The aim of cancer diagnosis is to circumscribe the cancer com pletely, or as the therapists desire, to go well beyond it to ensure the efficacy of treatment, and thus provide a cure. This seemingly simple task has maintained its Sisyphean character for the following, essentially biological, reasons:
1. Cancer is a disease of the whole organism: 17 Having started at one place, cancer imperceptibly involves the whole body of an individual by also spreading to, and colonizing, many more areas in the body. Whenever the cancer acquires a sufficient bulk at the original (primary) site and/or at the subsequent (secondary/meta- static) sites, it forms and presents itself as a lump, or a tumour.
2. By the time a cancer presents itself to the clinician, it is many- cells-strong, and usually many-sites-strong.
3. What the clinician looks for, or can look for, is the formation of a lump, popularly called a tumour (L. tumere , to swell).
4. The acceptance of the tumour as the diagnosis is ipso facto the admission of diagnostic defeat. It is tantamount to noticing only the proverbial tip of the iceberg.
5. There is no escape from the conclusion that 'the clinician, even if he diagnoses cancer at the earliest possible stage, is dealing only with the late stages of a disease process.' 17 The lateness is not just a matter of time, but of space, the cancer having gone well beyond the circumscribing capacity of the diagnostician. No wonder, time is not of the essence in cancer diagnosis, 'late' cases often outliving the 'early' ones. 'The survival-rates after different periods of delay before seeking medical advice often show a cu- rious paradox'- 'the greater the delay and the longer the history of symptoms, the greater was the survival-rate.' 66
6. The proof of all our diagnosing lies in our gaining ground against cancer. The facts point otherwise. What we therefore achieve is a pseudodiagnosis which has refused to change its character no matter what gadgetry is at our disposal.
Attempts at detecting a cancer even before the appearance of any symptoms 261,262 have proved futile: 'In a group of sixteen cases in which esophageal cancer was diagnosed prior to the development of symptoms while the patient was under active medical surveil- lance, Palmer could demonstrate no improvement in survival.' 261
An editorial 42 in The New England Journal of Medicine crisply com- mented:' "Early" is an adjective of time - not of size, dissemination or clinical manifestations. Yet, enslaved by medical semantics, too many people equate "early" with small, localized, asymptomatic (or minimally productive of symptoms).' (Parenthesis not added.)
What about those cancers that are truly early in the temporal sense? Here, too, the situation is unredeeming: The Lancet edi- torialized 66 that 'the stage of disease is a function not of time, but of the (inherent) tumour type.'
7. Clinical cancerology runs on the illusion that tumour diagnosis is equivalent to cancer-diagnosis. This is an act of great faith, both of the clinician and of the patient. This faith accounts for, what Wilfred Trotter called, the mysterious viability of the false .
8. What the diagnostician really achieves, is to locate the area where the cancer dis-eases the individual, while the submerged part of the cancerous iceberg remains unseen. A clinician's ability to lo- cate the site and nature of this dis-ease, and the ability to ease the condition, is the brightest and the most indispensable part of clinical practice.
9. Cancerophobia and indifference to the biology of cancer conspire to induce a clinician to err towards the false positive diagnosis.
10. Efforts have been made to catch a cancer before it dares to be a cancer, by detecting 'pre-cancer.' The whole science of pre-can- cer is marred by ambivalence - semantic and microscopic.
Both 9 and 10 lead to, what Park and Lees 67 called, pragmatic diag- nosis , detailed below:
i. 'Pragmatically diagnosed cancer' is' probably not cancer, but safer away' type of approach. 67 This consists of diagnosing a lump as cancer, merely to play safe.
ii. In 1923, Bloodgood, 68 from his experiences at the Johns Hopkins over thirty-three years in retrospect, wrote of 'Benign Lumps Di- agnosed Cancer or Suspicious of Cancer.' Bloodgood 68 remarked that during the thirty-three years of observations, the above group had been seen with increasing frequency in the laboratory - with breasts that were the seat of chronic cystic mastitis, tuberculosis, encapsulated adenomas, or cysts with an intracystic papilloma having been diagnosed as carcinoma. Such a group of cases relatively quite large - when clubbed with unequivocal carcino- mas, increased the percentage of five-year cures and made it impossible to correctly assess the controllable factor (of pre- operative duration) in the cure of cancer. Bloodgood 68 concluded the topic with an objective and far reaching generalization: 'As this element of error has been present in my own investigations for years, I feel justified in the conclusion that it is present in all statistical studies throughout the world.'
iii. In 1951, Park and Lees 67 diagnosed the pragmatism prevalent in cancerology whereby non-cancers were declared as cancers to inflate the cure-rates.
iv. In 1954, McKinnon 69 stated: 'Today it is a safe generalization that all competent cytologists and pathologists agree that, in histopa- thology, there is no sharp line dividing malignancy and non- malignancy. But, in practice, the division is made sharply, as it must be, in all cases presenting, and naturally and unavoidably, with the diagnosis tending to the positive rather than the negative side.'
v. In 1968, Cowdry 263 detected, from extensive epidemiologic stud- ies, the mysterious 'paradox of increasing incidence and decreas- ing mortality rates ' of carcinoma cervix. By 1974, carcinoma in situ of cervix was reported as 100% cured. 264
vi. In 1973, such pragmatism meant 690,000 hysterectomies performed in a year in the USA, many 'unnecessarily!' 70
vii. With nothing else changed, such pragmatism meant a sudden, nearly four-fold, leap in cancer rates for the year 1975. 48
viii. In 1977, a coordinated study of breast cancer, between the NCI and the ACS in the USA, revealed 204 that as many as sixty-six women were diagnosed to have cancer when there was none, and another twenty-two were branded as having cancer, when in reality the microscopic basis was 'unclear': all these women were operated upon because of the cancer-diagnosis.
