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A CNQddEaGE - 4© FEaR , , (THE FACTS ABOUT CANCER Il1T THEUS.A) By Elyse M. Rogers Cancer is probably the most feared disease in society today. Not since leper-colony times has a disease been associated with so much fright and emotion. Journalists describe, often in grisly detail, some famous per- son's agonizing death from cancer, television flashes into our living rooms with grim pictures of barren lands, warning us of the dangers from chemical "carcinogens" (cancer pro- ducing materials); and our govern- ment responds to this climate of terror by passing unrealistic laws, or clamping suffocating restrictions on our scientific community. We look fondly back on the "good old days" when life was simpler, more wholesome than is our jet-age century-to a time when cancer was not the major threat that it is today. We picture mother, rosy-faced and smiling, baking bread over the old wood stove; we dream of pure well water, and milk "fresh from the cow;" we envy doctors making house calls for 50¢; we long. for a life-style devoid of powerful chemicals and the threat of the atomic bomb. But a closer look at the Gilded Age of a hundred years ago might make us hesitate in our longing to relive yes- terday. Mother was indeed rosy faced • ~ over her wood stove-and weary and overworked as well. Her cooking. unit heated the only warm water the household offered, and her rough hands and stooped back were the result of a dawn-to-dark workday and a wood stove that gobbled up cords of wood that had to be sawed and split by muscle power. Pure well water was rare. In most rural areas, modern sanitation was unknown, and wells were dug far too close to privies, household slop sta- tions, and animal pens. On dairy farms, milk was not refrigerated or pasteurized, and was left uncovered to be contaminated by dust and flies. It most cities, liquid sold as "farm fresh milk" was diluted with water and frequently laced with chalk or plaster of Paris to make it look "creamier." Typhoid and cholera wiped out families, villages, and swarmed through cities leaving a path of death. In the last century doctors made house calls, but they had little to offer the sick patient, as they were often ignorant of basic anatomy and phys- iology, and relied heavily on power-

i i , i ful pain killers like morphine and opium which often comprised about 70% of the medications they carried in those imposing black bags. Pa- tients were bled, purged, and' dosed with ineffectual`or dangerous medi- cines, many dying from the cures or becoming hopeless drug addicts for life. And although the 50¢ fee would certainly be a bargain today, remem- ber that the average worker of the last century made about $3-5 per week, or, if lucky, $1.25 per day. The life-style in the "good old days" may have been more leisurely and untroubled for the privileged few, but for most of our ancestors it was a battle of survival against a twelve-hour workday, tainted food, contaminated water, and polluted air. The horse provided colorful transportation in the 1800's, but also provided appalling amounts of ma- nure and urine-soaked hay which was dried by the sun and whipped about by the wind to produce an air- pollution index that would be shock- ing by today's standards. Cancer may have been less preva- lent, but that is hard to know. Statis- tics were rare, and diagnostic techniques were so inadequate that most diseases were classified more by guesswork than by any scientific standard. Doctor's notebooks, how- ever, tell us that there were many incurable "tumors," and that patients often died of "wasting diseases" that could possibly have been cancer. So, 0 although _we heve_ no_ co_untry-wide documentation, we know that cancer existed. If there were fewer cases, remember that there were many more threats to life in the 1800's. Childbirth was extremely dangerous and many new mothers died of infection before they could raise their families; young children were often killed by acci- dents, childhood diseases, or mal- nutrition before they could reach an age where their bodies were more prone to developing cancer; and men were frequently felled by pneumonia or other diseases before they were out of their teens. Cancer was not as feared by our forefathers because there were too many other perils to face daily; fright over a disease that mainly attacks the aging was foolish, since the average life span was 40-45 years! Actually, most of us don't want to nudge the clock of technology back- wards, we just want to modify it or mold it so that we can "have the best of all possible worlds." How can we modify or change our environment so that cancer is less frightening and less prevalent? Sur- prisingly, we are not helpless against this dread disease. There are many things we can do both as individuals and as members of society. But we must learn the facts, evaluate the data, and make the modifications necessary to preserve our improved life-style and life span, while mini- mizing the risks of developing cancer.

