The Many Faces of Surgical Oncology

ARTHUR I. HOLLEB, MD*

ORE THAN 50 YEARS AGO, on April 27, 1929, M Dr. James Ewing spoke at the Scientific Session of the Board of Directors of the American Society for the Control of Cancer-now known as the American Cancer Society.

The Proceedings’ of that meeting, which have been buried in the Society’s archives, illustrate the genius and foresight of this pioneering pathologist. In 1929, James Ewing recommended designating cancer diagno- sis as a specialty, offering special fellowships in can- cer, educating the primary care physician, and strengthening public education.

He said, “ I don’t believe that the average surgeon, public health officer or even pathologist recognizes the unique position which cancer occupies in the field of lethal disease . . . Cancer . . . unless interfered with invariably causes death . . . the situation may be transformed dramatically by early diagnosis and proper action at the right time in a way which applies to no other major cause of death.” Even then Dr. Ewing noted, “These are plain statements of very well known facts. Yet I find those statements have called for more questioning as to their validity than almost any other statement-and one cannot yield one inch on the importance of those facts regarding cancer- cancer has arrived at a point which it is a specialty . . . the really competent work in the diag- nosis and treatment of cancer is done by a specialist.”

Dr. Ewing also stated, “It would be desirable to establish a limited number of broadly organized, fully equipped cancer institutes, covering every arm of the service” and stressed that, “It was a very questionable procedure to gather together in any one place any considerable number of cancer patients. The atmos- phere was too melancholy. But now it is possible, because there is hardly a stage of cancer that you can‘t do something for. Now the time is ripe for it and past ripe.” This was in 1929.

Presented at the James Ewing Lecture. Meeting of thc Society of

I: Senior Vice President for Medical Affairs. American Cancer

Address for reprints: Arthur I . Holleb, MD. American Cancer

Accepted for publication July 2 3 , 1980.

Surgical Oncology, San Francisco. California, May 13, 1980.

Society. Inc.

Society. 777 Third Avenue, New York. NY 10017.

He continued, “We don’t think special cancer hos- pitals should be started because some rich man in the community has enough money to start a hospital; unless he understand the scope and size of the proj- ect he is entering into, he had better not undertake it. . . . The main point . . . is the recognition that group work is necessary for the correct, full diagnosis, wise choice of treatment and followup as to re- sults. . . . I am inclined to think that there are very few surgeons, no matter how expert they are, who would not profit by the critical opinion of a competent colleague on almost any private case that he proposes to operate upon.”

Dr. Ewing on surgical oncology: “If I were surgeon of note and had the decision which generally means the life or death of the patient in my hands, I wouldn’t get down on my knees and pray, as I believe some noted surgeons are said to have done, but I would call upon my colleagues on earth to give me the best advice they had and then weighing their advice with my own opinion, I would proceed with the weapons which God has provided.”

He also pointed out,“The unattached physician with- out experience and equipment can no longer give a square deal to the cancer patient” and that “Cancer homes, again, is a mere gesture . . . it is wholly inexcusable today to bring any group of advanced cancer cases into an institution where they rely entirely upon nursing and spiritual aid. I think the time is past when we should as a society of physicians commend any such method . . . with a little care by the social service and aid by competent nurses, the great majority of cancer patients can be taken care of in the last stages in their home . . . I am against the cancer home! I think it ought to be the policy of the Society to urge against the establishment of any such institutions and to try to take care of all these advanced cases where they can get a little optimistic point of view, at least mingle with others, some of whom are getting well, so it need not be perfectly obvious that they have been robbed of the last chance of life. The atmosphere of the cancer home today is absolutely irreconcilable with the modern philosophy of living.”

Dr. Ewing on the fringe practitioner: “As for the cancer quacks, I am of the opinion that the least

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we say about them, the better. We have so many defects of our own to correct that I am not in- terested particularly with the cancer quacks. And the second reason is you can’t do anything with them anyhow .”

Ladies and Gentlemen, I share this honor with all of you who were so patient with me during by surgical training and so supportive at Memorial Hospital, M. D. Anderson. and the American Cancer Society. I share i t also with the giants on whose shoulders we stand today, my Chiefs at Memorial: Drs. Fred Stewart, Frank Foote. Frank Adair, Alexander Brunschwig, Harold Dargeon, Lloyd Craver. Bradley Coley, Jr.; George T. Pack, Norman Treves. William Watson, Joseph Farrow, Gordon McNeer, Hayes Martin, Henry T. Randall, and my Chief at M. D. Anderson. Dr. R. Lee Clark. Add to this golden era the last 12 years of association with the following Presidents of the American Cancer Society: I h . Roger A. Harvey, Sidney Farber, Jonathan E. Rhoades. H. Marvin Pollard; A. Hamblin Letton. Arthur G . James, Justin J. Stein, George P. Rosemond, Benjamin Byrd, Jr., R. Lee Clark, R. Wayne Rundles. LaSalle Leffall, Jr. From this, you can see that just being a part of the cancer control effort was more than enough. Yet, the James Ewing Lecture of the Society of Surgical Oncology is the high point of my medical career.

