WAR ON CANCER

Dominion, Volume 22, Issue 131, 27 February 1929, Page 12

WAR ON CANCER

DEFINITE AND AUTHORITATIVE ADVICE

SUFFICIENT RADIUM IN NEW ZEALAND

CENTRAL INSTITUTION FOR TREATMENT Definite and authoritative advice on the treatment of cancer in New Zealand was given by Mr. Sampson Handley, thes eminent English specialist, on Saturday, before a conference attended by the Minister of Health, medical officers of the Department, and representatives of the British Medical Association. The report of the proceedings, released for publication by the Minister yesterday morning, indicates that .Mr. Handley recommended the establishment of a central institution for the treatment of patients, and expressed the opinion that travel abroad to all the radium centres was the counsel of perfection. He considered that there was sufficient radium in the Dominion to make a start with, and that the most economical method was the use of radium tubes; at present he would not put more than a limited percentage of radium in emanations. One upshot of the conference was a decision to call a preliminary meeting for the formation of the New Zealand branch of the British Empire Cancer Campaign.

Those present at the conference were the Hon. A. J. Stellworthy, Minister of Health (chairman), Mr. Sampson Handley, Dr. J. S. Elliott, president of the New Zealand Branch of the British Medical Association, Dr. W. Young, Professor C. E. Hercus. Otago Medical School, Dr. T. H. A. Vaiintine, DirectorGeneral of Health, Dr. M. H. Watt, Deputy-Director-General of Health, Dr, T. McKibbin, Director, Division of Public Hygiene, and Dr. T. R. Ritchie. Dr. M. H. Watt said that the certification of cause of death was now much more exact than formerly, and therefore the actual increase in the deathrate from cancer was probably not so great as would appear from a casual inspection. In regard to facilities for treatment in New Zealand, there were no special cancer hospitals and no special cancer beds. It was the function of hospitals generally to afford treatment for cancer cases. The four main centres were regarded as reasonably well equipped, and the surgical treatment which could be given cancer cases there was of a reasonably good order. None of the centres, outside of the four main towns, possessed any radium, etc.; some of them had X-ray apparatus capable of deeptherapy. None of them had a medical man as officer in charge of the bacteriological service; some of them had technicians who were able to give limited bacteriological and pathological service. Comparatively little had been done in New Zealand in regard to research. Two or three years ago Dr. N. Fulton investigated cancer from the statistical and clinical aspect. The work was financed by a donation of £lOOO from a resident of Invercargill. This carried pound-for-pound subsidy from the Government, making a sum of £2OOO. A former resident of the Wellington Hospital District left a bequest of £lOO to the hospital board for cancer research. The hospital board offered to hand this over to the Otago Medical School as it recognised that that institution was more competent of carrying out research in cancer than it was. This sum also carried equal subsidy from the Government, making a total of £2200’. Dr. Fulton was financed from this fund, and it was understood there was still a sum of approximately £l6OO which was available for cancer research in the possession of the Otago University. Dr. Watt said that in addition there was a bequest in Christchurch, known as the Travers Bequest, of which there was no official information or knowledge. . £60,000 Bequest.

Dr. Hercus: The bequest amounts to £60,000. As a matt'er of fact X gave Mr. Sampson Handley a letter from Dr. Fox dealing With it. It is not absolutely stated that it must be spent on cancer, but that is the trustees’ feeling The Minister: Is the.£6o,ooo invested? Dr. Hercus: There has been a. great deal of difficulty about it. They hlive been trying to get the Government m the light of the nature of the bequest, to forgo death duties and that has been continually debated ever since the Travers death. It is only now available, with a large sum off for death duties. The death duties have been paid. The Minister: Is any application in f ° Dr. U Herciis: They have not gone as far aS Dr. a Watt: As a Department we haye nlwavs been sympathetically disposed towards any research in cancer in. New Zealand, but we have recognised the dif Acuities of finding suitable workers and finding subjects which cated in this country.! Dr. h niton sin vestigation wks a collation of results which obtain in New Zealand- results nf treatment. We feel that that type of ‘investigation is the sort we could more properly finance.

Educating the Public.

Dr. Watt said that education of the public was rather a difficult , matter. For many years a pamphlet giving cardinal symptoms of early cancer and urging the necessity of people with such symptoms and signs seeking. medical attention at the earliest possible moment had been issued, and during the last three or four years there had been a weekly issue of health notes, containing a periodical review of the question ot cancer, and giving such information as the public should have in their possession. Letters which reached the Department indicated that the public gen. orally read these articles.

