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STATE AID FOR CANCER RESEARCH

THE LANCET

LONDON: SATURDAY, MARCH 25, 1939

STATE AID FOR CANCER RESEARCH

THE peers taking part in the debate on thesecond reading of the Cancer Bill in the House ofLords, which centred on an amendment moved

by Lord BALFOUR OF BURLEIGH regretting that noprovision was made for increased research, showedan encouraging appreciation of separate issues-the need for more general application of currentknowledge and the need for adding to that know-ledge. The bill is concerned entirely with the firstof these, except in so far as clinical records andtheir statistical analysis will provide guidance inthe choice between methods of treatment. Thechief remediable defect in our present system, orlack of system, of combating cancer, in the light ofexisting knowledge, is delay-in seeking diagnosis,in making diagnosis and in securing prompt treat-ment. It is hoped to eliminate or at least toreduce this dangerous waste of time at each stageby the establishment of over 300 local consultationcentres and some dozen new treatment centres inareas now without them. About 1000 additionalbeds will be needed and these are to be attachedto existing hospitals in order to avoid the stigmawhich might adhere to special " cancer " clinics.The modern unit for treating cancer consists of

a team of skilled workers who collaborate in the

study of each case and decide which of the avail-able methods-surgery, X rays and radium-orwhat combination of methods should be used. AsLord DAwsorr pointed out, there is no difficulty infinding good surgeons but there is a dearth ofskilled radiotherapists, and the number of men

seeking training and experience is much too smallto meet the future demand. The risk of takingup this specialised work is that radiotherapy maybe replaced by some other form of treatment formalignant disease ; but there is probably enoughevidence that it is in an actively developing ratherthan a regressing phase to overcome this objection.A much more potent deterrent is the lack of goodprospects now; when the posts advertised offeradequate remuneration and a hospital status equalto that of other members of the team there will beno shortage of candidates. The position of theradiotherapist must be assured if he is to exert aproper influence on the decisions made ; surgeonshave long been used to undivided responsibilityfor the treatment of cancer and are not alwayseasily persuaded to change their practice indeference to his views. The ideal team shouldconsist, as Lord DoNOUG-HMOBE said in describingthe organisation already established in some

centres, of " equals all equally concerned."None of the clauses of the bill were criticised

and there was a general desire that it should speedily

become law. But while all the speakers loyallyentered into the spirit of optimism that the bill isdesigned to engender, and emphasised successesrather than failures in treatment, there was obviousconcern lest a too complacent attitude had beenadopted. Lord BALFOUR OF BURLEIGH made an

eloquent plea for state subsidy of research-" aninvestment which may result in great economy "-and this was warmly supported by every speakerwho followed him. The balance between know-

ledge and ignorance of cancer is still so over-

whelmingly on the debit side that the expenditureof some 700,000 a year (more than three times thetotal amount of the annual grant to the MedicalResearch Council) on diagnosis and treatmentwithout any corresponding allocation for researchcould hardly escape criticism. Broadly speaking,we do not know enough about the causation ofcancer to be able to prevent it; and if more thanhalf the "early" cases of cancer in accessiblesites presenting themselves at a centre are alive5 years afterwards we regard this as a creditableachievement. Lord BALFOUR OF BURLEIGH didnot detail the type of research unit that theMedical Research Council, over which he presides,have in mind, but he estimated the cost at something like z30,000 a year for 10 or 15 years ; andhe hinted that besides fundamental research intocausation the council might undertake the studyof new methods of treatment, including neutrons.The gist of the message conveyed by the debatewas that while applying what we know we mustredouble attempts to learn more, and that thestate should support both these efforts. In theend Lord STANHOPE, while unable to committhe Government, said how greatly he had beenimpressed by the support which the amendmenthad received from every quarter of the House,and undertook to convey to the Chancellor of theExchequer the desire that further provision forresearch should be made. In view of this under-

taking the amendment was withdrawn, and thebill was read a second time.

The tone and outcome of this debate, whichwas maintained throughout at a high level, willbring satisfaction to those interested in medicaland indeed in all branches of applied science. Itindicates a surprisingly wide acceptance by ourlegislators of the view, held by all scientificworkers, that success in administrative actiondirected towards problems of health is not

primarily determined by the size of the organisa-tion or of the money available, but by greaterknowledge of the disease to be combated and ofthe weapons in the service of the doctors.

M. & B. 693 IN THE U.S.A.EVERYONE concerned with the treatment of

pneumonia has awaited with interest the impactof M. & B. 693 on therapeutic practice in theUnited States. Pneumonia has for many yearsbeen investigated more thoroughly and on a

larger scale in that country than anywhere else,and until last year almost every advance in its

study and treatment has been due to the efforts

704 M. & B. 693 IN THE U.S.A.

of American workers. Their most notable achieve-ment has been the progressive perfection of serumtreatment, and the sudden advent of a chemothera-peutic alternative creates a situation for whichthere is certainly no exact parallel in the annalsof specific therapy.The first records of American opinion and

experience of this drug are now appearing in print,and they contrast strangely with what has beenwritten about it in this country. We referred onMarch 4 to E. K. MARsHALL’s report on its

