Education END-RESULT OF CANCER CASES TREATED IN PHILADELPHIA HOSPITALS IN 1923, AS SHOWN BY SPECIAL 1930 FOLLOW-UP STUDIES ARTHUR H. ESTABROOK (From the~Re8earch Department oJ the American Society Jor the Control oj Cancer) One of the particular objects of the American Society for the Control of Cancer, according to the certificate of incorporation, is tI to investigate the conditions under which cancer is found and to compile statistics in regard thereto." The primary purpose of the study described herein was to ascertain how many of the individuals receiving treatment for cancer in seven general hospitals in Philadelphia in 1923 were alive five years later. It was possible to secure a five-year follow-up in approximately 90 per cent of the cases. Although the follow-up as regards end-results is entirely reliable, the conclusions drawn from these statistics are not significant as to the efficacy of treatment in a general hospital unless the other variables which enter into the situation have been controlled or evaluated. In any statistical study of the end-results of treatment of any disease the following four factors must be considered: Accuracy of diagnosis i adequacy of treatment; success of follow-up; adequacy of records. A large element of error evidently exists in the matter of accuracy of diagnosis. Pathological specimens were taken in only 29 per cent of the 1802 cases diagnosed as cancer in these seven general hospitals. In one hospital which specializes in tumors, biopsy had been done in only 2 per cent of the entire group of cancer cases. Cabot (1) has shown in an analysis of 3000 autopsies that the percentage of clinical success with respect to diagnosis was 74 in cancer of the colon and 72 in gastric cancer, and that out of 20 cases of cancer of the esophagus present at autopsy 4 were not recognized in life. An error of 25 to 30 per cent in accuracy of diagnosis for statistical purposes may be present if clinical diagnoses are made without autopsies. If biopsies are not made, there is probably an even:greater error (2). 1206 END-R~SULT OF CANCER CASES 1207 The second variable is the adequacy of treatment. Treatment in cases of cancer is influenced by the stage of the disease at the time of hospital treatment, previous treatment (if any) by private physicians, and the type and quality of the equipment, both professional and material, of the hospital. The survey by the American Society for the Control of Cancer of the facilities in Philadelphia in 1929 shows that at that time the material equip­ ment in a number of the hospitals was not in accord with the standard suggested by the American College of Surgeons. Adequacy of records, the fourth variable mentioned, is more easily evaluated. In order to classify any cancerous condition, the life history of the cancer must be available. The date of recog­ nition of the first symptom, diagnosis and treatment by private physicians, the degree to which the cancer had developed at various times, and hospital treatment must be carefully recorded. The period of delay was indicated in only about three-fourths of the records studied in 1923. The degree to which the cancer had advanced at the time of treatment was given in the generally loose terms of primary or advanced, operable or inoperable. The data regarding hospital treatment were much more adequate. While this study shows that follow-up with a high degree of accuracy is a possibility, the element of error in the other variables, especially the accuracy of diagnosis and adequacy of records, is so great that the end-results presented here are not significant with respect to the actual curability of the various types of cancer classified only by site. Attention must be paid, therefore, by the worker in the cancer field and especially in the American Society for the Control of Cancer, to the problem of reducing these variables. The diagnosis of cancer must be made with more accuracy, the stage of growth must be ascertained, and this and other pertinent data must be carefully recorded. Inclusive groups, as cancer of the skin or buccal cavity, should not be used in tabulation, since various types of growths act differently in the same location. Analysis of the end-results of treatment should be made only by site, histologic type, and the stage of the growth at the time of treatment. The use of the abstract record forms of the American College of Surgeons would aid greatly in this process.

Special follow-up studies carried on during the past two years have located 85 per cent of the total number of cancer patients 1208 ARTHUR H. ESTABROOK

admitted to the Philadelphia hospitals in 1923; 10 per cent were found to be alive and 75 per cent dead. These studies, carried on partly by correspondence and partly by personal visit, demonstrate that even five years after treatment follow-up is possible, and entirely feasible, in a large percentage of cases, thus furnishing both hospital and physician with concrete data on the results of their treatment. In 1929 the American Society for the Control of Cancer made a study, as a part of the Philadelphia Hospital and Health survey, of

TABLE I Sources of Data of 268 Philadelphia Cases Studied by Philadelphia Health Council and Tuberculosis Committee, 1930

Letter or Vi.it Death Hospital Certifi- No Total Record oate data Patient Family Doctor Other ------Living.... " .. , 34 10 7 7 6 64 Dead., ", .. , ,. 33 49 19 6 12 119 Unknown., .... 85 85 ------TOTAL .• ,. , 67 49 10 26 13 18 85 268 the prevalence of cancer and the facilities for its diagnosis and treatment. The preliminary report (3), published in 1929, before the special follow-up studies were made, showed that nearly 20 per cent of all patients admitted in 1923 died in the hospital within a few months after treatment, and that less than 5 per cent were known to the hospital to be alive in 1929, chiefly because of lack of follow-up service to secure adequate information. The Philadelphia Health Council and Tuberculosis Committee, at the request of the American Society for the Control of Cancer, made a follow-up study in 1929 of 391 cancer patients who were residents of the city of Philadelphia in 1923and who at the time the study was made were not noted on the hospital records as alive or dead. This study was made by a trained nurse. Cards were made for each case, the record at the hospital was checked for diagnosis and treatment, and the name of the physician who had treated the case was secured. Where there was no record in the hospital of the 1929 status of the case, a letter was sent to the physician asking for information. If the desired information was not available, permission to visit the house was requested. END-RESULT OF CANCER CASES 1209