Stocks of Radium.

In New Zealand stocks of radium were found only in the four main centres. The Government in 1926 laid down a policy that it would not sanction _ more than £lO,OOO expenditure on radium in any one of these centres, -unless the extra amount was solely made up of voluntary contributions. The reason for that was that at about that time there were very active demands for radium from some of the smaller centres, and the Department felt that it was contrary to the best interests of the Dominion to allow them to purchase the radium. It was held that radium was a therapeutic agent which should be used only by people highly skilled and thoroughly’ trained in its use. Stocks of radium at present in New Zealand were as follow : — , Auckland—3l9.6l milligrams. This was stated to be in the form of 67 needles and two plaques. Wellington had a total of 1 gramme, of which one-quarter was in the form of needles.

Christchurch —508 milligrams. Dunedin—2B6 milligrams. That amounted approximately to 2.1 grammes of radium for the whole of New Zealand, of which practically one-half was in Wellington. • Minister: What is the cost of radium? Dr. Elliott: I read a few days ago that it is £12,000 a gramme. Desire For Supplies. “There has been a keen desire on the part of some of the sub-centres of New Zealand to obtain supplies of radium,” Dr. Watt continued. “A little while ago we had a considerable dispute with Invercargill. Some two or three years ago there was, I think, an agent of one of the firms which had radium in its possession and wished to dispose of it, sent all round New Zealand, and this agent was able to excite very considerable public interest in the matter. In the' Otago province a large sum of money was raised, The radium ,wa# purchased

and was located in Dunedin, and Invercargill still feels that, it has not been treated properly insofar as it has not its own supply of radium in its possession. Wanganui was a town which wished to purchase radium. The Department, however, prevailed upon the hospital board there to install instead a first-class X-ray equipment. Gisborne is another town which probably may be making overtures to the Department in the near future. The medical superintendent informs' me that a resident is prepared to hand £5OOO to the hospital board but pnly on condition that it is expended in the purchase of radium for that district. We informed him that we would be against it; but this is a matter in ■ which we shall be guided entirely by Mr. Sampson Handley’s advice."

First-hand Advice.

“It appears to me that you have enough radium to make a serious start with treatment, although the amounts available at Auckland and Dunedin seem rather said Air, Handley. “At present you have not enough (g em ‘ ploy all the methods available for using radium. There is a method jn which a large amount of radium is used at a distance from the patient that has certain technical advantages, but of course it is an expensive, some would say a_n extravagant, method of using radium, and you have not enough at present to try that method even. Australia has one distance apparatus in which a large amount raised for the purchase of radium by,the Commonwealth Government is at present locked up. I think that the most economical method of using radium is from tubes, the tubes being buried in the tissues right in close contact with the

growth. This is, I think, the most effective way in proportion to the amount of radium used. Of course, that involves the close co-operation of the surgeonsj jt involves that a large proportion of the radium should be at the disposal of the surgeon, and should not be entirely in the hands of the radiologists, who.jise radium from the surface, while the surgeon buries it in the tissue.

Enough for a Start.

“I have no doubt that in the future you will need a very considerable increase in the amount of radium here; but you have enough, I think, to start with. It would be easy to develop as you go along.

“Then there is another method of using radium—the emanation method, in which the stock of radium is kept at one centre, and the gas which it gives off is gathered into capillary tubes, each of which has for a few days the qualities of the. solid radium from which it came. That has advantages in that the emanations can be sent about the country without fear of loss. On the other hand, an emanation is not a standard article like a tube of solid radium; its strength is diminishing with every hour, and the distances in a country like this, and any delay which might occur in the’ post might njake it difficult to use. I prefer the .solid radium, for I know what I am dealing with. There is apjqther point about the emanation method: if you have a tube of radiitm of fifty milli(jram strength you Can use that tube for twenty-lour hours every day in the week all through the year at full strength, but if you use it to produce emanation, you would only have available a tube of emanation equal in strength to the original tube once a week, so that there is a serious economic loss by using radium emanation. I should not put more than a limited percentage of your radium into emanations for that reason.

Dr. Valintine: Therefore, would it not be better and more economical to send patients from remote hospital' districts down to one of the nearest centres, than attempt to treat them by emanations in the smaller hospitals?

