[ Film running ]

[Cancer Among Veterans, Early Diagnosis]

[Presented by The Administrator of Veterans' Affairs.]

[Produced by Division of Motion Pictures, Department of the Interior.]

[Under the direction of Veterans Administration Exhibits Committee. Photomicrography by L. H. Prince, M. D., Hines, Illinois. Photography by Walter K. Scott.]

[Narrative by... Max Cutler, M. D., Consultant, Tumor Clinic, Veterans Administration Facility, Hines, Illinois.]

[Narrator:] Under the direction of the Administrator of Veteran's Affairs, the Veteran's Administration is making every effort towards furnishing ex-servicemen with the benefits of early diagnosis and the prompt and skillful treatment of cancer.

This parent hospital at Hines, Illinois provides more than 400 beds for tumor cases and serves as a training ground for physicians selected to specialize in the diagnosis and treatment of this disease.

Leaving the beautiful and spacious grounds, we enter the hospital where the Tumor Board is in session and hear the voice of Dr. Max Cutler, consultant in tumors at the Hines facility, who will present his subject the early diagnosis of cancer. Dr. Cutler.

[Dr. Max Cutler:] Early diagnosis is the keystone to cancer control. An accurate diagnosis is the basis of correct and effective treatment.

All the progress that has been realized in the surgical and radiation treatment of cancer is of no avail unless the lesion is recognized early and treated correctly before it has become disseminated.

[Dr. Max Cutler:] Thus early diagnosis resulting in the elimination of precancerous conditions and in the cure of early cancer is by far the most important single factor in the curability of this disease.

The external cancers can be detected in their very early stages and are both presentable and curable. The internal cancers unfortunately present a much more complex problem.

And although much can be accomplished by careful attention to early diagnosis, real progress in this group awaits the discovery of a diagnostic test much more delicate then is now available.

We will now consider three forms of cancer which pass through definite precancerous stages and are, therefore, not only curable but preventable.

Cancer of the mouth, preceded by leukoplakia; cancer of the skin preceded by hyperkeratosis; and melanoma preceded by apparently innocent moles.

We begin with leukoplakia, one of our most important precancerous conditions. This lesion is ten times as common in men as in women. Hence, 90 percent of cancers of the mouth occur in men.

The well known relation between tobacco and leukoplakia has given rise to the term, "Smoker's patch."

Here you see a leukoplakia of the mucous membrane of the cheek in which smoking is the etiological factor. An underlying susceptibility of the tissues to nicotine must be present for leukoplakia to develop.

In susceptible individuals, it is probable that infinitesimal amounts of the stimulating chemical agent can result in this condition.

The relationship between leukoplakia and cancer is well-illustrated in this case, where you see an intense radiation reaction after treatment of a cancer of the right cheek, which developed in a patch of leukoplakia.

Leukoplakia often occurs at the site of artificial dentures as in this case. Here we see a diffuse leukoplakia of the roof of the mouth in a patient whose mucous membrane is evidently susceptible to chronic irritation and to nicotine.

A combination of factors is usually responsible for this type of lesion. When a patch of leukoplakia begins to undergo malignant degeneration, it exhibits certain clinical signs.

It becomes thickened and somewhat indurated and its surface becomes fissured and eroded. In this stage the lesion is either precancerous or already fully malignant.

True ulceration almost invariably means that carcinoma has become established. When these clinical signs appear, a biopsy is usually necessary to establish the diagnosis of cancer.

In this connection it should be emphasized that a negative biopsy by no means excludes the presence of cancer and one must be guided largely by the clinical picture.

Dental caries is etiologically related to cancer of the oral mucous membrane. A sharp or broken tooth can produce repeated trauma to the adjacent mucous membrane and results in a traumatic ulcer and finally in carcinoma.

This is a remarkable example of this type. Note the precise relationship between this jagged tooth and the lesion in the mucous membrane of the cheek. Removal of the source of irritation results in prompt disappearance of the ulcer when it is only inflammatory.

Leukoplakia of the oral mucous membrane frequently arises at the site of dissimilar metal fillings in patients who are non-smokers and in the absence of both non-specific inflammation and syphilis.

The development of the leukoplakia at the exact site of the dissimilar filling as in this case and the absence of other etiologic factors constitute significant evidence of this probable relationship.

The lateral border of the tongue being in close proximity to carious and infected teeth is a common site of leukoplakia. The dorsum is affected more commonly when the lesion is diffuse. Often it is on a syphilitic basis.

Extensive diffuse leukoplakia is usually associated with syphilis. The cancers of the lip and tongue are quite independent. Each arose in a separate patch of leukoplakia. Such lesions may arise simultaneously or they may be separated by months or years.

The prognosis of cancer of the mouth associated with syphilitic leukoplakia is extremely grave.

The modification in the connective tissue and blood vessels resulting from the syphilitic infection has a most unfavorable influence upon the surgical and radiation result and a cure is almost never accomplished in spite of the efficiency and thoroughness of the treatment.

