the New York State Health Department film library and may help physicians in carrying out cancer education before pro- fessional groups. ‘After Masteclomy; Breast Cancer—The Problem of Early Diagnosis; Cancer Detection; Cancer of the Cen- tral Neryous System; Cancer of the Lung; Cancer of the er of the Thyroid: Cancer of the Uri Bladder: Cancer: The Problem of Early Hiagnosi foliative Cytologic Method in the Diagnosis of ¢ Cancer. The Hela Cell Strain; Lung rly Diagnosis; Management Cancer; Moles and Melanomas; Oral Cancer Problem of Early Diagnosis; Pancrcato- duadenal Resection for Carcinoma of the Head of the Postoperative Management of Colostomy; Diagnosis of Cervix by Cytology; Phe Psy- Aspects of Cancer. Head anid Neck Cance The Problem of E Pancreas: Precance thologic Radical Operation for Cancer of the Cervix; Routine Pelvic Examination and the Cytologic Method; Surgical ‘Treatment for Careinoma of the Lower d of the Esopliag gical Treatment for Splenic Flexure Carcinoma With Solitary Liver Metastasis; Teaching Speech After Laryngectomy; Tumors of Bone; Tumors of the Bronchi: Uterine Cancer—The Problem of Early Diagnosis; We Speak Again—The Rehahilitation of Laryngectomized Patients; Early Clinical Signs of Intra- oral Mal Oral Exfoliative Cytology; Cinegastroscopy With The Liberscope; Proctosigmoidoseopy——A Part of the. Physi- cal Examination; The Cancer Detection Examination; Lymphography in Female Genital Cancer; Radiother apy: High Dosage Treatment; Surgery in Chest Disease; Aldominoperineal Rescetion and the Management of stony. Cancer Incidence Date The State Nealth Department is able to publish annual incidence tables and other statistics in reference to can- cer because of the excellent cancer registry made pos- sible by the cooperation of practicing physicians in Upstate New York. Cases of cancer or other malignant tumors are required by law to be reported. Such case reports are sent to the fulltime health officer and then to the central registry in Albany. Physicians may obtain figures regarding local eancer incidence from their full- time health officer or from the Barean of Cancer Control since statistical summaries are sent to cach health officer annually, tabulating cancer data for his area as well as for the State as a whole. Such data could he helpful to the private practitioner in preparing discussions of the cancer problem for presentation before a hospital staff, county medical society, or public mecting. Nursing Service The public health nurse, working abvays under the direction of the patient’s own physician, can greatly ex- Advances in cancer diagnosis and therapy are discussed at hospital staff meeting. tend the effectiveness of the physician’s treatment plan in several ways: as skilled observer, trained nursing practitioner, and discriminating case finder. She is ex- perienced in observing and reporting promptly and accurately any signs and symptoms that may have real significance in the progress of a patient who has had cancer treatment. The public health nurse brings com- fort to the patient and family because of her trained ability to perform skillfully such nursing measures as dressings, bathing, positioning, feeding and toileting when the patient is unable to do these things for himself. Furthermore, she teaches a family member or friend techniques to provide for the patient’s comfort between her visits. Sometimes these techniques are related to the site of the cancer as, for example, when the nurse teaches colostomy irrigation, arm exercises following radical mastectomy, or the preparation and administra- tion of a nutritious and acceptable diet for the patient with oral cancer or advanced gastrointestinal cancer. The public health nurse can also be useful to the physi- cian in cancer case-finding and in patient follow-up. Formal and informal educational opportunities supple- ment and update her clinical knowledge of cancer and she uses this information effectively in alerting the pub- lic to the significance of certain deviations from normal health. She encourages the individual to secure a medi- cal opinion promptly and to follow through on any recommendations. During the sometimes extended pe- riod of diagnostic work-up for suspected cancer as well as following the period of treatment, the public health nurse can do much to keep the patient under the super- vision of his physician because of her ability to inter- pret his medical objectives to the patient. This often takes more time and repetition than the physician is able to give, and the nurse utilizes every contact with the patient and family to reinforce the established physician- patient relationship. Also, because of her knowledge of community facilities, she can often assist the physician in more effectively utilizing other community