VOL. 117, No. 3. Whole Body Radiotherapy of Advanced Cancer patients treated by whole body irradiation, the survival times are significantly different (Chi square 11.63, p <0.005) (Fig. 3). EWING'S TUMOR This subgroup of 3 patients constituted the only one in which an attempt at curative therapy was made; all 3 patients are surviving. The times of survival are 854, 1,243 and 1,553 days from the time of diagnosis to August 31, 1972. The patient with the longest survival has recently developed a solitary pulmonary metastasis. The use of whole body irradiation to eliminate small clumps of cells in the disease has been reported by others."." A fourth patient with Ewing's tumor had pulmonary metastases when first seen. Therapy in that case was only palliative. LUNG CANCER-SURVIVAL IN DAYS AFTER D 675 TABLE III 797 33 150 300 UB+100 •See footnote to Table 1. Median survival—193 days. CANCER OF THE BREAST In 15 cases treated by us the median survival from diagnosis to death was 479 days and after treatment to death was 446 days (Table Iv). Two comparable reports in the literature include the one by the Committee on Estrogens and Androgens" and the other by Samp and Ansfield using 5-fluorouracil." Again a life table analysis was done for our 15 patients and indicates that the survival of our patients appears somewhat better than that of the patients treated solely by estrogens and androgens, but not quite as good as the group treated with 5-fluorouracil (Fig. 4). The patients survive longer than those receiving the "standard therapy" as described by Samp and Ansfield;" this includes appropriate administration of estrogen and androgen, oophorectomy, local irradiation, adrenalec tomy and hypophysectomy. OTHER CANCERS A remaining group of 25 cases reflected several different kinds of cancer. It is not %% Survival 676 Saenger et al. MARCH, 1973 SURVIVAL BY ACTUARIAL METHOD FOR 61 PATIENTS WITHOUT EVIDENCE OF DISTANT METASTASES AT FIRST PRESENTATION 100 97% FIG. 2. The survival by actuarial analysis is shown for a total of 61 patients with carcinoma of the bronchus and distant metastases, who presented between December, 1961 and June, 1964 at Cincinnati General Hospital. The only patients excluded from this group are those in whom distant metastases were present at the time of diagnosis (17 patients). If they were to be included, the 1 year survival figure would drop to about 7 per cent. It is emphasized that these figures take account of all cases seen (including those apparently “early” and amenable to complete surgical resection). Although other reported figures may be somewhat higher, differences are more realistically attributable to biologic factors rather than to therapy." possible to make an analysis of these at this point since the individual case groups are too small to warrant this DISCUSSION RELATION OF RADIATION THERAPY TO Some analyses can be made which give information on this point. The doses of whole body radiation given could initiate only the hematologic form of the acute radiation syndrome. In the healthy individual, after prodromal symp toms of malaise and vomiting lasting about 6-48 hours, there is a latent period lasting until 18-21 days after exposure. At this time there is a marked rapid fall in white blood cells and platelets and a less rapid fall of red blood cells reaching a nadir at 30-40 days and then recovering. These changes are associated frequently_with episodes of infection and bleeding. Epila. tion will occur at doses over 300 rads. Many of these patients had received much radiation and chemotherapy prior to total or partial body treatment and in many cases this treatment was followed immediately by planned local therapy to various portions of the body. TABLE IV CANCER OF BREAST SURVIVAL POST D (15 Patients) No.* 089 955 029 022 ΟΙΟ 008 035 1,068 859 150 If one assumes that all severe drops in blood cell count and all instances of hypo- Study cellular or acellular marrow at death were due only to radiation and not influenced by the type or extent of cancer and effects of previous therapy, then one can identify 8 cases in which there is a possibility of the therapy contributing to mortality. Of this subgroup, 2 patients received localized radiation between total body irradiation and death at 31 and 32 days, respectively. Two had extensive previous chemotherapy and I also had local radiotherapy. In 2 other cases, autologous marrow transfusion was unsuccessful because the preradiation marrow was hypocellular. Both of these latter patients had had intensive localized irradiation and I had received intensive chemotherapy. •See footnote to Table 1. tent of disease in these patients. Another interpretation would be that a physician selecting far advanced cancer patients for a given treatment would have about the same degree of difficulty in selecting any form of treatment for these very ill patients. The same probabilities, p=0.19, 0.2 and 0.21 are found for patients dying between o and 20 days post treatment, from 0-60 days, and from 20-40 days, when compared to the untreated group. Current status of survival for these 88 treated patients is as follows: Prophylactic therapy (Ewing's tumor) REACTIONS FROM TREATMENT AND EFFECTS OF PALLIATION 7 70 88 The acute radiation syndrome develops in stages. In the prodromal stage, nausea and vomiting of a transient nature occur. MARCH, 1973 VOL. 117, No. 3 Whole Body Radiotherapy of Advanced Cancer These complaints are often highly subjec tive; therefore, they are not discussed with the patient before treatment. The analysis of our 88 treated patients shows that 44 per cent experienced no symptoms at all, that 27 per cent had transient nausea and vomiting within 3 hours, 14 per cent within 6 hours and 3 per cent within 12 hours. In only 4 patients (4 per cent) were the nausea and vomiting of a severe nature (Table v). These symptoms are no greater than found after surgery or after treatment with cancer chemotherapy drugs, the reactions of which are often far more severe than those from these kinds of radiation therapy. Lahiri et al." observed that when 5-fluorourail is given orally at a dose of 15 mg./kg. daily for 6 days, and then weekly at the same dose, nausea, vomiting, diarrhea or stomatitis are found in 55 per cent of the patients treated, and marrow depression is observed in 50 per cent. A recent study by the Western Cooperative Cancer Chemotherapy Group, employing 5-fluorouracil without a loading dose at 15 mg./kg./wk. for a month, reported mild to major gastrointestinal or hematologic toxicity in 85.5 per cent of 430 patients." Higgins et al.12 in treating cancer of the colon using 12 mg./ kg. of 5-fluorouracil intravenously for 5 successive days, observed that 27.9 per cent of 359 patients experienced a toxic reaction. The same group reported one or more surgical complications following resection of colon carcinoma in 29.6 per cent of 433 patients. Parsons et al." note that 61-72 per cent of patients suffering from so-called radiation sickness responded favorably to placebo medication, indicating that suggestibility may have a big part to play in the appearance and control of these symptoms. Mukherji et al." in evaluating the effectiveness of a combination of 4 drugs in the treatment of 23 patients with lymphosarcoma and reticulum cell sarcoma found severe myelosuppression in 4 patients (17 per cent) and possibly attributed this depression to their deaths from infection. During the latent period of 18-21 days TABLE V 679 the patient is asymptomatic. The period of manifest illness then begins with evidence of malaise, infection and bleeding. These findings occur only with whole body irradiation and not with partial body treatment. Also when marrow is successfully replaced these findings do not occur. In regard to palliation, a review of patient records shows that some palliation was achieved in 56 per cent and that 31 per cent were made neither better nor worse (Table vi). In another 3 cases we were unable to obtain follow-up history concerning palliative effects. The 3 cases of Ewing's tumor are not included in this table as therapy was prophylactic. POSSIBLE UNIQUE MECHANISMS OF WHOLE AND Whole body irradiation in the doses reported herein could be effective against cancer in several ways: (1) alteration of the immune mechanism of the body altering the balance in favor of the host; (2) by a direct effect on the metabolism of the cancer cells. In this case wide-field radiotherapy would have one advantage over drug therapy, since it would reach all cancer cells without depending upon blood |