Am Fam Physician. 2000;61(12):3531-3534
This feature is part of a year-long series of excerpts and special commentaries celebrating AFP's 50th year of publication. Excerpts from the two 1950 volumes of GP, AFP's predecessor, appear along with highlights of 50 years of family medicine.
This feature, titled “A Cancer-Finding Team” and written by Lowell S. Goin, M.D., is reproduced from the April 1950 issue of GP. The commentary was written by Jim Nuovo, M.D., associate professor in the Department of Family and Community Medicine, University of California, Davis, School of Medicine, Sacramento, Calif., and assistant editor for AFP.
…All agree that if the terrible toll of cancer is to be lessened, earlier diagnosis is the answer. This puts a tremendous responsibility upon the private practitioner, for it is he who sees the patient first. Unfortunately, some practitioners are not recognizing and accepting this responsibility. It is not because they are indifferent to, or ignorant of the problem; it is because they are not cancer conscious. It has been estimated that the general practitioner sees about five cancer cases yearly. This being true, it is easy to see why his diagnostic awareness of cancer may be slightly dulled. Seeing so few cases lowers one's index of suspicion and the practitioner very likely thinks of cancer last, rather than first, and thus the golden opportunity of an early diagnosis is lost.… The problem now confronting us is: (1) How can we control cancer? (2) How can we recognize cancer in earlier stages? (3) How can we treat cancer more adequately? (4) How can we reduce the suffering and the death rate from this disease? …
How can the radiologist help us? Of all malignant disease, about 50 per cent occurs in areas which may be inspected directly, or with only simple instrumentation, such as the head mirror, tongue depressor, vaginal speculum, and proctoscope. Why then, should cancer of the tongue be overlooked? Why should skin cancer become a hopeless lesion? Why should a rectal carcinoma, easily accessible to the gloved finger in 80 per cent of all cases, become inoperable? These are mistakes of not looking.
Raising one's index of suspicion as to the possibility of cancer being present in a lesion is not enough. A biopsy must follow, remembering that until a competent pathologist has studied tissue sections, one has merely a clinical diagnosis or, perhaps, only a suspicion and not an actual diagnosis…
There remain a large number of malignant tumors which will ordinarily be first found by the radiologist, and it is here that the general practitioner-radiologist team begins to function. If the team is to function well, there are certain criteria that must be met. The first of these involves a wise choice of the radiologist. Radiologic examination and “getting an x-ray” are not the same thing. Assume that a physician has a 10-year-old daughter and that he notices an irregular hardness in the child's upper arm and that an x-ray film shows an alteration in the architecture of the humerus. If the alteration represents simple osteoma, nothing need be done, but if there is a possibility of a malignant bone tumor, biopsy will have to be performed, perhaps followed by amputation. The opinion of a radiologist will likely be the deciding factor and certainly the physician will want the best opinion he can obtain. The radiologist that he selects is the one to whom he should send his patients, in whom similar problems may occur.
Second, there must be complete and sympathetic cooperation between the general practitioner and the radiologist. It does not suffice to send one's patient for a “chest x-ray.” Rather, the practitioner should give the radiologist some idea of the problem in hand; he should inform him of his thinking, and give him a clue as to what he suspects. Sometimes quite elaborate examinations must be carried out, so elaborate that they would not be undertaken without some specific indication. Also, the practitioner should give the radiologist freedom and latitude to do what he thinks essential to making the diagnosis. . .
The radiologist will find none of these diseases unless they are first suspected by an alert general practitioner. The first and greatest responsibility therefore rests with the latter. He must not forget that a diagnosis of malignancy is not very profitable when it is quite obvious, and that our only hopes of increasing the survival rate lie in early diagnosis.—lowell s. goin, m.d.
Most of us struggle to remain as up-to-date as we can with current medical literature. We hope that by doing so we can find nuggets of information that will help our patients. After reading this article by Dr. Goin, I am struck by the need to be just as cognizant of the past literature. Goin's article gives us a look into a very different time in the field of medicine, yet the issues he brings up remain important today. His words were a call to action for general practitioners to increase their awareness of the signs and symptoms of cancer.
Specifically, he asked that physicians make greater use of radiologic methods to enhance early detection of cancer and to decrease human suffering—that the clinician and radiologist form a “cancer-finding team.” He challenged clinicians for not recognizing and accepting this responsibility, although this stance is tempered by the realization that many physicians are simply not “cancer conscious” because they see relatively few cases. He presents a number of scenarios that imply that the majority of cancers are detectable directly or with simple instrumentation, like “a head mirror, tongue depressor, vaginal speculum or proctoscope.” Failure to investigate is described as a “mistake of not looking.” An effective “cancer-finding team” enhances better communication between radiologist and clinician, to “give him [the radiologist] a clue as to what he [the clinician] suspects.”
There is no question that generalists today are faced with the same challenge described by Goin—the need to remain aware of the early signs of a problem, be it cancer or any of the other illnesses we face. The need to be wary of problems that may not be common, to develop an appropriate threshold for diagnosis, to know the appropriate tests to order and to be effective communicators with specialists are relevant goals today and will continue to be so in the future.
On the other hand, I think Goin's enthusiasm for diagnostic testing and early detection must be tempered. It seems there has always been enthusiasm for tests to help us achieve the goal of early detection. However, many promising tests simply failed to perform in the promised manner; subsequent studies have shown us that early detection did not affect outcomes. Goin did not have the benefit of the criteria for screening tests spelled out in reports by Frame,1 the Canadian Task Force2 or the U.S. Preventive Services Task Force.3
I remember that when I was an intern, patients came to my continuity clinic expecting a chest x-ray as a routine part of their annual physical examination. It was assumed that the chest x-ray would assist early diagnosis of cancer and that early diagnosis meant a chance for a cure. I remember when it became clear that routine chest x-rays were of no value. It was a challenge to stop ordering the test and to convince patients that it was unnecessary.
It is also important to acknowledge what was not said by Goin. There was in his article no mention of the need to address cancer risks and to implement primary prevention. (Interestingly, just one month after this editorial appeared, the landmark article connecting smoking with bronchogenic carcinoma was published.4) There is no discussion of the sensitivity or specificity of the diagnostic tests he mentions or of the impact on the patient of a false-positive result. There is no mention of the few treatments available or whether randomized trials were proposed to help answer important clinical questions. There is no mention of the need to develop clinical guidelines or a scientific approach to screening. The latter steps would take more than two decades to get underway. Finally, there is no mention of the costs associated with his proposed approach or of access-to-care barriers.
So much has happened since Goin took the time to write this article, and yet many of the questions confronting us today are the same: How can we control cancer? How can we recognize cancer in earlier stages? How can we treat cancer more adequately? How can we reduce the suffering and death this disease causes? While it is likely that the practice of medicine will be very different 50 years from now, it is also likely that Goin's article will still be of interest to us.—jim nuovo, m.d.