agencies in regard to rehabilitation. co The following is a list of Counties offering public health nursing services in UpstateNew York. The serv- ice is available to patients by referral of the private physician. Public Health Nursing Service County Available for Patient at Home Albany Co. Health Dept. Nursing Service Allegany Co. Nursing Service Broome Co. Health Dept. Nursing Service © Cattaraugus - Co. Health Dept. Nursing Service Cayuga Co. Health Dept. Nursing Service Chautauqua + Co. Health Dept. Nursing Service 10 County Chemung Chenango Clinton Columbia Cortland Delaware Dutchess rie Essex Franklin Fulton Genesee Greene Hamilton Jefferson Lewis Livingston Madison Monroe Montgomery Nassau Niagara Oneida Onondaga Ontario Orange Orleans Oswego Putnam Rensselaer Rockland St. Lawrence Saratoga Schenectady Schoharie Public Health Nursing Service Available for Patient at Home Co. Health Dept. Nursing Service Co. Nursing Service Co. Health Dept. Nursing Service Co. Health Dept. Nursing Service Co. Health Dept. Nursing Service Co. Nursing Service Co. Health Dept. Nursing Service Co. Health Dept. Nursing Service Co. Nursing Service Co. Nursing Service Co. Nursing Service Co. Health Dept. Nursing Service Co. Nursing Service ~ Co. Nursing Service Co. Nursing Service Co. Nursing Service Co. Nursing Service Co. Nursing Service Co. Health Dept. Nursing Service Co. Nursing Service Co. Health Dept. Nursing Service Co. Health Dept. Nursing Service Co. Nursing Service Utica City Health Dept. Nursing Service Co. Nursing Service Syracuse City Health Dept. Nurs-. ing Service Co. Nursing Service Co. Nursing Service Co. Health Dept. Nursing Service Co. Nursing Service Co. Nursing Service Co. Health Dept. Nursing Service Co. Health Dept. Nursing Service 3 Co. Nursing Service Co. Nursing Service City Health Dept. (Schenectady City Limits) Co. Health Dept. Nursing Service = Public health nurses can extend the effectiveness of the physician’s treatment plan and also be useful to the physician in cancer case- e finding, patient follow-up, and in many other ways. Public Health Nursing Service Cancer Detection Facilities County Available for Patient at Home 4 . . . Cancer detection programs or case-finding programs Schuyler Co. Nursing Service have been accepted by the organized medical profession as an important procedure in cancer control. The public Seneca Co. Health Dept. Nursing Service : : a . . has become increasingly aware of the value of periodic Steuben Co. Nursing Service ae By . wue OF P health examinations and of special examinations for the Suffolk Co. Health Dept. Nursing Servi P wire 0. Health Dept. Nursing service detection of cancer in apparently well people. Since can- Sullivan Co. Nursing Service cer detection is closely tied in with the whole field of Tompkins Co. Health Dept. Nursing Service ersonal preventive medicine, and since there is a recog- Pp P & p Pp g Ulster Co. Health Dept. Nursing Service nized need for periodic health examinations that are Warren Co. Nursing Service adequate, thorough and meaningful, cancer detection as Washi . . a principle cannot be abandoned or ignored. asnington Co. Nursing Service At the present time, cancer detection examinations Wayne Co. Nursing Service are carried out by many private practitioners in their Westchester Co. Health Dept. Nursing Service offices. The procedures include a careful history, inspec- Mt. Vernon Health Dept. Nurs- tion and examination of the accessible areas such as ing Service skin, oral cavity, breasts, pelvis and rectum, together New Rochelle Health Dept. Nurs- with laboratory tests such as uterine cytology and stool guaiac. Sigmoidoscopy should be done on individuals over 40. The educational material previously mentioned can be used by the physician for patients as an aid in ing Service Yonkers Health Dept. Nursing Service ; . a Lys . . Health Dept. Nurs . interpreting the kind of health examination he is doing. Wyoming Co. Health Dept. Nursing Service [Uterine cytology should be done on all adult female pa- Yates Co. Nursing Service tients receiving a cancer detection examination since it ll Physician performs complete pelvic examination, including speculum and bimanual, as part of cancer detection examination. js one of the most effective methods of case-finding that we have. Cytology reveals abnormal cells in secretions from the body of the uterus and cervix long before signs and symptoms develop. If the pathologist finds such cells, the patient is examined further and a biopsy is done. Thus, cytological examination of vaginal and cervical smears is an effective device in screening women without symptoms for evidence of uterine malignancy, and should be a part of the physical examination of every woman over 20, Physicians should promote such screening among special high