Annual cancer symposium in Regina reviews carcinoma of the breast By H.E. Emson, FRCP[C] Carcinoma of the breast was the major tificates. These criteria are fulfilled in showed a consistent low level with a topic for the 19th annual cancer sym¬ Saskatchewan where a population of slight peak around age 45, while in posium held in Regina May 8 to 9, 900 000 from 1946 onwards has had Saskatchewan there is a steady climb 1975. The symposium is jointly spon¬ 99% of patients recognized, identified in incidence with a small "hook" at sored by the Allan Blair Memorial and followed until death. age 45. Dr. Barclay discussed the pos¬ The reported incidence of carcinoma sible effect of dietary fat and demon¬ Clinic of the Saskatchewan Cancer
Commission and the section on surgery of the Saskatchewan Medical Associa¬ tion. These regular symposia present an annual review of some aspect of cancer for specialists, generalists, junior doc¬ tors and senior doctors. The past 30 years have represented a period of standstill in the effective diagnosis and treatment of breast can¬ cer, and it was heartening at the 1975 symposium to observe a lightening of
the horizon, if not in terms of better overall results of detection, diagnosis, treatment and survival, at least in the penetration of new ideas. Dr. J.W. Baker showed a film on radical mastectomy; the comment was made later that this represented an outmoded form of therapy. The session, chaired by Dr. C. H. Rusnak, chief of surgery of the Plains Medical Centre, Regina, continued with a statement of the magnitude of the problem; in Sas¬
of the breast in Saskatchewan has in¬ creased since 1946. This is not due to improved case finding. The change in age distribution of the population over the period 1946 to 1972 has been studied and crude incidence rates of 36/100 000 in 1946 and 69/100 000 in 1972 were modified to respective fig¬ ures of 36 and 50 per 100 000. This gives an increase of 40% in the inci¬ dence of carcinoma of the breast after elimination of changes due to age dis¬ tribution. The increase is apparent in age-specific rates for all groups apart from those under 35. Study has also shown that changes in incidence are not due to changes in histological cri¬ teria of diagnosis. Review by Dr. M. Black of New York has shown almost complete agreement with the diagnoses made by Saskatchewan pathologists. The virtual doubling of the incidence rate in 30 years is therefore a real
phenomenon. Dr. Barclay discussed the possible etiology of this increase. Factors that tend to reduce incidence of carcinoma of the breast are early age at first preg¬ nancy, multiple births, early menopause and prolonged breast feeding. Factors contributing to an increased incidence of breast carcinoma include early age at menarche, nulliparity or late first finding involving all patients suffering pregnancy, and late natural menopause. from the disease and access to subsi- Comparative figures for carcinoma of diary sources of information, including the breast in Japan and Saskatchewan all pathological reports and death cer- were shown; the Japanese figures katchewan there is one new patient each day with carcinoma of the breast, and in Canada one new patient each hour. The problems of the etiology and prognostic factors were discussed by Dr. T.H.C. Barclay of the Allan Blair Memorial Clinic. He detailed the cri¬ teria for valid studies: a population of proper and manageable size, good case
682 CMA
JOURNAL/OCTOBER 4, 1975/VOL. 113
strated the increase in incidence of carcinoma of the breast with increase in oil fat intake per day, ranging from a low in Japan with an increase in Fin¬ land and Germany to a high in British Canada. The effect of fat might be an indirect one involving conversion of renal steroid hormones, he suggested.
Selective
screening
Diagnostic methods in breast cancer discussed by Dr. R. L. Egan, chief of the mammography section and director of radiology at Emory Uni¬ versity, Atlanta, Georgia. It did not appear possible to use mammography to screen the overall female population, but application to a selected population at high risk could be very rewarding. Ninety-four percent of women do not were
get carcinoma of the breast; if the 6% of women at risk could be identified, intensive screening could be applied. An attempt is being made to identify multiple-risk factors, and their inter¬ action, on a computer program. In theory it is possible to find 85% of the carcinomas in the only 0.2% of the population which is at risk, if that group could be identified. This is an
ongoing study involving multiple-risk a complex mathematical relationship. Dr. Egan discussed the place and techniques of mammography in the de¬ factors and
tection of minimal breast carcinoma.
It formed part of a team approach by surgeon, pathologist and radiologist. The disease discovered was frequently
diffuse, the equip¬ simple and the procedure technically simple and safe. Factors in¬ dicating mammography should include signs and symptoms in the breast; pre¬ vious breast biopsy; a family history of carcinoma; opposite mastectomy; lumpy or large breasts, and cancerophobia. Of the carcinomas discovered, 10% are clinically unsuspected. When a presumptive carcinoma has been identified by mammography and the specimen ex¬ cised, the routine procedure of frozen section is not indicated; a whole-organ study with slicing, freezing, x-ray of specimen and blocking of areas of in¬ terest should be substituted. These studies showed frequent multicentric origin of carcinoma. Healthy blnsh Dr. R.D. James, Regina, a general Belliveau: Halsted abandoned surgeon, discussed "poor man's thermocoolinvolves This technique graphy". assistant profes¬ ing of the breast by ethyl chloride sorDr.in NJ. Belliveau, at McGill University, surgery onto a and observing sponge sprayed for a "blush" during recovery. In 58 detailed the many unknown factors in patients with no blush, 48 showed a breast carcinoma. He stated that in final diagnosis of malignant breast dis¬ Montreal the classical Halsted approach of radical mastectomy has been dis¬ ease. Dr. P.J. Waight, director of nuclear continued. All methodologies of detec¬ medicine at Allan Blair Memorial Clin¬ tion, including self-examination, ex¬ ic, discussed the function of bone scans amination by the physician, aspiration, in the diagnosis of breast carcinoma. drill biopsy and ductography were dis¬ cussed. Dr. Belliveau commented that Investigation with radioactive strontium the patient frequently asks, "What are has been replaced by more sophisticated you giving me in return?" And in his now is a the methods; image produced opinion Halsted's operation gives little measure of physiologic osteoblastic activity in the skeleton and is very in return. Mutilation is severe and ex¬ sensitive and nonspecific. Abnormal amination would show that lymph changes can be noted months before nodes remain in the axilla in 100% of those identified by conventional x-ray cases following classical radical mas¬ techniques and are detected by the use tectomy. The approach in Montreal in of a whole-body scanning camera. the past 15 years has changed markedTheir impact is maximal in the initial ly, with considerable diminution in the of radical mastectomies and staging of a patient, where clinical ex¬ number in modified radical marked increases amination and biopsy are not enough. A bone survey will frequently reveal and local excision. Dr. Belliveau the disease to be more advanced than showed slides of three sisters, each of had been appreciated clinically. Fol¬ whom had suffered carcinoma of the had been treated re¬ low-up can evaluate the result of ther¬ breast and who the classical Halsted spectively by and the of occult meta¬ apy presence stases. Carcinoma of the breast occurs method, by modified radical excision in age groups where the benign bone and by partial excision. He detailed the disease is common, and nonspecific criteria for selection of patients for results of bone scanning have to be local excision and the excellent clinical and cosmetic results. He commented evaluated with this in mind. on the methods of detection, including Few false positives mammography and thermography also employed in follow-up of the operated Dr. F.I. Jackson, senior radiologist patients, and observed, interestingly, of the Cross Cancer Institute, Edmon¬ that thermography remains positive sev¬ ton, who also discussed bone scanning, eral days after excision of the tumour. said there are few false positives and Dr. Belliveau's and Dr. Egan's con¬ the abnormal scans for nonmalignant tributions gave fascinating and ap¬ disease can be recognized by correla¬ parently contradictory views on the na¬ tion with conventional radiographs. ture of breast carcinoma; if the lesion not localized but ment was
is really multifocal and whole-organ disease as frequently as Dr. Egan asserted, how is it that proponents of local excision can show such apparently good results? The question remains unresolved but of fundamental importance. Radiation results Dr. James Pearson, professor and head of the department of radiotherapy in the W.W. Cross Cancer Institute, discussed the radiotherapeutic manage¬ ment of breast carcinoma. Vital in ra¬ diation treatment is the fact that, of 100 patients with carcinoma of the breast, only 3 would be cured by ex¬ tended radiation treatment. Since many patients would be treated unnecessarily and the course of their disease unaffected, it is essential that the radiation therapy show no deleterious effects. Dr. Pearson discussed the results of radia¬ tion therapy from many centres, in¬ cluding Copenhagen, Manchester and Edinburgh. There appears to be no statistical difference in long-term sur¬ vival in patients treated with or without radiotherapy, and at any rate a part of the aim of the surgeon should be to leave the tissue with maximum suit¬ ability for radiotherapy if this becomes necessary. The present practice in Ed¬ monton following radical or modified radical mastectomy is to reserve radio¬ therapy for recurrences; however, de¬ pending upon the findings at axillary node biopsy after local mastectomy, radiation to the chest wall and regional nodes may be given. Dr. CH. Crosby, Regina, discussed the results of treatment in Saskat¬ chewan. Stage I carcinoma shows a 5-year survival rate of 75%, declining to 37% at the end of 20 years, whereas for all stages of breast carcinoma the overall 5-year survival rate is approxi¬ mately 55%. The results are broadly comparable with those of other centres, and there is little argument on the modalities of treatment at either end of the spectrum in stages I and IV; the problem that arises is how to treat the large group of patients between these extremes.
