Common origins: The two ACSs-100 years of collaboration to improve the lives of cancer patients

When we talk about medical history, we often focus on the way events unfolded, but never really think deeply about why they happened. I maintain that history-making events are usually the result of persistent people with vision and ideas that respond to the problems in their environment at the time. Historic events often happen in groups of individuals who push themselves to resolve the problems of their era, and we need to cultivate these types of individuals today as we look forward to the future.

The successful collaboration between the American College of Surgeons and the American Cancer Society can be attributed to our common origins, our common evolution, and the common goals set forth by our founders and subsequent leaders. Progress is not happenstance. In our active, busy, digitally propelled lives, it is good to take a little time to look back at how we arrived where we are and to envision where we are going. A shared centennial in 2013 seems to be a proper time for organizations with shared beginnings to jointly celebrate their accomplishments.

Seneca said, “The journey is long by way of precepts, but short and effective by way of example.” This article shares the stories of some of the individuals who have led us to where we are today.

Early efforts

Let us set the stage. At the beginning of the last century, the medical and surgical professions, despite the presence of some considerable giants, were in a sad and undesirable situation. We were losing one-third of the U.S. population in childbirth or from disease by age five. Life expectancy was 45 years. Communicable diseases were rampant. Hospitals were to be avoided. Operations were rare and usually ended in infection, which led to death. Physicians were able to offer little but comfort and morphine, and medical education at the time was a scandal.

Four entities—the College, the American Cancer Society, the American Joint Committee on Cancer, and The Joint Commission—began with the belief that medicine and surgery needed to develop higher standards for patient care, particularly cancer care. We shared a commonality of threads of origin, which has enabled our success and survival.

In the early 1900s, cancer was viewed as a dangerous, fatal disease. It was not very prevalent because most people did not live long enough to develop cancer, and those who did usually presented at a very advanced stage and did not survive long after the diagnosis. It seemed that not much could be done for cancer patients. There was both public and professional despair and resultant indifference.

A few physicians defied these notions. One of them was J. Marion Sims, MD, a South Carolinian who practiced surgery in Alabama and then was called to New York to establish the Women’s Hospital of New York. Dr. Sims had a reputation for successfully applying surgical techniques in the treatment of fistulas in women and for performing hysterectomies and other gynecologic procedures. While at the Women’s Hospital of New York, he developed a keen interest in cancer. He knew that it was against the rules of the hospital to admit cancer patients because many health care professionals and members of the public thought cancer was contagious and incurable. He admitted cancer patients anyway. Dr. Sims has been dubbed “the father of gynecology” and was the first American physician to have a statue erected in tribute. It still stands in New York City’s Central Park.

As a result of his defiance, however, he was thrown off the hospital staff, but he had two potent allies, Elizabeth Cullum and Augusta Astor. Mrs. Astor was the wife of the tycoon, John Jacob Astor, and Mrs. Cullum was the granddaughter of the illustrious Alexander Hamilton and the widow of the General in Chief of the Union Army. Mrs. Cullum had a child with cancer, and she enlisted her cousin, Mrs. Astor, in an effort to reach out to the business community to raise money to establish the New York Cancer Hospital, which subsequently became the Memorial Hospital for Cancer and Allied Diseases in 1899. That hospital eventually became Memorial Sloan-Kettering Cancer Center, which has played such an instrumental role in the development and leadership of the American Cancer Society. These women brought cancer out of the closet, enabling a more open dialogue on the subject. Unfortunately, Mrs. Cullum’s only child died of cancer, and she subsequently died of cancer, as did Mrs. Astor.

Thought leaders

Several other individuals revolutionized medicine in the last century. One such individual was Abraham Flexner. Mr. Flexner was a first-generation son of immigrants from Europe. His father was a pharmacist in Louisville, KY. Mr. Flexner became an excellent and noted educator, and the Carnegie Foundation gave him a charter to survey all of the 163 existing U.S. medical schools. At the time, many of these institutions were diploma mills, with no requirements for entering medical school, no practical training (lectures only), and no requirements for graduation other than the payment of fees. Medical education was in a terrible and vexing state.

Mr. Flexner did a remarkable job. He did visit every medical school, traveling by train, and he wrote an impactful report on medical education that has become a classic. He recommended the closing of 124 of the 163 schools extant at the time. Soon after his findings were published, many of these proprietary facilities were closed. The whole pattern of medical education was changed.