In a militantly litigant society, the pathologist and the clinician are wont to play safe. The credit is theirs if a non-cancer removed as cancer, yields a ' cure '. Moreover, the 'safe away' approach also promotes surgery, as evinced from (vi) above.
Microscope Unreliable in Cancer/Precancer Diagnosis
From all the cancerologic experience the world has had, one could generalize that a cancer cell may be defined as one that has proved itself by behaving as such . There is no cellular feature that can help predict that such and such a cell will, at or after such and such a time, behave as cancerous - namely, proliferate unrestrainedly to form a mass/ tumour and/or spread from its site of origin to other organs. Cancer cytologists and histologists (experts who pass the judgement of cancer on the basis of microscopic features of cells and tissues) rely on the usually taken for granted features such as cell size, nuclear size/shape, cellular arrangement, and so on, but such judgements betray their fal- sity and unreliability when 'cancerous' tissues behave non-cancerously and vice versa . Notwithstanding this appalling state of ambivalence in the field of cancer, cancerologists have chosen to use the proved-unre- liable cellular criteria to spawn the new science of precancer.
Cancerologists and cancer societies, so vociferous on the issues they champion, have almost deliberately failed to educate the public on how unreliable the judgement of cancer / precancer passed on a le- sion under the microscope can be. Cytological research has revealed the cancer cell to be no distinctive structural entity, but an organ of behaviour (see para above). Smithers 71 in an attack on cytologism, generalized that 'there is no such thing as a cancer cell - only cells behaving in a manner arbitrarily defined as being cancerous.' This observation has been amply vindicated by many a cancer refusing to declare itself as cancer under the microscope. 20,72 Despite this unreliability of the microscopic view, the almost universal concepts of benignancy and malignancy are based on the microscopic features, as typified by the statement that 'many cerebral tumours, histologi- cally benign, are biologically malignant.' 73 Similarly, many lesions, his- tologically malignant, are biologically benign. 20,74 Histologically prov- able prostatic cancer is present in a high percentage of men above 50 years of age. A majority of these cancers act benign - they do not kill. 75 The startling discrepancy, The Lancet editorialized, 'between the clinical and post-mortem prevalence of prostatic carcinoma has virtu- ally demolished ideas of cancer as an essentially killing disease.' 74
While cancer itself went begging for microscopic definition, cancerologists opened up an altogether new field called pre-cancer, a sort of earlier-than-early cancer. Applied extensively to the cervix of the uterus and the breasts, in females, the science relies in examin- ing cells and tissues and grading them regarding their assumed prox- imity to cancer, or otherwise. The terms frequently used are dyspla- sia, carcinoma-in-situ (meaning-in-its-place, without any spread else- where), precancer, and minimal cancer.
The diagnostic measures used for the cervix are cytology, histopa- thology, and colposcopy. Cervical cytology was initiated by George Papanicolaou and the technique is mostly referred to as Pap smear - a thriving industry by itself. For the breast, histo-pathology is assisted by mammography, xerography and thermography, all of which aim at locating 'suspicious' areas in the breast.
The semantic ambivalence, reflecting the conceptual confusion is enormous: This terminological difficulty is greater in gynaecological pathology than in any other chapter on pathology, different authors using one and the same term in a different sense.' 76 The unreliability of Pap smear may be guaged from the incidence of reported 'malig- nancy' ranging from 33% to 100% and 5% to 60% in the same grades of smears. 52 The histopathologic descriptions of carcinoma-in-situ of the cervix are as many as the publications on it. 77 Siegler 78 sent the histopathologic slides of cervical precancer to twenty-five different pathologists and their interpretations betrayed 'disconcerting' varia- tions and disagreements in the fundamental evaluations. Colposcopy, for detecting cervical precancer, has been characterized by Way 79 as 'the biggest gynaecological hoax of this or any other century.' Need- less to say, the ambivalent situation - semantic and microscopic - is no different vis-a-vis the assumed precancer above the female umbi- licus, i.e., of the breasts.
And what does all this microscopic uncertainty in the field of cancer lead to?' Uncertainty is resolved by doing more: the patient asks for more, the doctor orders more.' 80 And this in cancerology means far more diagnoses than are warranted. It has not as yet been appreci- ated, that as much as cancer can be left untreated, it can be left undi- agnosed as well. And there lies a cure for the paralyzing canceropho- bia. Fischer 81 has a point here: 'Do you ever ponder the advisability of not making a diagnosis and thereby avoiding a death sentence?'