Cervical Cancer Classification, Treatment Debate, and Research Efforts

Key Insight

The medical community in 1951 was engaged in a heated nationwide debate concerning the classification and treatment of cervical cancer, specifically between invasive carcinoma and carcinoma in situ. Most doctors believed invasive carcinoma was deadly, warranting aggressive treatment, while carcinoma in situ—or 'cancer in its original place,' sometimes called 'sugar-icing carcinoma' for its smooth layered growth—was not considered dangerous because they thought it couldn't spread. Richard Wesley TeLinde, a leading expert and surgeon, challenged this, theorizing that carcinoma in situ was merely an early stage of invasive cancer that would become deadly if left untreated. Consequently, he advocated for aggressive treatment of carcinoma in situ, often involving the removal of the cervix, uterus, and much of the vagina, which his critics deemed extreme and unnecessary despite his belief it would drastically reduce cervical cancer deaths.

The detection of carcinoma in situ became possible in 1941 with the development of the Pap smear by George Papanicolaou. This test involved scraping cervical cells for microscopic examination of precancerous changes, which were otherwise undetectable, causing no physical symptoms, and being neither palpable nor visible to the naked eye. While the Pap smear had the potential to decrease the annual death rate of over 15000 women from cervical cancer by 70 percent or more, its effectiveness was hampered by two major issues. Many women did not get tested, and among those who did, few doctors accurately interpreted the results, leading to misdiagnoses such as mistaking cervical infections for cancer, or malignant changes for infections, with dire consequences for patients.

To resolve this diagnostic and treatment uncertainty, TeLinde aimed to minimize 'unjustifiable hysterectomies' by documenting what wasn't cervical cancer and by urging surgeons to verify smear results with biopsies before operating. Crucially, he sought to prove that carcinoma in situ necessitated aggressive treatment to prevent it from becoming invasive. After his theory was publicly dismissed, he initiated a study—the largest of its kind—reviewing a decade of Hopkins medical records and biopsies, which revealed that 62 percent of women with invasive cancer who had prior biopsies initially presented with carcinoma in situ. To further solidify his claims, TeLinde proposed growing living tissue samples—normal, carcinoma in situ, and invasive—for comparative study in the laboratory, leading him to collaborate with George Gey, head of tissue culture research. This research often involved using patients from public wards without their knowledge, a common practice at the time, viewed as payment for free treatment, particularly leveraging the 'large indigent black population' available at the institution.