CANCER -the facts Learning some statistics about cancer is the first step in understanding the true picture of this disease in o~u_ country today; when we know the basic facts we can decide on a plan of action. Since statistics are compli- cated, let's use a few simple charts to illustrate the trend of cancer in the United States. Chart one confirms what we've all read in the newspapers and heard on TV -that the number of cancer deaths is increasing. But sometimes facts, even scientifically accurate facts, can be misleading. Remember that our population has exploded since 1900, so obviously more births mean more eventual deaths. Chart i-Number of Cancer Deaths In 4oorthe United States 200 01 1 1 1 1 1 1 1 1 1900 20 .40 60 S0 Chart two reflects this population increase by showing the cancer death rate per 100 thousand people, which is the standard way most charts of this type are plotted. The curve is still frightening in chart two, but we haven't finished adjusting the chart for our changing citizenry._ Not only do we have more „_._._ . people, but have many more older people. Since the senior citizen is more prone to cancer (and other dis- ease) this should be reflected in any chart. Chart 2-Cancer Death Rates In the b~. United States 200 r 120 80 40 Z.+ 01 1 1• I I I I I 1 1900 20 40 60 80 Now we come to chart three. Here we have the cancer rate age-adjusted to reflect our aging population. If we examine this chart closely, we find that the cancer death rate since 1940 has only increased ten per cent- from a rate of 120 to 132 deaths per 100 thousand. An increase, true, but not the meteoric rise that many peo- ple imagine. Total numbers on cancer are useful and interesting; however, they can- not show us the state of cancer in regard to specific groups in our so- ciety-mainly the cancer rate in the 0

male and female. It's important to examine the sex differences in cancer deaths because the rates are signifi- cantly different between men and -women. Chart 3-Cancer Death Rates In the _ United States m 200 r c ao ~ ~ Q 160 ~ ~ 120 c,o c.~ ~ a 80 oa ,.o 0 40 E '. Z° The incidence of cancer in men is increasing, so let's start with the male segment of our population. Chart four shows the main types of cancer that are male killers. One glance at the steep red line on the chart makes one fact very clear: most male deaths are from lung cancer-a type of can cer that is climbing at an alarming rate. In 1930 only about five men in every 100 thousand died of lung can- cer. In 1975 the increase was ten times that figure-and climbing! If you haven't already guessed, ciga- rette smoking is the main reason for this sharp increase in cancer of the respiratory system. No wonder phys- icians encourage their smokers to give up the habit. You can also under- stand why each cigarette package___ .. _, contains a grim warning. Chart 4-Age-Adjusted Cancer Death - Rates In the United States For Men 50 Chart 5-Age-Adjusted Total Cancer 160 140 120 100 so Death Rates In the United States For Men ...~....._...~~~.. .,........ .~ ....... 1950 55 60 65 70 75 If we group all the different types of cancer in men together, you can see that there is an increase as illustrated in chart five. However, if we elimi- 0

nate the respiratory system (lung can- cer) we quickly see that cancer deaths are on the decline. That's encourag- ing news, and will probably surprise some readers. - Chart 6-Age-Adj.usted Cancer Death Rates In the United States For Women ~ 9 dence of deaths from lung cancer has been gradually increasing; since 1960 it has climbed more steeply. Sadly, more women are joining the ranks of cigarette smokers each year; there- fore we know that the rate of lung canc.er aeaths in women will increase dramatically also. The Women's Lib- eration Movement and the Equal Rights Amendment have empha- sized the strides women have made in sex equality. Equal rights in smok- ing, however, mean equal risk in de- veloping and dying from lung cancer. Since it is usually the person who has been smoking for twenty years or so who develops cancer, the influ- ence of today's smokers will not be seen on charts until late in our century. Chart 7-Age-Adjusted Total Cancer ,, Death Rates In the United F $ o States For Women 312 5 ~ 100 I 40 In women, most types of cancer are decreasing or remaining fairly con- stant, as you can see in chart six. Notice uterine cancer and its down- ward curve. With better hygiene, an- nual pelvic examinations for many women, and the important Pap smear (a smearnf secretions from the mouth of the uterus examined under a mi- croscope to find cancer cells- named for its discoverer Dr. Pa- panicolaou) the rate of cervical or womb cancer has been reduced. Stomach and colon cancer have also shown significant drops, probably due to better food preservation and storage systems. The one frightening, but very understandable, upward curve of cancer deaths on chart six is the red line of lung cancer. Since women started smoking, the inci- 4 75 ~0 501 i i 1 1 i Z 0~ I 1950 55 60 65 70 75 One more chart. Number seven shows that even with the increasing lung cancer rate in women, cancer deaths for our fair sex are on the decline. An exciting trend that we can maintain in the coming years if we are prepared to meet the challenge.

