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JAMA
Cancer of the Breast
Figures Which Show That Education Can Increase the Number of Cures
I have had the impression, especially during the past five years, that the relative proportion of benign lesions of the breast is steadily changing, and that the percentage of benign lesions is on the increase. This change was associated with a shorter duration of the disease, that is, women were seeking advice earlier. I did not realize, however, or even dare hope that this fortunate change would be as great as it proved to be.
Joseph C. Bloodgood, M.D.
December 12, the figures were completed in a study of 1,577 cases recorded in the Surgical Pathological Laboratory of the Johns Hopkins Hospital. Further investigation may change these figures slightly, but the evidence is sufficient to justify a preliminary report now, because, it seems to me, it is the most favorable and encouraging evidence that we have up to date—so favorable, that it seems almost just to state that education of women and of the profession can cure cancer of the breast.
From 1889 to 1900, the percentage of benign lesions was 32; from 1900 to 1910, 41; from 1910 to 1913 it was 47, and from 1913 to 1915, 59, or from 1910 to 1915, 54. Therefore, in about six years as compared with the previous ten, the percentage has increased from 41 to 54 (13 per cent.). But in the past three years it has increased 12 per cent. over the previous three years.…
The percentage of adenocarcinomas from 1889 to 1900 was 10, while since 1913 it has increased to 22 per cent. Fully developed cancer of the breast has decreased from 90 per cent. during the years 1889 to 1900, to 78 per cent. since 1913.
Up to 1910 we had recorded eleven cases of benign cystic adenoma, and nine cases of cancer in cystic adenoma. Since 1910 we had thirteen examples of the benign adenoma, and only one of the malignant. There is apparently only one reason for this remarkable change—if women with cystic adenoma seek advice early after the appearance of the tumor, the surgeon will find an encapsulated benign adenoma, and the patient will be protected from cancer by the removal of only the tumor. If they delay, cancer may develop.…
These 1,577 cases are now being tabulated according to the duration of the disease, and the evidence so far shows that patients since 1910, and especially since 1913, are seeking advice much earlier. In each case we are trying to investigate the educational factor.
We have this evidence, which clearly shows that women are understanding the information and that the educational propaganda is so far a success.
However, when women come at this earlier period, in which a clinical diagnosis can rarely be made… we shall find that the borderline group is large, and the difficulties of the surgeon will increase. On the one hand, he will wish to avoid the complete operation for cancer when the lesion is benign, and the almost fatal mistake of the incomplete operation when the lesion is malignant. It seems to be agreed that if there is any doubt, the complete operation for cancer should be done.
I have submitted over sixty borderline cases to a number of pathologists, and have found that in not a single one has there been a uniform agreement as to whether the lesion was benign or malignant.… If I took one group of pathologists I could report them all as malignant, and another group would allow me to report them as benign. This is no reflection on the diagnostic abilities of the pathologists: it is simply evidence that at the present time there are certain lesions of the breast about which we apparently do not agree from the microscopic appearance only. I shall consider this phase of the subject in a second paper.
Women will be warned that there is some trouble in the breast by pain, lump, discharge from the nipple, retraction of the nipple, eczema and ulcer about the nipple, dimpling of the skin, and the presence of lumps in the axilla. If they come under the observation of a surgeon within a few days, the differential diagnosis, clinically, at the exploratory incision and from the frozen section offers difficulties which at present we do not seem to be able to overcome in the sense of exact diagnosis. It is my opinion, however, that when every case is carefully investigated, the mistake of an incomplete operation for cancer should never be committed, but the mistake of performing the radical operation for a benign lesion will occur in from 10 to 20 per cent. of the cases. This is a mistake that must be made until we have developed a method of more exact diagnosis.
I am quite certain that when women understand the situation, they will prefer the slightly mutilating operation to the danger of an incomplete removal of a malignant tumor.