In 123 instances follow-up was impossible. Permission was withheld in 58 of these cases; in 43 the name could not be found in the hospital files; 18 cases were reported as not cancer, and 4 of the patients were not actual residents of Philadelphia in 1923. Of the remaining 268 patients, 183 were located; concerning the other 85 no information could be secured. Information was secured from the hospital records for 67 patients, from physicians for 13, and by means of home visits for 54. A search of vital statistics gave information on 49 cases. Sixty-four of the 183 patients traced were found to be living in 1923, and of this number 55 were reported to be in good health. One hundred and nineteen had died, 49 of these from causes other than cancer. A study of the status of the cancer patients treated in 1923 who resided outside of Philadelphia was begun by the American Society for the Control of Cancer in October 1930. This group, not including the Lankenau Hospital, which had reported a follow­ up system, numbered 474. A form letter enclosing a return addressed stamped envelope and requesting information concerning the present status of the patient was sent to each individual listed as living outside of Philadelphia and not noted on the hospital records as alive or dead. In approximately 170 cases answers were received in response to the form letter from either the patient himself or from some relative. A number of letters were returned by the post office marked "deceased," "unknown," or "removed, present address unknown." To individuals who had apparently received the first letter but had not acknowledged it, registered letters were mailed asking for a response to the first questionnaire. This second letter brought in a large number of responses. Letters were sent to the state registrars of vital statistics in New Jersey, Pennsylvania, Delaware, Maryland, Connecticut, West Virginia, and Illinois, asking that the death records be searched for those individuals whose status had not already been ascertained through answers to the questionnaire. Later the state registrar's office in Trenton was visited and a final search made for certain names. Records of 96 deaths were secured from the state records. Contact was made by letter with local boards of health re­ questing them to follow up individuals not otherwise traced. The director of the Division of Communicable Diseases in the Pennsyl- 1210 ARTHUR H. ESTABROOK vania Department of Health offered the services of his district heads and local health officers to make the investigation in that state. Eighty individuals in the several states were investigated by the health officers; 19 of these were found to be living and 32 dead, while no trace could be found of 29. A field trip in eastern Pennsylvania, Delaware, and central New Jersey was made to trace approximately 50 individuals about whom no data had been secured previously. The status of a number was thus ascertained through information obtained from local physicians, from visits to the last known addresses, and from the local death records. TABLE II Sources oj Data of 474 Out-oj-Philadelphia Cases Studied by American Society jor Control oj Cancer

Death Certificate Follow-up Letter Vi.it '3 ~ .. 8 ] :h -II -II c:i ~:;l ~:;l ~i ~ ! '3 !J ;>!J ;>. ... ~ .. i :Ii s ~ o• .~ ].s ,s.s fa 'il .s .. r: ... '3 ;.alZl .slZl ]l 11 8 0 0 0 0 ~ g := lZl := ~ ro.• l:I Eo< Eo< Z Eo< ------Living.... 4 19 74 4 3 1 105 22.2% Dead..... 76• 10 96 13 32 90 4 7 3 331 69.9% Unknown. 29 4 3 36 7.6% ------TOTAL .. 80 10 96 13 80 74 94 7 11 4 3 2t 474

• Five of these were also located by death certificate from State Registrar and four also from relatives. t Both living. A final analysis showed that of the 474 persons residing outside of Philadelphia with whom this particular part of the study dealt, two were eliminated (one as not having cancer and one stating she had never been in a Philadelphia hospital) j 105 or 22.2 per cent of the group were found to be living six years after treat­ ment; 331 or 69.9 per cent were dead, while only 36 or 7.6 per cent could not be traced. The source of the data covering the living and the dead was as follows: END-aESULT OF CANCER CASES 1211

Hospital records...... 80 Death certificates , 119 Follow-up by local health officers...... 51 Physicians (letter or personal visit) ", .. " 10 Patient 74 Family 94 Neighbors, etc.....•...... 7 Personal visit...... 1 436 The nine Philadelphia hospitals which furnished data on their cancer cases to the American Society for the Control of Cancer (including only 48 from the Graduate Hospital) treated 1802 different individuals during the year 1923. In a number of instances the same individual had been treated several times in the same hospital and had been given more than one case number. A number of patients also had been treated in more than one hospital during this period; there were 304 such duplications in all, making the total number of cases reported by the several hospitals and included in this analysis 2106. This number is slightly different

from the total used in the printed report of l( Cancer in Phila­ delphia," as only part of the Graduate Hospital group is included, due to the fact that data were available for only a few and that 39 Germantown Hospital patients were included in this analysis and not in the previous report.

SOURCE OF INFORMATION OF PRESENT STATUS OF ENTIRE GROUP The present status of 85.7 per cent of the entire group of 1802 patients admitted to the nine Philadelphia hospitals in 1923 was ascertained from an analysis of the hospital records and the two special follow-up studies made in 1930, six years after treatment. Information has been secured concerning 1545 patients. The hospital records themselves gave the status of 1050 patients: 57 were known to the hospital to be alive. This is 3.2 per cent of the entire group. Nine hundred and ninety-two, or 55 per cent, were dead, according to the hospital records, and one was noted as having returned to a foreign country. The 1930 status of the remaining 752, or 41.7 per cent, was unknown to the hospitals, and the two special follow-up studies were made to secure information concerning them and thus ascertain the feasibility of follow-up of a group of cancer patients five years after treatment. The procedure in the two studies varied slightly. The greater part of the Council study was made by personal visits, and the element of cost of 1212 ARTHUR H. ESTABROOK

travel did not enter, as no cases outside of the limits of Philadelphia were considered. The Society follow-up was done almost entirely by correspondence: first by letters to the patients, then to the families. If these did not bring a response, letters were sent to the state and local registrars asking that the death records be searched. When data were not obtained through this means, letters were sent to local health officers asking that visits be made to the last known address shown in the hospital record. The Pennsylvania Department of Health, when the problem of follow-up was

TABLE III Source of Information of End-result of Treatment of 1802 Cases Treated in Philadelphia Hospitals (1923) Six Years Later (1930)

