WEBVTT 00:00:01.890 --> 00:00:05.040 [Passed by the Committee on Medical Motion Pictures American College of Surgeons, 1949] 00:00:05.040 --> 00:00:12.710 [Cancer, Copyright MCMXVLIX -- American Cancer Society, Inc.] 00:00:12.710 --> 00:00:21.430 [The Problem of Early Diagnosis, Copyright MCMXVLIX -- American Cancer Society, Inc.] 00:00:21.430 --> 00:00:31.360 [Presented by The American Cancer Society and The National Cancer Institute of the U. S. Public Health Service] 00:00:31.360 --> 00:00:40.380 [Produced by Audio Productions, Inc., New York, N. Y.] 00:00:41.190 --> 00:00:49.690 [This first film in a series for the medical profession is general in scope.] 00:00:49.690 --> 00:00:59.510 [Subsequent films will deal with Cancer by specific sites.] 00:01:02.620 --> 00:01:13.830 [Narrator:] The time, the year 1881, the place, the General Hospital in the city of Vienna, Austria. 00:01:13.830 --> 00:01:19.540 [ Music ] 00:01:19.540 --> 00:01:45.320 Theodor Billroth, teacher of medicine, pioneer surgeon, the event so important that medical history records it as the beginning of a new era. The problem: to attempt a cure for a disease as old as humanity. 00:01:45.320 --> 00:01:54.140 [ Music ] 00:01:54.140 --> 00:02:12.090 The patient, Theresa Heller, admitted to the hospital four days ago, symptoms: Gastric pain for three months. Her diet, a few spoonfuls of sour milk daily. 00:02:12.090 --> 00:02:27.700 Pulse: Thready. Evening temperature: 38.2 Centigrade. Diagnosis, carcinoma of the pylorus. 00:02:27.700 --> 00:02:30.390 [ Music ] 00:02:30.390 --> 00:02:36.620 Up to this time no malignant tumor of the stomach had ever been successfully removed. 00:02:36.620 --> 00:02:41.900 [ Music ] 00:02:41.900 --> 00:02:51.280 The hazards attending such an operation were many. The ever-present threat of infection. 00:02:51.280 --> 00:03:09.330 The possibility of surgical shock. The dangers of prolonged anesthesia. The knowledge that others had failed. 00:03:09.330 --> 00:03:23.550 But pitted against this was Billroth's conviction that this was an early lesion, an operable case, that his years of research could now be applied to the aid of a human being. 00:03:23.550 --> 00:03:31.310 [ Music ] 00:03:31.310 --> 00:03:38.960 Complete removal of the diseased tissue was the only way to prevent this patient's certain death. 00:03:38.960 --> 00:03:46.240 [ Music ] 00:03:46.240 --> 00:03:57.220 But removal of the cancer was not enough. A safe and adequate repair was of equal importance. 00:03:57.220 --> 00:04:13.400 As history now knows, this operation, the Billroth I was a success. More than any other fact, it proved the importance of early diagnosis followed by prompt adequate treatment. 00:04:13.400 --> 00:04:23.670 [ Music ] 00:04:23.670 --> 00:04:35.680 Today, gastric cancer is still a serious medical responsibility. Today, as in Billroth's day, surgery offers to the patient the only hope of cure. 00:04:35.680 --> 00:04:46.130 However, thanks to the great technical and intellectual progress achieved in all branches of medical science, the management of the cancer patient is vastly improved. 00:04:46.130 --> 00:05:17.440 [ Music ] 00:05:17.440 --> 00:05:29.030 The surgeon today, as did Billroth, intervenes in gastric cancer in the hope that the disease is limited solely to the stomach. 00:05:29.030 --> 00:05:44.910 With this in mind, careful palpation of known sites of spread and of the stomach determines the extent of the disease in these areas. 00:05:44.910 --> 00:05:59.840 Radical resection of the omentum together with wide clearance of the lymph nodes is a routine measure to remove all possible disease. 00:05:59.840 --> 00:06:09.130 In the Billroth tradition, the pyloric tumor can now be isolated by a safe margin of the duodenal segment. 00:06:09.130 --> 00:06:16.750 Similarly, the major portion of the gastric segment will be sacrificed. 00:06:16.750 --> 00:06:35.290 In most of the modifications of the Billroth operation, the duodenum is closed and the re-approximation of the remaining portion of the stomach with the small intestine is established. 00:06:35.290 --> 00:06:47.140 The resultant anastomosis, tension-free and airtight, will permit the patient normal dietary comfort with but slightly modified dietary habit. 00:06:47.140 --> 00:07:00.980 Thus, the operation initiated by Billroth more than 60 years ago remains today the only treatment of gastric cancer that offers any hope of cure. 00:07:00.980 --> 00:07:18.330 Of five major sites for malignant neoplasms, cancer of the stomach has the third highest incidence. However, of the mortality averages for these sites, the mortality of gastric cancer is among the highest. 