The faces of surgical oncology have been many in the 30 years since I started my surgical residency at Memorial; with Dr. Harvey Baker as my roommate. In my anecdotage, I recall the pride we residents took in our surgical feats, which included en bloc intraoral excision mandibulectomy and radial neck dissection; Urban’s extended radical mastectomy with early re- sults resembling Cyclops; total pelvic exenteration and pumping blood for Dr. Brunschwig; Dr. Theodore Miller‘s hemicorporectomy: the Andy Gumps we pro- duced; the common euphemism, “Let’s send the specimen to the room and the patient to the lab;” the commando: the North American: the South American: the all-American; and the massive struggle to keep patients alive in the embryonic days of fluid and electrolyte balance with the great help of Dr. Henry T. Randall. It seemed as though surgical resection had no bounds. Radiation therapy was referred to as “the big burn;“ and chemotherapy, “those poisons.” were hardly considered adjuncts to primary surgical management but were relegated to inoperable situa- tions or to the recurrence after surgical intervention.

As surgeons in those days. we walked hand in hand with God, and the surgical resident was a haloed. remarkably capable young male with considerable dexterity. Little did we know of the battles we would

later encounter with burgeoning medical oncology and how the radiation oncologist would treat our breast can- cer patients by nonsurgical methods.

Perhaps the greatest semantic mistake surgical oncology brought on itself in creating its image was coining and even exulting in applying the word “radical” to surgical procedures. In the public’s mind, and more particularly in the view of the media, “radical” suggests not a good cancer operation, but something evil, sadomasochistic, dehumanizing, devastating, and basically thoughtless of a patient’s welfare and quality of life. Surgical oncologists-once the heroes of the cancer world-have become the grim-faced, tight-lipped “bad guys” in the medical profession. The white hats now belong to the surgeons who do less, to the medical oncologists who consider cancer a disseminated disease not curable by surgery, and to the radiation oncologists who pre- fer that their therapeutic beam be directed to an intact patient. Physicians who are now in the good graces of consumer groups are those who never advocate radical surgery; who invariably recommend second and sometimes third opinions; who never rely on frozen sections: who always wake patients up for a second anesthesia and second operation; who serve as master surgeons as well as psychosocial counsellors to entire families: and who recognize, of course, that “if it were cancer of the penis or testicle we wouldn’t be in such a damn hurry to operate.”

In their practice, surgical oncologists are also confronted by benignly devised federal “Consensus Meetings,” which produce their recommended thera- pies for patients with cancer and other diseases. Although well motivated, treatment by committee or treatment that views the patient as an impersonal statistic eliminates flexibility in management, imagina- tive approaches, and individualization based on the patient’s specific needs and the surgeon’s considered judgment. Surgical oncologists have been reassured that consensus statements, issued first to the media and only later published and distributed, are merely “guidelines“ and nothing more. Yet. after a recent consensus meeting, newspaper accounts, for example, 7110 Nr\\. Y o 1 4 Tirm.s, September 23, 1979. quote federal officials as saying, “Medicare was obliged to consider the advice in determining reimbursement policies,” and “The consensus findings would prob- ably be cited in malpractice suits.“ How heavy leans the hand of government on the practice of surgical oncology! Today, the woman who elects to have a preoperative work-up and a Halsted radical mastec- tomy following a frozen section diagnosis of cancer is looked upon as a poor innocent who is placing too much confidence, if not her life. in the hands of her

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highly qualified surgeon, instead of listening to a self- appointed consumer representative who said on the radio recently that frozen section diagnoses were “fre- quently wrong.”

The image of surgical oncology is also tarnished by an antiestablishment ”Watergate attitude” of investigative reporters, who sometimes draw their con- clusions without sufficient investigation. It has also become the fashion to report only the bad news. to exploit the controversy of the week, and to report it in sensational headlines that scream “guinea pig surgery,’’ ”ghost surgery,” “unnecessary mastec- tomies,” or “wrong pathology diagnosis.”