Death Certificate Follow-up Letter Visit

~ "~ ~ '.;:l ." ... § 0 1 -] ~ 0 @ ." ." &l :h '3.~ !l3 -:= 'a Q).~""~ ;>] ]ci 0 @ .~ ~ .~ :1 a'" '3 ;S .. ~ 'a ..= 'a ... '3 s 'iil & £! :u ~i> '.::l !1 '3 s ;.am ~ci 1 's 2 ~ 0 .... '"0 0" 0 0 ~ ~ 0 ~ ~ ~ ~ 0 ...... ZZ ... ------Living ...... 57 19 74 4 3 6 28 191 Dead ...... 992 74 97 13 32 90 4 18 31 3 1354 Unknown .... 1 * 29 4 81 43 99 257 ------TOTAL ... 1050 74 97 13 80 74 94 7 28 140 3 43 99 1802

* This patient had been followed up by the hospital until his return to a. foreign country; hence the hospital is given credit for the information, presented to them in a personal visit, offered the services of its field men and local health officers. Following this, one field trip was made in eastern Pennsylvania and New Jersey to check up on the few remaining cases on which the local health officers had not obtained information. Finally, a personal visit was made to the State Registrar's officeat Trenton to check up on the few remaining names in New Jersey. No attempt was made to follow up 142 of this group of 752 remaining unknown after the hospital records were studied: in 43 cases permission to follow up was withheld by the physician; in 55 cases (from the Lankenau Hospital) no follow-up was done, as the hospital had previously reported a follow-up system, while 44 other cases were not investigated for various reasons, mainly because of lack of address or other identifying information in the hospital records. There remains, then, a total of 610 cases that were investigated: the present status of 496 or 81 per cent of these END-RESULT OF CANCER CASES 1213 was ascertained in the two follow-up studies. If the 142 for whom no follow-up was attempted is deducted from the entire group of 1802 patients, there remains a total of 1660 patients for whom information was actually sought; 1545 were finally located, i.e., a total of 93 per cent of those followed up. The status of 199 of the group of 610 patients was secured by correspondence alone: 74 patients answered directly, stating their present condition; information about 94 was secured from the immediate family (90 of the patients being dead); data about 7 were returned by physicians, while neighbors or unrelated indi­ viduals gave information about 24 others (6 living and 18 dead). The status of 59 was ascertained by correspondence with local health officers who, following the request, had visited the homes. One hundred and eighty-four were located through death certifi­ cates, 74 of these being secured directly from the Philadelphia Vital Statistics. In the remaining 110 cases, data for a large number were secured by correspondence with the local registrars (other than Philadelphia), and the rest by personal visit to such officers. Sixty-two cases were traced by personal visit either to the patient, the family, or the local physician. The local health officersreported failure to locate the individual or family in 29 cases, and in 81 other cases the family could not be located either by the Council's or Society's investigator through personal visits. Correspondence alone, therefore, was the means whereby 32 per cent, or approximately one-third of the special group studied, was located; another 30 per cent was found through death records; 9 per cent were located by health officers through visits requested by letter, while 10 per cent were located by personal visit. Nine­ teen per cent of this group was not found. The two investigations, carried on partly by correspondence and partly by visit, and using existing available agencies, have thus demonstrated the possibility of follow-up even after the lapse of a five-year period, with only a small percentage of untraced indi­ viduals. The cost of this follow-up when spread over a large number of cases, as was done here, is very small for each case.

END RESULTS A final tabulation of the status of the 1802 patients after the Council and Society follow-ups were completed shows that in 1930, six years after the 1923 period of treatment, 191, or 10.6 per cent of the total group under treatment, were alive. One 1214 ARTHUR H. ESTABROOK

TABLE IV End-Re8ult 01 Treatment by Site 01 Cancer

Livilllii Dead Unknowu· Bite Total Well Poor Canoer Other Unknown N.P. U.T.T. N.A. ------Buccal Cavity, etc. Lip ...... '" 72 19 2 30 6 1 10 4 Tongue ...... •..... 67 7 2 49 1 2 6 Mouth ...... 39 2 33 2 2 Jaw ...... '" 37 4 23 2 1 6 1 Tonsils ...... 18 15 1 1 1 Palate ...... 6 1 4 1 Parotid ...... 14 1 8 3 2 ------TOTAL ...... , 253 34 4 162 15 3 22 13 ------I------Stomach, etc. Pharynx ...... 12 11 1 Esophagus ...... 60 1 54 1 2 2 Stomac1,l...... 158 8 2 119 3 1 9 16 Liver ...... 30 2 23 1 2 2 Gall bladder...... 9 8 1 Pancreas ...... 21 16 2 1 2 1------TOTAL ...... 290 9 4 231 6 2 15 23 ------Peritoneum, Intestines and Rectum Mesentery, peritone- um ...... 4 1 2 1 Cecum ...... 7 1 6 Intestines ...... ". 11 1 8 1 1 Sigmoid ...... 14 11 3 Colon ...... 20 2 14 1 2 1 llectum...... 96 5 81 2 1 1 6 1------TOTAL ...... 152 10 122 3 2 4 11 ------Male Genitals Testis ...... '" 7 1 6 Prostate ...... 50 2 39 4 2 3 Penis ...... 15 3 11 1 Scrotum ...... 1 1 ------TOTAL ...... '" 73 7 56 4 2 4

• N.P. No permission. U.T.T. Unable to trace. N.A. No attempt. hundred and seventy of these were in good condition physically, while 21 were in poor condition. The skin cancer group showed the highest proportion alive at the end of five years-55, or 22.2 per cent of a total group of 248. If those in which the end-result is unknown (53 in number) and those who died of conditions other END-R~SULT OF CANCER CASES 1215

