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542 STATEMENT OF HIRAM THOMAS LANGSTON, M.D. CLINICAL PROFESSOR OF SURGERY (EMERITUS) -NORTHWESTERN UNIVERSITY MEDICAL SCHOOL I am Hiram Thomas Langston, a thoracic surgeon in private practice in the Chicago area. I am the Chairman of the Department of Surgery at St. Joseph's Hospital in Chicago, and a Clinical Professor of Surgery (Emeritus) at Northwestern University H.R. Bill 4957/Senate Bill 1929. I am concerned, however, with several claims made in them, especially those which endorse the hypothesis that smoking is the.main cause of lung cancer. Smoking has been said to be responsible for causing an unbelievable array of illnesses, including lung cancer. Much of the support for these accusations comes from research that is basically statistical. Since the early 1960 s, I nave read most of the scientific literature on smoking and lung cancer. In my capacity as a thoracic surgeon, I do not feel qualified to respond directly to the reported statistical associations between smoking and cancer. However, I must respond to the interpretation of these associa- tions as causal because it is inconsistent with the clinical c ~ reaiities of the disease that I h years. Adopting the old adage ". (tests) the rule," I identified c by observing firsthand the clinic These exceptions cast doubt.upon tnat smoking causes lung cancer. a- 1. Inhaled cigarette both lungs. Why, then, as the da in my own practice, do lung cance ously in both lungs? The answer is inconsistent with the smoking It is of further intere of people who have been successfL tumor in the lung do not.develop 2. Cancer rarel_y_.occc The trachea is exposed to more tc because all the smoke is inhaled the material deposited in the muc exits through the trachea...,n:s- . , 3: ••?' The trachea is anatomic physiologically identical.to the Therefore, if cigarette smoke we would also expect to see a large

;sroN, M.D.-- (EME2ITUS)- :AL SCHOOL loracic surgeon in :m the Chairman of the )ital in/Chicago, and a it Northwestern University ) present my views on icerned, however, with iose which endorse the of lung cancer. :onsible for causing an 3 lung cancer. Much of ^om research that is ^ead most of the scientific 1 my capacity as a to respond directly to Neen smoking and cancer. :ion of these associa- t with the clinical 543 realities of the disease that I have observed `or tie aas;, for*_y years. Adopting the old adage "it is the exception tnat proves (tests) the rule, I identified certain very pertinent "exceo*-ions' by observing firsthand the clinical behavior of iung cancer. These exceptions cast doubt upon the validity of the hypothesis - that smoking causes lung cancer. I. Inhaled cigarette smoke is equally distributed in both lungs. Why, then, as the data show, and as I have observed in my own practice, do lung cancers very rarely appear simultane- ously in both lungs? The answer is not known, but this phenomenon is inconsistent with the smoking causation hypothesis. It is of further interest to note that the vas*t majority of people who have been successfully treated for one malignant tumor in the lung do not develop subsequent lung tumors. 2. Cancer rarely occurs in the trachea (windpipe). The trachea is exposed to more tobacco smoke than are the lungs, because all the smoke is inhaled and exhaled through it. Also, the material deposited in the mucous lining of the air passages exits through the trachea. _ The trachea is anatomically, embryologically and physiologically identical to the rest of the bronchial ai•rway. Therefore, if cigarette smoke were a cause of lung cancer, one would also expect to see a large number of tracheal cancers. The -2-

544 fact is, however,"that tracheal cancer continues to be an extremely rare disease. 3. Cancer of the Tarynx-or voice box is also statis- ticalTy linked with smoking. Because cigarette smoke passes through the larynx on its way to the lung, the larynx is exposed to at least the same concentration of smoke as are the lungs. .Were the smoking-causation hypothesis valid, one would expect to see a rise in laryngeal cancer similar to the rise in lung'cancer. Yet, the data show that there has been little change in the incidence of laryngeal cancer over the past decades. 4. 1 regard with a certain amount of suspicion the view that we are in the midst of a lung cancer epidemic because of cigarette smoking. Any discussion of this "eoidemic" must take into account two frequently overlooked clinical factors that have had a tremendous effect on the reliability of reported lung cancer rates: '(I) diagnostic techniques and (2) official cer- •tification of cause of death. --_ ' Even in the time span of my own practice, I have seen remarkable changes in our ability to diagnose lung cancer. SJhen one considers that even diagnostic x-rays were not readily avail- able a scant decade or two before I started practicing, it is hardly surprising that our ability to detect lung cancer..has increased dramatically. `And as that ability has increased, so naturally have the reported lung cancer rates. -3- c O Earlier.in this centur diagnose lung cancer, resulting incidence of the disease. `Thus, rates are compared with rates fo tools were gradually becoming av impression of the-real increase. • .. :.tI b:, The other factor I_bel whether there is a lung cancer e certificate information. Death calculating death rates, but unf is extremely unreliable.'tMost 1 accurately reflect the cause of not. Coroners and non-treating cates, and they may have little the actual cause of death.= Even That is why I have refused to co studies any case as lung cancer ;.onfirmation of the diagnosis: j This is not to'Say'tha lung cancer. I am quite convinc I an equally convinced, however, its cause or causes. 5. In my review of t argument that the epidemiologica