risk groups, such as women in the lower socioeconomic levels and those attending clinics, such as prenatal clinics, planned parenthood clinics, or em- ployee clinics. A total of 186 local laboratories is ap- proved for cytology examinations Upstate. For those physicians who do not have access to an approved laboratory in their county, cytology service is offered by the Division of Laboratories and Research of the State Health Department in Albany. As of October 1, 1961, there were 11 counties in which approved labora- tory service was not available. The counties are Alle- gany, Delaware, Lssex, Northern Franklin, Hamilton, Herkimer, Putnam, Schuyler, Schoharie, Seneca, and Sullivan. Physicians in these counties can receive cytol- ogy kits from the Division of Laboratories and Re- search, Albany, and have smears interpreted without cost by the Division of Laboratories and Research. 12 Physicians who do not do cancer detection examina- tions may wish to refer their patient to one of the cancer detection clinics in their areas. Admission procedures to the clinics and fees vary, but no patient is refused ad- mission because of inability to pay. The State Health Department financially assists cancer detection centers in the medical school areas. The following Cancer Detection Centers operate in hospitals in Upstate New York: Albany Albany Albany Hospital Albany Memorial Hospital Dutchess Poughkeepsie ‘St. Francis Hospital (Oral Cancer Detection and Pre- vention Center | Lrie Buffalo k. J. Meyer Memorial Hospital Monroe Rochester Baden St. Health Center Nassau Ikmont Nassau Cancer Detection Center Bethpage Mid-Island Hospital Woodbury Waldemar Medical Research Foundation » ‘Cayuga Niagara Niagara Falls Suffolk West Islip Memorial Hospital Good Samaritan Hospital Gancer Diagnosis and Treatment Facilities Most individual later tind theniselves with a patient who has a suspected malig- nancy. Since time is critical, physicians may Ww ish to utilize the services of their local tumor clinic az an aid in diagnosis or in planning the treatment regimen. One may ask why use the services of a tumor clinic rather than a colleague as a consultant. Cancer is a protean disease. not limited to the scope of any one spec ialty. Hence it is almost impossible for any person, ree ardless of his professional qualifications, to recognize cancer mn every one of its manifestations. Proper treatment in a wiven case depends on many factors: the type of tumor. the extent of the disease, the age and general physical condition of the patient, etc. As a team, the surgeon. radiologist and pathologist achieve an enlarged and over-all view of cancer not possible to one who pursues his investigation in a limited field. The clinic represents an ageregation of physicians, a collection of o] vinions, practitioners sooner or and a joining of skills. Tumor clinics were first established by the American College of Surgeons in 1930 because it was recognized that the diagnosis and management of cancer patients demand the effort of a group of several specialists rather than an individual physician. Basically, the tumor clinic staff should consist of an internist, surgeon, pathologist, and radiologist, with other specialists on a consulting basis. Tumor clinics offer diagnostic, therapeutic. and consultant services. Only patients with symptoms or signs suspicious of cancer are accepted at a tumor clinic. The private physician can perform a great service to his community by using and supporting the services of his local tumor clinic. “Referral is usually through the family physician, and appointments are usually made in advance. Fee schedules vary but here again no patient is refused admission hecause of inability to pay. The State Health Department financially supports a number of these clinics. t umor clinics operating in Upstate New York are: Albany Albany Albany Hospital Albany Memorial Hospital Albany St. Peter’s Hospital Broome Johnson City Wilson Memorial Hospital Auburn Auburn Memorial Hospital Chemung hnira Chenango Norwich Delaware Walton Dutchess Poughkeepsie Erie Bullale Buffalo Bullalo Buffalo Bu Valo Franklin Saranac Lake Jeffersen Watertown Monroe Rochester Rochester Rochester Rochester Rochester Nassau Hempstead Mineola Oneida Ltica Onondaga Syracuse Ontario Clifton Springs Orange Newburgh Otsego Cooperstown Oneonta Rensselaer Troy Rockland Nyack Suffern Schenectady Schenectady Ulster Kingston St. Josephs Hospital Chenango Memorial Hospital Delaware Valley Hospital Vassar Brothers Hospital Buffalo General Hospital Mercy Hospital Children’s Hospital Ih. J. Meyer Memorial Hospital Roswell Park Memorial Institute General Hospital ef Saranac Lake Good Samaritan Hospital Genesce Hospital Highland Hospital Rochester General Hospital St. Mary’s Hospital Strong Memorial Hospital