“¿�Presentrates of cancer control are farshort of what is theoretically achievable,particularly when the disease occurs incertain accessible sites. The case for cancer detection procedures is based on thepremise that periodic physical surveys ofasymptomatic persons would uncoverconcealed cancer at a curable stage insuch numbers as to be a rewarding effort,commensurate with the time, effort andcost involved. Statistical evidence indicates that this objective can be reached,but only if there is an informed segmentof the population which will persist inbeing screened year after year.

“¿�Inour present state of knowledge, theonly effective means for improvement ofend results is to bring the patient to effective treatment at an earlier anatomicalstage of the disease, which can best bedone when the process is still occult orasymptomatic.

“¿�Thepublic is being indoctrinated withthe importance of detection procedures;it is the responsibility of the profession toprovide periodic health surveys for thosewho seek such service. It should be emphasized that the objective should be thedetection of incipient or occult disease ingeneral, even though the theme of cancerdetection may be the most effective leverin securing the interest of presumablywell persons.―

Such were some of the conclusions ofthe Cancer Commission of the CaliforniaMedical Association, based on a continuing study of cancer-detection proceduresover a period of eight years. During atwo-year period, the Commission conducted an experiment in the operation offour cancer-detection centers. From thisstudy and from investigation of other suchprojects, the Cancer Commission concluded that the detection centers did notachieve the potential value of the pro

cedure, mainly because they failed generally in securing consecutive yearly examinations of more than a small fraction oftheir examinees. The true yield of asymptomatic cancer reported by detection centers is less than 1 per cent. By calculation,it seems certain that consecutive, yearlyexamination of a representative segmentof the population more than 40 years ofage would produce, at the end of tenyears, a cumulative yield of about 8 percent.

The Cancer Commission became convinced that the best approach to obtaining long-term co-operation of well persons, with the widest possible geographicalcoverage, would be through the development of an intensive program of cancerdetection in the physician's office. Itseemed most probable that the rapportestablished by the family physician withhis patients and their families would bemost conducive to an objective of thegreatest good for the greatest number. Atthe same time, the Commission is awarethat, by reason of special interests or plaindisinterest, the slogan “¿�EVERYphysician'soffice a cancer detection center― is unrealistic and emphasizes the enlistment of“¿�everyINTERESTED physician.―

The Commission undertook a calculated estimation of the potential benefitsof yearly detection procedures, in asymptomatic individuals, more than 40 yearsof age, for a ten-year period. On the basisof a thorough survey of accessible sites, asdepicted so effectively in the Society'smovie “¿�LivingInsurance,― the physiciancan detect occult cancer in sites responsible for almost 50 per cent of cancerdeaths in women (breast, cervix, rectum,skin, oral cavity, thyroid, and larynx). By

Fromn tile Cancer Co,nmnission, Calif ornia MedicalAssociation, 450 Sutter Street, San Francisco 8, Califorilia.

123

Cancer Detection in the Physician's Office

A Coutity Medical Society Reports a SuccessfulPilot Experiment

Ian Macdonald, M.D., and L. Henry Garland, M.D.

treatment during the presymptomaticphase, mortality from this group of cancers in women would be reduced by morethan one half. For men, the calculateddividends of cancer detection are not sogreat, because of the predominance ofcancer of inaccessible, visceral sites. Accessible sites of cancer contribute some30 per cent of the total mortality in themale (rectum, prostate, oral cavity, skin,thyroid, and larynx), and detection procedures should eliminate one third ofthese deaths.

The Commission thus committed itselfto a program of cancer detection in private practice, mainly by family physicians, internists, and general surgeons,and to the advocacy of widespread use ofa standard detection examination in thephysician's office. We believe that morecancers will be discovered by such a program than by a more restricted use ofelaborate procedures. The Commissiondoes not discount the value of well-conducted detection centers, particularly inthe development of screening techniquesand for their educational benefits.

The next step in sponsoring an officedetection program seemed obvious—thenecessity for a test of its effectiveness.Some valid evidence that the programwould promise to equal or even exceed theperformance of detection centers wouldendorse the Commission's philosophy;failure to secure such evidence in practice would invalidate the program.

