The dispute as to whether radiationor surgery is the best means for thetreatment of cancer of the cervix isalready about half a century old, forit is almost exactly fifty years since theradical operation for carcinoma of thecervix, commonly called the Wertheimprocedure, first began to be performedand it was at about the same time thatthe first halting and tentative stepswere made toward the development ofradium therapy. Since that time a fewclinics have consistently adhered to onemethod of therapy or the other, but,for the most part, there has been analternation in the priority accorded tothe two methods.

During the first twenty years, orroughly until about 1920, the surgicalapproach received the most general approval, although it could be appliedonly to that fraction represented by theoperable cases. After 1920, however,the trend was strongly toward radiation therapy and between that year andthe end of the second World War, radical surgery was rarely employed, atleast in the United States, for the treatment of cancer of the cervix. The risein the popularity of radiation therapywas due to a better understanding ofradium dosage and radiation distribution and to the addition of high voltageroentgen-ray therapy to the originalmethod of radium insertion. The trendtoward radiation in these years wasalso strongly influenced by two greatradiation clinics, the Radiumhemmet inStockholm and the Curie Institute inParis.

Unexpectedly perhaps, a renaissanceof the surgical method of therapy beganin the United States in 1945 and hasbeen strong enough to put the two

rivals again on almost an equal plane.The renewedpopularityofsurgeryhasbeen due in part to the fact that radicalpelvic surgery can, with the aid ofblood transfusions and antibiotics, nowbe performed almost without mortality.There is also the alleged ability to curea proportion of those cases in whichthe iliac lymph nodes are involved, asituation in which many believe thatradiation therapy is ineffective. Finally,there is a possibility that pelvic surgerymay be so extended that it may be usedin cases of radiation failure in whichrecurrences involve the bowel, bladder,orotherorgansinthelowerhalfoftheabdomen.

Statistical Results of Surgicaland Radiation Therapy

Although it might seem relativelyeasy to distinguish between the resultsof two such contrasted methods oftherapy, nevertheless, proof that onemethod or the other is better is not yetavailable. Statistical analyses themselves give uncertain results. When statistics are based on all cases, in the socalled “¿�absolutecure rate,― there always remains the possibility that theoriginal material coming to variousclinics has differed so greatly as to bethe determining factor in the differences observed in percentage of cures.Furthermore, if attempts at comparisonare made between cases of the samedegrees of advancement, such as stageI or stage-Il cases (especially those followed in different clinics), there remains the possibility of great personalerror owing to individual habits ofclassification. The cure rate in stage-Icases, for example, is probably more

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Radiation versus Surgery in the Treatment

of Cancer of the Cervix

Howard C. Taylor, Jr., M.D.

influenced by what the observer regards as a stage-I case than by the precise method of treatment. In general,however, it appears that either surgeryor radiation, when administered competently, will procure a cure rate instage-I cases of 70 to 85 per cent andin stage-I! cases, of about 35 to 45 percent.

Quality of the Treatment Employed

A reservation must further be madethat one is comparing the best surgerywith the best radiation. From a practical point, indeed, the decision as tothe best method of treating an individual case may depend upon the relative excellence of the available surgeryor the available radiation.

The best surgery requires that aradical operation be performed, withthe meticulous dissection of all lymphnode—bearingtissuesin theiliacandhypogastric areas; that the cardinalligaments and uterosacral ligaments beremoved to their points of insertions;and that the cervix be excised withenough of the vagina to allow a marginof at least 2 in. beyond any visible tumor. This is a difficult operation, forwhich an individual operator canscarcely be thoroughly competent untilhe has performedtwenty-fiveto onehundred such procedures.

Defects in a radiation plan of therapy may not lead to immediate or spectacular accidents, but the need for proficiency with this technique is as greatas for surgery. The application of theradium to the uterine cavity and to thevaginal fornices requires skill and experience if maximum distribution is tobe obtained to the critical areas. Thebest practice requires also that stereoroentgenograms be taken of the pelviswhiletheradium isinplace,to assureits optimal placing. Following radium,high-voltage roentgen-ray therapy mustbe given in a way, once again, to givemaximal intensity in the dangerousareas along the iliac lymph nodes onthe side of the pelvis. Incomplete radia

tion is quite as blameworthy as incomplete surgery but is much less evident.

Although the end results, in terms ofcure rates, do not give a clear direction as to whether radiation or surgeryis the best method, a few points may bemade, based on general impressions.The radical hysterectomy with lymphnodedissectionhasnow a mortalityofonly about 1 to 2 per cent, and, as arule, the operation is not followed by aparticularlyuncomfortablepostoperative course. Temporary urinary retention, however, is common and in acertain percentage of cases ureteralstrictures or fistulas develop, apparently as a result of the surgical interference with the blood supply of theseorgans. The risk to structures in theurinarytractis,in fact,perhapsthechief obstacle that surgical techniquesmust overcome. The application ofradium is, in general, less of an ordealto the patient, but together with thepostradium roentgenotherapy, the totalperiod of invalidism may be almost aslongaswithsurgery.Few immediateaccidents occur, but there is an undetermined, although small, incidence ofsubsequent complications from intestinal injury. It is possible also that agreater degree of shrinkage of the connective tissues of the pelvis followingradiation results sometimes in discomforts not present following surgery.Yet, again, it must be admitted thatgeneral impressions do not, any morethan statistics, give us a clear answer.