In spite of the early signs they produce, cancers of the oral cavity still reach an advanced stage in many patients. The last two cases are examples of this fact.

Cancer of the lower lip is overwhelmingly a disease of men. The lesion begins as a small localized nodularity which has to be differentiated from a benign hyperkeratosis.

Lesions of this extent are readily curable by surgery or by irradiation. In later stages the disease spreads to the adjacent skin and oral mucosa. And the lesion becomes indurated, ulcerated and painful as in this example.

Lesions of this extent are usually accompanied by cervical adenopathy and when the growth approaches or crosses the midline, one must assume that the adenopathy is bilateral, even though this is not demonstrable clinically.

A projecting tooth, especially when it is sharp, sometimes traumatizes the lip causing first an ulcer than a carcinoma. This is a clinical example. Note the precise anatomical relation between the tooth and the carcinoma.

[ Showing lesion on lip ]

Cancer can begin in the mucous membrane of the upper or lower lip or cheek as a small, firm, circumscribed and movable tumor, which grows slowly and remains non-ulcerated for a long time.

These lesions originate in the epithelium of ducts of mucous glands. Because they are non-ulcerated and freely movable they resemble simple benign mucous cysts and are invariably so diagnosed.

They are usually removed inadequately and recur promptly. They are often highly malignant and unless this peculiar type of carcinoma is diagnosed properly and treated correctly the first time, the results are disastrous.

[ Feeling around chin ]

The differential diagnosis of cancer of the mouth must consider benign papillomatous lesions, primary and tertiary syphilis, papilloma durum of the tongue, tuberculosis and mixed tumors of salivary glands.

Here we have two cases of tuberculosis of the mouth. Tuberculosis of the tongue is rare. When it occurs, it is usually associated with an active pulmonary lesion. Tuberculous ulcerations appears as a flat non-indurated lesion which is painful and tender.

The ulcer lacks the surrounding infiltration and induration which is so characteristic of carcinoma. When the nature of the lesion is in doubt clinically a biopsy should be performed to establish the diagnosis with certainty.

The aberrant salivary glands give rise to an interesting and peculiar group of tumors. In the mouth these tumors arise within the cheek, the lip, the base of the tongue and the soft palate. Salivary glands and tumors of the soft palate may reach a large size as seen in this case.

The small tumors are generally cured by wide surgical removal. Inadequate excision is followed by prompt recurrence. When these tumors reach a large size and recur in older individuals, the patient's comfort and life expectancy are often benefited by a conservative course.

The chief points in the differential diagnosis are their location, their slow growth, and the fact that they remain circumscribed for long periods. Unlike the carcinomas, they remain non-ulcerated for many years in spite of their large size.

There are three main types of skin cancer. This is the basal cell form and it's commonly referred to as "rodent ulcer." The next is the squamous cell type with [inaudible] and pearl formation.

And the third is the adenoid cystic type, which is usually classified as a sub-variety of basal cell cancer. The majority of cancers of the skin appear on the face.

Adenoid cystic carcinoma of the skin is a form of basal cell cancer. This type is often multiple and commonly affects the eyelids, forehead and nose.

The lesions are first elevated, then ulcerated. As a rule they are more radio-resistant than the typical basal cell carcinomas.

The nose is a common site of cancer of the skin. The majority of the basal cell type, regional metastasis generally does not occur until the lesion has involved the mucous membrane.

A great effort should be made to cure these skin lesions at the first attempt, for each recurrence presents greater difficulty. The first therapeutic procedure, be it surgery or irradiation, generally seals the patient's fate.

The crucial importance of eradicating the disease the first time can hardly be exaggerated. Advanced lesions such as these can be avoided only by early diagnosis and thorough treatment when the patient first comes under observation.

Here is a basal cell carcinoma of the lower eyelid. The lesion is early and easily curable. A surface application of radium administered under correct conditions results in almost certain cure. But those must be the maximum which the normal tissues will tolerate.

Here is a basal cell carcinoma of the nose, which has been treated and is beginning to undergo repair. Note that the edges of the lesion have disappeared.

Seventy-five percent of cancers of the eyelid are of the basal cell type. Regional lymph node metastasis occurs in 20 percent. The inner [inaudible] of the lower eyelid is the most common site.

In this case a carcinoma of the left lower eyelid has disappeared after irradiation. But the sterilization was incomplete and several years later an extension of the disease developed. Adequate irradiation as a rule avoids this complication.

Here we see one of the great tragedies of this disease. How long did this patient wait before consulting his physician?

Did the physician choose the best method of treatment? How accurately and skillfully was the treatment executed?

These are the searching questions we as physicians must constantly keep before us. Carcinomas of the scalp grow very slowly and almost never invade the regional lymph nodes.

They tend to adhere to the underlying bone and are usually first seen in their late stages. Curable in the beginning, these lesions ultimately destroy the bone and involve the meninges and the brain.

Note the pulsation of the brain in this tragic case.