00:07:18.330 --> 00:07:30.440 This disease causes more than one-fourth of all cancer deaths. The reason for this high mortality is seen in the clinical behavior of cancer of the stomach. 00:07:30.440 --> 00:07:46.030 Although cancer may occur primarily in any area of the stomach, more than three-fourths of these lesions occur in the region of the pylorus. Dyspepsia or indigestion is the most common first complaint. 00:07:46.030 --> 00:07:57.580 Here, as the cancer continues to grow, mechanical obstruction may take place. As a result of this growth, pain unrelated to food becomes evident. 00:07:57.580 --> 00:08:10.750 In addition, there may be loss of appetite, vomiting, and fatigue. It is in this stage of disease, and because of these symptoms, that the average patient sees his physician. 00:08:10.750 --> 00:08:32.000 At the time of surgical exploration, often delayed as much as several months, the disease is usually found to have invaded the regional lymph nodes; however, one-third to one-half of all patients seen in this stage are still candidates for resection. 00:08:32.000 --> 00:08:50.890 Nevertheless, despite radical resection, the tragic factor of delay permits local recurrence of disease together with distant metastases, which result in the deaths within five years of three-fourths of these patients. 00:08:50.890 --> 00:09:06.500 These deaths added to all other gastric cancer deaths account for the dark overall picture of gastric cancer. Any appreciable reduction of this mortality requires that cancer be suspected while it is still confined entirely to the stomach. 00:09:06.500 --> 00:09:17.620 Unfortunately, this clinically young lesion provides little evidence upon which to hang this suspicion either by the patient himself or by his physician. 00:09:17.620 --> 00:09:27.170 As a rule, the gastric cancer patient is a mature adult with a complaint of vague dyspepsia, whose tentative diagnosis is gastric ulcer. 00:09:27.170 --> 00:09:36.980 In other cases, the only early complaint may be unexplained loss of weight associated with some degree of secondary anemia. 00:09:36.980 --> 00:09:45.570 And sometimes the symptoms may not be suggestive of gastrointestinal disease at all. 00:09:45.570 --> 00:09:58.210 In general, a mass is not palpable in early gastric cancer. Although these symptoms -- chronic dyspepsia with or without pain, anorexia, weight loss, secondary anemia -- 00:09:58.210 --> 00:10:06.570 are suggestive of many disorders, the most serious single disease, which may cause one or any of them, is cancer. 00:10:06.570 --> 00:10:15.290 Therefore, whenever this suspicion exists, the patient should be given the benefit of a thorough examination. 00:10:15.290 --> 00:10:25.200 [Only the physician's high index of early suspicion, followed by accurate diagnosis, can make possible the benefits of effective treatment.] 00:10:25.200 --> 00:10:47.210 [Narrator:] Early suspicion, accurate diagnosis, effective treatment -- by application of this triad of management, early stomach cancer can be excised sufficiently to reduce the likelihood of recurrence. 00:10:47.210 --> 00:10:58.750 The statistics in such cases of early gastric cancer show a mortality decrease of nearly half. 00:10:58.750 --> 00:11:11.040 A similar result can be achieved in breast cancer. Of the four quadrants of the breast, the upper outer quadrant is the usual site of cancer. 00:11:11.040 --> 00:11:22.760 Regardless of site, however, the behavior of breast cancer is quite uniform. In its early stage, this tumor, like most cancer, develops silently. 00:11:22.760 --> 00:11:36.790 However, as growth continues, the connective tissue is involved, resulting in flattening or dimpling of the skin. By the same process, there is often retraction of the nipple. 00:11:36.790 --> 00:11:50.760 In addition, the regional nodes become involved because of lymphatic spread. It is at this stage of disease that the average patient is seen by her physician. 00:11:50.760 --> 00:12:04.550 The treatment permitting the greatest chance for survival is a radical mastectomy. However, about three out of four patients so treated will succumb within five years, 00:12:04.550 --> 00:12:20.290 due to a local recurrence and to distant metastases to the supraclavicular nodes, the other breast, and to the lungs and bones. 