Immunological response The immunological aspects of breast carcinoma were discussed by Dr. M. Black, professor of pathology in the New York medical college. Much of
his work has been based on Saskat¬ chewan material and done in coopera¬ tion with the Allan Blair Memorial Clinic, in particular with Dr. T.H. Bar¬ clay. Dr. Black discussed the various immunological aspects of carcinogenesis and the changes during the course of the disease which might be associated with immunological changes. As evalu-
CMA JOURNAL/OCTOBER 4,
1975/VOL. 113 683
ated by various criteria, mainly on the basis of tissue examination, most breast carcinomas show a strong immuno¬ logical response while at the in situ stage. This could be evaluated by biop¬ sy, reactions in the regional lymph nodes and by a "skin-window" tech¬ nique utilizing stimulus by the patient's own dead carcinoma cells. As the breast carcinoma progresses to invasion and metastasis, immune response diminishes and is lost. Dr. Black empha¬ sized the therapeutic implications of the necessity of plan¬ these findings ning the various types of therapy, in¬
who have come
The
previously recovered from or
to terms with the same disease.
pill
and
cancer
The first day of the symposium con¬ cluded with a panel discussion. Ques¬ tions included one on the effect on breast carcinoma of fat ingestion and the comment was made that breast cancer is virtually an unknown disease in Eskimos. Broaching the subject of birth control pills, Dr. Black noted that in patients under 55 there appears to be no alteration in the incidence of carcinoma; in patients over 55 cluding radiotherapy, immunotherapy breast and chemotherapy, with a knowledge there appears to be a negative correla¬ of the changes in the natural immune tion between long-term medication with response of the body to the carcinoma. contraceptive steroids and the incidence Dr. A.J.S. Bryant described a study of breast carcinoma. There is also a of oophorectomy in the primary treat¬ suggestion that benign disease of the ment of breast carcinoma. The group breast may be slightly more frequent chosen was those with pathologically in patients taking contraceptive steroids demonstrated stage I or II breast carci¬ over a long period. Dr. Egan discussed in greater detail the identification of noma who either were premenopausal a high-risk group; since the study or had demonstrated estrogen activity. A prospective randomized trial was be¬ started in 1963, the multiple indicators, gun in 1963. Excluded were patients each with a weighting factor, had ex¬ with stage III or IV breast carcinoma panded to include no less than 114 and those with contraindications to sur¬ items. These were assessed by a com¬ gery. Also excluded were patients who puter program and while not yet used in screening there is possible utility in were pregnant, lactating or receiving hormones. All patients included under¬ the future. The question of multifocal breast went radical mastectomy or modified radical mastectomy with uniform ther¬ carcinoma and localized mastectomy apy. To 1974 a total 180 patients were was discussed; Dr. Black felt that mul¬ included in the control and 187 in the tifocal carcinomas were in the minority. treatment series. There was no differ¬ Surgery might help to reduce the antigenic load over a period of time. It ence in survival rates, but prophylactic remains noteworthy: of breast carci¬ did reduce oophorectomy apparently the incidence of distant metastases in noma victims with a 15-year survival, 25% will in the end still die of that patients with stage II disease and, to a carcinoma. Parallels with other carci¬ lesser extent, the incidence of local re¬ nomas were pointed out: the fact that currences. carcinoma is present in the epithelial Consumer viewpoint system does not necessarily mean that it will become clinically expressed dur¬ Therese Lasser of New York, found¬ ing the life of the patient. And com¬ er of the "Reach to recovery" program, parisons were drawn with papillary car¬ presented a patient's view. She experi¬ cinoma of the thyroid and carcinoma enced, 22 years before, a mastectomy of the prostate. On bilaterality of breast for carcinoma in New York City. Pre¬ carcinoma, Dr. Egan stated he believes operatively neither the surgeon nor the carcinoma is a diffuse epithelial dis¬ nurse had discussed with her the pos¬ ease of one breast and possibly of both, sible need for mastectomy, and all the and mammography would display 10 therapeutic team appeared completely times as many bilateral breast carcino¬ ignorant of the postoperative problems. mas as could be detected by physical Mrs. Lasser described from this begin¬ examination. The panel discussed the ning the growth of the "Reach to re¬ selection and follow-up of patients for covery" program. Under this program, local mastectomy; Dr. Belliveau stated at the request of the attending surgeon, criteria include a cooperative, intelli¬ a patient who has had mastectomy will gent patient within easy reach of the assist and advise the patient who has centre of treatment willing to return been recently operated on. Your cor- for review. They also include a moder¬ respondent has commented before on ately large breast with a peripheral le¬ the value of these programs: they point sion, a negative thermogram and mamout to the physician that for many pa¬ mogram on the opposite breast. Total tients the end of active therapy is only mastectomy was much easier. Only the beginning of their lifetime prob¬ 20% of his patients were submitted to lems; vital assistance can be given, and partial mastectomy. In 1975 the ques¬ apparently has been given, by patients tion was whether we, by any tests, 686 CMA JOURNAL/OCTOBER 4, 1975/VOL. 113 .
could assign patients to different groups with different prognoses. We cannot sacrifice therapeutic results for cos¬ metic results, and the population is not homogenous; therefore an important redirection of investigation was seen to be the identification of patients with tumours of different biological beha¬ viour and prognosis and the selection of appropriate therapeutic modalities, as opposed to a uniform approach.
Breast carcinoma management Dr. Pearson returned to the speaker's podium the following morning to dis¬ cuss management of breast carcinoma. This must be reviewed as part of an integrated program of treatment, not in isolation, he said. It could include radiotherapy, surgery, and hormonal and support aspects. Palliative radiation can greatly ameliorate the symptoms of inoperable local disease; of patients so treated many develop distant meta¬ stases but a few do not. More than 50% show a good immediate response and 25% a 5-year survival. Diffuse metastatic disease is not amenable to radiotherapy in general, but the inten¬ sive palliative radiation of localized metastases which are symptomatic might be well worthwhile. These in¬ clude bone or brain metastases. Radio¬ logical ablation of the pituitary gland or ovarian function or both also can be of use in the patient with advanced cancer.
Dr. H.L. Davis, University of Wisconsin hospitals, Madison, discussed the hormonal and chemotherapeutic man¬ agement of advanced breast carcino¬ mas. Identification of hormonal de¬ pendence of breast carcinomas depends on identification of the estrogen recep¬ tors, the function of which is to take and escort estrogen into the nucleus of the cell. The presence of estrogen receptor protein has been found in vir¬ tually 50% of all cancers in a popula¬ tion of breast carcinoma patients. Of patients whose neoplasms demonstrate this presence, 60% would show a re¬ mission of their malignant disease in response to major endocrine ablative surgery, while such a response would be seen in only 5% of patients where no estrogen-binding receptors can be found in tumours. Dr. Davis discussed multiple regimens of drugs and hor¬ monal therapy and urged honest assess¬ ment of the side effects of treatment and an attempt to balance a possible minimal increase in survival time against the suffering of the patient. Dr. Black discussed the viral implica¬ tions of human breast carcinoma. His investigations have been directed to determining the occurrence of "private" antigens versus common antigens in human breast carcinomas and to trac-
cross reaction in pa¬ the in¬ tients with breast carcinoma teraction of antibodies with antigenic components of the mouse mammary tumour virus. About 30% of patients with breast carcinoma show some cross reaction to mouse tumour viral com¬ ponents as assessed by various means. These patients also tend to show in¬ creased reaction to components of other, naturally occurring, human breast carcinomas, and there appears to be homology of segments of DNA from human breast carcinomas with those from mouse lesions. The major¬ ity of tumours showing such crossreaction were well differentiated histologic¬ ally, and there was also correlation with a positive family history of breast carcinoma. The results show a possible use of components from the mouse tumour virus to produce in human patients cel¬ lular hypersensitivity as protection against human breast carcinoma. And these results again demonstrate that human breast carcinoma is apparently not an homologous disease but rather a group of diseases of varied biological expression and possibly varied etiology.
ing patterns of
.