nues to be an extremely box is also statis- tte smoke passes ne larynx Is exposed as are the lungs. one would expect to e rise in lung'cancer. e change In the decades. t of suspicion the er epidemic because s "epidemic" must cliriical factors that ity of reported lung (2) official cer- d I o^< > - actice, I have seen e lung cancer. LJhen re not readily avail- practicing, it is lung cancer..has has increased, so s. 545 545 Earlier in this century, physicians may have failed to diagnose lung cancer, resulting in rates lower than the actual incidence of the disease. Thus, when these unrealistically low rates are compared with rates for later periods when diagnostic tools were gradually becoming available, one would obtain a false impression of the real increase. The other factor I believe to be important in evaluating whether there is a lung cancer epidemic is the accuracy of death certificate information. Death certificates are the sources for . calculating death rates, but unfortunately, information in them is extremely unreliable. 'Most layman assume that death certificates accurately reflect the cause of death, but in many cases they do not. Coroners and non-treating physicians sign many death certifi- cates, and they may have little or no relevant information about the actual cause of death. Even treating physicians make mistakes. That is why I have refused to consider in my own population studies any case as lung cancer unless there was microscopic confirmation of the diagnosis. Many cases lack that confirmation. This is not to say that there has been no increase in lung cancer. I am quite convinced that a portion of it is real. I am equally convinced, however, that we have not yet identified its cause or causes. 5. In my review of the literature, I have seen the argument that the epidemiologicai studies show a dose-response -4-

546 relationship, that Is, the greater the exposure to cigarette smoke, the greater the risk of developing lung cancer. Ahereas I cannot directly challenge the statistical analyses used to obtain these associations, I have been able to consider another aspect of "dose-response" -- age at diagnosis. The age at diagnosis of lung cancer does not seem to be related to the age at which a person started smoking, nor how long he smoked, nor even the number of cigarettes he smoked per day. I have observed this in my own patients, and indeed I have found it to be confirmed in the literature. 6. Age-specific lung cancer death rates almost always have a special pattern. In most series of lung cancer patients, the greatest rates occur in the 50 to 70 year age group, with a peak at 60 years. The literature also reveals that a certa.in .generation (those born before the turn of•the century) may have higher lung cancer rates than other generations. Intrigued by these findings and the possibilities that they suggested, I reviewed approximately 4,000 lung cancer cases spanning 30 years at the Veteran's Administration Hospital in Hines, Illinois. All cases carried the diagnosis of lung cancer supported by microscopic evidence. I found that (1) the generation born between 1&90 and 1900 contributed the largest number of cases; (2) if this trend continued, this generation would fade from prominence due'to old -5- I age; (3) the younger generat this generation in cancer pr, predicted that the number of in Hines would decrease. - In a subsequent in, discovered that the contribu earlier produced the.greates- fact decreased significantly cases at Hines in the period imately 17%. This seems.-to supported my earlier predict years and encompassesapprox 7. Lung cancer i its occurrence patterns and ever changing.. For example, in the rate of increase of 1 incidence may have, in fact, including some who believe t to concur with this observat before the Health Congress i said "it is encouraging to f lung cancer in men decreasec the first time in 50 years."