00:12:20.290 --> 00:12:36.540 These cases, together with other breast cancer fatalities, result in this statistical picture. Any reduction of this mortality requires that breast cancer be suspected while it is confined entirely to the breast. 00:12:36.540 --> 00:12:52.340 The mass of early breast cancer, however, maybe interpreted as benign disease. Palpation alone is not enough to differentiate between a benign and a malignant mass. 00:12:52.340 --> 00:13:03.700 Visualization of the breast in various positions may be required before eliciting a diagnostic sign of early cancer. 00:13:03.700 --> 00:13:14.820 This sign, skin retraction, so consistent in malignancy, should call for an immediate microscopic examination of suspected tissue. 00:13:14.820 --> 00:13:23.590 [Early Suspicion, Accurate Diagnosis, Effective Treatment] 00:13:23.590 --> 00:13:41.650 A local excision and examination of all breast tumors should be made in the operating room. If the excised mass is found to be malignant, a radical mastectomy can be performed immediately. 00:13:41.650 --> 00:14:15.390 Except in rare cases, a simple mastectomy has no place in the surgery of breast cancer. Adequate flap development permits better exposure of the operative field. This exposure makes possible thorough removal of both pectoral muscles. 00:14:15.390 --> 00:14:37.930 Removal of the pectoral muscles now permits meticulous dissection of the axilla. 00:14:37.930 --> 00:14:53.930 Only by such radical dissection, can suspected areas of spread be included in the removal of the breast itself. In a great majority of cases following this operation, the patient will have the normal use of her arm. 00:14:53.930 --> 00:15:16.340 But what is vastly more important, the diseased breast has been excised widely enough and early enough to diminish the probability of recurrence. Thus, the mortality of early breast cancer can be effectively reduced. 00:15:18.590 --> 00:15:26.120 Cancer of the large bowel offers an equal challenge. In as much as nearly half of these growths occur in the rectum. 00:15:26.120 --> 00:15:42.300 Cancer of the rectum usually begins as a lesion confined to the mucosa. As it grows, however, ulceration of the mucosa takes place, producing intermittent rectal bleeding. 00:15:42.300 --> 00:16:01.370 At the same time, mechanical venous blocking may initiate hemorrhoids. A surprisingly large number of patients are treated for hemorrhoids without any investigation made to rule out the possibility of underlying cancer. 00:16:01.370 --> 00:16:13.780 As further growth of the tumor takes place, intraluminal obstruction produces constipation or diarrhea or both alternately with the stools frequently containing mucus and blood. 00:16:13.780 --> 00:16:32.760 It is with these symptoms and in this stage of disease that the patient generally sees his physician. An abdominoperineal resection offers this patient the best opportunity for survival. 00:16:32.760 --> 00:16:49.210 But here again, the frequent delay of treatment results in the recurrence of disease, both locally and distantly, and accounts for the deaths within five years of more than three-quarters of these patients. 00:16:49.210 --> 00:17:01.450 These losses from recurrence together with cases considered inoperable result in the high mortality of rectal cancer. 00:17:01.450 --> 00:17:17.320 Since more than half of rectal cancers originate within reach of the examining finger, here is the first and perhaps simplest line of attack against this disease. 00:17:17.320 --> 00:17:26.930 If a rectal lesion is suspected or if rectal symptoms are present, the patient should immediately be given the benefit of a thorough examination. 00:17:26.930 --> 00:17:38.820 This should, in addition to the digital examination, include proctoscopy and x-ray together with microscopic study of tissue specimens. 00:17:38.820 --> 00:17:44.690 [Early Suspicion, Accurate Diagnosis, Effective Treatment] 00:17:44.690 --> 00:18:01.890 In the treatment of rectal cancer, the rectum is first approached through an abdominal incision. This is necessary in order to free the lower bowel, a considerable segment of which must be included in the resection. 00:18:01.890 --> 00:18:23.780 Here again, radical resection is a requirement in order to ensure the removal of all tissue, which may potentially be involved. 00:18:23.780 --> 00:18:43.210 The distal segment, after being carefully capped to prevent contamination, is tucked beneath the pelvic floor to be removed through the perineum. 