Meadowbrook Hospital Nassau Hospital St. Elizabeth Hospital Syracuse Memorial Hospital Clifton Springs Hospital / St. Luke’s Hospital Bassett Hospital Fox Memorial Hospital Samaritan Hospital Nyack Hospital Good Samaritan Hospital Ellis Hospital Ulster County Tumor Clinic 13 14 This cigarette smoking machine at Ros- well Park Memorial Institute, the State Health Department’s cancer research facility in Buffalo, is used to help deter- mine the correlation between cigaretie smoking and lung cancer. D Warren Glens Falls Glens Falls Hospital Westchester Mt. Vernon New Rochelle Port Chester Valhalla White Plains White Plains Yonkers Yonkers Mi. Vernon Hospital New Rochelle Hospital United Hospital Grasslands Hospital St. Agnes Hospital White Plains Hospital St. John’s Riverside Hospital Yonkers General Hospital Research No description of services and facilities available to cancer patients would be complete without mentioning the New York State Health Department’s cancer re- search hospital in Buffalo—Roswell Park Memorial In- stitute. This hospital has one of the most outstanding cancer research programs in the country, and provides hospital services for patients in connection with its re- search program. Each physician in the State ultimately benefits from such productive research. Various aspects of Roswell Park Memorial Institute’s program have been described in Health News, issues of January 1963. April 1963, April 1961. November 1958 and June 195°. Book Review... Summary Many services and resources are available to the Up- state physician to facilitate the effective detection. diag: nosis. lreatment. and rehabilitation of the cancer pa- tient. Educational materials about cancer are at his disposal for his patients and for the public at large, as well as for himself and his colleagues in order to extend and reinforce clinical information and experience, Sta- tistical data ean be obtained either from the local health officer or from the Bureau of Cancer Control. Such material is usually obtained from the cancer registry. The practicing physician has played an integral part in the development of the registry. An awareness of the statistical picture locally and in the Upstate area will help sharpen the focus of the physician’s attention in reference to the more common sites of cancer. most susceptible age groups, and over-all incidence trends. The physician can extend and enhance his services in the home hy using the services of qualified and skilled public health nurses for bedside care, teaching. super- vision of his patients, and for assistance in utilizing other community agencies and resources. Clinic facili- ties are also available in many areas for detection and assistance in diagnosis and treatment. The physician has many resources on which he can call. They are all geared to assist him since he is the keystone in the proper management of the cancer pa- tient. PRINCIPLES OF PUBLIC HEALTH ADMINISTRATION, by John J. Hanlon, M.D., M.P.H. (fourth edition). Sz. Louis: C. V. Mosby Company. 1964. $11.50, pp. 538. mp I HIS new edition of a well-accepted text is organized to give a broad view of public health administration. It contains liberal use of practical examples and personal experiences and is easily read. Written in a direct. straight-forward manner and at a very practical level. -this book is not for those who desire a deep discussion of administrative theory or public health practice. It should be of value to the student of public health and public health practitioners who desire an overview of public health administration. The first part of the new edition is devoted to the philosophy and history of public health and its relation- ship to the hehavorial sciences and social pathology. The second part covers governmental, legal, organizational, personnel, public relations, and fiscal considerations in public health. The third part deals with the present pat- tern of public health activities in the United States. Proper emphasis is given to addictive discases, chronic diseases and accidents. The text concludes with a brief look into the future. The organization of the material and the approach used make reading the text enjoyable. by Robert P. Whalen, M.D. Associate Commissioner Community Health Services N.Y.S. Department of Health 15 Activities Of The New York State Health Department In . Dp . . C h rome Respiratory Di SCaSC by Henry TH. Snunrz. M.D. Director, Bureau of Chronic Respiratory Disease New York State Department of Health Vue Bureau of Chronic Respiratory Disease was formally established in the New York State Health De- partment’s Division of Chronic Disease Services, April 1. 