The Pilot Test

The Cancer Commission prepared amodel program for trial in one or moreof the component county medical societies in the state medical association. Discussions were held with the officers of theRiverside County Medical Associationand plans were completed for trial of anoffice detection program in that countyfor a period of twelve months. In June1952, Dr. J. S. O'Toole, chairman of theCancer Committee of the RiversideCounty Medical Association, sent a letterto internists, general surgeons, and general practitioners inviting their co-opera

tion. At the end of twelve months thecards were tabulated and the effectivenessof the project analyzed by Dr. C. P. McCullough, who co-ordinated and reportedthe program.

Purposes of the Pilot Test

This survey was undertaken in an effortto answer the following questions:

1. How successful is publicity in increasing the number of people who regularly see their physicians for physical examinations?

2. What has been the effect of publicity in encouraging people to visit theirphysicians at the first appearance of signsor symptoms of cancer?

3. How many and what types of cancer can be detected by physical examination in the supposedly well patient, withspecial reference to the accessible sites ofthe body?

4. How successful is this type of cancer detection?

Method of Procedure

1. Publicity: an extensive publicitycampaign by members of the RiversideCounty Medical Association, aided by theCounty Branch of the American CancerSociety, California Division, was carriedon for one year prior to the survey. Thispublicity stressed the value of annualphysical examination of adults in detection and prompt treatment of cancer,especially of the accessible sites.

2. Secretarial service in collection ofreports from physicians and compilationof statistics was arranged by a grant of$1500 from the American Cancer Society, California Division.

3. Members of the Riverside CountyMedical Association were canvassed andthirty-four physicians agreed to take anactive part in the survey.

4. Doctors' secretaries were personally interviewed and contributed greatlyto the success of the project.

5. Distinctive colored cards were sentto each secretary, to be clipped to the history form of the physician for each new

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TABLE 1

Results—TheStatistical Report

Number of physicians participating in surveyNumber of patients examinedNumber of proved malignant tumors discoveredPercentage of patients found to have malignant tumorsNumber of lesions biopsiedNumber of lesions biopsied classed as malignantPercentage of biopsies classed as malignantNumber of lesions biopsied classed as precancerousPercentage of biopsies classed as precancerousPercentage of precancerous lesions in patients examinedNumber of other pathological conditions found which required

observation or treatmentPercentage of patients with other pathological lesionsAverage age of patients examinedProportion of males to females in this surveyPercentage of malignant tumors in asymptomatic patients

(Varied methods of reporting allowed too much error for an accurate appraisal)

346,765

2804.1612212

34.687

14.01.3

5327.846

I to 3not known

case examined. This card listed the following: Date, initials, age, sex, briefpertinent history, pathological conditionfound, pathological diagnosis, and signature.

6. It required only a few minutes ofthe physician's time to make notations onthe card. This card was removed from thehistory and sent to the control secretary'soffice weekly. Each month all cards werereviewed by the Cancer Committee andtabulated.

7. To avoid duplication of reports,only the referring physician reported patients who were seen by others in consultation.

Conclusions

Cancer-detection examinations by phy

sicians in their private offices were performed as a county medical society project for a period of one year.

In a series of 6765 patients examined,612 were found to have lesions clinicallysuspect for tumor. The total number ofproved cancers discovered was 280 andthe number of lesions classified as precancerous was eighty-seven.

This yield of neoplasms discoveredcompares favorably with reports fromspecial cancer-detection centers.

The Cancer Commission believes thatperiodic health examinations in the officesof private physicians of persons beyondthe age of 40 is a practical approach tothe problem of earlier detection of tumorsat accessible sites—the tumors that arethe most readily curable by current surgical and radiotherapeutic techniques.

References

I. Anon.: Cancer detection: a statement by timeCalifornia Cancer Comumission. An outline of methodology, implementation and potential value of cancerdetection as a part of general health surveys. Call'fornia Med. 78: 473-476, 1953.

2. Garland, L. H., and McCullough, C. P.: Can.

cer detection: a County Medical Society programn,Riverside, California. California Med. 80: 65-69.1954.

3. Macdonald, I.: Cancer detection: a realisticappraisal 0/ its value. Arizona Med. 10: 1.10, 1953.

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