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to suggest any form of study which would establish the prime cause beyond any shadow
of doubt. The total time lag between onset and first symptoms and start of treatment
does not seem markedly different as between lung cancer and cancer of other common
sites as breast, rectum and uterus.
To state a truism, the success or failure of treatment depends in large measure on the
timing of diagnosis and unfortunately lung cancer, more often than not, remains clinically
unobserved during most or all of the period when surgical treatment, which holds
out the only real prospect of a cure, is most likely to be successful. It is, therefore, to
be hoped that as middle-aged men (and women) become more "cancer conscious" they
will consult their general practitioner when they have a persistent cough or other
symptoms. Fortunately, as the Minister of Health said in part answer to a Parliamentary
question on 21st October, 1954, 'diagnosis has been improved by the introduction of
cytological methods and the wider use of radiography, particularly mass miniature
X-rays'. Cytological examination of sputum (Brit. Med. J., 1954) appears to give
better and earlier results than bronchoscopy but relatively few pathologists in this
country have as yet the necessary training.
As regards case finding through the medium of mass miniature radiography, certain
figures have been received for the years 1943-53 through the good offices of Dr. Norman
Smith of the Ministry of Health. These figures, some of which are set out in Table D
on page 155, relate to cases of intrathoracic malignant disease found by the units operating
in the areas of the four Metropolitan Regional Hospital Boards plus the Ministry's own
unit—thus they do not relate wholly to London or wholly to lung cancer, although
as regards the latter out of 2,501 cases of intrathoracic malignant disease mentioned in
the annual Report of the Chief Medical Officer of the Ministry of Health for 1953
2,226 (89 per cent.) had lung cancer. It will be seen from the Table that the increased
rate of case finding far exceeds the increase in mortality in the comparable or similar
age groups shown in Table B; to what extent this excess is due to improvements in
diagnostic technique, to greater willingness to be X-rayed or to a real increase in incidence
it is impossible to say, but the inferences are that improved technique leading to
earlier diagnosis plays a substantial part. In support of such an inference there is evidence
of a greater proportion of cases now being found suitable for surgical treatment and,
incidentally, of a greater prospect of survival after treatment—here again improved
techniques must have played a part. As regards the practicability of radical surgery,
Harnett shows that of the 1,024 patients in hospital in 1938-9, only 1.5 per cent. received
this treatment, while in addition 3.6 per cent. had a transthoracic exploration but
pneumonectomy was abandoned. He goes on to say that figures published by Brock
(1948) showed that an operability rate of 11 per cent. in 666 cases had recently increased
to 21 per cent.; Holmes Sellors (1955) gives figures showing that between 1940
and 1950 out of 689 thoracotomies, 446 (65 per cent.) were resected. It should be added
that suitability is often surmised—of 723 cases explored, according to Ochsner, Ray
and Acree (1954), 254 (23 per cent.) were non-resectable in fact.
Another factor influencing mortality is the type of growth, prognosis being relatively
good for the squamous-cell type, more doubtful for adenocarcinoma and very poor
for the oat-celled type (Lancet, 1955).
According to Harnett, of 1,012 cases which could be traced out of the 1,024 occurring
in 1938-9, 931 (90.9 per cent.) died in the first year after coming under treatment,
54 (5.3 per cent.) in the second year, 8 (0.8 per cent.) in the third and fourth years and
1 (0.1 per cent.) in the fifth, leaving 10 survivors—a five year survival rate of 0.98 per
cent. or an average expectation of 0.69 years of life during treatment. Stocks (1950) shows
that in 1945-6, of 1,711 traceable males, 1,501 (87-7 per cent.) died in the first year,
the corresponding figures for females being 243 and 211 (86.8 per cent.). Stocks (1952)
gives crude survival rates for three years as being:—
149
Diagnosis and
treatment
Survival