Guest lecturer In the John Whittick memorial lec¬ ture, Dr. H.J.G. Bloom, consultant in radiotherapy and oncology at the Royal Marsden Hospital, London, England, discussed "The tumour, the host and the treatment policy in breast carci¬ noma". The value of the classical, radical
now widely questioned, he said. It is often replaced by a wide range of procedures depending on the philosophy, experience and emotional outlooks of surgeon and patient. The world anxiously awaits the results of controlled clinical trials of various modalities of therapy, but the major ques¬ tions are "what do we do in the meantime?" and "will the trials provide the
operation is
answer to our
questions?"
The staging of breast carcinoma by clinical means is a very crude method which totally ignores two major factors, the intrinsic malignancy of the tumour and the resistance of the host. The problem of very different biological behaviour of apparently similar tu¬ mours is well known, and many of the controversies on treatment of breast carcinoma arise because of this wide spectrum of natural biological beha¬ viour. Dr. Bloom reiterated Dr. Black's contention: before treatment can be planned or assessed a much better clas¬ sification of breast carcinoma is neces¬ sary, and such classification will also be essential for meaningful results from future randomized trials. Dr. Bloom discussed studies based
detects changes months before conventional x-ray Records of histological examination, on histological methods of tumour grading used from 1936 to 1949 at the available from 1900, showed that all Middlesex Hospital in England. These patients with grade 3 tumours were included clinical staging also and a dead at 5 years after diagnosis, while
Whole body
scan
combined classification taking into ac¬ malignancy and stage of the lesion. The study included a total 1411 cases of which 3.8% were lost to fol¬ low-up (these were counted as dead from the disease to avoid unduly optimistic weighting of the results). Histologically, the carcinomas were classified into three grades of malig¬ nancy as arbitrary subdivisions of a continuous scale. The distribution was approximately 26% in grade 1, 45% in grade 2 and 29% in grade 3 with respective 5-year survival rates of 70, 50 and 39% and an overall 29% 20year survival rate. The 5-, 10- and 20year survival percentages also showed similar variations according to the his¬ tological grade of the tumour. There was a slow, persistent decline in the number of survivors even with grade 1 tumours, possibly expressing slow progress of latent metastases present at the time of initial surgery. Most of the patients with grade 3 tumours died in the first 5 years, and thereafter few in this group died as a result of the disease. count the
128-year
record
30% of those with grades 1 and 2 survived beyond this period. Dr. Bloom combined the results of histo¬ logical grading and clinical staging, and he compared these with the patients from the untreated series. He com¬ mented on the close correlation be¬ tween the degree of axillary involve¬ ment and length of survival and stated that accurate and detailed assessment of the axillary content is vital to prog¬ nosis. Histological assessment of the axilla is very inaccurate unless serial sections are taken, and the degree of node involvement, the size of the meta¬ stases and the axillary level of involve¬ ment are all important. There is close correlation between the histological grade of the tumour and node involve¬ ment and between these and the in¬ cidence of metastases within 5 years. Dr. Bloom also discussed the rela¬ tionship of staging and grading, which might indicate the malignancy of the tumour but nothing of the patient's immune response. The host reaction has a marked effect on the survival of the high-grade tumours, but not much on the lower grade tumours. Car¬ cinomas with a marked lymphocytic reaction, such as the classical "medul¬ lary carcinoma with lymphoid stroma", should be eliminated from studies and separately classified for proper assess¬ ment of treatment results. Unless the degree of lymphocytic response is taken into account, the survival statistics make no sense. Dr. Bloom also commented that the apparently deleterious results of post¬ operative radiotherapy might, in part, be due to the inclusion of nonhomogenous material in the treatment series. Both lymphocytic reaction and tumour grading should be noted in comparing results from Japan, Boston and Glam-
Dr. Bloom compared this with the natural history of a series of untreated breast carcinomas drawn from the rec¬ ords from the Middlesex Hospital 1805 to 1933. A total 250 cases of untreated breast carcinoma had been isolated from the records for this period of 128 years; all had been subjected to autopsy. In this untreated series, 44% were alive at 3 years post diagnosis and 18% at 5 years; 3% were alive at 10 years and by 19 years following diag¬ nosis all were dead. The natural sur¬ vival was compared with a 41% sur¬ vival of treated patients at 19 years. CMA JOURNAL/OCTOBER 4, 1975/VOL. 113 687
organ; the Japanese series shows a fense mechanisms adversely. The simple restriction of respiratory function have greater prevalence of medullary carci¬ mastectomy with radical radiation ther¬ been excluded from the study. There
noma and lymphoid infiltrates and a higher prevalence of grade 1 tumours; both elements point to the better prog¬ nosis for the Japanese patients. Breast carcinoma in pregnancy shows a very variable and mainly poor prog¬ nosis. Very few cases fail into the grade 1 grouping and the prognosis for preg¬ nant patients with grade 3 cases is worse than that for the general series. Dr. Bloom commented on the results in long-term treatment of medullary carcinoma with lymphoid stroma, where a corrected 20-year survival shows an apparent 122% survival for these patients, following radical mastec¬ tomy and postoperative radiation. The implication is that these patients are less susceptible to the common illnesses of life and might in some respect re¬ present a "superfemale". Summing up, Dr. Bloom discussed the appropriate therapy for patients with carcinoma of the breast in our present state of knowledge. He felt that a complicated grade and stage classi¬ fication would better demonstrate the effects of modalities of therapy than does the lumping together of all cases.
At present he considers it wrong to support a general withdrawal from rad¬ ical treatment; there is no evidence that radical treatment influences host de-
apy appears to offer as good results as does classical radical mastectomy. Many more comparable groups of cases and studies are needed, and we might have to accept that we may do too much in some cases in order to do enough in others.
Bronchogenic carcinoma A
session
on
consideration of
bronchogenic carcinoma was sponsored by the section on surgery of the Sas¬ katchewan Medical Association. Dr. D. Sanderson of the Mayo Clinic, Roches¬ ter, Minnesota, discussed screening for bronchogenic carcinoma in the patient at high-risk. The ideal state at which to discover lung carcinoma is a welldifferentiated lesion, showing slow growth, near the periphery, small and surrounded by normal lung tissue. The Mayo lung screening project in¬ cludes a chest radiograph, a cytological study of sputum and a health question¬ naire every 4 months. The question is whether, assuming such an intensive program can be applied, it will affect the course of bronchogenic carcinoma. The population selected was male, over45, cigarette smokers who smoke more than one pack per day. Patients with a serious medical problem or severe
URINE EXTRACTS1
random allocation to two groups: group having the sputum and x-ray examinations at 4-month intervals and the other, the same investigation at 12-month intervals. All radiographs are read twice and compared with the pre¬ vious films. The population screened at a monthly rate of 250 now includes 6259 patients; the ultimate goal is 10 000. On the first screen an unsuspected carcinoma was found in 0.8%, and carcinoma was detected on follow-up in 13 patients at a rate of 5 per 1000 per year. Both sputum and x-ray ex¬ aminations are useful. Difficulty has arisen in the localization of carcinoma in patients who have positive sputum cultures and normal x-ray films. Asymptomatic patients with abnormal radiographs account for 50% of the cases already in stage III. The screen¬ ing program has achieved success, in that only 10% dropped out and it ap¬ pears to detect and localize small pri¬ mary carcinomas. The two forms of investigation are complementary, but radiological examination detects more carcinomas than does cytological study. The small-celled anaplastic carcinoma has been discouraging; here the x-ray film, in general, first indicated presence of carcinoma. In squamous carcinoma, was one
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on the other hand, the occult lesion was demonstrated in sputum but not in the film; it can frequently be localized by the fiberoptic bronchoscope. Prolonged and close follow-up is necessary; one depressing feature of the investigation has been the very low proportion of patients in the survey who discontinued smoking. Dr. Egan discussed the radiological manifestations of bronchogenic carcinoma, of which there are 55 000 new cases each year in the USA. Only 1% are not demonstrable by x-ray investigation. The average lesion is demonstrable 20 months before symptomatology, and the average patient delays approximately 3 months after the onset of symptoms before seeking advice. The average delay, therefore, between the theoretical demonstrability of the lesion and treatment is 23 months. Nondetection of bronchogenic carcinoma in x-ray screening could be traced to smallness of the lesion, its extreme situation at the proximal or peripheral field, or its being mistaken for a nonsignificant lesion. Techniques The surgical, diagnostic and therapeutic techniques in bronchogenic carcinoma were discussed by Dr. E.F.G. Bussey of Regina. He assessed the value of bronchoscopy, mediastinoscopy,
October Workshop in PRACTICE MANAGEMENT, Oct. 18, Toronto. Info: Peter Fraser, Ontario Medical
sociation, 240 St. George St., Toronto, ON.