TABLE IV-Continued

Livillii Dead Unknown Site Total Well Poor Canoer Other Unknown N.P. U.T.T. N.A. ------I- Female Genitals Cervix ...... 117 9 97 4 2 4 1 Uterus... " ..... , ... 90 6 67 3 2 6 6 Vagina ...... 10 2 1 6 1 Vulva ...... 12 1 11 Ovary ...... 24 2 16 2 1 3 ------I- TOTAL ...... 253 19 2 197 9 6 10 10 ------Urinary Tract Kidney, ureters ... '" 6 1 4 1 Bladder...... 57 1 43 5 2 6 ------TOTAL ...... 63 1 1 47 6 2 6 ------I- Rellpiratory Tract Larynx ...... 59 7 45 4 1 2 Lungs ...... 2 2 ------TOTAL ...... 61 7 47 4 1 2 ------I----- Breast ...... 245 18 2 178 12 9 16 10 Skin ...... 248 48 7 110 30 16 25 12 Eye ...... 22 4 1 11 1 1 4 Thyroid ...... 9 1 8 Bone ...... 72 10 45 3 2 7 5 Lymphosarcoma, Hodg- kin's disease, and Leu- kemia ...... 19 17 1 1 Abdomen ...... 10 7 3 Carcinomatosis ...... 11 7 1 1 2 Miscella.neous ...... 21 2 13 1 3 2 ------TOTAL ...... 1802 170 21 1258 96 43 115 99 than cancer (24 in number) are deducted, there remain a total of 165 in this group, 55 of whom are living and 110 of whom died of cancer, giving a survival rate of 33 per cent. If the skin cancer group, which is usually treated in the out-patient department, is deducted, 136, or 8.8 per cent of the remaining 1554 patients, are found to be alive. By this type of analysis the bone group showed 10 living and 45 dead of cancer, or a survival of 18 per cent. The group with the next highest survival rate was cancer of the buccal cavity, with 38, or 15 per cent, alive out of a total of 253. Only 15, or 7.2 per cent, of the 207 women treated for cancer of the uterus or cervix were alive. Twenty, or 8.2 per cent, of a total of 1216 ARTHUR H. ESTABROOK

245 patients with cancer of the breast were alive. Twenty-nine per cent of the survivors were from the skin group, 20 per cent from the buccal cavity group, while cancer of the breast and of the female genitals each furnished 8 per cent of those living. Three-fourths of the entire group of 1802 (1354 or 75.1 per cent) were known to be dead six years after treatment. Nine hundred and fifty-seven, or 53.1 per cent of the total group, died of cancer within one year following treatment, and 163 in the second year, making a total of 1120, or 62.2 per cent of the entire group, who

TABLE V End-Result of Treatment of 1802 Patients with Cancer in the Philadelphia Hospitals in 1923, as of 1930

Site (by major groups) Total Living Dead Unknown ------Buccal cavity, etc...... 253 38 177 38 Stomach, etc...... 290 13 237 40 Intestines and rectum ...... 152 10 125 17

Male genitals. ••••••••••••• 0 •••••••••••••••••••• 73 7 60 6 Female genitals ...... " ., .... " ...... 253 21 206 26 Urinary tract ...... 63 2 53 8 Respiratory system ...... 61 7 51 3 Breast ...... 245 20 190 35 Skin ...... 248 55 140 53 Eye ...... 22 5 12 5 Thyroid ...... 9 1 8 0 Bones ...... 72 10 48 14 Lymphosarcoma, Hodgkin's disease and leukemia ..... 19 18 1 Abdomen ...... 10 7 3 Carcinomatosis (general) ...... 11 8 3 Miscellaneous ...... 21 2 14 5 ------TOTAL .••..•.•.....•.•••..•••••••.••..••... 1802 191 1354 257 died of cancer within two years following treatment. Twenty-nine died of causes other than cancer within the two-year period, making a total of 1149, or 63.8 per cent of the entire group, dying within two years of treatment. The number of deaths in the group decreased each succeeding year, only 30 dying in the sixth year after the period selected, 15 of these from cancer, 12 from other known causes, and 3 from unknown causes. Twelve hundred and fifty-eight, or 93 per cent of the group now dead, died from cancer, while 96, or 7 per cent, died from other causes. The status of 257, or 14.3 per cent of the entire group, was unknown. END-RESULT OF CANCER CASES 1217

PERIOD OF DELAY BETWEEN FIRST SYMPTOM AND VISIT TO PHYSICIAN Data with respect to the delay between recognition of some abnormality of the affected part and the first visit to a physician are available for 1400 of the 1802 patients. This information on the hospital record is based on the statement of the patient, and there is undoubtedly an element of error in some cases, due to the fact that the patient may wish to conceal certain facts. Fifty, or only 3.5 per cent, sought treatment within a month, i.e., 96.5 per cent delayed over one month. Three hundred and forty-seven, or 24.8 per cent, secured treatment within three months, which means that 75.2 per cent delayed over three months. Four hundred and fifty, or 32 per cent of the 1400, delayed from three to twelve months before securing treatment. Six hundred and three, or nearly one-half, delayed more than one year before receiving treatment. The period of delay in those alive in 1930 (191) was unknown in the case of 62; 60 of those now alive, or 32 per cent of the group alive, delayed more than one year before receiving treatment. Thirty-four delayed from three to twelve months, while only 35 received treatment in the first three months following recognition of some disturbance. In the buccal cavity group, which furnished 20 per cent of the living group, of the 38 living only one received treatment in the first month following discovery; 7 were treated within three months, while 5 delayed from three to six months and 20 delayed more than one year. Further analysis shows that 14 of the 20 still alive in the buccal cavity group who delayed more than one year had cancer of the lip, that most of them had had the condition for a number of years previous to securing treatment, and that evidently in these cases the cancer was of slow growth. It is evident from this that the analysis of end-results is not significant if the major groupings are considered as units, but that the analysis must be made by individual site. Seven of the 55 living in the skin group received treatment within three months, while 19 delayed one year or more. The numbers of those living in the other groups, classified by site and period of delay, are so small that analysis cannot be made. Analysis with respect to delay in securing treatment of those who died shows no relationship between period of delay alone and end-result. Forty-two, or 24 per cent, of the 177 dead in the buccal 1218 ARTHUR H. ESTABROOK