Later. when the good news arrives to contradict these preliminary and incorrect statements, it is no longer considered newsworthy. or is relegated to the last page, or is considered suspect and self-serving to the world of pathology and mammography. In the media, the community pathologist has already been reduced to the level of total incompetence and radiologists as nothing more than inducers of breast cancer.

I t is unfortunate indeed that the medical profession has been shamed by a very few involved in welfare frauds, nursing home scandals, drug peddling, and the espousal of laetrile. which became more a political than a scientific issue. The prevalent freedom of choice concept endorsed by quacks permitted parents to re- move their child from a first-rate hospital and proven treatment and to take the child to Tijuana, where the child died of leukemia after so-called holistic therapy, including laetrile. Freedom of choice must be questioned as faith healers, astrologists, bizarre cults, food faddists, and psychic surgeons try to dominate the world of cancer.

To further tarnish our image, some of our own colleagues in surgery openly accuse their fellow sur- geons of continuing to perform major operations only for financial reward. Surgical oncologists, once revered for their dedication to saving lives from cancer, are now frowned upon as villains-heartless, cruel, and thoughtless doctors whose primary interest is making money.

The image of surgical oncology has also become one of big business-health being one of our major expenditures. And anything big equates with the establishment-the American Medical Association. the American College of Surgeons, the American Can- cer Society and, yes. even the Society of Surgical Oncology.

Since physicians have changed from entrepreneur to recipient of the largesse of government-in the forms of medicaid. medicare, research and clinical investiga-

tions grants. medical school support, scholarships, student loans-the practice of medicine has become a public commodity. The media now look upon the broad field of medicine as they look upon the De- partment of Defense or the State Department. In other words, medicine is a public trust. One can anticipate even more government influence and regulations, since there is no annual report to the stockholders from us; the medical profession. Perhaps, we should of- ficially report our considerable progress each year.

We must learn to expect attacks from those who prosper by the sale of magazines and newspapers that print half-truths and promote every imaginable quack cure for cancer or unproven method of cancer manage- ment. Some legislators. movie stars, and even a few of our own oncologic colleagues have endorsed these false remedies on television. radio, and in the press, with self-congratulations for having an open mind, which surgical oncologists presumably do not have. I submit that there is a considerable difference between an open mind and an empty head.

Some surgical oncologists fear and disdain the media and try to communicate directly to the public. Some do it well, too many do it poorly. Some surgical oncologists are publicity seekers and headline hunters and are intolerably arrogant with the public they serve.

This attitude is most unfortunate because the media can do us considerable damage when oncologists do not communicate carefully enough. The media thrive on the controversies we often originate among our- selves-sometimes without professional dignity.

American men and women have become so- phisticated and eager health-oriented consumers. We can no longer talk down to them with broad platitudes. We must be clear and explain our views succinctly. If we do not speak honestly and forth- rightly, the extremists will prevail, and we will have lost our friends in the media.

Surgical oncology must restore and renew the public’s confidence in those who have spent so many years in specialized training to better serve their pa- tients. We must convince the public that we really do live by the principles of Hippocrates and that whenever a new concept appears on the horizon rec- ommending no surgery, modified surgery, minimal sur- gery, or some nonsurgical treatment for cancer, it need not be accepted solely because it is against surgery and therefore must be better.

Extensive clinical experience must prevail over the therapeutic fashion of the month, or we might find our surgical successes deflated by an increased mortality from cancer many years hence.

The science of epidemiology and statistics, an ally

No. 9 SUKGICAL ONCOLOGY . Hollch 2 175

of surgical oncology, has been described as the “prac- tice of medicine without the tears.” It deals with large populations and massive impersonal data as it helps us decide what is best for our cancer patients. What this science cannot do is sit in the consultation room, face-to-face with anxious and concerned families who require the special skills of the surgical oncologist; what it cannot do is individualize the clincial setting and shape the treatment to specific needs; what it cannot do is minimize the psychosocial trauma of a diagnosis of cancer and the impact of a surgical procedure. We must explain to our epidemiologic allies that it is not an easy task to treat patients by the numbers or by tests of statistical significance and that clinical and humanitarian factors play a significant role in surgical judgment.

Carlyle said: “ A judicious man looks at statistics not to get knowledge; but to save himself from having ignorance foisted on him.” Statistics are more help- ful to those who are not able to draw on considerable experience-analogous to a textbook in the hands of a new medical student.