00:18:43.210 --> 00:18:57.010 The proximal segment is carried through the abdominal wall to form a colostomy. Patients may get along without soilage and even without a colostomy bag providing the bowel is irrigated thoroughly at regular intervals. 00:18:57.010 --> 00:19:17.790 The perineal phase of the operation can usually be undertaken immediately. Careful dissection, much accomplished bluntly, prevents injury to the prostate and to the seminal vesicles. 00:19:17.790 --> 00:19:25.020 Extirpation of this disease is accomplished by the complete removal of the rectum. 00:19:25.020 --> 00:19:48.360 By such adequate surgery, rectal cancer can be treated so as to reduce the likelihood of recurrence. The statistical picture of these early cases rewards our efforts by showing a mortality decrease of dramatic proportions. 00:19:48.360 --> 00:19:57.270 The female genital tract is a frequent site of cancer and of these lesions, about two-thirds occur in the cervix. 00:19:57.270 --> 00:20:04.270 In its early stage, this lesion may be misinterpreted as a benign condition, such as cervical erosion. 00:20:04.270 --> 00:20:20.800 As growth continues, however, leukorrhea usually becomes evident or more pronounced, and with ulceration of the cervical mucosa, spotting or frank bleeding may occur. 00:20:20.800 --> 00:20:33.730 This bleeding in women of menopausal age is often mistakenly viewed as a sign of the change of life. Further extensive growth may take place without new symptoms being added. 00:20:33.730 --> 00:20:41.940 Here again, we have a typical picture caused by delay, which too frequently the patient presents to her physician. 00:20:41.940 --> 00:21:03.820 Radiation has been widely used in the treatment of this disease. External radiation by high voltage x-ray, supplemented by intracavitary radium therapy, has sufficient effect upon these lesions to permit the five-year survival of one out of four of these patients. 00:21:03.820 --> 00:21:22.370 Radiation therapy, however, is not the only form of treatment. Today, modern surgery together with improved pre-and postoperative care permits complete extirpation of the disease with safety in selected cases. 00:21:22.370 --> 00:21:32.230 In addition, the surgical approach allows visualization and the removal of the regional lymph nodes. 00:21:32.230 --> 00:21:39.730 Despite radical surgery, despite irradiation, most of these patients are seen too late, and again, 00:21:39.730 --> 00:22:05.700 local recurrence of disease, lymphatic spread, and metastases cause the deaths within five years of about three out of four and so the average five-year result. 00:22:05.700 --> 00:22:15.430 Cervical cancer must and can be suspected early. True this lesion may be masked by leukoplakia or by cervical erosion. 00:22:15.430 --> 00:22:27.350 Therefore, the family physician should take advantage of tissue biopsy in the presence of any cervical abnormality. 00:22:27.350 --> 00:22:43.700 Tissue biopsy is a diagnostic method of proved accuracy, but on the other hand, a perfectly normal-appearing cervix may mask underlying early cancer. 00:22:43.700 --> 00:23:01.000 To determine the likelihood of such occult disease, the physician has at hand the cytologic method of cancer detection. 00:23:01.000 --> 00:23:10.870 Such cytologic tests followed by biopsy examinations, when indicated, have an encouragingly high incidence of accuracy. 00:23:10.870 --> 00:23:23.200 A pelvic examination including tissue or cytologic studies should be made routinely in all cases of vaginal complaint if cervical cancer is to be found early. 00:23:23.200 --> 00:23:30.960 And when such a routine study is found suspicious of cancer, the patient has the benefit of immediate treatment. 00:23:30.960 --> 00:23:37.630 [Early Suspicion, Accurate Diagnosis, Effective Treatment] 00:23:37.630 --> 00:23:57.900 Effective treatment by irradiation often calls for massive x-ray dosage of the entire pelvis. This is frequently supplemented by the intracavitary application of radium, or in some instances, radium may be the only form of therapy. 00:23:57.900 --> 00:24:22.890 Thus by adequate treatment, whether radiological or surgical, cancer of the cervix can be interrupted early enough to minimize the danger of recurrence. The statistical picture of early cervical cancer shows a marked reduction in five-year mortality. 00:24:26.310 --> 00:24:46.150 In recent years, cancer of the lung has been diagnosed with increased frequency. A major bronchus is the site of about four-fifths of all lung cancer. The early growth of this tumor takes place by submucosal extension. 