Another key figure dedicated to improving surgical education was Franklin H. Martin, MD, FACS  (see photo). Dr. Martin was a tall, red-headed country boy from Wisconsin who went on to practice in Chicago, IL, and became a very well-known surgeon. He established the journal Surgery, Gynecology & Obstetrics (now known as the Journal of the American College of Surgeons) as one means of educating surgeons. He established the Clinical Congress of North America as a forum where surgeons could meet and learn about surgery and watch surgeons apply excellent technique, and he was the principal person responsible for establishing and sustaining the College through its formative years. Dr. Martin altered surgical history and began our heritage.

Ernest A. Codman, MD, FACS, was perhaps the most interesting of the group (see photo, this page). He was a Boston Brahmin. Educated at Harvard University, he married the daughter of the professor of anthropology (Bowditch) at Harvard. He established an active surgical practice at the Massachusetts General Hospital (MGH) in Boston and was a leader in the use of diagnostic X ray. He was also an expert in the shoulder. Everything was going right, but Dr. Codman had strong ideas and an abrasive personality. He had the notion that if a physician was going to do something to a patient in a hospital, then it was important that the health care professional and the institution keep accurate records, document the outcome, and be very transparent with the findings. “Don’t just operate and discharge the patient; see what happens and learn from that,” Dr. Codman famously said. He also had the unusual (for the time) belief that hospitals should have some quality standards. Dr. Codman established a bone sarcoma registry, which was the first collection of cancer data. He was an extemporaneous person. He was brilliant. His ideas were different and challenging, and he managed to offend nearly every group with which he worked. Dr. Codman stated that it might be 100 years before his ideas would be accepted. He was a true visionary.

W. Hardy Hendren III, MD, FACS, recently sent me a restoration of the original cartoon that Dr. Codman drew (see Figure 1). He was lampooning the medical profession in Boston. In the comic he depicted his belief that as long as the Back Bay Peacock was laying golden eggs, the medical establishment there saw no need to collect and examine data. With that presentation to the Suffolk Massachusetts District Surgical Society, he was removed from the society and from the staff at the MGH. He then established his own hospital (the End Result Hospital) and continued to collect and publish data on each and every patient. He was outspoken, thus offending his peers. As a result, he received no referrals and the hospital failed.

Figure 1

Figure 1

Dr. Codman’s accomplishments were many; he established the first morbidity and mortality conference, at MGH; with his Harvard classmate, he developed what they called “the ether record” and what is today referred to as the anesthesia record; he published books on the shoulder and on bone sarcoma; he established the “end-result” idea; he is now known as the father of outcome studies and evidence based medicine; he believed in transparency of data; he was appointed the first Chair of the Standards Committee of our burgeoning College and was responsible for developing the Minimum Standard for Hospitals, issued in 1917, focusing on medical staff organization, on critical evaluation of clinical practice, and on medical record standards. Following the publication of the Minimum Standard, hospitals were surveyed relative to the Standard, by the College. The results, reported at a meeting at the Waldorf Astoria hotel, revealed that only 89 of 692 hospitals met the standard. Following the meeting, the results of the report were burned and never released.

With all of his many contributions, many are just coming into acceptance today (as he predicted). Dr. Codman died in 1940 of melanoma, was a virtual pauper, and chose to be buried in an unmarked grave in the famous Mt. Auburn Cemetery (Cambridge) so as to not impose the expense of a headstone upon his widow. I believe that The Joint Commission, the American Cancer Society, the American College of Surgeons, and the American Academy of Orthopaedic Surgeons should erect a headstone at the grave site to properly acknowledge this visionary and our debt to him. Our centennial year would be the perfect time for this to occur.

William Halsted, MD, FACS, who was the first chair of surgery at Johns Hopkins University, Baltimore, MD, revolutionized surgery in this country (see photo). His accomplishments were many, and I will enumerate only a few of them in this article. He requested that the Goodyear Company make the first pair of rubber surgical gloves for his nurse and future wife—Carolyn Hampton, niece of the South Carolina Gen. Wade Hampton—because she was allergic to carbolic acid. He encouraged the use of fine sutures and ligatures and advocated treating tissues with respect, with an emphasis on gentle handling. Dr. Halsted developed thyroid surgery. He evolved local, regional, and spinal anesthesia. He created the surgical training program that became the model for virtually all surgical resident training programs in the last century. He introduced radical mastectomy. Dr. Halsted has since been castigated for the latter, but we should acknowledge that at that time, hardly anyone survived breast cancer, and that the Halsted mastectomy resulted in a 40 to 45 percent five-year survival rate. He revolutionized surgical practice and training and established a paradigm regarding the way in which cancer spread, which survived over the last century.