As-
Workshop In PRACTICE MANAGEMENT, Oct. 20, Winnipeg. Info: Mr. J. Sherstone, Manitoba Medical Association, 201 Kennedy St., Winnipeg,
MB. National conference, BREAST CANCER, Oct. 31 Nov. 1, Hotel Bonaventure, Montr6al. Info: Dr. Guy St-Arneault, Institut dh6matologie.oncologie de Montr6al, 5400 Blvd. Gouin W, Montreal H4J ICS.
November International symposium on REHABILITATION, Nov. 1, Ontario Institute for Studies In Education, 252 Bloor St. W, Toronto. Info: Dalton E. McOualg, Ontario Society for Crippled ChIldren, 350 Rumsay Rd., Toronto.
LABORATORY INVESTIGATION OF PERINATAL DISORDERS, Nov. 7-8, London. Info: A.B. Atkinson, 351 Hill St., London N6B 1E4. ACUPUNCTURE FOUNDATION OF CANADA, Nov. 7.9, Toronto. Info: Dr. J. Richman, Acupuncture Foundation of Canada, 730 Yonge St., Suite 228, Toronto M4Y 2B7. 33rd annual interdisciplinary clinical meeting, AMERICAN ASSOCIATION OF MARRIAGE AND FAMILY COUNSELORS, Nov. 7.9, Inn-on-the-Park, Toronto. Info: Dr. Ray Fowler, AAMFC, 225 Yale Ave., Claremont, CA 91711. 4th INFORMATION AND FEEDBACK CONFERENCE, Nov. 12-13, Toronto. Info: IF conference commit-
node biopsy and biopsy of the lung, including needle or wedge biopsy, lobectomy and pneumonectomy. Dr. Howard Hopkins of Regina assessed unusual manifestations of lung carcinoma, particularly in the varied hormonal activities of the tumour. The value of radiotherapy and chemotherapy in treatment of lung carcinoma was discussed by Dr. F.I. Jackson, who detailed the results from Edmonton. Dr. Sanderson summarized the results of treatment at the Mayo Clinic and presented the theoretical results on 100 patients with bronchogenic carcinoma on present modalities of therapy. The small-celled anaplastic type would constitute 15% of the series and show no 5-year survivals; the squamous would constitute 50% of the series and show approximately 65% five-year survival and the adenocarcinoma and large-cell carcinoma would constitute 35% of the series and show about 35% 5year survival. The contrast between the theoretical and the actual results was stressed. A panel agreed that a high-risk group comprises men and women of more than 45 years, smoking more than one pack of cigarettes per day. Occupationa[ high-risk groups include asbestos and insulation workers and uranium workers. Encouragement to stop smoking has a very disappointing result; only 3% discontinue their habit. The gen-
tee, Counselling and Development Centre, York University, Toronto. INFECTIOUS DISEASES, Nov. 13-15, St. Paul's Hospital, Saskatoon. Info: Margaret P. Sarich, Continuing medical education, 408 Ellis Hall, Saskatoon S7N 0W8. INTRAOCULAR LENS IMPLANT, seminar, Nov. 15, Queen Elizabeth Hotel, Montreal. Info: Dr. M. L. Kwitko, 5591 COte des Neiges Rd., Montreal H3T IYB. DEFENCE MEDICAL ASSOCIATION OF CANADA. Nov. 20.22, CanadIan Forces Base Petawawa. Info: ICol C.P. Smith, 2111 Niagara Dr., Ottawa KIH 6G9. MEDICAL SOCIETY OF NOVA SCOTIA, Nov. 20. 22, HalIfax. Info: D. Peacocke, MSNS, Sir Charles Tupper Medical Bldg., University Ave., Halifax. GREY CUP MEDICAL SYMPOSIUM, Nov. 22, CalHalgh, 3630 Morley Trail NW,
erally gloomy outlook on bronchogenic carcinoma emerged from the panel discussion with a story of high and increasing incidence, minimal early manifestations and poor response to treatment of this tragic disease - made the more tragic because most cases are preventable. This year's annual cancer conference again provided the specialist and the generalist with an overview of two very common malignant lesions. Your reporter has attended many of these sessions and finds them of great value from three points of view: * First, the opportunity afforded the specialist for total view of a condition, of which he may normally only see a small segment intensively; the diagnostic pathologist needs more education in the etiology, presentation, treatment and results of breast carcinoma, since he is concerned almost exclusively with the diagnostic aspects. * The meeting also brings to Saskatchewan experts from larger centres and other countries, affording an opportunity for interchange of opinions and results, in both formal sessions and informal discussions. * Finally, the program brings together Saskatchewan's specialists and generalists and the personnel of the cancer clinics, making them aware of their separate contributions to the common problem.E
Seminar, CREATIVE SEXUALITY, sponsored by the Ontario Medical Association, Nov. 26.28, Hotel Toronto. Info: Creative Sexuality, Suite 400, 73 Richmond St. W, Toronto M5H 2A1. Basic and intermediate workshop on CLINICAL HYPNOSIS, sponsored by the Ontario Society for Clinical HypnosIs, Nov. 28-30, Royal York Hotel, Toronto. Info: Dr. S. Kushnir, 243 St. Clair Ave. W. Toronto M4V 1R3.
PROBLEMS IN SURGERY, Royal College sponsored course, Dec. 4-6, Saskatoon. Info: Margaret ContinuIng medical educatIon, 408 EllIs Sarlch, Hall. Saskatoon S7N 0W8. PROLACTIN, conference sponsored by UniversIty of Toronto faculty of medicine and Canad Ian Society of Endocrinology and Metabolism supported by Sandoz, Dec. 6, Toronto. Info: Dr. Robert Volp6, Room 112D, Jones Bldg., Wellesley pItal, 160 Wellesley St. E, Toronto M4Y 1J3. HosJanuary ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA, annual meeting, Jan. 22-24, Ou6bec City. Info: R. A. Davis, 74 Stanley, Ottawa. CANADIAN ASSOCIATION OF PAEDIATRIC SURGEONS, eighth annual meeting, Jan. 20, Ou6bec City, Info: Dr. Gordon Cameron, 4E.11 University Medical Centre, 1200 MainMcMaster St. W, Hamilton 18S 4J9. COLLEGE OF FAMILY PHYSICIANS OF ALBERTA CHAPTER, 21st annual scientificCANADA, bly, Jan. 18-21, Calgary. Info: Mrs. M. 1. assemJeppe. sen. P0 Box 3846, Postal Station D. Edmonton T5L 4K1. Seminar, CONFLICTS IN THE PHYSICAL REHABILITATION TEAM, Jan. 26.27, UnIv of Ottawa. Info: Mrs. Carolyn Beizile, School of Health Administration, University of Ottawa, Ottawa. OUTSIDE CANADA
December ALBERTA HOSPITAL ASSOCIATION, 57th annual convention, Dec. 3.5, Edmonton. Info: Alberta Hospital AssociatIon, 10025 - 108 St., Edmonton.