TABLE VI Period of Delay between FirBt Symptom and Visit to PhYBician ClaaBified by End-ReBult and Site

6 moo. to 1-3 moo. ~moo. 1 year 1 year + Unknown Totall delay delay delay delay

Buccal cavity, etc. Living ...... 7 4 1 20 6 38 Dead...... , 42 29 20 46 40 177 Unknown ...... 9 6 1 10 12 38 TOTAL...... •... 58 39 22 76 58 253

Stomach, etc. Living ...... 4 3 1 3 2 13 Dead...... , 7l 44 24 61 37 237 Unkno~ ...... , 14 4 4 13 5 40 TOTAL.•...••...... 89 51 29 77 44 290

Peritoneum, Intestines, Rectum. etc. Living ...... 2 1 - 2 5 10 Dead...... 26 27 12 37 23 125 Unkno~ ...... 6 2 - 6 3 17 TOTAL .•••..••..... 34 30 12 45 31 152

Male Genitals Living ...... 1 - - 3 3 7 Dead ...... 8 11 7 24 10 60 Unkno~ ...... , 1 1 - 4 - 6 TOTAL.•••••.•.••.. 10 12 7 31 13 73

Female Genitals Living ...... 5 3 - 3 10 21 Dead...... , 31 37 29 71 38 206 Unkno~ ...... 4 6 7 5 4 26 TOTAL••.....•.... , 40 46 36 79 52 253

Urinary Tract Living ...... - - - - 2 2 Dead...... , 6 7 2 21 17 53 Unkno~ ...... , 2 2 - 2 2 8 TOTAL...... •..... 8 9 2 23 21 63

Respiratory Tract Living ...... 1 1 - 1 4 7 Dead...... 3 10 8 13 17 51 Unkno~ ...... , 1 - - 2 - 3 TOTAL...... 5 11 8 16 21 61 cavity group received treatment within three months after the discovery of the first symptom; delay of more than twelve months was found in the case of 46 deaths, or 26 per cent, in this group. In the female genital group 31, or 15 per cent of the 206 who END-RESULT OF CANCER CASES 1219

TABLE VI-Continued

6 moe. to 1-3 moe. 3-6 moe. 1 year 1 year + Unknown Totala delay delay d81ay delay Breast Living...... 5 3 1 5 6 20 Dead ...... , 38 19 25 73 35 190 Unknown ...... , 12 4 1 10 8 35 TOTAL ...... 55 26 27 88 49 245 Skin Living...... 7 6 7 19 16 55 Dead...... 15 15 9 67 34 140 Unknown ...... '" 2 5 2 37 7 53 TOTAL ...... 24 26 18 123 57 248 Eye Living...... - 1 - 2 2 5 Dead...... , 2 1 1 3 5 12 Unknown ...... - - - 2 3 5 TOTAL ...... , 2 2 1 7 10 22 Thyroid Living...... - - - 1 - 1 Dead...... , 1 - 1 6 - 8 Unknown ...... , ------TOTAL ...... 1 - 1 7 - 9 Bone Living...... 3 2 - 1 4 10 Dead...... 9 11 5 11 12 48 Unknown ...... , 3 1 1 3 6 14 TOTAL ...... •• 15 14 6 15 22 72 Miscellaneous Living...... " ...... , - - - - 2 2 Dead...... , 5 10 4 11 17 47 Unknown ...... '" 1 1 - 5 5 12 TOTAL ...... 6 11 4 16 24 61 Total Living.•...... 35 24 10 60 62 191 Dead...... 257 221 147 444 285 1354 Unknown ...... , 55 32 16 99 55 257 TOTAL ...... 347 277 173 603 402 1802 died, received treatment within three months after discovery of some abnormality; 37 received treatment within three to six months; 29 within six to twelve months. Seventy-one, or 34.5 per cent, had delayed one year or more. Fifteen, or only 11 per cent of the skin group which died, received treatment within three months after discovery. Thirty­ nine, or 28 per cent, received treatment within one year, while 1220 ARTHUR H. ESTABROOK

delay of a year or more was found in the case of 67, or 48 per cent. In 34 the period of delay was unknown. The period of delay alone does not seem, from these observa­ tions, to have any correlation with the end-result following treatment. The hospital records give the stage of the disease at the time of treatment in only a few cases; if this were known for all cases, analysis of the period of delay in securing treatment with respect to end-result would undoubtedly give more significant results.

TABLE VII Summary of Delay between First Symptom and Visit to Physician of 1400 Known Cases

Number Per cent Total Per cent Number known Per cent known Period of delay number of total known dead from known dead from alive canceralive cancer

Less than 3 months.... 347 24.8 35 257 10 74 3-6 months...... 277 19.8 24 221 9 80 6 months to 1 year .... 173 12.3 10 147 6 85 1 year ...... 603 43.1 60 444 10 74

TOTAL ...... 1400 100. 129 1069 9 76

No analysis has been made of the period elapsing between the date of the first treatment by a physician and the time of first treatment in the hospital. In many cases some time had inter­ vened between the date of first treatment and treatment in the hospital; in others the hospital treatment was the first received. The date of first hospital treatment mayor may not be the date of first adequate treatment. For this reason an analysis of the total period of time elapsing between first recognition of the condition and date of adequate treatment cannot be made.