The Percentage of Operability

Although the question is usually regarded as an alternative between radiation and surgery, this is, in fact, an incorrect statement of the problem. Thequestion is really in how great a proportion and in what particular segmentof all cases of cancer of the cervix isradiation or surgery indicated? For atthis time there are few adherents ofradiation who would assert that surgery should never be undertaken, andfew surgeons so obstinate as to state

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that there is no place for radiation inthe treatment of cancer of the cervix.

This question may be further explored by considering four theories astotheplaceofsurgeryinthetreatmentof cancer of the cervix. These are thefollowing:

1. The Low Operability Plan. Insome reports, it is evident that surgeryis reserved for cases giving a very special indication. The most clear of theseis the case that, having had maximumradium applied to the cervix, still haspersistent cancer localized in the uterusor closeto it,inadjacenttissues.Insuch cases, radical surgery gives adefinite possibility of cure and is theonlymethod of treatment.Otherspecial indications have been mentionedsuch as coexisting pregnancy, fibroidsor pelvicinflammatorydisease,or thepresenceofavaginalvaultsonarrowedas to make efficient radium applicationdifficult. Another view is that radicalsurgery should be limited to very favorable cases from the standpoint of operative risks, such as relatively youngwomen and those not too obese. Sucha plan may result in an operabilityrate of about 10 per cent, with the remaining 90 per cent of cases referredfor radiation therapy.

2. The Medium Operability Plan.In other clinics the effort has been tooperate on all stage-I cases and all ofthe more favorable stage-il cases. Theinclusion of the stage-Il case is madeon the theory that surgery is most likelyto be superior to radiation in thoserelatively early cases that none theless have metastatic lymph-node cancer. Such a theory and plan of therapymay result in about 30 to 40 per centof cases being operated upon.

3. A High Operability Plan. Thishas been resorted to in a few institutions, in which an effort is made to remove the uterus in all cases in whichthe disease has not reached the pelvicwall and in which other organs havenot been involved or distant metastasesdeveloped. Operabilities of 60 per centhave been reported.

4. A Plan of Almost Total Operability. This may be arrived at, if it isagreed that even cases in which thebowel and rectum are extensively involved should be operated upon. Thisleads to the procedure of “¿�pelvicexenteration― and requires that the uretersbe implanted in the descending colonand that a colostomy be performed sothat the entire contents of the pelvismay be excised. Such operations carrya considerable postoperative mortalityand leave the patient handicapped asa result of the loss of function of vitalorgans. Some cures apparently resultwhen otherwise hopeless cases are sotreated. Some palliation and prolongation of life may be attained in a furtherportion of these cases. Whether thefinite economic and personal resourcesavailable to medicine should be devoted to an effort when such small results may be expected, and whether apatient should be subjected to such amutilating procedure with so slight achance of cure remains another of theunanswered questions in this field.The solutionofthecontroversybe

tween surgery and radiation is furthercomplicated by the evident possibilitythat a combination of these twomodalities may be better than eitheralone. Indeed, it seems probable thatthe best treatment for cancer of thecervixisbeingcarriedoutinthoseinstitutions in which the needs of eachcase may be considered individuallyand surgery, radiation, or a combination may be decided upon. There are,indeed three obvious combinations thatare being applied in an attempt to getresults better than could be anticipatedwith either technique alone. Thus, itmay be wise that all patients should receive initial radium and roentgen-raytherapy and only those in whom complete regression does not occur shouldhave surgery. Another point of view isthat all operable cases should betreated by surgery, and the expectedcure rate increased somewhat by systematic postoperative radiation. Finallythere is the possibility that the best

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treatment for cancer in the cervix andin the immediate parametrium is bythe application of radium, while theoptimum results in the treatment of thelymph-node metastases may be obtained by dissection of the iliac lymphnodes by an operation two or threemonths after radium application.

Conclusion

In conclusion, it seems best to returnto the one certain point that may bemade today in this controversial field.

Although there is no means of arrivingat a general conclusion, still it is evident that excellent surgery will givebetter results than mediocre radiationand that superlative radiation will yieldfar more cures than surgery by the beginner. The responsibility of the physician who may be advising his patientwhere to go for the treatment of hercancer of the cervix is primarily to assure himself of the quality of the treatment to be given rather than to try tomake an individual decision betweenthe two competing types of therapy.

John Leake, in 1792, in his text on female diseases, gave a remarkablyclear presentation of manifestations of cancer of the cervix and of itsmethod of spread. He recorded that women at or past the menopausewho had prolonged periods and passed blood clots often developed cancer. He stated that the seriousness of cancer of the womb is not thedestruction of that organ but its involvement of the surrounding structures. He recorded difficulty in discovering the disease until it was toofar advanced for complete extirpation. Then all that could be done wasto assuage pain and combat the intolerable stench. He recommendedtampons soaked in carrot paste. He described terminal cancer:

“¿�Thecancerous matter frequently fixes upon some other glandular part, so what was at first only local, now becomes a universalmalady, and like a pestilential blight overspreads and lays waste theconstitution. Thus reduced to the extremest weakness, and destituteof hope, she lives in a long continued state of exquisite misery, aprey to the cruel disease, till death's benumbing opium composesher to final rest and at once puts a period to her life and suffering.―

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