OBESITY AND ASSOCIATED CONDITIONS, symposium, Oct. 31 - Nov. 3, Las Vegas, NV. Info: Dr. W. 1. Asher, 333 W Hampden Ave., Suite 307, Englewood, CO 80110.
November
CMA JOURNAL/OCTOBER 4, 1975/VOL. 113 689
Commission and the section on surgery of the Saskatchewan Medical Associa¬ tion. These regular symposia present an annual review of some aspect of cancer for specialists, generalists, junior doc¬ tors and senior doctors. The past 30 years have represented a period of standstill in the effective diagnosis and treatment of breast can¬ cer, and it was heartening at the 1975 symposium to observe a lightening of
the horizon, if not in terms of better overall results of detection, diagnosis, treatment and survival, at least in the penetration of new ideas. Dr. J.W. Baker showed a film on radical mastectomy; the comment was made later that this represented an outmoded form of therapy. The session, chaired by Dr. C. H. Rusnak, chief of surgery of the Plains Medical Centre, Regina, continued with a statement of the magnitude of the problem; in Sas¬
of the breast in Saskatchewan has in¬ creased since 1946. This is not due to improved case finding. The change in age distribution of the population over the period 1946 to 1972 has been studied and crude incidence rates of 36/100 000 in 1946 and 69/100 000 in 1972 were modified to respective fig¬ ures of 36 and 50 per 100 000. This gives an increase of 40% in the inci¬ dence of carcinoma of the breast after elimination of changes due to age dis¬ tribution. The increase is apparent in age-specific rates for all groups apart from those under 35. Study has also shown that changes in incidence are not due to changes in histological cri¬ teria of diagnosis. Review by Dr. M. Black of New York has shown almost complete agreement with the diagnoses made by Saskatchewan pathologists. The virtual doubling of the incidence rate in 30 years is therefore a real
phenomenon. Dr. Barclay discussed the possible etiology of this increase. Factors that tend to reduce incidence of carcinoma of the breast are early age at first preg¬ nancy, multiple births, early menopause and prolonged breast feeding. Factors contributing to an increased incidence of breast carcinoma include early age at menarche, nulliparity or late first finding involving all patients suffering pregnancy, and late natural menopause. from the disease and access to subsi- Comparative figures for carcinoma of diary sources of information, including the breast in Japan and Saskatchewan all pathological reports and death cer- were shown; the Japanese figures katchewan there is one new patient each day with carcinoma of the breast, and in Canada one new patient each hour. The problems of the etiology and prognostic factors were discussed by Dr. T.H.C. Barclay of the Allan Blair Memorial Clinic. He detailed the cri¬ teria for valid studies: a population of proper and manageable size, good case
682 CMA
JOURNAL/OCTOBER 4, 1975/VOL. 113
strated the increase in incidence of carcinoma of the breast with increase in oil fat intake per day, ranging from a low in Japan with an increase in Fin¬ land and Germany to a high in British Canada. The effect of fat might be an indirect one involving conversion of renal steroid hormones, he suggested.
Selective
screening
Diagnostic methods in breast cancer discussed by Dr. R. L. Egan, chief of the mammography section and director of radiology at Emory Uni¬ versity, Atlanta, Georgia. It did not appear possible to use mammography to screen the overall female population, but application to a selected population at high risk could be very rewarding. Ninety-four percent of women do not were
get carcinoma of the breast; if the 6% of women at risk could be identified, intensive screening could be applied. An attempt is being made to identify multiple-risk factors, and their inter¬ action, on a computer program. In theory it is possible to find 85% of the carcinomas in the only 0.2% of the population which is at risk, if that group could be identified. This is an
ongoing study involving multiple-risk a complex mathematical relationship. Dr. Egan discussed the place and techniques of mammography in the de¬ factors and
tection of minimal breast carcinoma.
It formed part of a team approach by surgeon, pathologist and radiologist. The disease discovered was frequently
diffuse, the equip¬ simple and the procedure technically simple and safe. Factors in¬ dicating mammography should include signs and symptoms in the breast; pre¬ vious breast biopsy; a family history of carcinoma; opposite mastectomy; lumpy or large breasts, and cancerophobia. Of the carcinomas discovered, 10% are clinically unsuspected. When a presumptive carcinoma has been identified by mammography and the specimen ex¬ cised, the routine procedure of frozen section is not indicated; a whole-organ study with slicing, freezing, x-ray of specimen and blocking of areas of in¬ terest should be substituted. These studies showed frequent multicentric origin of carcinoma. Healthy blnsh Dr. R.D. James, Regina, a general Belliveau: Halsted abandoned surgeon, discussed "poor man's thermocoolinvolves This technique graphy". assistant profes¬ ing of the breast by ethyl chloride sorDr.in NJ. Belliveau, at McGill University, surgery onto a and observing sponge sprayed for a "blush" during recovery. In 58 detailed the many unknown factors in patients with no blush, 48 showed a breast carcinoma. He stated that in final diagnosis of malignant breast dis¬ Montreal the classical Halsted approach of radical mastectomy has been dis¬ ease. Dr. P.J. Waight, director of nuclear continued. All methodologies of detec¬ medicine at Allan Blair Memorial Clin¬ tion, including self-examination, ex¬ ic, discussed the function of bone scans amination by the physician, aspiration, in the diagnosis of breast carcinoma. drill biopsy and ductography were dis¬ cussed. Dr. Belliveau commented that Investigation with radioactive strontium the patient frequently asks, "What are has been replaced by more sophisticated you giving me in return?" And in his now is a the methods; image produced opinion Halsted's operation gives little measure of physiologic osteoblastic activity in the skeleton and is very in return. Mutilation is severe and ex¬ sensitive and nonspecific. Abnormal amination would show that lymph changes can be noted months before nodes remain in the axilla in 100% of those identified by conventional x-ray cases following classical radical mas¬ techniques and are detected by the use tectomy. The approach in Montreal in of a whole-body scanning camera. the past 15 years has changed markedTheir impact is maximal in the initial ly, with considerable diminution in the of radical mastectomies and staging of a patient, where clinical ex¬ number in modified radical marked increases amination and biopsy are not enough. A bone survey will frequently reveal and local excision. Dr. Belliveau the disease to be more advanced than showed slides of three sisters, each of had been appreciated clinically. Fol¬ whom had suffered carcinoma of the had been treated re¬ low-up can evaluate the result of ther¬ breast and who the classical Halsted spectively by and the of occult meta¬ apy presence stases. Carcinoma of the breast occurs method, by modified radical excision in age groups where the benign bone and by partial excision. He detailed the disease is common, and nonspecific criteria for selection of patients for results of bone scanning have to be local excision and the excellent clinical and cosmetic results. He commented evaluated with this in mind. on the methods of detection, including Few false positives mammography and thermography also employed in follow-up of the operated Dr. F.I. Jackson, senior radiologist patients, and observed, interestingly, of the Cross Cancer Institute, Edmon¬ that thermography remains positive sev¬ ton, who also discussed bone scanning, eral days after excision of the tumour. said there are few false positives and Dr. Belliveau's and Dr. Egan's con¬ the abnormal scans for nonmalignant tributions gave fascinating and ap¬ disease can be recognized by correla¬ parently contradictory views on the na¬ tion with conventional radiographs. ture of breast carcinoma; if the lesion not localized but ment was
is really multifocal and whole-organ disease as frequently as Dr. Egan asserted, how is it that proponents of local excision can show such apparently good results? The question remains unresolved but of fundamental importance. Radiation results Dr. James Pearson, professor and head of the department of radiotherapy in the W.W. Cross Cancer Institute, discussed the radiotherapeutic manage¬ ment of breast carcinoma. Vital in ra¬ diation treatment is the fact that, of 100 patients with carcinoma of the breast, only 3 would be cured by ex¬ tended radiation treatment. Since many patients would be treated unnecessarily and the course of their disease unaffected, it is essential that the radiation therapy show no deleterious effects. Dr. Pearson discussed the results of radia¬ tion therapy from many centres, in¬ cluding Copenhagen, Manchester and Edinburgh. There appears to be no statistical difference in long-term sur¬ vival in patients treated with or without radiotherapy, and at any rate a part of the aim of the surgeon should be to leave the tissue with maximum suit¬ ability for radiotherapy if this becomes necessary. The present practice in Ed¬ monton following radical or modified radical mastectomy is to reserve radio¬ therapy for recurrences; however, de¬ pending upon the findings at axillary node biopsy after local mastectomy, radiation to the chest wall and regional nodes may be given. Dr. CH. Crosby, Regina, discussed the results of treatment in Saskat¬ chewan. Stage I carcinoma shows a 5-year survival rate of 75%, declining to 37% at the end of 20 years, whereas for all stages of breast carcinoma the overall 5-year survival rate is approxi¬ mately 55%. The results are broadly comparable with those of other centres, and there is little argument on the modalities of treatment at either end of the spectrum in stages I and IV; the problem that arises is how to treat the large group of patients between these extremes.