PERIOD OF TIME BE'rWEEN DATE OF TREATMENT AND TIME OF DEATH The period of time elapsing between date of treatment and time of death shows, according to Table VIII, no significant dif­ ferences in any of the groups either as a whole or if individual sites, as lip, tongue, etc., are considered. END-RESULT OF CANCER CASES 1221

TABLE VIII Period of Time Elapsing between Date of Treatment and Death

Total Less 1-2 2-3 3-4 4-5 Over 5 Cause of Death than a years Unknown Cases year years years years years ------Buccal cavity Cancer ...... , 162 123 27 9 - 2 1 - Other...... 4 - - - 1 - 3 - Unknown ...... 11 1 - 1 - 1 2 6 TOTAL ...... , 177 124 27 10 1 3 6 6

Stomach, etc. Cancer ...... 231 212 9 5 1 - - 4 Other ...... , ... , 3 2 - 1 - - - - Unknown ...... 3 1 - -- - - 2 TOTAL ...... 237 215 9 6 1 - - 6 Peritoneum, intestines, and rectum Cancer ...... 122 97 16 5 3 - 1 - Other ...... , 3 3 ------Unknown ...... ------TOTAL ...... •.. 125 100 16 5 3 - 1 - Male genitals Cancer ...... , 56 45 6 - 3 1 1 - Other...... , 3 1 -- - 1 1 - Unknown ...... 1 1 ------TOTAL ..••.... , 60 47 6 - 3 2 2 - Female genitals Cancer ...... , 197 149 23 12 8 3 2 - Other ...... , 3 2 -- - 1 - - Unknown ...... 6 ------6 TOTAL ....•.... 206 151 23 12 8 4 2 6 Urinary tract Cancer ...... 47 39 4 2 1 - 1 - Other...... 5 1 1 -- 1 2 - Unknown ...... 1 - - - - 1 - - TOTAL ...... , 53 40 5 2 1 2 3 - Respiratory tract Cancer ...... 47 39 6 - 1 - 1 - Other ...... , ------Unknown ...... 4 1 - - 1 - 1 1 TOTAL ...... 51 40 6 - 2 - 2 1

[Continued on p. 12f2]

ANALYSIS OF END-RESULT BY TYPE OF TREATMENT Tables showing the end-result by type of treatment and by site have been constructed. Inasmuch as the hospital records in many cases do not give the stage of the disease or the prognosis at 1222 ARTHUR H. ESTABROOK

TABLE VIII-Continued

Leaa CaUllll of Death Total than a 1-2 2-3 3-4 4-5 Over 5 Unknown e_ year years yean yean years yean ---- Breast Cancer ...... 178 109 41 15 9 2 2 - Other...... 5 - - 1 - 3 1 - Unknown ... '" .... 7 - - - 1 - - 6 TOTAL ...... , 190 109 41 16 10 5 3 6

Skin Cancer...... 110 68 19 9 5 2 5 2 Other...... 24 9 4 4 1 1 5 - Unknown ...... 6 1 - 2 1 - - 2 TOTAL ...... 140 78 23 15 7 3 10 4

Eye Cancer...... 11 5 2 1 - 2 1 - Other...... 1 ------1 Unknown ...... ------TOTAL ...... 12 5 2 1 - 2 1 1 Thyroid Cancer...... 8 6 - 1 - 1 - - Other...... ------Unknown ...... ------TOTAL ...... 8 6 - 1 - 1 - - Bone Cancer...... 45 34 6 2 2 1 - - Other...... 3 - - 1 - -- 2 Unknown ...... ------TOTAL ...... 48 34 6 3 2 1 - 2

Miscellaneous Cancer...... 44 31 4 - 1 -- 7 Other...... 2 1 - -- - - 1 Unknown ...... 1 ------1 TOTAL ...... 47 32 4 - 1 - - 9 Total Cancer...... 1258 957 163 62 34 14 15 13 Other...... 56 19 5 7 2 7 12 4 Unknown ...... 40 5 - 3 3 2 3 24 TOTAL ...... 1354 981 168 72 39 23 30 41 time of treatment, the early cases cannot be separated from the advanced cases in the tabulation, nor can those with a good prognosis at the time of first treatment in the hospital be separated from those with a poor prognosis. These tables, therefore, do not give data upon which to base any conclusion as to the actual efficacy of the various types of treatment. They show merely what actually happened in the 1802 cases as a result of the treat- END-RESULT OF CANCER CASES 1223 ment received at the time. In other words, these tables merely show the end-results which, on the average, are to be expected by the local physician when a cancer patient is sent to a general hospital under the present conditions of treatment. A number of other factors renders it difficult to make a statisti­ cal analysis of the end-results by type of treatment; some of the hospitals specialized in one type of treatment for certain conditions, while other hospitals treated the same conditions without special facilities; some hospitals specialized in treatment by surgery, not using radiation, while other hospitals treated all types of cancer with no special facilities for anyone type of treatment. Some hospitals specialized in treatment of certain kinds of cancer. The University of Pennsylvania Hospital, for example, treated 45 cases of cancer of the breast, but only 2 cases of cancer of the cervix in a total of 209 cancer cases, while the Hahnemann Hospital had 42 cases of cancer of the uterus, one-sixth of its total number of cancer cases in 1923. The following groupings have been used for the several types of treatment. Radium alone; x-radiation alone; x-radiation and radium; surgery alone; surgery in combination with anyone or other types of treatment; other treatment, as toxins, etc.; no treatment; treatment refused; treatment questionable (not indi­ cated on hospital record). Approximately 5 per cent of the patients were treated in more than one hospital. A larger percentage had been treated in the same hospital several times during the year 1923 under different case numbers; all treatment, wherever given, is considered in the analysis. Radium alone as a form of treatment was given to 544 of the 1802 patients: 71, or 13 per cent of this group, are now alive; 383, or 70 per cent, are dead, while in90, or 17 per cent, the end-result is unknown. X-radiation alone was given to 148 patients: of these, 12 are alive and 122 dead, while in 14 the result is unknown. Both radium and x-ray were given to 118 patients, 18 of whom are now alive, 89 dead; in 11 the result is unknown. If all the cases treated by radiation alone are considered to­ gether, it is found that, of 810 thus treated, 101, or 12.5 per cent, were alive in 1930; 594, or 73.3 per cent, were dead; the status of 115 was unknown. Surgery alone was used in 336 cases, with 39 or 11.6 per cent surviving; surgery in combination with other forms of treatment, TABLE IX End-Result by Type of Treatment and Site of Disease *