CANCER - The disease and its causes. Understanding both the physiology of cancer and its causes is no simple task, because cancer itself is not one single, simple entity. Cancer stands for a group of diseases characterized by the fact that cells grow uncon- trollably in many different bodily sites. No discussion of cancer can begin without studying that basic biolog- ical unit of plant and animal life- the cell. In humans, as in all higher animals, life begins with the union of a male and female sex cell. These reproductive cells contain only half the material that makes us human beings, but the product of their join- ing becomes a different human being. After sex cell union, cell division begins in a very disciplined manner. The cells group into different areas and the shape of the fertilized egg changes from a round to irregular shape. This phase of cell division is called differentiation; the cells are aligning themselves into the dif- ferent layers that will form the many tissues and organs of the body. So, in this stage, the identical cell units change into a complex, integrated community of some 100 billion cells that comprise the adult human body. Amazingly, each cell contains the ge- netic identity of that one human being to which it belongs, but differs from the other bodily cells in struc- ture and function. One may be a liver cell, another a nervous system cell, and still another a bone cel1.. Another important cell process is one of regeneration. When tissue in- jury occurs, some cells are destroyed. Other cells from that tissue divide and reproduce to repair the damage, or, if the damage is too great or is in an area where the cells cannot divide, connective tissue takes the place of the cells and scar tissue is formed. Both these basic processes have one important factor in common: when the process of differentiation or regeneration is completed, the cells stop growing. In other words, in some mysterious way, nature, when working properly, governs the cells so that growth is perfectly defined. It is this "growth limitation" of cells that is absent in cancer. Cancer occurs when cells continue to divide in an uncontrolled manner. Even though initial cancer cells often look similar to normal cells, even under a microscope, they do not act normally in their patterns of growth. Whereas the replacement of injured 0

I tissue is controlled, with cell growth ceasing or modifying if the healing process runs into neighboring struc- tures, the cancer cells exhibit no such restraint. They grow over, under, around, and eventually invade other tissues. Often their undisciplined growth chokes off or kills other can- cer cells. Because the cell is the basic bodily unit and also the starting point for cancer, a new breed of scientists called molecular biologists are in- volved in the study of the cell and other minute bodily matter. Studying the inner workings of the cell has progressed to the point where we know that the nucleus of a cell con- tains chromosomes linked together in a molecule called deoxyri- bonucleic acid (DNA). DNA governs the genetic identity of a cell, and the division of the cell; it also manages daily functions. Two chemicals aid the DNA in its cell-management functions-ribonucleic acid (RNA) and proteins. A quick glimpse into the complicated functions of just one cell shows us that an estimated 2,000 chemical-reactions can occur within that microscopic particle. Converting one chemical to another inside the cell may involve as many as ten or more different enzymes from the cell's store of over 100,000! That a tiny cell can be so complex is part of the marvel of the human body; it's also one of the main frustrations for scientists who are attempting to solve the mystery of cancer. Cancer -the causes. Knowing that a cell grows without restraint, and even knowing a great deal about the inner workings of the cell has not as yet led to one, defini- tive "cause of cancer." However, in the study of cases of cancer and'the growth of the cell, we have learned a- great deal that can be helpful in can- cer prevention. When we discuss "causes" of can- cer we generally focus more on "causative conditions" or "factors" which tend to produce the disease. Since cancer is a multi-sourced dis- ease, the causative factors are many and varied as well. If we liken the occurrence of cancer to that of auto- mobile accidents, it's easier to see the cause / effect relationship. We know that automobile accidents are respon- sible for many injuries and deaths in our country, but we also know that there is no one single answer to stop- ping this killer. Since we have deter-