1964. The extent of the chronic respiratory disease I y problem was outlined. what is known about the epi- demiology was defined. and the known existing re- sources for control in Upstate New York were listed. A plan was developed which outlined the program ob- ] g jectives, proposed services and research studies. The new Bureau’s immediate predecessor was the Bureau of Tuberculosis Case Finding which was estah- lished in 1946. For 18 years it was engaged in finding new cases of tuberculosis hy the N-ray screening tech- nigue. Over the years this activity became less produc- tive and more expensive. Therefore, it was gradually discontinued. Tuberculosis case finding by examining contacts of known cases and people with symptoms, how- ever, was continued and intensified. During this period due note was taken of the increasing mortality from bronchitis and emphysema and the emergence of the chronic respiratory diseases as a major health problem. Development of The Program Consequently, in the summer of 1962, the Director of the Bureau was assigned full-time to develop a pro- gram plan for chronic respiratory disease. The plan was completed in June 1963 and was approved by the Com- missioner of Health. Some months later it was approved by the Division of the Budget. Without entering into a detailed account of the extent 16 of the problem, it should be pointed out that from 1950 to 1960 the tuberculosis death rate in Upstate New York declined from 26 to 7, while the death rate from bronchitis and emphysema rose from 4 to 14. Actual prevalence data are not available but it is estimated that at least 10,000 persons are disabled from chronic res- piratory disease in Upstate New York. In addition. little :; known about the basic causes of obstructive airway disease, the results of treatment of the so-called “early” case or the natural history of these conditions. As the first step in initiating a plan of study and re- search, a medical advisory committee to the new Bureau was appointed. The committee consists of seven mem- bers, experts in the fields of pulmonary physiology. epidemiology, clinical and administrative medicine. The program of the new Bureau is as follows: Research on Pathophysiology and Treatment Several hospital-connected centers in Upstate New York study and treat patients with advanced bronchitis and emphysema. However, their facilities and personnel are limited. Each program director questioned indicated . more patients could be eared for and more basic clinical research carried out if services could be expanded, Iy- pansion of such facilities would enable more patients with “early” or “moderately advanced” bronchitis and emphysema to be studied in relation to the effect of proper care and improved treatment and rehabilitation on the cause and natural history of their diseases. Therefore, a major research center will he established ‘B to carry out basic research and clinical studies on in- patients and outpatients. The center will be associated with one of the medical centers in Upstate New York. Epidemiological Studies Two carefully planned investigations of prevalence of obstructive airway disease are under way in New York State: one in the Buffalo area and one in New York City. No others have been done in the Upstate area. Surveys of rural or semi-rural population groups and of selected industrial groups should prove fruitful. These surveys will employ the standard questionnaire, a spirographic tracing and a chest X-ray. These studies will be planned to control for age and for smoking before assessing the effect of other varia- bles such as air pollution. Coordination of epidemiologi- cal surveys with measurements of the levels of various pollutants should provide valuable information. It must be emphasized that such surveys will be solely for investigational purposes and will not be utilized as a case-finding activity for chronic pulmonary disease. Of course, persons whose tests indicate the possible presence of disease will be referred to their physicians. In addition, the epidemiology program will gather in- formation regarding morbidity and mortality from all available sources, such as death certificates and hospital discharge diagnoses. in order to determine the size of the problem. The Natural History of Disease Long-term longitudinal studies are needed to learn more about the prevalence of these conditions, particu- Facing the camera during a press conference called by Dr. Hollis S. Ingraham, New York State Health Commissioner, to announce the estab- lishment of the Bureau of Chronic Respiratory Disease in the State Health Department are, from left to right: Dr. 1. Jay Brightman, Assistant Com- missioner for the Division of Chronic Disease Services; Dr. Ingraham: Alexander Rihm, Jr., Director of the Bureau of Air Pollution Control Services; and Dr. Henry Shultz, Director of the new Bureau. ESTIMATED NUMBER OF DAYS PER YEAR OF RESTRICTED ACTIVITY AND BED