Overview

Abstract

Self-awareness is a particularly human trait. When it evolved, proto-humans became aware that they were destined to die. When language evolved, they were able to share this understanding with others. When written languages were developed, their thoughts about mortality were recorded in permanent form. The documents that have survived to the present convincingly demonstrate that humans have sought to understand why they become ill and die for a very long time. Cancer, in its many forms, is featured in the earliest of these documents [1]. It is feared and many forms of treatment have been employed throughout the ages, almost all of which were unsuccessful. By the nineteenth century, with the introduction of effective anesthesia, relatively safe major surgery became feasible. As a result, for the first time in history some patients with cancer were cured [2]. This created a cohort of cancer survivors. Shortly thereafter, it became clear that this population is prone to recurrence of the index cancer and/or new primary cancers and/or adverse effects of therapy. Treatments often failed, however, and major medical texts in the early-twentieth century made no mention of second primary cancers [3,4] but adverse effects of therapy were well known. This soon led to the concept of postoperative surveillance. This was facilitated in the late nineteenth century by the development of diagnostic x-rays [5]. Cancer patients also benefited by the introduction of radiation as a powerful treatment. Its hazards soon were recognized and those who had received radiation therapy as the initial treatment were soon candidates for surveillance. Relapse often occurred, as for those treated with surgery. Effective systemic therapy (oophorectomy for metastatic breast cancer) had its start in the late nineteenth century also [6]. The complications of this operation were presumably infrequent and manageable, but surveillance was probably carried out to determine how useful this novel form of therapy would be—since the concept of “chemical messengers” (hormones) was unknown until secretin was discovered in 1906 [7,8]. By the time effective systemic cytotoxic therapy was introduced into practice in the mid-twentieth century, the idea that it might eventually be curative was imagined by the few medical oncologists of that time and became a reality shortly thereafter, providing another cohort of survivors. The use of cytotoxic chemotherapy was regulated by regimen-specific drug administration protocols and institutional review boards (both novel concepts at that time). The posttreatment course was carefully documented. Documentation of initial disease status and estimation of prognosis were improved by the introduction of systematic staging methods such as the Federation Internationale de Gynecologie et d’Obstetrique and American Joint Committee on Cancer-Union for International Cancer Control systems. These common descriptors improved data collection and analysis. Introduction of new diagnostic testing modalities (serologic tumor marker measurement, computer-assisted tomography, magnetic resonance imaging, monoclonal antibody-based cellular stains, and the like) found immediate application in surveillance.