Rogue cancer
John Rowan Wilson
One of the greatest problems about cancer lies in its variability. Since cancer cells are not invaders from without but rogue cells Within the patient's body, they have individual characteristics of their own, and arouse a defensive reaction in the body Which is also individual. For this reason, Speed of growth, invasiveness, and the response to treatment vary widely.
In these circumstances it is hardly surprising that disputes arise about the relative value of different forms of treatment. In recent months an argument has arisen about the treatment of breast cancer whch has aroused savage emotions in medical breasts. As one of the participants plaintively remarked, the violence Of the language used has been reminiscent Of the controversy surrounding the publication of Darwin's Origin of Species.
While some of the details are difficult to follow, the main area of disagreement is fairly clear. It is a question of whether early breast cancer is best treated by a socalled ' radical' operation or not. For many years the necessity for such an operation was accepted without question. What we used to do, as an absolute rout10e, was to remove not only the breast containing the growth, but also a great
deal of surrounding tissue in the chest and armpit. Nobody doubted the necessity for this procedure and surgeons prided themselves on the skill and thoroughness with which they carried it out.
The first assault on this piece of conventional wisdom was launched in Edinburgh in 1948 by Professor Robert McWhirter, who claimed that a much smaller and simpler operation, confined to the removal of the breast alone, was just as effective as the radical procedure. McWhirter's view acquired some support, particularly north of the Border, but in most of England and the United States of America, surgeons and radiotherapists continued to believe that the older procedure was necessary to eradicate the growth. Now, however, two surgeons of unimpeachable eminence, one from Cleveland, Ohio, and another from Guy's Hospital, London, have out-McWhirted McWhirter. They have published figures which suggest that for the very early case it may not even be necessary for the woman to lose the breast: a simple excision of the lump will produce equally good results.
Such a revolutionary change in treatment has been vigorously challenged. While surgeons have no desire whatever to perform a time-consuming and somewhat mutilating procedure if it is unnecessary, many of them remain unconvinced that it is possible to get rid of such a diffuse tumour without removing the entire organ in which it is located. They have challenged both the theory of the new method and the statistics of cure which have been produced to support it.
The situation is so deadlocked at the moment that only a large-scale comparative experiment can resolve it. To this end a number of highly elaborate trials have been initiated, both in Britain and the United States. But it is going to take time. Trials on cancer patients are notoriously difficult and cancer of the breast is one of the most difficult of all. The main problem is that cases come to the doctor at greatly differing stages of development, and the outlook and curability varies according to how far advanced the growth is. It is quite useless to compare late or medium stage cases with early stage cases, so the experimenter has to pick a sufficient number of cases of a fairly standard degree of advancement. He then has to treat one group with one form of treatment and an exactly similar group with the other.
Even when the groups of cases have been treated, the results of treatment take a long time to assess. No patient can be regarded as cured untl she has been five years without symptoms. A valid trial therefore has to last for at least five years from the treatment of the last case.
So the final answer to the controversy is not a great deal to choose between the two meantime, the treatment received by women who suffer from this condition is likely to vary according to the surgeon they go to. That is not quite so alarming as it sounds — the likelihood is that if there was any dramatic difference between the two methods of treatment it would have already been obvious beyond possibility of argument. The very violence of the dispute probably means that there is not a great deal to choose between toe two sides.
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