Thomas Cullen, MD, FACS, and Clement Cleveland, MD, FACS, together were the founders of the American Society for the Control of Cancer (ASCC) in 1913, which subsequently became the American Cancer Society. They were general surgeons with a focus on gynecologic surgery. Dr. Cullen analyzed his cases of cervical cancer and reported his findings to the American Gynecological Society in 1912, noting that at five years, only 23 percent of his patients were surviving. Around that same time, the Prudential Insurance Company had noted a marked increase in the incidence of cancer. Cancer was becoming a very prominent clinical problem. Dr. Cullen, practicing in Baltimore, MD, was appointed head of a committee of the evolving American College of Surgeons, to collect and to promulgate data regarding cancer. Joining forces with Dr. Cleveland in New York, NY, these two men put together a group of physicians and laypeople with the purpose of collecting data about cancer and educating the public about the condition. As a result of their activities and the group they brought together, the ASCC was established to continue those efforts.

Their patient education efforts led to the publication of an article in the May 1913 issue of the Ladies Home Journal, titled “What can we do about cancer?” This article—which was also noted in Collier’s and McClure’s magazines—is believed to have been read by 11 million people, revolutionizing the public’s understanding of the disease and educating people that with early detection, cancer was treatable—although treatment options were limited at the time. The concept of fighting cancer by educating the public had begun. John Bowman, PhD, was the first director of the College at that time (1915 to 1921) and began establishing hospital standards for the cancer program.

Dr. Cullen became a leader in cancer care through his work with Joseph Bloodgood, MD, a pathologist at Johns Hopkins Hospital. Together, they established the frozen section as a diagnostic tool for cancer. They also created and publicized a list of the “danger signals of cancer,” which was translated into 22 different languages; more than 700,000 requests for these signals were received. When they started this activity in 1910, the average delay in diagnosis of cancer was one year from the onset of symptoms. By 1923, it had fallen to four months, so the impact was significant.

Table 1

Table 1

Evolution of collaboration

Above is a timeline depicting the evolution of collaborative efforts between the American College of Surgeons and the American Cancer Society. It is interesting to note that in 1913 the Prudential Insurance Company published a bulletin called “The Menace of Cancer,” which showed a rapid increase in the incidence of cancer (from tenth to fourth). In that same year, the College and the ASCC were established. The epidemiologic influence on cancer began to occur. In 1923, epidemiologist George Soper, MD, managing director of the ASCC, began to criticize the organization’s Cancer Campaign Committee for being too optimistic about cancer, and he asked, “Should we motivate the public by optimism or by fear?” This is an interesting question, even today. In 1914, this committee established a New York office with a budget of $5,000. In 1923, it was legally incorporated.

Meanwhile, Dr. Codman’s registry for sarcoma had been established and led to the formation of other cancer registries and to the collection of appropriate data. In 1922, the College formed the Committee on the Treatment of Malignant Disease by X-ray and Radium, which subsequently became the Committee on Cancer. The first chair, Robert Greenough, MD, FACS, of Boston (see photo), established the first consultative U.S. tumor clinic at the MGH. He emphasized the need for microscopic confirmation of the diagnosis of cancer, and called for the collection of five-year survival rates. Dr. Greenough subsequently became President of the American College of Surgeons in 1934 and was president of the ASCC in 1937, the year of his death.

The ASCC’s Committee on Cancer precipitated the 1927 formation of the Program for Survey and Approval of Cancer Facilities. The ASCC (later known as the American Cancer Society) funded that activity, and it should be noted that from 1926 to 2005, the Society spent $26 million dollars to fund this program.
Bowman Crowell, MD, a pathologist from Nova Scotia, was an important figure in these early efforts, as he took over the bone sarcoma registry in 1926 (see photo). He began to further emphasize the wider collection of data so that the cancer facilities that the Cancer Society had urged to be formed could be evaluated properly. By 1930, there were 198 approved cancer centers in the country; and by 1943, 380 cancer clinics had been approved by the College, with 80,000 patients a year being seen in those facilities. Dr. Crowell was very influential. As Co-Director of the College, he led the organization’s quality improvement efforts and accomplished much for the College. He gave an address at the 25th anniversary of the American Society for the Control of Cancer, and in 1949, he became the first person to receive the Medal of Honor from the American Cancer Society. It should be noted that in addition to the Medal of Honor, Dr. Crowell was given a cigarette lighter!

In 1930, Dr. Greenough was appointed to chair the College’s Committee on the Treatment of Malignant Disease, which would become the Committee on Cancer. Again, the American Cancer Society—which was still the ASCC at the time—gave a grant to the College to develop standards for surveying oncology centers. This step marked the beginning of the Hospital Cancer Approvals Program. In 1931, a service for the diagnosis and treatment of cancer (cancer clinics) was again led by Dr. Crowell. That same year, there was a joint meeting of the boards of the American Cancer Society and the College to study and to further develop this issue. By 1935, 25,000 patients were listed in the cancer database with information indicating who had died or survived, and 2,800 patients were in the bone sarcoma registry.