. " ~ 0'" I~ '+j :ll ~ ~ ]] "

Tongue: 67 cases Living ...... 9 3 4 7 1 1 2 Dead cancer ...... 49 25 1 4 30 1 12 13 1 5 other ...... 1 1 1 Unknown ...... 8 6 6 1 1 2

Mouth: 39 cases Living ...... 2 1 1 1 1 Dead cancer ...... ·33 19 2 21 2 5 7 5 other ...... 2 1 1 1 1 Unknown ...... , 2 1 1 1

Jaw: 37 cases Living ...... 4 2 1 1 4 Dead cancer ...... 23 12 3 15 3 4 7 1 other ...... " .... 2 1 1 1 1 Unknown ...... 8 3 1 1 5 2 2 1

Esophagus: 60 cases Living ...... 1 1 Dead cancer ...... 54 7 3 1 11 24 8 32 2 9 other ...... " .... 1 1 1 Unknown ...... 4 1 3

Stomach: 158 cases Living ...... 10 8 8 1 1 Dead cancer ...... 119 1 7 5 13 36 7 43 1 2 3 57 other ...... 3 1 1 2 1 Unknown ...... 26 1 1 7 7 1 2 2 13

* No site with 25 cases or less has been included in this tabulation because of the small numbers involved. No totals for groups such as buccal cavity, ete., are included because such groupings give an erroneous impression.

1224 TABLE IX-Confinued .., ~ 0 '" 'a '" =0 .... .§ ~ ~ ~J ..,13 II .... co 0= ~] "C '" -=0" ~ ~o ~ 8" E-<'"' Location ~ ~ ~ ",8 ~ ;., eo 000 E-< i ~ & 3 ~ i 3"S '"' ~ ] ·nIll'"' ~ 0 :0 0 0" .s.., 0 :lE-< E-<~ >< >< E-< 00 0 E-< 0 Z ~ 13 ------Liver: 30 cases Living ...... 2 1 1 1 Dead cancer ...... 23 2 1 3 7 2 9 1 10 other ...... Unknown ...... 5 1 1 2 2

Intestines (not including rectum): 56 eases Living ...... 5 4 4 1 Dead cancer ...... 41 12 2 1 15 12 4 16 1 9 other ...... 1 1 1 Unknown ...... , 9 1 1 2 2 1 3 1 1 2

Rectum; 96 cases Living ...... 5 3 3 2 2 Dead cancer ...... 81 12 11 5 28 23 15 38 1 1 13 other ...... 2 1 1 1 Unknown ...... S 3 2 5 3

Prostate: 50 cases Living ...... 2 1 1 2 Dead cancer ...... 39 5 7 1 13 8 9 17 3 6 other ...... 4 1 1 2 2 1 Unknown ...... 5 2 2 3

Cervix: 117 cases Living ...... 9 4 1 5 2 2 4 Dead cancer ...... 97 44 5 8 57 2 9 11 29 other ...... 4 1 1 2 1 1 1 Unknown ...... 7 3 3 2 2 4

Uterus: 90 cases Living ...... 6 2 2 2 2 4 Dead cancer ...... 67 35 1 5 41 7 13 20 1 5 other ...... 3 1 1 2 2 Unknown ...... 14 10 1 11 2 2 1

(Continued on p. 1226]

1225 1226 ARTHUR H. ESTABROOK

TABLE IX-Continued

s:l ... ~ 0 ... .,s:l s:l .,s:l 0 ~ ... ~ ::l ~.~ a s:l § ... -s:l... g','S ~ 11 t 0., " ::l f-; Location ...... s:l El 1 ~ ~ ~8 f-; ~ 0'" ~ »» ~ ... al ::l~ 3] ., f-; :rJ'" ~ ~ &l 3 .J:l 0 ::of-; 0 ~ i 0" f-; ~ ~ ~ f-; u: Q f-; 0 Z ! CJ ------Ovary: 24 cases Living ...... 2 1 1 1 1 Dead cancer ...... 16 4 4 8 3 11 1 other ...... 2 1 1 1 1 Unknown ...... 4 3 1 4

Bladder: 57 cases Living ...... 1 1 1 Dead cancer ...... 43 5 7 1 13 9 9 18 1 11 other ...... 5 2 1 3 2 2 Unknown ...... 8 1 1 6 6 1

Larynx: 59 cases Living ...... 7 1 1 3 3 6 Dead cancer ...... 4.'j 20 2 22 7 8 15 8 other ...... 4 1 2 3 1 1 Unknown ...... 3 1 1 2 2

Breast: 245 eases Living ...... 20 1 2 2 5 6 9 15 Dcad cancer ...... 178 26 20 16 62 37 54 91 1 24 other ...... 12 2 1 3 4 5 9 Unknown ...... 35 7 2 1 10 8 14 22 1 2

Skin: 248 cases Living ...... 55 37 3 6 46 1 8 9 Dead cancer ...... 110 55 8 12 75 6 17 23 12 other ...... 30 19 3 3 25 1 2 3 1 1 Unknown ...... 53 34 2 5 41 7 3 10 1 1