Immunological response The immunological aspects of breast carcinoma were discussed by Dr. M. Black, professor of pathology in the New York medical college. Much of
his work has been based on Saskat¬ chewan material and done in coopera¬ tion with the Allan Blair Memorial Clinic, in particular with Dr. T.H. Bar¬ clay. Dr. Black discussed the various immunological aspects of carcinogenesis and the changes during the course of the disease which might be associated with immunological changes. As evalu-
CMA JOURNAL/OCTOBER 4,
1975/VOL. 113 683
ated by various criteria, mainly on the basis of tissue examination, most breast carcinomas show a strong immuno¬ logical response while at the in situ stage. This could be evaluated by biop¬ sy, reactions in the regional lymph nodes and by a "skin-window" tech¬ nique utilizing stimulus by the patient's own dead carcinoma cells. As the breast carcinoma progresses to invasion and metastasis, immune response diminishes and is lost. Dr. Black empha¬ sized the therapeutic implications of the necessity of plan¬ these findings ning the various types of therapy, in¬
who have come
The
previously recovered from or
to terms with the same disease.
pill
and
cancer
The first day of the symposium con¬ cluded with a panel discussion. Ques¬ tions included one on the effect on breast carcinoma of fat ingestion and the comment was made that breast cancer is virtually an unknown disease in Eskimos. Broaching the subject of birth control pills, Dr. Black noted that in patients under 55 there appears to be no alteration in the incidence of carcinoma; in patients over 55 cluding radiotherapy, immunotherapy breast and chemotherapy, with a knowledge there appears to be a negative correla¬ of the changes in the natural immune tion between long-term medication with response of the body to the carcinoma. contraceptive steroids and the incidence Dr. A.J.S. Bryant described a study of breast carcinoma. There is also a of oophorectomy in the primary treat¬ suggestion that benign disease of the ment of breast carcinoma. The group breast may be slightly more frequent chosen was those with pathologically in patients taking contraceptive steroids demonstrated stage I or II breast carci¬ over a long period. Dr. Egan discussed in greater detail the identification of noma who either were premenopausal a high-risk group; since the study or had demonstrated estrogen activity. A prospective randomized trial was be¬ started in 1963, the multiple indicators, gun in 1963. Excluded were patients each with a weighting factor, had ex¬ with stage III or IV breast carcinoma panded to include no less than 114 and those with contraindications to sur¬ items. These were assessed by a com¬ gery. Also excluded were patients who puter program and while not yet used in screening there is possible utility in were pregnant, lactating or receiving hormones. All patients included under¬ the future. The question of multifocal breast went radical mastectomy or modified radical mastectomy with uniform ther¬ carcinoma and localized mastectomy apy. To 1974 a total 180 patients were was discussed; Dr. Black felt that mul¬ included in the control and 187 in the tifocal carcinomas were in the minority. treatment series. There was no differ¬ Surgery might help to reduce the antigenic load over a period of time. It ence in survival rates, but prophylactic remains noteworthy: of breast carci¬ did reduce oophorectomy apparently the incidence of distant metastases in noma victims with a 15-year survival, 25% will in the end still die of that patients with stage II disease and, to a carcinoma. Parallels with other carci¬ lesser extent, the incidence of local re¬ nomas were pointed out: the fact that currences. carcinoma is present in the epithelial Consumer viewpoint system does not necessarily mean that it will become clinically expressed dur¬ Therese Lasser of New York, found¬ ing the life of the patient. And com¬ er of the "Reach to recovery" program, parisons were drawn with papillary car¬ presented a patient's view. She experi¬ cinoma of the thyroid and carcinoma enced, 22 years before, a mastectomy of the prostate. On bilaterality of breast for carcinoma in New York City. Pre¬ carcinoma, Dr. Egan stated he believes operatively neither the surgeon nor the carcinoma is a diffuse epithelial dis¬ nurse had discussed with her the pos¬ ease of one breast and possibly of both, sible need for mastectomy, and all the and mammography would display 10 therapeutic team appeared completely times as many bilateral breast carcino¬ ignorant of the postoperative problems. mas as could be detected by physical Mrs. Lasser described from this begin¬ examination. The panel discussed the ning the growth of the "Reach to re¬ selection and follow-up of patients for covery" program. Under this program, local mastectomy; Dr. Belliveau stated at the request of the attending surgeon, criteria include a cooperative, intelli¬ a patient who has had mastectomy will gent patient within easy reach of the assist and advise the patient who has centre of treatment willing to return been recently operated on. Your cor- for review. They also include a moder¬ respondent has commented before on ately large breast with a peripheral le¬ the value of these programs: they point sion, a negative thermogram and mamout to the physician that for many pa¬ mogram on the opposite breast. Total tients the end of active therapy is only mastectomy was much easier. Only the beginning of their lifetime prob¬ 20% of his patients were submitted to lems; vital assistance can be given, and partial mastectomy. In 1975 the ques¬ apparently has been given, by patients tion was whether we, by any tests, 686 CMA JOURNAL/OCTOBER 4, 1975/VOL. 113 .
could assign patients to different groups with different prognoses. We cannot sacrifice therapeutic results for cos¬ metic results, and the population is not homogenous; therefore an important redirection of investigation was seen to be the identification of patients with tumours of different biological beha¬ viour and prognosis and the selection of appropriate therapeutic modalities, as opposed to a uniform approach.
Breast carcinoma management Dr. Pearson returned to the speaker's podium the following morning to dis¬ cuss management of breast carcinoma. This must be reviewed as part of an integrated program of treatment, not in isolation, he said. It could include radiotherapy, surgery, and hormonal and support aspects. Palliative radiation can greatly ameliorate the symptoms of inoperable local disease; of patients so treated many develop distant meta¬ stases but a few do not. More than 50% show a good immediate response and 25% a 5-year survival. Diffuse metastatic disease is not amenable to radiotherapy in general, but the inten¬ sive palliative radiation of localized metastases which are symptomatic might be well worthwhile. These in¬ clude bone or brain metastases. Radio¬ logical ablation of the pituitary gland or ovarian function or both also can be of use in the patient with advanced cancer.
Dr. H.L. Davis, University of Wisconsin hospitals, Madison, discussed the hormonal and chemotherapeutic man¬ agement of advanced breast carcino¬ mas. Identification of hormonal de¬ pendence of breast carcinomas depends on identification of the estrogen recep¬ tors, the function of which is to take and escort estrogen into the nucleus of the cell. The presence of estrogen receptor protein has been found in vir¬ tually 50% of all cancers in a popula¬ tion of breast carcinoma patients. Of patients whose neoplasms demonstrate this presence, 60% would show a re¬ mission of their malignant disease in response to major endocrine ablative surgery, while such a response would be seen in only 5% of patients where no estrogen-binding receptors can be found in tumours. Dr. Davis discussed multiple regimens of drugs and hor¬ monal therapy and urged honest assess¬ ment of the side effects of treatment and an attempt to balance a possible minimal increase in survival time against the suffering of the patient. Dr. Black discussed the viral implica¬ tions of human breast carcinoma. His investigations have been directed to determining the occurrence of "private" antigens versus common antigens in human breast carcinomas and to trac-
cross reaction in pa¬ the in¬ tients with breast carcinoma teraction of antibodies with antigenic components of the mouse mammary tumour virus. About 30% of patients with breast carcinoma show some cross reaction to mouse tumour viral com¬ ponents as assessed by various means. These patients also tend to show in¬ creased reaction to components of other, naturally occurring, human breast carcinomas, and there appears to be homology of segments of DNA from human breast carcinomas with those from mouse lesions. The major¬ ity of tumours showing such crossreaction were well differentiated histologic¬ ally, and there was also correlation with a positive family history of breast carcinoma. The results show a possible use of components from the mouse tumour virus to produce in human patients cel¬ lular hypersensitivity as protection against human breast carcinoma. And these results again demonstrate that human breast carcinoma is apparently not an homologous disease but rather a group of diseases of varied biological expression and possibly varied etiology.
ing patterns of
.
