Cancer in 1941: Strengths and Limits of Surgery, Radiotherapy and Hormonal Therapy, Halsted to Huggins | Day 114

Cancer on the Threshold of 1941: Three Methods, Three Limits

An imagined consulting room

This paragraph is an imaginative reconstruction, not a documented event. Say that in 1941, in any large city, a physician has test results open on the desk. The patient has a mass. The physician has three options: remove the mass and the tissue around it by operation, apply X-rays or radium, or, if the tumour depends on a hormone, remove the source of that hormone. A fourth option, a drug that is given into the blood and reaches every corner of the body, is not on that desk. The whole subject of this post is the absence of that fourth option.

Each of the three tools has a history in this series. Surgery: Wertheim's radical hysterectomy (Day 93), Patey's "cut less" mastectomy (Day 104), Graham's lung operation (Day 107), the reconnection of the oesophagus inside the chest (Day 111). Radiotherapy: Röntgen's rays and radium (Days 92, 94 and 95). Hormonal therapy: the line running from Beatson to Huggins (Days 91, 105, 110 and 112). Today we do not retell them; we set them side by side and look at something they share.

Halsted's 1894 balance sheet

In surgery, the yardstick was set in 1894 by William Halsted's series of radical mastectomies at Johns Hopkins. Published in the Annals of Surgery (volume 20, pages 497-555), the series covers 50 radical mastectomies and 26 incomplete operations performed between June 1889 and January 1894. According to Halsted, no patient was lost to the operation itself. Of the 46 patients whose long-term course could be assessed, 73 percent had neither local nor regional recurrence, and 93 percent had no local recurrence. Three patients had local and eight had regional recurrence. Some patients were left with problems of the arm.

For local control these figures were impressive, and for decades they served as a yardstick. But the question the number answered was "did the tumour come back in the same place?" The question "is something growing elsewhere in the patient's body?" was one the operation neither asked nor answered. As we saw on Day 104, over the following half century surgery turned from "cutting more" to "cutting less"; yet no operation went looking for cells that could not be seen during the operation.

Coutard and fractionated dosing

This tells us two things. First, one of the best-established principles of radiotherapy (dividing the dose over days) was born not of a strong experiment but of clinical intuition and accumulated observation. Second, that intuition was later supported by laboratory findings as well; but that story belongs to later days of this series.

A paper from Zurich cites a figure reported by Coutard: 52 percent of the patients who remained free of local disease had lost their lives to distant metastases by the end of the eighth year. I could not verify the citation of that paper, so I carry the figure not as established fact but as a clue. If it is right, its meaning is this: radiation can silence a tumour where it sits, but it has no say over cells that had already set out elsewhere in the body. It is a structure similar to what Halsted saw in surgery.

The third pillar and its narrow door

Hormonal therapy was the first method to speak to the whole body of a person with cancer: removing the ovary or the testis changes the hormone level in the blood and can act wherever the tumour is. Beatson tried this in breast cancer in 1896; we told the riddle of the "one third" on Day 91. Huggins and Hodges showed the same principle in prostate cancer in 1941, with a measurable chemical marker (Day 112). But two limits of the method were clear from the start: it worked only in hormone-dependent tumours, and its effect was mostly temporary. Moreover, the hormone itself does not directly destroy the tumour cell; it only changes how the cell is fed.

An attempt at a balance sheet

I could not find a solid nationwide survival figure for the early 1940s. The "one in five" statement that circulates on this subject had an unclear basis, so I did not write it. The consistent data we do have come from the End Results Group within the National Cancer Institute: a compilation from more than 100 hospitals covering about 400,000 white patients. According to it, five-year survival in colon cancer rose from 31 percent in 1940-49 to 46 percent in 1955-59, and in rectal cancer from 28 to 40 percent. In absolute terms the rise is 15 points for colon and 12 for rectum; in relative terms about 48 percent for colon and about 43 percent for rectum.

It would be wrong to read this rise as the success of a single treatment. The series consists of selected hospitals and only white patients; five-year survival does not mean cure; and earlier diagnosis can make survival look longer independently of treatment. Even so, the figures show one thing: even the tools of 1941 made a difference when they were applied better and reached patients earlier. The second source of progress, informing the public, is the subject of the scene below.

What was the situation in Turkey in 1941?

I could not reach verified information on cancer treatment in Turkey in 1941, so I am not drawing a local link. The general inference is this: the three methods in this post were known internationally in the same period, but how far a patient in any given country could reach them is a separate research subject. In the part of the series devoted to Turkey this question will be taken up, with its sources.

This post is Day 114 of the "365 Days of Cancer History" series and treats the strength and limits of surgery, radiotherapy and hormonal therapy as of 1941 as a historical balance sheet. It is a historical-popular account, not advice on diagnosis or treatment. For your own health, consult your physician. Sources have been verified; details resting only on secondary sources are marked in the fact-check notes.