Charles Aring of the University of Cincinnati said: “Many of the most difficult medical decisions depend mainly on character, the slowly matured power of judgment, and a grasp of fundamental principles; and detailed knowledge and technical skills are not as helpful as we sometimes would like to think. In making decisions, statistics are useful; but secondary . . . they are relegated to a position below empathy and compassion aided arid abetted by experience. In trying situations one assembles all the help he can muster.”’

The image of surgical oncology is not enhanced when the American Board of Surgery remains intransigent about establishing criteria for recognizing and identi- fying surgical oncology as a specialty. Our colleagues in Gynecology. Internal Medicine, Radiation Therapy, and Pediatrics have obtained recognition. Yet sur- geons; the physicians responsible for the primary treatment of most cancers, remain in limbo, neither fish nor fowl, nonpersons in the world on oncology. We find ourselves between Scylla and Charybdis in the incongruous situation of seeing the American Col- lege of Surgeons approve more than 800 cancer pro- grams in the United States, where other oncologic specialties prevail. while the American Board of Sur- gery makes us orphans, if not outcasts, in the world of cancer.

Surgical oncology must now learn to exist in a world of clinical trials. The pace has been set primarily by medical and radiologic oncologists who have volun- teered to randomize their patients. Surgical oncologists remain the reluctant dragons who rely on the tried and

proven. This is understandable when there is often but one chance to cure the patient with cancer. Clinical trials are expensive in both time and money; they can furnish only partial answers to many important questions, and this only if the questions can be ethically asked and if a sufficient number of partici- pants can be found to cooperate in the study. Randomized clinical trials do not escape the self- selection problems of those who choose not to par- ticipate. We are now hearing of “pre-randomization” before a study even starts. Furthermore, unmeasured biases occur when the participants self-select them- selves as those who follow the specified regimen and those who do not. There are also inconsistencies over a period of time as personnel change and new technologies of detection and therapy evolve. Also. a clinical trial does not clarify whether or not length bias in cancer detected and treated is an important con- sideration. In short, like everything else in this world, even clinical trials are subject to human fallibility.

Finally. the image of surgical oncology is still con- fronted today, as it was 30 years ago, by the therapeutic negativists and the biologic determinists-the nay- sayers, the prophets of doom. who tell us, “If you think you’ve cured cancer, then it wasn‘t cancer,” or “It makes no difference whether or when you detect, or when or how you treat cancer-the results are always the same.” These naysayers will not succeed because of their Cassandra complex. A prophet of doom loses respect and self-respect unless evil really does come to pass. We must understand that pessi- mistic prophets of all ideologies always pray for bad news. Only our surgical triumphs over cancer will still their glum and dismal views. These vultures of defeat have but one advantage. All they need do is wait, because sometime. somewhere. something will go wrong, and they can gloat through their retro- spectoscopes. Yet in the long run. they will not suc- ceed. The fundamental drive of all dedicated on- cologists will bring about progress against cancer de- spite the naysayers. When things look bleak we should remember that the cave man must have burned his hands a few times after he discovered tire. We, too, will undoubtedly burn our hands from time to time, just to keep the fires burning.

Let me close with comment from Norman Cousins: “To practice medicine at a time when the earth has become a single geographic community calls for an enlargment of the Hippocratic Oath. In today’s world the physician must make his commitment not just to individual life, but to the institution of life. To the extent that medical societies are concerned only with professional questions. they restrain

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physicians from involvement in ethical issues. In- sulated in that manner from his central role. the physician can trail happily after illness while ignoring his obligation to help humanize society and to make i t safe and fit for human beings.”g

I believe that surgical oncology is worthy of this charge; I believe that surgical oncology is weathered enough to survive the insults; I believe that surgical oncology is dignified and knowledgeable enough to re- spond with wisdom; and I believe that surgical on- cology is courageous enough to counter not only with life-saving progress against cancer but also with an emphasis on returning postoperative patients to a nor- mal community life.

However, a surgical oncology society that recog- nizes its unity only in opposition to other oncologists and one that understands its purpose only in resistance

to another purpose becomes a surgical oncology society with no unity or purpose of its own. It does not become a great society, whatever its power and prestige may appear to be.

The great societies in medical history have been those that proposed, those that asserted, and those that conceived. We must know our own mind, declare our belief, and act to create the kind of medical world surgical oncologists want to live in.

REFERENCES

I . Proceedings of the American Society for the Control of Cancer,

2. Aring C. Beyond statistics, editorial. J A M A 1979; 241:

3 . Cousins N . Medical ethics: is there a broader view‘! JAMA

New York, April 1929.

2193-2194.

1979; 241:2711-2712.