And now we come to the story of what can happen to an apparently innocent mole. There are few tragedies in the whole realm of medicine that equal the complications which sometimes develop in connection with these apparently innocent lesions.

Since the average individual harbors about 20 moles, the malignant transformation of a mole is comparatively rare. Traumatism plays an important role in transforming the course of a benign nevus.

Moles, which are so located as to be subjected to repeated trauma and moles showing clinical signs of activity should be treated by careful and complete surgical removal.

You have just seen a fleshy, pedunculated mole, a type which is removed without danger. The hairy non-segmented mole belongs to the same category.

Pigmented macules are common and my be single or multiple. They may be present at birth or develop later in life. The danger of melanoma is slight. They should be removed only on the indications mentioned.

It is the flat bluish black or brownish black mole that is the most dangerous of all. And here we see a remarkable example of malignant transformation of a bluish black mole.

Metastases to the regional lymph nodes are already present. Microscopic examination of a melanoma may disclose all of the cellular features without showing the presence of pigments or the characteristic brown intracellular pigment may form a striking feature of the microscopic picture as you see in this photo microgram.

Extensive metastasis to the axillary lymph nodes has occurred in this case following excision of a pigmented mole on the left forearm.

Sometimes invasion remains limited to one or two regional lymph nodes for a long time. And it is in this group that radical dissection has resulted in apparent cure in isolated cases.

The scar on the left forearm indicates the site of excision of the primary melanoma. Melanoma may affect the scalp and metastasize to regional lymph nodes as in this case.

Metastasis to axillary and supraclavicular glands also occurred in this case following traumatic treatment of a mole on the left arm. Electrodessication is uncertain and probably dangerous.

Careful and complete surgical excision offers the safest course. The presence of small secondary nodules around a melanotic tumor is an important sign of its malignant nature.

The heel is a favorite site for melanomas. This lesion was already accompanied by pulmonary metastasis when first examined.

In discussing early diagnosis it is necessary to review the steps to which a lesion passes before it becomes malignant. In other words, we must attempt to form a mental picture of the nature of the cancer process.

We are now fairly certain that cancer is not a sudden event or an accident in a previously normal tissue, but on the contrary it is the result of a series of changes, which may have begun many years before.

A combination of factors seems necessary for the initiation of abnormal growth. Hereditary susceptibility unquestionably plays a part, an excess or deficiency of certain hormones and probably the presence of certain chemicals we call carcinogenic agents combined to initiate excessive growth of cells.

We have learned the remarkable fact that abnormal cell growth need not necessarily result in clinical cancer. At one extreme the growth may be so rapid as to overwhelm the individual in a short period of a few months.

And at the other extreme the growth may be so slow that the patient does not live long enough to develop clinical cancer and he dies of other causes, harboring one or more precancerous lesions.

Thus certain precancerous lesions require 10 years, others 20 years, still others 30 years to reach the stage of clinical cancer. And it is well known that the older we get the more chances we have of developing this disease.

There is also considerable evidence to indicate that precancerous lesions can regress and perish in the body as a result of some defensive mechanism, the nature of which we do not yet understand.

And it is probable that even fully established cancers can under certain conditions cease to grow, regress, and even disappear.

When we use the term precancerous we generally think of it in microscopic terms. We mean a lesion which exhibits all the morphological features of cancer, but which has not yet escaped outside normal boundaries.

We must remember, however, that the morphological appearance of a cell is a very crude index of its biological state and even a less accurate guide as to its future intentions.

Thus the group of neoplastic epithelial cells confined within the normal boundaries of the duct of the breast may be ready to invade the lymphatics and blood vessels immediately, or they may remain stationary for many years or they may regress and disappear.

And yet, the microscope, as a rule, can neither distinguish these cells nor predict their future. Thus it is evident that cancer is a highly complex clinical, pathological and biological problem.

Through the medical and hospital service the Veteran's Administration has developed over the past 10 years an organization for the study and treatment of cancer that is unique in the world.

In addition to the Hines Tumor Clinic, there are five subsidiary units in the five geographical areas into which the country is divided, each representing a unit organized, equipped, and manned to offer to the veterans suffering with cancer the latest knowledge in diagnosis and treatment of this disease.

An elaborate system of records is maintained and a register of tumor cases has been established, which permits a study of resultant treatment.

In addition to highly trained full-time personnel, all six units have consulting staff composed of some of the leading experts in their field whose help and advice are available when special problems arise.

The Hines facility is not only a hospital but is a practical governmentally controlled training school as well. For doctors, it presents a broad opportunity to study diseases, inviting new methods of eliminating suffering.

For patients, the library facilities and the many phases of properly supervised occupational therapy such as wood carving, weaving, metal work, recreation, etc. offer a greater incentive to develop new channels of thinking.

Today this great facility at Hines is considered the largest government hospital of the Veteran's Administration, a monument which should continually inspire us to strive to conquer this dread disease.

It is with such institutions as this that the helping hand of the United States government, extended through the Veteran's Administration, practically demonstrates its appreciation of the spirit and loyalty of its veterans.