Table 2

Table 2

In 1936, a significant act of the ASCC, now led by Clarence Little, MD, was the formation of the Women’s Field Army, which became the primary fundraising unit and the service unit for this burgeoning organization. It should be noted that Dr. Cullen was the first to recognize the importance of women in the battle against cancer. As he noted, “They direct the family in health care,” a fact that persists to the present.

I have recognized the importance of women in the American Cancer Society, and devoted my year as president (1995) to not only the women in the American Cancer Society but to cancer in women. At that time, there had been only one female chairman of the board, no society president, and few leadership positions for both female volunteers and staff. Since then, considerable improvement has occurred for women, with the appointment of six national board chairs, three presidents, and multiple senior staff officers.

With vigorous support from both the American Cancer Society and from the College, in 1937, the National Cancer Institute Act was passed, and the National Cancer Institute was formed. Progress has occurred but, admittedly, at a slower than desired pace.

In 1939, the College created its Committee on Cancer, with Frank E. Adair, MD, FACS, as Chair (see Table 1). Dr. Adair was a prominent surgeon at Memorial Sloan-Kettering and was president of the American Cancer Society in 1945. In 1953, the Cancer Society and the College came together to form cancer detection centers, with the Cancer Society providing funding for the College’s efforts to survey these cancer detection centers. However, that collaboration only lasted two years because it was so difficult to establish and evaluate standards. In 1952, the committee became multidisciplinary (American College of Surgeons, National Cancer Institute, American College of Radiology, American College of Physicians, and the College of American Pathologists), and in 1970, the College’s Committee on Cancer became the Commission on Cancer under the direction of R. Lee Clark, MD, FACS, who was also the founder of the MD Anderson Cancer Center in Houston, TX. There has been a continuing expansion of multidisciplinary members on the Commission.

Continuing evolution

Table 3

Table 3

Dr. Little was the managing director of the ASCC, beginning in 1929, and he focused on professional and lay education and the regionalization of the organization. He formed the Women’s Field Army mentioned previously. He encouraged the society to support the National Cancer Institute (NCI) Act of 1937 and led the reorganization of the Cancer Society in 1941.

Mary Lasker is generally recognized as the person who made the modern American Cancer Society what it is today. She was the wife of a prominent advertising executive in New York City; she had connections. She became very interested in cancer because one of her household staff had the disease, and she was amazed at how poor the care was. Under her direction, the Cancer Society’s fundraising capabilities were remodeled and she raised $4 million in the first year—which totally revolutionized what was happening in the organization. There was some regionalization at the time, and the 60 percent (division)/40 percent (national) split of funds began. She insisted that the organization be led by 50 percent laypeople and 50 percent health care professionals, and that arrangement has persisted. She insisted that 25 percent of the funds raised be directed toward research efforts. Isn’t it interesting that that expectation continues to be in place? Also, she insisted that the name be changed from the ASCC to The American Cancer Society. Ms. Lasker was a strong and highly principled person, and her influence continues today.

Elsie Mead became Chair of the ASCC, following Dr. Clement Cleveland (her father). She was a fundraiser par excellence, and she is the individual who involved the American Federation of Women’s Clubs with the organization. Ms. Lasker and Ms. Mead laid the strong foundation that has enabled the American Cancer Society to become the largest, best-recognized volunteer health organization in the world today.

Post-World War II, the Mary Lasker influence took hold; Lane Adams was the chief executive officer of the Cancer Society at that time. He moved the organization forward, increased visibility, increased prominence, increased patient services, and increased the local presence.

During this era, the College worked to establish what we now know as The Joint Commission because the College could no longer afford to sustain its hospital standards inspection program. The College had spent $2 million on this effort, so a group composed of representatives from the College, the American Medical Association, the American Hospital Association, the American College of Pathologists, and the Canadian Medical Association was brought together to form the Joint Commission on Accreditation of Healthcare Organizations. Today, The Joint Commission accredits approximately 20,000 national organizations and 450 international institutions. The Joint Commission’s accreditation is the gold standard.