Guest lecturer In the John Whittick memorial lec¬ ture, Dr. H.J.G. Bloom, consultant in radiotherapy and oncology at the Royal Marsden Hospital, London, England, discussed "The tumour, the host and the treatment policy in breast carci¬ noma". The value of the classical, radical
now widely questioned, he said. It is often replaced by a wide range of procedures depending on the philosophy, experience and emotional outlooks of surgeon and patient. The world anxiously awaits the results of controlled clinical trials of various modalities of therapy, but the major ques¬ tions are "what do we do in the meantime?" and "will the trials provide the
operation is
answer to our
questions?"
The staging of breast carcinoma by clinical means is a very crude method which totally ignores two major factors, the intrinsic malignancy of the tumour and the resistance of the host. The problem of very different biological behaviour of apparently similar tu¬ mours is well known, and many of the controversies on treatment of breast carcinoma arise because of this wide spectrum of natural biological beha¬ viour. Dr. Bloom reiterated Dr. Black's contention: before treatment can be planned or assessed a much better clas¬ sification of breast carcinoma is neces¬ sary, and such classification will also be essential for meaningful results from future randomized trials. Dr. Bloom discussed studies based
detects changes months before conventional x-ray Records of histological examination, on histological methods of tumour grading used from 1936 to 1949 at the available from 1900, showed that all Middlesex Hospital in England. These patients with grade 3 tumours were included clinical staging also and a dead at 5 years after diagnosis, while
Whole body
scan
combined classification taking into ac¬ malignancy and stage of the lesion. The study included a total 1411 cases of which 3.8% were lost to fol¬ low-up (these were counted as dead from the disease to avoid unduly optimistic weighting of the results). Histologically, the carcinomas were classified into three grades of malig¬ nancy as arbitrary subdivisions of a continuous scale. The distribution was approximately 26% in grade 1, 45% in grade 2 and 29% in grade 3 with respective 5-year survival rates of 70, 50 and 39% and an overall 29% 20year survival rate. The 5-, 10- and 20year survival percentages also showed similar variations according to the his¬ tological grade of the tumour. There was a slow, persistent decline in the number of survivors even with grade 1 tumours, possibly expressing slow progress of latent metastases present at the time of initial surgery. Most of the patients with grade 3 tumours died in the first 5 years, and thereafter few in this group died as a result of the disease. count the
128-year
record
30% of those with grades 1 and 2 survived beyond this period. Dr. Bloom combined the results of histo¬ logical grading and clinical staging, and he compared these with the patients from the untreated series. He com¬ mented on the close correlation be¬ tween the degree of axillary involve¬ ment and length of survival and stated that accurate and detailed assessment of the axillary content is vital to prog¬ nosis. Histological assessment of the axilla is very inaccurate unless serial sections are taken, and the degree of node involvement, the size of the meta¬ stases and the axillary level of involve¬ ment are all important. There is close correlation between the histological grade of the tumour and node involve¬ ment and between these and the in¬ cidence of metastases within 5 years. Dr. Bloom also discussed the rela¬ tionship of staging and grading, which might indicate the malignancy of the tumour but nothing of the patient's immune response. The host reaction has a marked effect on the survival of the high-grade tumours, but not much on the lower grade tumours. Car¬ cinomas with a marked lymphocytic reaction, such as the classical "medul¬ lary carcinoma with lymphoid stroma", should be eliminated from studies and separately classified for proper assess¬ ment of treatment results. Unless the degree of lymphocytic response is taken into account, the survival statistics make no sense. Dr. Bloom also commented that the apparently deleterious results of post¬ operative radiotherapy might, in part, be due to the inclusion of nonhomogenous material in the treatment series. Both lymphocytic reaction and tumour grading should be noted in comparing results from Japan, Boston and Glam-
Dr. Bloom compared this with the natural history of a series of untreated breast carcinomas drawn from the rec¬ ords from the Middlesex Hospital 1805 to 1933. A total 250 cases of untreated breast carcinoma had been isolated from the records for this period of 128 years; all had been subjected to autopsy. In this untreated series, 44% were alive at 3 years post diagnosis and 18% at 5 years; 3% were alive at 10 years and by 19 years following diag¬ nosis all were dead. The natural sur¬ vival was compared with a 41% sur¬ vival of treated patients at 19 years. CMA JOURNAL/OCTOBER 4, 1975/VOL. 113 687
organ; the Japanese series shows a fense mechanisms adversely. The simple restriction of respiratory function have greater prevalence of medullary carci¬ mastectomy with radical radiation ther¬ been excluded from the study. There
noma and lymphoid infiltrates and a higher prevalence of grade 1 tumours; both elements point to the better prog¬ nosis for the Japanese patients. Breast carcinoma in pregnancy shows a very variable and mainly poor prog¬ nosis. Very few cases fail into the grade 1 grouping and the prognosis for preg¬ nant patients with grade 3 cases is worse than that for the general series. Dr. Bloom commented on the results in long-term treatment of medullary carcinoma with lymphoid stroma, where a corrected 20-year survival shows an apparent 122% survival for these patients, following radical mastec¬ tomy and postoperative radiation. The implication is that these patients are less susceptible to the common illnesses of life and might in some respect re¬ present a "superfemale". Summing up, Dr. Bloom discussed the appropriate therapy for patients with carcinoma of the breast in our present state of knowledge. He felt that a complicated grade and stage classi¬ fication would better demonstrate the effects of modalities of therapy than does the lumping together of all cases.
At present he considers it wrong to support a general withdrawal from rad¬ ical treatment; there is no evidence that radical treatment influences host de-
apy appears to offer as good results as does classical radical mastectomy. Many more comparable groups of cases and studies are needed, and we might have to accept that we may do too much in some cases in order to do enough in others.
Bronchogenic carcinoma A
session
on
consideration of
bronchogenic carcinoma was sponsored by the section on surgery of the Sas¬ katchewan Medical Association. Dr. D. Sanderson of the Mayo Clinic, Roches¬ ter, Minnesota, discussed screening for bronchogenic carcinoma in the patient at high-risk. The ideal state at which to discover lung carcinoma is a welldifferentiated lesion, showing slow growth, near the periphery, small and surrounded by normal lung tissue. The Mayo lung screening project in¬ cludes a chest radiograph, a cytological study of sputum and a health question¬ naire every 4 months. The question is whether, assuming such an intensive program can be applied, it will affect the course of bronchogenic carcinoma. The population selected was male, over45, cigarette smokers who smoke more than one pack per day. Patients with a serious medical problem or severe
URINE EXTRACTS1
random allocation to two groups: group having the sputum and x-ray examinations at 4-month intervals and the other, the same investigation at 12-month intervals. All radiographs are read twice and compared with the pre¬ vious films. The population screened at a monthly rate of 250 now includes 6259 patients; the ultimate goal is 10 000. On the first screen an unsuspected carcinoma was found in 0.8%, and carcinoma was detected on follow-up in 13 patients at a rate of 5 per 1000 per year. Both sputum and x-ray ex¬ aminations are useful. Difficulty has arisen in the localization of carcinoma in patients who have positive sputum cultures and normal x-ray films. Asymptomatic patients with abnormal radiographs account for 50% of the cases already in stage III. The screen¬ ing program has achieved success, in that only 10% dropped out and it ap¬ pears to detect and localize small pri¬ mary carcinomas. The two forms of investigation are complementary, but radiological examination detects more carcinomas than does cytological study. The small-celled anaplastic carcinoma has been discouraging; here the x-ray film, in general, first indicated presence of carcinoma. In squamous carcinoma, was one
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on the other hand, the occult lesion was demonstrated in sputum but not in the film; it can frequently be localized by the fiberoptic bronchoscope. Prolonged and close follow-up is necessary; one depressing feature of the investigation has been the very low proportion of patients in the survey who discontinued smoking. Dr. Egan discussed the radiological manifestations of bronchogenic carcinoma, of which there are 55 000 new cases each year in the USA. Only 1% are not demonstrable by x-ray investigation. The average lesion is demonstrable 20 months before symptomatology, and the average patient delays approximately 3 months after the onset of symptoms before seeking advice. The average delay, therefore, between the theoretical demonstrability of the lesion and treatment is 23 months. Nondetection of bronchogenic carcinoma in x-ray screening could be traced to smallness of the lesion, its extreme situation at the proximal or peripheral field, or its being mistaken for a nonsignificant lesion. Techniques The surgical, diagnostic and therapeutic techniques in bronchogenic carcinoma were discussed by Dr. E.F.G. Bussey of Regina. He assessed the value of bronchoscopy, mediastinoscopy,
October Workshop in PRACTICE MANAGEMENT, Oct. 18, Toronto. Info: Peter Fraser, Ontario Medical
sociation, 240 St. George St., Toronto, ON.