absorption and toxicity, and his scathing remarkson the inadequacy of its pharmacological study.An even more downright protest in more generalterms has now appeared under the formidablenames of Bur.LOwA, PLUMMER and MAxwELLFINLAND.l They think that the clinical reportshitherto published are " grossly inadequate for

any evaluation," they deplore the indiscriminateuse of the drug-which is apparently receivingmuch publicity in the lay press and by radio-andthey conclude by urging that serum treatmentshould be used as before, " until those in a positionto undertake carefully controlled observationshave had an opportunity to ascertain the valueof this drug and its limitations, and are preparedto present properly documented results in significantnumbers of cases." This is the attitude taken byDr. THOMAS ANDERSON in our correspondencecolumns on Feb. 25, and if anything in theeditorial article he then criticised had belittledthe need for the more intensive and critical studywhich is now in progress in the U.S.A., we shouldhave to admit that his protest was justified.The same note of reserve and caution, which many

workers here will think unnecessarily discouraging,pervades a report of the council on pharmacy andchemistry of the American Medical Association,2which has now adopted the name " sulfapyridine "as a non-proprietary name for the remedy. (Itwill be remembered that this council proposedthe name " sulphanilamide " for p-aminobenzene-sulphonamide and that this country at once

accepted it; but " sulfapyridine " does not seem

quite so happily descriptive a choice, nor is therea need for it such as was created by the enormousdiversity of proprietary names invented for

sulphanilamide.) The report itself is written byPERRIN H. LONG and he records observations ofhis own as well as adjudicating on those of others.He has confirmed the efficacy of the drug in experi-mental streptococcal, pneumococcal, staphylococcaland meningococcal infections in mice, and addsthat it is also effective against Fried] iinder’s bacillusand Clostridium melchii. He refers to MARSHALL’Swork on its incomplete absorption, and he hashimself noted that it is " irregularly absorbed inman and animals and in comparison with sulfanil-amide is also more slowly and definitely less wellabsorbed." In discussing the treatment ofpneumonia, the only conclusion reached is thatuntil further evidence has been obtained, the useof serum should not be abandoned. One minor

1. Bullowa, J. G. M., Plummer, N., and Finland, M., J. Amer.med. Ass. Feb. 11, 1939, p. 570.

2. Ibid, p. 538.

but interesting point is that the alleged immunityto reinfection of mice infected with pneumococciand successfully treated with the drug is denied.This finding is perhaps consonant with the nowfamiliar clinical observation that, unless thetreatment is continued for a week, pneumonia isapt to recur. From these and other considerationsit is concluded that the general use of the drug isnot yet warranted, and that it should only beemployed by those in a position critically toevaluate it.As a set-off to these somewhat severe pronounce-

ments, the same journal contains two clinical

reports which, though guarded, are generallyfavourable. BARNETT and his colleagues 3 describethe treatment of 14 cases of pneumonia and 9 ofmiscellaneous conditions, all in children; theymade numerous estimations of the concentrationof the drug in the blood, and found that this couldbe maintained by giving a 2 per cent. solution ofits sodium salt per rectum, a proceeding whichmay obviate the nausea and vomiting often

produced. FLIPPIN and his associates 4 treated 100cases of pneumonia with only 4 deaths, 3 of whichwere in type III infections ; of 8 patients shownto have bactereemia only 1 died. They alsoestimated the concentration of the drug in theblood, and found exceedingly wide variations,evidently due to varying rates of absorption.Contrary to expectation, the therapeutic effectwas as good in patients with a blood concentrationof under 3 mg. per 100 c.cm. as in those in whomit lay between 10 and 18 mg. This is quite atvariance with what would be expected by analogywith sulphanilamide treatment, and whatever theexplanation of this observation it illustrates theneed for the further controlled study on whichAmerican authors are now insisting. The facilitiesfor this study, especially in connexion with

pneumonia, are immensely superior in the UnitedStates to any that exist here ; and just as theirresults with serum have been far more significantthan any obtained elsewhere so no doubt in timewill those of their trials of M. & B. 693. Americancriticism of the investigations so far reported inthis country seems to us excessive ; but all will agreethat much remains to be done in studying theaction of the drug, and we can only be glad thatthe vast organisations and unrivalled experienceavailable in the United States should now be

taking this task in hand.

FIFTY YEARS OF LONDON GOVERNMENT

THE jubilee of the London County Council is

worthily commemorated by the publication of ahistory,5 written at the instance of the council

by Sir GWILYM GIBBON and Mr. REGINALD W.BELL, of what our greatest local-governmentauthority has done in the 50 eventful years that

3. Barnett, H. L., Hartmann, A. F., Perley, A. M., and Ruhoff,A. B., Ibid, p. 518.

4. Flippin, H. F., Lockwood, J. S., Pepper, D. S., and Schwartz,L., Ibid, p. 529.

5. History of the London County Council, 1889-1939. BySir Gwilym Gibbon, C.B., C.B.E., D.Sc., and Reginald W.Bell, LL.M., Barrister-at-Law. London : Macmillan andCo. Pp. 696. 21s.