The Directors of the Commission on Cancer (CoC) are listed in the Table 2 on page 12. I became active with the CoC when Andy Mayer, MD, FACS, a Vanderbilt University (Nashville, TN) surgeon, was Director of the Commission. It was interesting at the time; not only did Dr. Mayer smoke cigarettes, but every member of his staff smoked. The first meeting I attended was in Richmond, VA. I checked into the hotel and received a message to join the group for dinner. I joined the group at this big round table; everyone was smoking. The smoking went on throughout Dr. Mayer’s entire tenure as director. Further, he stated that he would never have a computer in the CoC. Then Charlie Smart, MD, FACS, came on as Director. He was from Utah, a Mormon—there was no tobacco to be found, and he was very computer-oriented.

Table 4

Table 4

Needless to say, things evolve. David P. Winchester, MD, FACS (see photo), took over as director in 1984, and continuing progress has occurred. The CoC has been responsible for the modern Hospital Cancer Approvals Program, with nearly 1,500 approved programs, where 70 percent of U.S. cancers are treated; the Cancer Liaison Program; the National Cancer Data Base (NCDB) (with 26 million patients, making it the largest in the world); hospital tumor registries; cancer management courses; the annual CoC Oncology Lecture at the College’s yearly Clinical Congress; the National Accreditation Program for Breast Centers (NAPBC); the Cancer Program Manual; the Cancer Quality Improvement Program; and so on. Many of these programs have been funded and developed in collaboration with the American Cancer Society. It has been impossible in the allotted space to properly note the strong leadership provided over time by many volunteer surgeons serving in a variety of roles.

The evolution of the many important efforts that have been carried out through what we now know as the American Joint Committee on Cancer (AJCC) is outlined in Table 3 on page 12. The AJCC was first formed in 1950 as the Joint Committee on Reporting Cancer End-Results. Dr. Lee Clark and Murray Copeland, MD, FACS (see photo, page 8), were the most important figures in the development of the AJCC. Dr. Copeland, at that time, was the chair of the department of surgery at Georgetown University in Washington, DC, and he headed the Committee on Clinical Stage Classification and Applied Statistics of the International Union Against Cancer, which subsequently became, in 1958, the American Joint Committee for Cancer Staging and End Result Reporting, and in 1980, the AJCC. The AJCC has been essential to progress in the staging of cancer, which is the basis for cancer therapy. The TNM classification of malignant tumors staging system and the Cancer Staging Manual, now in its seventh edition, are only two of the important contributions of the AJCC—another product of the collaboration between our College and the American Cancer Society.

Five surgeons have been privileged to be President of both the American College of Surgeons and American Cancer Society. Looking at Table 4, it is interesting to note the timing between when a surgeon was President of one and then the other organization. It is further evidence of the integration that has occurred over time.

 

Tree of Life

The Tree of Life depicted in Figure 2 shows the essence of the integration and evolution of all that has gone on. It shows how the American College of Surgeons and the American Cancer Society, through their various synergies, formed the Committee on Cancer, the Committee on Standards—which led to the Joint Commission on Accreditation of Hospitals, now The Joint Commission; the Commission on Cancer; the NCDB; the AJCC; the National Tumor Registrars Association (NTRA); and all of the different products and committees that are involved in the organizations’ efforts to improve care for cancer patients. My question now is: What follows? Where are we going? New outcomes measurement programs are being instituted, including the NCDB’s Rapid Quality Reporting System. An effort is under way to combine and analyze data from the College’s National Surgical Quality Improvement Program (ACS NSQIP®) and the NCDB. In addition, the College is working with the Centers for Medicare & Medicaid Services to use the ACS NSQIP as the basis for evaluating surgical quality improvement.

In addition, NTRA—now the National Cancer Registrars Association—was formed, and is continually striving to increase quality and efficiency in data collection and to maintain the pool of trained registrars. The understanding and management of cancer is changing rapidly and substantially and all cancer professionals must remain current and collaborative. We have many opportunities to grow and come together.

As we move forward, I would assert that collaboration works and that protective silos stymie progress, that significant impact is usually the result of persistent visionaries working in the right environment, and, finally, that a focus on improving health care is the only reality for health care professionals.

Today, cancer is the second leading cause of death in the U.S. and the leading cause of death among the non-communicable diseases worldwide. It takes us too long to achieve improvements and to creatively change, thus it ever-more essential for us to continue to be visionary, collaborative, and effectively productive. As Margaret Mead said, “We are continually faced with great opportunities which are brilliantly disguised as unsolvable problems.”


Editor’s note: This article is an adaptation of a presentation given to a joint meeting of the American Cancer Society, the American College of Surgeons, and the American Joint Committee on Cancer, in Atlanta, GA, October 3–4, 2011.


Acknowledgements
The author would like to thank David L. Nahrwold, MD, FACS, emeritus professor of surgery, Northwestern University, Evanston, IL, and Susan Rishworth, Archivist for the American College of Surgeons, for their assistance in compiling the information in this article.


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