It is not practical, possible, or necessarily desirable to examine all persons for the possible presence of cancer, let alone make provision for examination on a repetitive basis.

Some selectivity and discretion therefore must be exercised, and here the disposition or inclination of the physician will, of course, be the ultimate determining factor. A few guideposts can be pointed out, however, for modification to individual needs as necessary.

In General:

1. Age and sex are the most commonly used. A common recommendation is to examine:

Men 45 years of age and over

Women 30 years of age and over

2. The influence of certain predisposing factors (occupational exposures, habits, customs, etc.) in promoting a higher risk of cancer must be kept in mind.

3. The existence now or in the past of certain so-called precancerous conditions or, of course, a history of frank cancer should serve to single out an individual for particular attention.

To Be More Specific:

Table 1 includes those predisposing factors and premalignant conditions for which there is at least reasonable supporting evidence, as well as those about which there remains controversy. No claim is made that this list is all-inclusive or definitive. Many will question the presence or absence of certain factors or conditions. It does, however, serve as a basis for illustration and discussion.

Table 1. Some Predisposing Factors To Malignant And Premalignant Conditions

Carcinoma in situ is not listed as a premalignant condition. THIS IS ALREADY CANCER. The following are sometimes associated with internal cancer:

Dermatomyositis

Acanthosis nigricans

Migratory thrombophlebitis The predisposing factor of HEREDITY is not included since its role, although likely in certain sites, requires much definition and clarification.

General Remarks About The Examination

Before proceeding directly to a discussion of the cancer detection examination, it may be worth while to make a few general background remarks. These have to do principally with the introduction of such an examination into the ordinary office routine.

1. Many physicians find it desirable to indicate the availability of such an examination by means of an unobtrusive announcement in the waiting room. For example, a small sign saying, "This office is equipped to do cancer detection examinations-Please inquire," has been found useful by some.

2. Upon inquiry, the physician should be willing to take the few minutes necessary to explain the rationale, purpose, and method of the cancer detection examination (or the annual general medical checkup) to the patient. Even a brief period of time devoted to such indoctrination will usually result in a well-motivated, cooperative patient.

3. All such examinations should be scheduled by appointment. It is virtually impossible to ensure an adequate amount of time under any other circumstances.

4. Approximately 30 to 60 minutes of the doctor's time should be alloted, depending on circumstances.

5. Women should be given appointments that will fall approximately in the middle of the menstrual cycle. The pelvic examination with smears can be done then, and the breast examination will be more reliable.

6. Provision may also be made for a scheduled return visit, at which time the laboratory data will be available and the results of the entire examination can be discussed with the patient. Many doctors find that a telephone report is an adequate substitute for the return visit, however.

7. A reminder system should be instituted whereby, with his or her permission, the patient is contacted about one month prior to the anniversary of his or her preceding examination and reminded of the advisability of maintaining the habit of annual examination. A specific appointment can be offered at this time.

8. The physician should make certain basic decisions with regard to what he believes should be the scope of the examination to be conducted in his office. Many doctors will elect to make the examination more comprehensive-in fact, a general medical evaluation. Accordingly, certain additions may be introduced into the history, physical examination, and laboratory survey. The latter may be expanded to include such items as a blood sugar, electrocardiogram, serum cholesterol, etc.

9. Some degree of standardization of the office records on which the history, physical and laboratory data, and conclusions are recorded is usually desirable. The ordinary office forms designed for the single visit of the symptomatic patient are generally not suitable for this purpose. This is taken up in more detail below (p. 35 ff.).