Arthur I. Holleb

The technique of breast examination

More than 90% of breast cancer is discovered by the patient. A systema tized examination of the breasts will improve the rate of detection of early breast cancer by physicians and should result in a higher cure rate. A superficial and rapid examination of the breast with the patient sitting will often miss tumors of considerable size and will give the examiner a mea ger impression of the breast structure. Not only may cancer remain undiscov ered, but also the physician is unable to prepare adequate records for later com parative examinations. Routine breast examination should be systematized so that all breast tissue is palpated. At least two positions are required for the patient—erect and supine. The procedures recommended are relatively standardized, but may be modified in sequence according to the preference of the examiner. The three anatomic sites to be investigated are: (1) the supraclavicular areas; (2) the breasts (including nipples and areolae); and (3) the axillae. The initial phase is inspection and palpation.

Public awareness of cancer detection tests: Results of a recent gallup poll

ofa recentsurveyconducted by the Gallup organization, covering certaincancerdetection testsavailable tothepublic,arebothsatisfying anddis appointing. It shows that we have made some progress but that much more still needstobe done.The December, 1976 survey is based on personal interviews with a national sample of 1,527 adults, 18 years of age and older. Among other topics, men andwomen werequestioned concerning five examinations related to cancer detection: •¿ X-ray of the chest; •¿ A do-it-yourself test for colorectal cancer; •¿ Proctoscopy; •¿ Oral examination; •¿ Clinical breast examination and breast self-examination. The participants were questioned on: theirawarenessoftheparticular exami nation; whether or not they had been ex amined and used the technique within thelastyear;and,ifnot,would theybe interested inlearning how todo theself examination techniques. There was a 90 percent awareness abouttheuseof a chestX-raytodiag nose cancer but only 67 percent of those questioned had availed themselves of the examination. This was a marginal decline from 72 percent in 1974. How ever, the percentage of men dropped sig nificantly from 74 percent in 1974 to 64 percent in 1976, while the number of women having chest X-rays, 66 percent, remained the same. The proportion of men and women who had a chest X-ray within the last year was also down. In light of the high incidence of lung cancer, it is important that more people at higher-risk avail themselves of a chest X-ray. Only 38 percentoftherespondents in thepollsaidtheyhadheardofthedo-it yourself test for colorectal bleeding, which might suggest cancer. In the 18-34 age-group, only 28 percent had heard of the test; awareness, however, was higher, 43 percent, among those 50 years and older. Of the older group, 17 percent reported that they had used this technique; 9.1 percent of this group had done so in 1976. While these figures are not very impressive for a cancer that will occurin101,000new patients and take 51,000 lives in 1977, the survey did point out one hopeful note. Those who had never heard of the test were asked if they would perform it if shown how; 59 percent said yes. Awareness of proctoscopy, an exami nation usually recommended for those over 40 years of age, declined from 61 percentin 1974 to 56 percentin 1976, but it was at 60.4 percent for the 35-49 year old group and 61.6 for those over 50 yearsof age.The figures forthose reporting that they had had the examina tion in 1976 were 7.8 percent for the 35-49 year olds and 11.6 percent for the oldest group. The same level of awareness was re ported for oral examination in the 1976 and 1974 surveys (59 percent vs. 60 per cent). The number who said they had been so examined in 1976, 28 percent,

Editorial: The environmental time bomb … that never went off

based on a 10 percent sample of all death certificates reported to the National Cen ter for Health Statistics were added up for the first seven months of the year, and released to the press. These figures showed an apparent 5.2 percent in crease in cancer mortality rates com pared to the same period the year before. If true, the information would indeed be startling, since the cancer death rate has been increasing at less than one percent a year. Furthermore, when broken down by site, the trend over the past years shows that cancer mortality would be declining, but for the increase in lung cancer deaths, directly related to ciga rette smoking. Concern intensified when the Metropolitan Life Insurance Co. is sued figures that appeared to corroborate the sharp upward rise of cancer mortality in 1975. The result was frightening headlines and sensational news articles; a cancer scare was underway. These figures were given added im pact by the instant interpretations placed on them to support one or another suppo sition on the causes of cancer. Thus, the November, 1975 headlines were prompted by an inquiry from a member of Congress to the Director of the Na tional Cancer Institute, as to whether the sudden “¿ increase― was due to “¿ the growing use of an exposure to chemicals in our daily life.― It was in search of support for this hypothesis that an aide to the Congressman decided to add up the monthly mortality figures of the Na tional Center for Health Statistics, and release them to the press. However, a strange thing happened. The cancer statistics for early 1976 showed a decrease of cancer mortality in the monthly reports of the NCHS, compared to 1975. And the October, 1976 Statistical Bulletin of the Metro politan Life Insurance Co. declared: “¿ Cancer Mortality Declines in First Six Months of 1976.―These 1976 statistics, however, produced no headlines. It is highly unlikely that the impact of carcinogens in the environment could be eliminated from one year to the next. Surely, all the food additives could not have been miraculously removed from our diet since Metropolitan reported that among their policy holders, death rates from cancer of the digestive system de creased by nine percent. The effect of the environment on cancer is not instan taneous; 10-30 years are usually re quired from exposure to cancer inci dence and/or mortality. For a clear analysis of what really oc curred, we are indebted to Dr. Leonard Chiazze and his colleagues at the Na tional Cancer Institute who provided a sober and scientific exposition in JAMA, entitled “¿ The Cancer Mortality Scare: Problems of Estimation Using Monthly Data― (JAMA 236:23102312, 1976). Their analysis shows that

Fruits, vegetables and cancer dimensions

protruding cauliflower-like lesion is of medium size.― According to the United States Department of Agriculture, olives vary in size from “¿ subpetite― to “¿ superco lossal―; the dimensions of grapes, oranges and grapefruits depend on sea son, geographic origin and other factors; peas (presumably the black-eyed type as well) show considerable differences in the number required to make up one quart; eggs come in small, medium, large and extra-large, and from a wide variety of birds. Inexplicably, one phys ical examination report described a mass as the size of a “¿ hardboiled egg.― The above suggests a deterioration in the art of tumor description. It seems ap propriate, therefore, to register a plea for recording as accurately as possible the dimensions of tumors in centimeters. Attention to detail is important not only for maintaining high medical standards, but also for better clinical staging of cancer, evaluating prognosis when tumor size is pertinent, determining response to treatment and for adequate follow-up by others less experienced with agricultural products. Once and for all, let us eschew fruits and vegetables in reports of tumor size.