Four Centres Sufficient.

Mr. Handley: I certainly do think that at present these four centres are sufficient to deal with the question in New Zealand, and I think it would be better to develop slowly, and only increase the number of centres very gradually, although, no doubt, you will have to resist local pressure. At the same time, it is very questionable whether it is wise to refuse money for radium, unless you are sure that the money will be available for some other public purpose, because the radium would be there, although it would not be putting its full weight* at a smaller distant centre, yet it would be there, and would probably be roped in for a larger centre at some time. The Minister: Is radium treatment safe in the hands of other than a highly trained specialist? Mr. Handley: No, sir. You would have to make a condition that one of the staff of the local hospital should go, preferably to Europe, and see radium work in London, Stockholm, and in Paris, and, perhaps, in Brussels, and should then come back and take charge of this radium. The Minister: You advise that as absolutely necessary? ... Mr. Handley: I think to be safe, it is. Dr. Elliott: Would it be necessary for an experienced general surgeon of the common type here to go abroad to get information necessary to enable him to bury needles of radium into the vicinity of growths? Mr. Handley: That is rather bound up with the question as to whether a special cancer hospital is desirable or practicable in New Zealand. One of the reasons why a special cancer hospital is desirable here is that it would avert any necessity of that sort. The Minister: Would radium treatment in the hands of a general surgeon be reasonably safe taking into consideration the specialist training that he has already had? Mr. Handley: “In view of the high level of professional attainment here I think it would be safe in the hands of a surgeon who would take a special interest, but if a man were not interested in it and had not studied literature and taken thought about it it would not be safe.” He thought travel abroad to all the radium centres was perhaps the counsel of perfection and that that would be a satisfactory working arrangement. Dr. Elliott said that up till recently there was no co-operation between the physics departments of the four university colleges in’the cities where we had the four base hospitals and the radio-,

logical departments of the Department. The difficulty possjbly might be met if there could be that co-operation with the professor of physics or his assistants and those in charge of the radium plant at the hospital, and it would be valuable assistance in that way. At the Wellington Hospital in the radium department the professor of physics at the university has no status, and he did not think he was particularly interested. A Correction. Dr. Watt, correcting some information he had given earlier, said that Mr. Samp- • son asked whether the figures he gave for quantities of radium in New Zealand related to radium or radium salt. “I said I thought they represented radium element, but I was somewhat uneasy, and have caused verbal inquiry to be made from the Wellington Hospital for more details of the radium in the possession of that institution,” said Dr. Watt. They hold 650 milligrams of radium chloride available for use in the emanation plant, and 100 milligrams of the same salt in needles and applicators. The information from the other centres was got in a hurry by telegram, and I am afraid I cannot say whether the figures quoted for Auckland, Christchurch, and Dunedin represent radium element, or radium salt. I propose, however, to ascertain exactly in what form is the radium in these three centres, and I shall give the information to Mr. Handley at a later date.” Central Cancer Institution. Dr. Vaiintine said it would be very difficult to finance a central institution for cancey. There would be tremendous objections by the four centres to establish a hospital in any one of these centres; nor did he think just now that a special cancer hospital is necessary. “I am bound to say I think there are great advantages in having a central institution for cancer,” said Mr. Handley. “The disease is very potent, and it lasts a long time in some cases, so that to acquire experience in it a man will have to see a lot of cases, and see them through the years, and it is impossible to get sufficiently large experience, I think, outside a special institution. Then, it is needed, I think, as a teaching place; a place where the man who specialises in cancer can educate himself, and then educate first of all, the doctors who may come from different parts to learn how to use radium, and secondly, it should be a centre for. disseminating information about cancer to the public. Of course, it is not for me to deal with questions of finance, but only with what seems to me the best arrangement.

I think that to ensure a high standard of treatment of cancer in New Zealand that really you do need an institution, not necessarily one which would attempt to deal with half the cases of cancer. Some should be.left to the other hospitals, but a certain degree of centralisation of the disease would be of great advantage.

There is one other argument: New Zealand is rather an isolated country—isolated by a considerable tract of not very smooth sea—and must be dependent on its own resources, and that is one of the very strongest reasons why New Zealand should deal with cancer, not only with a central institution, but by way of research on its own particular problems... I think the hospital should have fifty beds. You might supplement it by special cancer wgrds at other centres. There is one important point, and that is that the staff ought to be more or less permanent. The Minister: I think if you had some concentration of cases it would certainly give more hope to the patients. It is a question of national policy whether a special cancer hospital is. desirable or practicable in New Zealand.