DISABILITY ASSOCIATED WITH ACUTE CONDITIONS, NEW YORK STATE, 1962 DAYS PER 100 PERSONS PER YEAR 0 100 200 300 ' ESTIMATED 400 500 600 DAYS PER YEAR C T q infectious and Parasitic T 1 1 (in millions) 27.7 12.3 Respiratory 59.1 23.2 Digestive - Injuries = All other acute conditions 6.1 2.8 31.1 C__} Restricted Activity 51 GH Bed disability 22.2 7.5 BASED ON DATA FOR NORTHEAST REGION OF UNITED STATES FROM NATIONAL HEALTH SURVEY, JULY 1960-JUNE 1961 Respiratory diseases are responsible for more bed disability and restricted activity in New York State than any other acute condition. larly which persons may develop disease over the years and how rapidly or slowly disease progresses. An oppor- tunity for such a study presents itself as part of the State Employees Health Services being developed by the New York State Department of Civil Service. This Department plans an elaborate health service for State employees, including comprehensive pre-employment and periodic physical examinations, health counseling, etc. All treatment problems will be referred to the indi- vidual’s private physician. It is estimated that 10,000 to 12,000 persons will be involved in the Albany area. Each person participating in this study will be ad- ministered a standard questionnaire on respiratory symptoms, a chest X-ray film, and certain tests of pul- monary function. Previous studies indicate the preva- lence of obstructive airway disease varies from 2.5 per cent to 30 per cent, depending on many factors, such as age, sex, smoking habits and the like. In a cross section of the population, it is likely that the low prevalence rates would apply. Consequently, it is esti- mated that between 200 and 300 people will be found to have evidence of chronic respiratory disease. 18 Confirmatory Tests These persons will undergo certain confirmatory tests. They will then be examined at intervals and objective evidence of changes in the disease process will be ob- tained. Since bronchitis and emphysema are usually slowly progressive, the study will have to be continued for a period of ten or more years. In this way, evidence will be collected that might shed light on which patients will progress to severe disability and which will remain stationary or regress. In addition, the results of treat- ment and preventive measures such as cessation of smoking can be evaluated. It must be emphasized that this study will probably include only those individuals with mild or moderate ventilatory impairment. To act as controls, a similar group of employees who present no signs or symptoms of chronic respiratory disease will be followed in the same manner by the same tests. The control group will be matched for age, sex, smoking habits and the like. This procedure will provide further epidemiological information regarding the incidence of these conditions and might aid in the identification of those who develop these conditions. n A spirometer, used to test lung function, ts demonstrated in the exhibit area of a medical conference. Professional Education A need for education and training of health personnel in the chronic respiratory disease field is widely con- ceded. For years emphysema was “the forgotten dis- ease” and little emphasis was placed on the management of this and similar conditions. The average practitioner is apt to refer all chronic pulmonary patients, including those with tuberculosis, to appropriate specialists since he feels he can do little for such patients and is not equipped to carry out the necessary physiological studies required for accurate evaluation. The State Health Department, in cooperation with the Medical Societies, the American Thoracic Society, the American College of Chest Physicians, and the New York State Tuberculosis and Respiratory Disease Asso- ciation and its local afhliates, will sponsor educational efforts directed not only to physicians but also to the paramedical groups. Numerous media can be used, such as staff meetings of hospitals, meetings of county medi- cal societies, formal courses in diagnosis and manage- ment of chronic respiratory diseases, and two-way radio conferences. Summary In view of the mounting problem of chronic respira- tory disease, the New York State Department of Health has established a Bureau of Chronic Respiratory Dis- ease which will be concerned with the three broad fields of research: basic pathophysiological research, epidem- iological studies, and a long-term longitudinal study of the natural history of obstructive airway disease. In cooperation with other agencies, educational efforts will be directed to practicing physicians and other pro- fessional groups. It is anticipated that in all the activi- ties of the Bureau there will be a close working relation- ship with the State and local tuberculosis associations. 19