Bone sarcoma: 72 eases Living ...... 10 3 1 4 1 4 5 1 Dead cancer ...... 45 7 12 4 23 4 8 12 2 8 other ...... 3 1 1 2 2 Unknown ...... 14 4 4 1 9 2 2 1 1 1 mainly radiation, was used in 317 cases, with 44 or 13.9 per cent alive. Surgery, therefore, either alone or with radiation, was used in 653 cases, with a six-year survival of 83, or 12.7 per cent. No striking results due to any particular type of treatment appear in any of the tabulations. Radium alone was used in the END-RESULT OF CANCER CASES 1227 treatment of 125 cases of cancer of the buccal cavity; 13 or lOA per cent are alive. Fifty-one cases of cancer of the stomach were treated by surgery, with a survival of 8 or 16 per cent; the type of treatment in 70 cases was unknown. In 96 cases of cancer of the rectum, radiation was used in 32, and surgery alone or in combi­ nation with radiation in 45; only 5 patients were alive in 1930. Radium alone was used in 100 cases of cancer of the uterus and cervix, with a survival of 6; radiation was used in 112 cases, with a survival of 7. Surgery was used in only 48 cases, with a survival of 8. Two hundred and forty-five cases of cancer of the breast were treated, with 20 living in 1930,190 dead, and 35 untraced. Thirty­ four were treated by radium alone, with one surviving. Radiation alone was used in 80 cases, with a survival of 5. Surgery alone was used in 55 cases, with 6 surviving, and in combination with radiation in 82 cases, with 9 surviving. Two hundred and forty-eight cases of skin cancer were cared for, with a survival of 55, or 22.2 per cent. One hundred and forty-five were treated by radium, with 37 now living, or 25.5 per cent. Radiation alone was used in 187 cases, with a survival of 46, or 24.6 per cent. Surgery alone was used in 15 cases, with one surviving; it was combined with radiation in 30 cases, with 8 now alive. In 277 cases the type of treatment was not clearly stated in the hospital records. Twenty-two patients refused treatment, while 34 were given no treatment. These data, based only on type of treatment in the hospital and not considering the stage of the disease at the time of treatment nor the treatment received previous to admission to the hospital in 1923, cannot be used to give any clear picture of the effect of the various types of treatment used in this group of 1802 patients. They merely show what type of treatment was actually used in the group and the results that occurred. They do not show the relative value of the different kinds of treatment.

SUMMARY 1. Two special follow-up studies of 1802 cancer cases treated in seven of the larger Philadelphia hospitals in 1923, carried on five years later, have shown that it is possible to make adequate follow-up studies for the purpose of securing information as to the end-results of treatment. 1228 ARTHUR H. ESTABROOK

2. By means of these two follow-up studies and the available data in the hospital records, it has been possible to follow up 85 per cent of the total number of cancer cases admitted to the hospitals in 1923. These follow-up studies, carried on mainly by correspondence directly with the patients and through existing official agencies, such as registrars of vital statistics and local health officers, and in part by personal visits, have located 93 per cent of the total number actually investigated. 3. Only 191, or 10.6 per cent of the entire group, were known to be alive six years later; 1354 or 75.1 per cent of the group were dead, while in 257, or 14.3 per cent, the result was unknown. 4. The period of delay in securing treatment is known in 1400 cases. Only 3.5 per cent of the entire group sought treatment within one month following recognition of some abnormality of the affected part; 347, or 24.8 per cent, secured treatment within three months; 603, or nearly one-half, delayed more than one year before receiving treatment. 5. The period of delay, without consideration of other factors in the life history of the cancer, seems to have little correlation with the end-result of treatment. Thirty-one per cent of those alive delayed more than one year before receiving treatment; 19 per cent of those who died received the first treatment within three months of first recognition of the condition; 35 per cent of those who died received treatment within six months following the first symptom. 6. With respect to the method of treatment, radiation alone was used in 810 cases, with 101, or 12.5 per cent of the total, alive; 594, or 73.3 per cent, dead and 115 unknown. Surgery with radiation was used in 653, with a six-year survival of 83, or 12.7 per cent. Surgery alone was used in 336 cases, with 39, or 11.6 per cent, surviving. Inasmuch as in many cases the stage of the disease is not indicated on the hospital record, and as many of the cases previous to hospitalization had received treatment not considered in the analysis, no conclusions can be drawn from these data as to the efficacyof the various types of treatment. The data merely show the actual end result. 7. The foregoing facts indicate clearly that more data concern­ ing the life history of the cancer must be ascertained and recorded if progress is to be made in the treatment and subsequently in the statistical analysis of the end-results of treatment. Such necessary data are (1) accurate information concerning the time of appearance of the first symptom of the disease, (2) data of the treatment END-RESULT OF CANCER CASES 1229

given by the private physician before hospitalization, (3) the stage of the disease at each examination, (4) microscopic proof of the nature of the growth, (5) complete details of hospital treat­ ment with appropriate follow-up. Such standard classification groupings as are suggested by the American College of Surgeons should be used in summarizing each case. The grade and radio­ sensitivity of the cancerous tissue should be ascertained and re­ corded not only for use in determining the kind of treatment at the time, but particularly for use later in proper grouping and classifica­ tion. The various types of neoplastic growths must be classified according to site, stage of disease, and histologic type, in order to prepare proper statistical analyses of the end-results of treatment.

REFERENCES 1. CABOT, RICHARD C.: Diagnostic pitfalls identified during a study of three thousand autopsies, J. A. M. A. 59: 2295, 1912. 2. WELLS, H. G.: Relation of clinical to necropsy diagnosis in cancer and value of existing cancer statistics, J. A. M. A. 80: 737, 1923. 3. PHILADELPHIA HOSPITAL AND HEALTH SURVEY: Philadelphia Hospital and Health Survey Committee, 1929.