Rectal Cancer

By Mason Goforth  


Concepts of Cancer

In the not so distant past, epidemic diseases were of the greatest concern to the inhabitants of the world, and especially to residents of urban areas like London. Bubonic plague, cholera, and dysentery are just a few noteworthy examples of rampant disease in the early 1900s. Today many of these diseases have been nearly abolished. But one still reigns supreme, growing ever stronger and more prevalent as time goes by, cancer.  According to the Cambridge World History of Human Disease:

Cancer is a process whereby a loss of control of normal cell division and multiplication produces a tumor that can invade adjacent tissues and metastasize, that is, implant cancerous cells at a site that is noncontiguous to their origin, where abnormal multiplication continues. . . . The oldest paleopathological evidence is limited to lesions that affected bones, such as those found in dinosaurs. Tumors have been found in Egyptian mummies dating from 2000 to 3000 B.C., and physicians of that ancient land knew of and treated patients for cancers of several sites.

Thomas G. Benedek and Kenneth F. Kiple. “Concepts of Cancer.” Chapter. In The Cambridge World History of Human Disease, edited by Kenneth F. Kiple, 102–10. Cambridge: Cambridge University Press, 1993.

Although many types of cancer were prevalent in London during the early to mid-1900s one particular type doesn’t play favorites and is well documented during this time period: rectal cancer. 

The first successful excision of the rectum for uncomplicated cancer was performed by Jacques Lisfranc in 1826 in the Hospital de la Piti de Paris. He employed a perineal or posterior approach excising the infra-peritoneal portion by pulling down and cutting a few centimeters of rectum.

L. Viso and J. Uriach, “The first twenty operations for rectal cancer” J. Int J Colorect Dis (1995) 10: 167.

Subsequent surgeries were attempted following Lisfranc’s first attempt at rectal cancer removal, twenty in total from 1826 to 1854. A man named Piechaud published a thesis called “Traitement du cancer du rectum” which outlined the steps used in rectal cancer surgery:

  • First step: The patient was under chloroform anesthesia and in the right lateral position. The cutaneous incision included a triangle with the vertex at the coccyx. The perianal fat was dissected up to the posterior wall of the rectum using the thermocautery.
  • Second step: The coccyx was resected.
  • Third step: At a level above the tumor and on both sides of the rectum, the rectal wall was perforated with a fistula director which was pulled out of the anus. Both sides of the rectal wall was divided with the thermocautery, leaving the anterior and posterior aspects where the tumor was situated.
  • Fourth step: A longitudinal division was made in the posterior rectal wall, cutting through the tumor.
  • Fifth step: Ligature and cross-section of the anterior and posterior rectal wall above the tumor. 
A lecturer pointing to a large screen, on which projected diagrams of the bodies of a man and a woman are marked with red flags indicating areas where cancer may be first seen. Colour lithograph after Fellnagel, 1941.
Credit: Wellcome Collection

Exploration of Reports Detailing Rectal Cancer

The MOH reports I examined were from 1909 to 1958. To start my exploration I began with some of the earliest, most thoroughly documented cases of rectal cancer in England starting with Woolwich 1909, The MOH notes that when comparing the number of deaths by cancer in 1909 with that of 1903 there was an increase of 12 deaths in both males and females, 24 deaths in total. “In males, the most notable increase is in cancer of the stomach and pylorus, and in females, cancer of the stomach, pylorus, intestines, and rectum. Whether this increase is real, or due to improved diagnosis, it is impossible to say.” In the Woolwich 1914 MOH report, the MOH notes that the past year had the highest recorded cancer death-rate. There was an increase in women with rectal cancer which “may be due to improved diagnosis.” The MOH shows a subtle shift in confidence in the improvement of diagnoses of rectum cancer. While the number of women with rectal cancer in Woolwich from 1909 to 1914 increased according to the MOH, in 1917 the MOH in Woolwich released a table detailing deaths from rectal cancer in males from 1903 to 1917. This table shows no upward or even clear trend in rectal cancer among males. Deaths from rectal cancer in Fullham in 1914 were recorded at 11 for males and 25 for females, two years later there were 18 male and 24 female deaths from rectal cancer in Fullham. In the 1927 Fullham MOH report the medical officer of health notes that “this disease may occur not only during middle and advanced age but also in younger persons.” Towards the end of his report, he quotes Sir George Newman who when asked what the hope of the future of rectal cancer treatment was and stated,  “It appears to lie primarily in the discovery of some means such as a biochemical test of early and certain diagnosis followed by the application of some method of treatment not involving operation and secondarily in providing an explanation of the method of causation opening up a way to prevention.” In Islington in 1912 cancer of the rectum was responsible for 36 deaths, 21 males and 15 females (all except two over the age of 45). Tottenham in 1923, on the other hand, reported exceedingly lower figures of death from cancer of the rectum, 12 male and 6 female. MOH reports for Tottenham in 1924 lists a table showing malignant cancer growths of the rectum at 11 for both males and females. And lastly, the MOH report of London County Council in 1958, the MOH lists a table detailing the number of deaths from rectum cancer (grouped with intestinal cancer) from 1949-51 and 1956-58, along with a percent change in rate. From 1949-51, 608 male and 678 female deaths were reported. And from 1956-58, 473 male and 638 female deaths were recorded. The percent change rate was -20 for males and -3 for females, which is truly astounding and likely due to better treatment options. 


cancer images 2
A diseased colon; and a section of diseased small intestine. Colour aquatint by W. Say after F. R. Say for Richard Bright, 1827.
Credit: Wellcome Collection

Looking Towards the Future Of Rectal Cancer

With the goal of improving data from studies years ago, a group called EUROCARE-5 conducted a study on the relative survival of patients diagnosed with colorectal cancer in Europe from 1999-2007. The average relative survival of these patients was 56 % for those with rectum cancer. The study found “persistent differences in cancer survival across Europe with the lowest survival for CRC [colorectal cancer] patients observed in Eastern Europe.” There was also a strong trend in age-specific survival. Survival rates between 1999-2001 and 2005-2007 increased by 6% for patients with rectum cancer. It was concluded from the study that although survival rates for CRC patients improved during the study period, geographic variations and age gradient remained. These existing disparities might be best reduced by “access to effective diagnostic procedures and treatment options.” Some preoperative diagnostic options for treatment currently are influenced by the location of the cancer-causing tumors.  Aggressive surgery is an option that may improve the survival rate and things such as CT scans, MRI, and endorectal ultrasounds also serve to help diagnosis and identify rectal cancers. 

Cancer images 3
Human colon cancer cells
Credit: Wellcome Collection

Bibliography

 

MOH Reports


MOH Woolwich 1914

MOH Fullham 1927

MOH Tottenham 1923

MOH Fullham 1914

MOH Fullham 1916

MOH London County Council 1958

MOH Woolwich 1917

MOH Woolwich 1909

MOH Islington 1912

MOH Tottenham 1924


Secondary Sources-

The First Twenty Rectal Cancer Operations

Concepts of Cancer

Colorectal cancer in Europe from 1999-2007

Colon and Rectum Cancer- Patterns of Spread and Workup