Mr. Handley: In my opinion it is certainly most desirable. Dr. Young: Do you tbjpk.it would be as satisfactory if we jp the first place asked the hospital boards of the four centres to set aside two wards, male and female, and call that their concer department? . . ,

Mr. Handley: Ido not think you would obtain the same results.

I believe that In twenty years' time If you have such an institution you will have a higher level in the treatment of cancer in New Zealand.

Geographical Situation.

The Minister: Are we all satisfied on that score?

Dr. Valintine t I am quite satisfied with Mr. Handley’s views. Dr. Elliott:. In the event of having an institution of that kind, questions will arise as to whether the institution should be central for the convenience of the patients or whether it should be in connection with the Medical School at Dunedin, which is not geographically so; but it might be a matter for. postgraduate study. Mr. Handley: The most important part of its functions would be to give post-graduate study. Dr. Elliott: I think it ought to be in Wellington. The Minister: It would help me, gentlemen, on this particular point on which it might be my function to bring some influence to . bear if you would put a definite question to Mr. Sampson Handley. Mr. Handley: As the institution is not to take more than a proportion of cancer cases its geographical situation is not a dominant consideration from the patients’ point of view. There would be enough cases in the South Island to keep it full. Dr. Elliott: Then the people in the North Island, which • contains much the larger population of the two islands, might want to have a duplication of the hospital. „ ~ , Mr. Handley : What I said applied equally to the North Island. I think it should be close to scientific laboratories so that questions cropping up in connection with cancer could receive answers: secondly, it should be in the best position for teaching the undergraduates and teaching the post-graduates. Dr. Young: I think we cannot help but approve of Mr. Handley’s suggestion of having a special Cancer hospital and that situated in the teaching school. At the same time in the North Island I think each centre, Wellington and Auckland. should each have special cancer wards.

Research Problems.

“In my opinion,” continued Mr. Handley, “research work is not a very suitable problem for the Government except in statistics, where I think the Government only can do such work satisfactorily, and I understand that the statistics here are very perfect, and I think it would be most valuable if we had from New Zealand more statistical information as to cancer in New Zealand. Otherwise might I suggest that the matter of research should be left to the cancer hospital and to the academic authorities. I think there should be research by the Government Department on the question of results, and in that connection that the Government hospitals should have a complete service for keeping in touch with patients after operation.” In regard to a point raised by other speakers Dr. Watt said he thoroughly agreed as to the necessity and importance of having facilities for pathological examination, and he suggested that the Department might circularise hospital boards concerned and ask them to instruct their pathologists that when a doctor sends in a specimen for examination indicated that the patient was unable to pay no charge was to be made, and, further, that the doctor migjit indicate the charge that the patient was able to pay.

Histologist Necessary.

Mr. Handley was of opinion that if the special cancer hospital were formed, it would be essential to have a first-rate histologist in connection with such a hospital, because to get a first-rate opinion on a difficult cancer slide was a very difficult matter, it requiring years' of experience to give such an opinion.

The Empire Campaign.

Mr. Handley, discussing what further measures should be taken, said it was necessary to get the lay people to take an interest in cancer, and not only the lay people but the dentists, because the care of the teeth was a very important matter in connection with the prevention of cancer. He hoped that the Minister would take a sympathetic interest in the formation of a branch; of the British Empire cwt campaign. Ha believed gnnh *

branch would be helpful to the Health Department. Dr. Elliott: The British Medical Association passed a resolution supporting the formation of a branch in New Zealand

Mr. Handley said that such a branch might offer scholarships to encourage young graduates to do useful research work, and to go Home. For purposes like that and for.helping to finance the research laboratories a considerable amount of money would be necessary, and it would be an important function of the branch to collect that money and to educate the public, and to accustom them to take-;an. interest in the cancer problem.

The Minister: We are all of one mind regarding the desirability of the formation of such a society. We cgn take that for granted. . On the motion of the Minister it whs decided that a provisional committee be set up to arrange the preliminaries of the inaugural meeting, the committee to consist of the Mayor, Mr. C. M. Luke. Drsl Elliott, Young, and Watt. Mr. Handley was warmly thanked for Ma., aAatM teO—.niittton-