547 .posure to cigarette ; lung cancer. :dhereas I analyses used to obtain :onsider another aspect The age at diagnosis of. :o the age at which a ;moked, nor even the I have observed this in it to be confirmed in seath rates almost always )f lung cancer patients, year age group, with a ~veals that a certain ` the century) may have ^ations. , .-. : :1~ . . .:. . i ` F C. . i the possibilities that 4,000 lung cancer cases istration Hospital in iiagnosis of lung cancer i born between 18.90 and ases; (2) if this trend 3m prominence due to old age; (3) the younger generations did not appear to be replacing this generation in cancer production. Given these points, i predicted that the number of lung cancer cases at the V„ Hospital in Hines would decrease. In a subsequent investigation of cases through 1978, 1 discovered that the contribution of the generation which had earlier produced the greatest number of cancers at Hines had in- fact decreased significantly. In addition, the total number of cases at Hines in the period 1968 through 1978 had dropped approx- imately 170. This seems to be a rather significantt change which supported my earlier predictions. This observation now spans 45 years and encompasses approximately 5500 cases. 7. Lung cancer is a dynamic disease in the sense that its occurrence patterns and clinical apoearance (cell type) are : ever changing. For example, there appears to have been a decline in the rate of increase of lung cancer. Indeed, lung cancer .„ incidence may have, in fact, crested. Uther investigators, including some who believe that smoking causes lung cancer, seem to concur with this observation. For instance, in his address before the Health Congress in England in 1977, Sir Richard Doll said "it is encouraging to find that the total death rate from lung cancer in men decreased in 1975 albeit very slightly, for the first time in 50 years." -6-

548 Perhaps what we are seeing in the case of lung cancer is what is called the "natural history" of this 'disease: Natural history has been succinctly described by a British thoracic surgeon as the "long drawn out process of the development and the decline of an individual disease." If you have trouble accepting the idea that a spontaneous decline in lung cancer can occur, I remind you of the documented decline In stomach cancer.- The spontaneous decline in stomach cancer over the years is a decline for which no convincing explana- tion has been offered.: Improvements in"nutrition or food storage, or diagnostic refinements,=or changes in-the general health of - the population do not•adequately explain these changes. " -What explains the changes in lung cancer rates? As Dr. Belcher has pointed out, the decline in lung cancer's rate of increase started before changes in the cigarette occurred. Is this simply another example of the poorly understood natural history of a disease? Clearly, no simple explanation for these lung cancer changes appears to be forthcoming. - Many important questions about cancer causation remain unanswered. For example, precise causal mechanisms have not been identified. Many theories have been proposed, but none have won universal acceptance. I do not agree that cigarette smoking is the major -7- J cause of lung cancer, beca: not know the cause or caus~ smoking causes lung cancer may realize that there is find that evidence to be.pe smoking hypothesis is an o% support legislation s_uchTas questionable hypothesis.

in the case of lung cancer -y" of this 'disease: Natural j by'a Britisti thoracic - • ss of the development and the ing the idea that a spontaneous remind you of the documented taneous decline in stomach or -which no convincing explana- in -nutrition 'or food storage, 5 in:the general health of lain these changes, in lung cancer rates? As Dr. in l-ung cancer's rate of :he Cigarette occurred. Is )oorly understood natural :imple'explanation for these )rthcoming.- ~ - 3bout cancer causation remain iusal mechanisms have not been 1 proposed, but none have won ette smoking is the major 549 cause of lung cancer, because I believe very strongly that we do not know the cause or causes of cancer of the lung. Charges that smoking causes lung cancer are so familiar that very few people may realize that there is strong evidence to the contrary: I find that evidence to be persuasive. In my estimation, the smoking hypothesis is an oversimplification. I therefore cannot support legislation such as these two bills based upon such a questionable hypothesis. -8- ~'l Hiram 1. Lanos_ oa', M.0