As-
Workshop In PRACTICE MANAGEMENT, Oct. 20, Winnipeg. Info: Mr. J. Sherstone, Manitoba Medical Association, 201 Kennedy St., Winnipeg,
MB. National conference, BREAST CANCER, Oct. 31 Nov. 1, Hotel Bonaventure, Montr6al. Info: Dr. Guy St-Arneault, Institut dh6matologie.oncologie de Montr6al, 5400 Blvd. Gouin W, Montreal H4J ICS.
November International symposium on REHABILITATION, Nov. 1, Ontario Institute for Studies In Education, 252 Bloor St. W, Toronto. Info: Dalton E. McOualg, Ontario Society for Crippled ChIldren, 350 Rumsay Rd., Toronto.
LABORATORY INVESTIGATION OF PERINATAL DISORDERS, Nov. 7-8, London. Info: A.B. Atkinson, 351 Hill St., London N6B 1E4. ACUPUNCTURE FOUNDATION OF CANADA, Nov. 7.9, Toronto. Info: Dr. J. Richman, Acupuncture Foundation of Canada, 730 Yonge St., Suite 228, Toronto M4Y 2B7. 33rd annual interdisciplinary clinical meeting, AMERICAN ASSOCIATION OF MARRIAGE AND FAMILY COUNSELORS, Nov. 7.9, Inn-on-the-Park, Toronto. Info: Dr. Ray Fowler, AAMFC, 225 Yale Ave., Claremont, CA 91711. 4th INFORMATION AND FEEDBACK CONFERENCE, Nov. 12-13, Toronto. Info: IF conference commit-
node biopsy and biopsy of the lung, including needle or wedge biopsy, lobectomy and pneumonectomy. Dr. Howard Hopkins of Regina assessed unusual manifestations of lung carcinoma, particularly in the varied hormonal activities of the tumour. The value of radiotherapy and chemotherapy in treatment of lung carcinoma was discussed by Dr. F.I. Jackson, who detailed the results from Edmonton. Dr. Sanderson summarized the results of treatment at the Mayo Clinic and presented the theoretical results on 100 patients with bronchogenic carcinoma on present modalities of therapy. The small-celled anaplastic type would constitute 15% of the series and show no 5-year survivals; the squamous would constitute 50% of the series and show approximately 65% five-year survival and the adenocarcinoma and large-cell carcinoma would constitute 35% of the series and show about 35% 5year survival. The contrast between the theoretical and the actual results was stressed. A panel agreed that a high-risk group comprises men and women of more than 45 years, smoking more than one pack of cigarettes per day. Occupationa[ high-risk groups include asbestos and insulation workers and uranium workers. Encouragement to stop smoking has a very disappointing result; only 3% discontinue their habit. The gen-
tee, Counselling and Development Centre, York University, Toronto. INFECTIOUS DISEASES, Nov. 13-15, St. Paul's Hospital, Saskatoon. Info: Margaret P. Sarich, Continuing medical education, 408 Ellis Hall, Saskatoon S7N 0W8. INTRAOCULAR LENS IMPLANT, seminar, Nov. 15, Queen Elizabeth Hotel, Montreal. Info: Dr. M. L. Kwitko, 5591 COte des Neiges Rd., Montreal H3T IYB. DEFENCE MEDICAL ASSOCIATION OF CANADA. Nov. 20.22, CanadIan Forces Base Petawawa. Info: ICol C.P. Smith, 2111 Niagara Dr., Ottawa KIH 6G9. MEDICAL SOCIETY OF NOVA SCOTIA, Nov. 20. 22, HalIfax. Info: D. Peacocke, MSNS, Sir Charles Tupper Medical Bldg., University Ave., Halifax. GREY CUP MEDICAL SYMPOSIUM, Nov. 22, CalHalgh, 3630 Morley Trail NW,
erally gloomy outlook on bronchogenic carcinoma emerged from the panel discussion with a story of high and increasing incidence, minimal early manifestations and poor response to treatment of this tragic disease - made the more tragic because most cases are preventable. This year's annual cancer conference again provided the specialist and the generalist with an overview of two very common malignant lesions. Your reporter has attended many of these sessions and finds them of great value from three points of view: * First, the opportunity afforded the specialist for total view of a condition, of which he may normally only see a small segment intensively; the diagnostic pathologist needs more education in the etiology, presentation, treatment and results of breast carcinoma, since he is concerned almost exclusively with the diagnostic aspects. * The meeting also brings to Saskatchewan experts from larger centres and other countries, affording an opportunity for interchange of opinions and results, in both formal sessions and informal discussions. * Finally, the program brings together Saskatchewan's specialists and generalists and the personnel of the cancer clinics, making them aware of their separate contributions to the common problem.E
Seminar, CREATIVE SEXUALITY, sponsored by the Ontario Medical Association, Nov. 26.28, Hotel Toronto. Info: Creative Sexuality, Suite 400, 73 Richmond St. W, Toronto M5H 2A1. Basic and intermediate workshop on CLINICAL HYPNOSIS, sponsored by the Ontario Society for Clinical HypnosIs, Nov. 28-30, Royal York Hotel, Toronto. Info: Dr. S. Kushnir, 243 St. Clair Ave. W. Toronto M4V 1R3.
PROBLEMS IN SURGERY, Royal College sponsored course, Dec. 4-6, Saskatoon. Info: Margaret ContinuIng medical educatIon, 408 EllIs Sarlch, Hall. Saskatoon S7N 0W8. PROLACTIN, conference sponsored by UniversIty of Toronto faculty of medicine and Canad Ian Society of Endocrinology and Metabolism supported by Sandoz, Dec. 6, Toronto. Info: Dr. Robert Volp6, Room 112D, Jones Bldg., Wellesley pItal, 160 Wellesley St. E, Toronto M4Y 1J3. HosJanuary ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA, annual meeting, Jan. 22-24, Ou6bec City. Info: R. A. Davis, 74 Stanley, Ottawa. CANADIAN ASSOCIATION OF PAEDIATRIC SURGEONS, eighth annual meeting, Jan. 20, Ou6bec City, Info: Dr. Gordon Cameron, 4E.11 University Medical Centre, 1200 MainMcMaster St. W, Hamilton 18S 4J9. COLLEGE OF FAMILY PHYSICIANS OF ALBERTA CHAPTER, 21st annual scientificCANADA, bly, Jan. 18-21, Calgary. Info: Mrs. M. 1. assemJeppe. sen. P0 Box 3846, Postal Station D. Edmonton T5L 4K1. Seminar, CONFLICTS IN THE PHYSICAL REHABILITATION TEAM, Jan. 26.27, UnIv of Ottawa. Info: Mrs. Carolyn Beizile, School of Health Administration, University of Ottawa, Ottawa. OUTSIDE CANADA
December ALBERTA HOSPITAL ASSOCIATION, 57th annual convention, Dec. 3.5, Edmonton. Info: Alberta Hospital AssociatIon, 10025 - 108 St., Edmonton.
OBESITY AND ASSOCIATED CONDITIONS, symposium, Oct. 31 - Nov. 3, Las Vegas, NV. Info: Dr. W. 1. Asher, 333 W Hampden Ave., Suite 307, Englewood, CO 80110.
November
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