00:24:46.150 --> 00:25:14.460 At this stage, a preexisting cough becomes aggravated. Mucus becomes manifest and may well be stained with blood. This cough is altogether too frequently interpreted by the patient or by his physician to be a cigarette cough or the result of a cold. 00:25:14.460 --> 00:25:23.730 [The false sense of security, often abetted by symptomatic treatment, accounts for the tragic delay of almost a year before the average patient is hospitalized.] 00:25:23.730 --> 00:25:37.420 Meanwhile, because of the delay, continued growth of the tumor, intraluminally, results in bronchial obstruction and resultant emphysema or atelectasis with the likelihood of superimposed secondary infection. 00:25:37.420 --> 00:25:50.910 Extraluminally, the cancer invades the lung peripherally and extends towards the pleura. This is the picture of disease which the average patient presents at thoracotomy. 00:25:50.910 --> 00:26:00.470 About half of these patients, considered operable are candidates for pneumonectomy; however, the delay is to be reckoned with. 00:26:00.470 --> 00:26:21.410 In metastases to lymph nodes such as peribronchial, paratracheal, mediastinal, and abdominal together with blood borne spread to the other lung, to the bones, and other organs. 00:26:21.410 --> 00:26:36.010 Within five years, three-fourths of these treated patients will be dead. Because of this insidious clinical behavior, lung cancer is one of our gravest cancer problems. 00:26:36.010 --> 00:26:54.230 Since early lung cancer provides little or no sign of its presence, the detection of this disease by clinical means is one of the physician's most difficult tasks. 00:26:54.230 --> 00:27:04.470 On the other hand, a chest x-ray may provide a simple effective method of disclosing lung cancer in its earlier stages. 00:27:04.470 --> 00:27:16.210 Such an x-ray should be made on all cases with persistent cough. Nor should the history of a cold or a smoker's cough preclude the search for underlying cancer. 00:27:16.210 --> 00:27:23.180 [Early Suspicion, Accurate Diagnosis, Effective Treatment] 00:27:23.180 --> 00:27:51.700 In recent years, the advances of thoracic surgery have made thoracotomy a safe operative procedure. In some cases, this technique may be the only method of establishing the diagnosis. 00:27:51.700 --> 00:28:23.950 Careful palpation of the chest wall for evidence of disease is the first step in exploration. If no extension is found and the tumor appears to be confined entirely to the lung, a pneumonectomy can offer this patient a good chance of survival. 00:28:23.950 --> 00:28:45.330 Closure of the bronchial stump is carried out simultaneously with the amputation of the bronchus. Except in rare instances, lobectomy has no place in the surgery of lung cancer. 00:28:45.330 --> 00:29:03.140 Only by total removal of the lung can cancer of this organ be treated effectively enough to dim the danger of recurrence. The benefit in such early management is fully worth the effort. 00:29:03.140 --> 00:29:20.050 Mortality of average cases, all cases, of these five sites is high, but in early cases, early suspicion, accurate diagnosis, and effective treatment have brought about marked reductions in mortality. 00:29:20.050 --> 00:29:32.570 What is true of these five sites is equally true of other sites of this disease. 00:29:32.570 --> 00:29:43.800 Our knowledge of cancer has grown tremendously in recent years and the quest for additional knowledge is going on constantly in many fields of study. 00:29:43.800 --> 00:29:59.250 In chemotherapy, hormones, radioactivity, carcinogenesis, virus research, genetics, and along numerous other avenues of approach. 00:29:59.250 --> 00:30:08.580 In one day to come, the results of this ever increasing knowledge will lead us to the final answer to the cancer problem. 00:30:08.580 --> 00:30:29.530 However, the immediate problem -- the cancer patient today -- must be answered here and now and by the man who has always borne the first responsibility for cancer detection, the family physician. 00:30:29.530 --> 00:30:33.760 [ Music ] 00:30:33.760 --> 00:30:38.080 [The End, Produced by Audio Productions, Inc., New York, N. Y.] 00:30:41.440 --> 00:30:57.300 [This brief presentation of the problem of early diagnosis is only the beginning. Subsequent films in this series will present details of diagnosis of cancer by specific body sites.]