550 320G.iAPNICAL DATA: FiL'iAM ':40YAS I: VGS:Y::1, M.C. Place of 3i rt4: Rio do Janeiro, Brazil Date of 3i_ zt1: Januarp 12, 1912 . . (U.S.A. Citizen by Der_vative C_tizenshi?) Father's Name: Alva B. Lar.gston Mother's Name: Louise Foe Diug•aid - ' 7-dacatiOn: . . Collegio Batista, Aio do Janeiro, Brazil, to 1928 Georgetovn College, Kentucky 1929 Vniversity of :ouisviile, Kentucky, 1929-30,t..9. Cniversity of Louisville, Rentucky. 1930-34, H.7. University of Yicaicar., Graduate Schocl. 1935-4'., M.S. (Sur?ery' Y,arr.ed: Belen M. 0-^_b ,. . . , Date of Xarr_age: June 22 1941 -4ildren: Paula F. angston, born June 15, 1946 - Thomas 0. Langston, born September 5, 1949 ,_ Carol 3. 2.angston, born Septemb.r 4, 1953 3AI'? G+R_9°3 SUMMARY 3orn of U.S. parents engaged in educational missions under the Soutaera Baptist Convention. =ducated through sophomore year of college in Ric do Jar.eirc, s•.:- sequer.t education as outlined above. Elected to Theta Kappa Psi medical framer- aity and A12 na Cmega Alpha honorary medical fraternity. Inte_sh:?: Gar_ie ~ Memoria: 3osnital. Washingtcn, ~.J. 1934-J5; Resident in ?atholoTy, Gar`ield Memorial 'ospital, 1935-37; Assistant Resident in Surgerf, Un_versity.Hosr_ta- an: arbor, Michigan, 1937-38; Resident in Surgery. University 3osPital, Ars Arbor, Michigan, 1938-40; Instructor in Thoracic Surgery, q niversity 3osrial, Ann xr~;or, Mic.*.igan, 1940-41; Private Practice and Associate in Surgery; No _'western Ur.i:er- sity, Chicago, 1941-42; February 1942 to February, -.46, rii':_taay Ser- vice, Northorestern Cniversiy sponsored hospital (12-t. General). Served in North Africa and Italy as CZiaf o' ^ieracic Surgerl. Rose to raailc of aa;or. ..CS; -_n'r.-iate- ly awarded Army Conmendation Ribbon, Bronze Star Medal and CrdeW do xerito +eroaa`_ tico (Offieer Grade) (Brazilian .wr iorce). Returned to No rt^vestern Cnivers_`.y with rank of Assistant Professor of Surgerj. In 1948 entered crivate grac:ice of :^:oracic Surgery in Detsroit, Michigan, and served as Associate ?refesse: c' Surgery at Wayne University. Returned to Chicago in 1952 with aPPoint=ents as follows: 1. Associate Professor of Surgery at University of Illinois College of Medicine. 2. C`.ief Surgeon, C`.icago State :Suberrslosis 5anitarium, 3e.ar-=.e^t of Health, State of _-lcncis, 1952-71. _. Co.^.su3tant ^^.:oracic Surger; to =:- veterar.s Adainistration Hospital,3ines, 211inois. (1974) Cn the star. ... ., c:sta:.a (to :97_), Gcttleib, Grant nr.d Saint :osepi -os_itals. a=x inted Cli::ical ?rofessor of Surge^: at the Cniversity of I--:ncis, t::e;e of Medicine - 1962 and Professor of Surgery, Abraham Lincoln Sc':ool o' :•[ediccne, University of 21iincis, 1973 to 1977 - Served as Chie` of -}:cracu -aicer,: (General) Abraham Lincoln School of Medicine, University ^ -_ncis, attend:ng T4oracic Surgeon - Cook County :os7ital 1966 - 1977. - :I:n1Ca1 Professor of Surgery, Nort.ivestern Univers•:ty Medccal Sc=oo1 - 1978-1981, Faeri:us 1981 3iog=a: hicsl Data of Fiirmn 'II-=.- PRL•iC=AL PrJF'''..5: Diplomate, anws•ican Bos T!horacie Surgery, 1948; `lenber of various mnni- American Association foi Auerican Association foi Association for '1~nracic gical Society, 1971-197: Q•ai..^nan, Decartnnt of :'Endx+r, F,c.°itoridl 8oard Publ:sher, 1q~L197$; -k Cardiovasaular Surgery, :noracic Surgery - SeprE Ciair:tan, 1969-1972. V' Menber, Hoa.-d of DirecG Representative, InterspE Surgr-ry, .4anPwa'-r Stody IL' inois D; s+;.g„i et,. d 5 Chaiuaan, Afenbesship Ca' S !a*+•a= and Ethics Ca- yate (Alternate) Hause L Surgeons, 1978-1980. 0. iiosnital, 1978 to .1980. Ciicago !7edical Society, American Col ARrsiCan Fs; Ar.erican Col AlpSican !RBC Ame--iean Su: Chicago b1ad: Chicago Sust I1linois Sta Illinois Sur The Institut Paa-Pacific Society of T t+iesteta Surg Societe Inffi Airerican 'lhc Illinois Thc San,at Tlrora Illinois 'Ihc

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