mined some of the factors that can lead to traffic deaths, we attack the problem on several levels: the gov- ernment makes safety belts manda- tory, we levy heavy penalties for ingesting alcohol before driving, and we schedule routine eye tests to in- sure that those with impaired vision do not take the wheel. Yet, we know, that these steps (and others) will not totally eliminate automobile acci- dents. Even those of us with keen vision have difficulty seeing ahead when there is a sudden cloudburst, or when the windshield is momentarily smeared by the splatter from a pass- ing truck. Such "factors" cause acci- dents, or at least present a climate for possible disasters. Even with ideal driving conditions, few drivers avoid a "near miss" or two in their hours behind the wheel. 0 In some cases of automobile deaths, the exact cause is unknown and mysterious. Wha-is-to know that the man found dead. in his pick-up at the bottom of-a ravine careened off the road because a deer bounded in front of his headlig.hts._only seconds after he rounded a blind curve on that mountaintop? The true "cause of death" will be buried with him. In much the same way, the cause of a specific cancer may remain myste- rious, since we still have no way of studying the minute workings of the human body. Inside the body fan- tastically complicated chemical and physical changes are occurring con- stantly. We recognize and understand many of these changes. But on a day- to-day basis we are unaware of how efficiently deoxyribonucleic acid (DNA) is governing our cells, if our body's immune system is primed and ready to reject foreign invaders, or even if our heart is pumping blood to our circulatory system in its usual, orderly fashion. Since the body is so complex, 'any one system or a com- bination of systems that change or are modified could be vitally important in ourbody's fight against cancer. For instance, we know that the immune system of the body is less efficient in children and in older adults-the two age groups most prone to cancer. But, although this immune system is probably a contributing factor, it's not the only factor since all children and all senior citizens do not develop cancer.

HEREDITY AND ENVIRONMENT . By separating the causes of cancer into two categories, it's easier to un- derstand just what factors are in- volved in developing the disease. Epidemiologists have studied case histories and death certificates of many people all over the country, and have categorized the causes of cancer as follows: 10-2096 due to hereditary factors 80-90% due to environmental factors Heredity. Hereditary factors are familiar to all of us. We know we inherited "grandpa's nose" or that we possess the "deep blue eyes" of our parents. Inherited traits can also be called host factors; they stem from the time of birth to a defective fertilized egg cell. As mentioned, a weak or under- developed immune system could be one of the host factors that influences the development of cancer. Other he- reditary defects range from the dra- matic disease, hemophilia (excessive or even fatal bleeding from simple wounds), to the minor problem of color blindness. Sometimes the in- herited trait is obscure, resulting only in weakened body cells that seem to respond more readily to cancer-stim- ulating influences. Furthermore, ge- netic defects can allow an increased susceptibility to certain diseases such as diabetes, which are called "cancer triggering diseases." Indi- viduals with these conditions have a significantly greater chance of de- veloping cancer in their lifetimes than do the rest of us. 0

Presently, there is little we can do portant that we understand just what about host or inherited factors in can- scientists mean when they say "en- cer, except to exercise care in choos- viroiimental" causes. Most of us as- ing our marriage partner to protect the generations to come. For those couples with a troublesome history of diseases or known genetic problems; genetic counselors can often provide some insight into the possible prob- lems of future pregnancies. In some cases, where a couple understand that the risk of passing certain dis- eases on to their children will be significant, they are adopting chil- dren, or electing to remain childless. Environmental factors. Environmental fActors remain the most significant cause of cancer inci- dence, since as many as nine out of ten cases can be traced to factors in the environment However, it's im- sume that "the environment" is an-- area over which we have little or no control - it's comprised of water, air, grass and trees,-as anrellas_that myste-_ . rious stratosphere of particles and gasses that surrounds our earthly planet. Surprisingly, "environmental fac- tors" as causes of cancer are things we would recognize more readily if they were defined as "life-style" or "habits." And, these things are ones over which we have a great deal of individual control. Take the obvious case of smoking. This "personal choice" or "life-style" factor has in- creased an individual's chance of de- veloping cancer considerably. Scientists estimate, that if the present trend towards tobacco consumption continues, there will soon be over a million Americans dying of lung can- cer every year! Those cancer-causing conditions over which we hive little or no per- sonal command get much more pub- licity in our newspapers and on television because it is very dramatic to say, "thousands could get cancer from a newly introduced drug," or to write that "unsafe working condi- tions have been linked to cancer deaths." The truth is, however, that "life-style" factors are involved in most of those cases of cancer that physicians and scientists place in the "environment caused" category. . 4'