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PUBLIC AFFAIRS PAMPHLETS INCOME AND ECONOMIC PROGRESS SECURITY OR TtlE DOLE? CREDIT FOR CONSUMERS 1HE SOUTH'S PLACE IN THE NATION THE SUPREME COURT AND TIlE C(~HSTITUTION TillS QUESlION OF REI..IEF RESTLESS AMERICANS DOCTORS, DOLLARS AHD DISEASE FARMERS WITttOUT LAND COLONIES, TRADE AND PROSPERITY SAVING OUR SOIL WHY WOMEN WORK ~tOW WE SPEND OUR MONEY CAH AMERICA BUILD HOItSES? YOUR INCOME AND MINE YOUTtl IN THE WORLD OF FODAY INDUS'rRIAL PRICE POLICIES T~EItlND TIlE SYPHILIS CAMPAIGN MACIIINES AND IOMORROW% WORLD ItOW GOOD ARE OUR COLLEGES? WIle CAN AFFORD HEALTH? OUt~ TAXES--AND WHAT TIIEY BUY AMERICA AND THE REFUGEES SCItOOLS FOR TOMORROW'S CITIZENS IOWARD A HEALTHY .AMFRICA COOPERATIVES IN THE 1HIS PROBLEM OF FO()D WHAT MAKES CRIME? JOBS AFTER FORTY DEBTS-GOOD OR BAD? STATE IRADE WALL':, ~o~ ~l'~,'~'al~ly ~'alel and li~l of new lill~ write: PU~ILIC AFFAIRS COMMITTEE, INC. ]0 I~oCt'.~l~'ll:'r PIo=a ~';ow York, l~. Y. BLIC AFFAIRS PAMPHLETS BY CLARENCE C. LITTLE DID YOU KNOW: That cancer is NO/ hereditary or contagious? That from SO to qS per cent of many Einds of cancer are curable if treated early? That there are only three accepted forms of cancer treatment? PUBLIC AFFAIRS PAMPHLETS No. 38 1939

THE FIGHT ON CANCER By CLARENCE C. LITTLE THIS EDITION PRINTED FOR AND DISTRIBUTED BY THE Ab/IERICAN SOCIETY FOR THE CONTROL OF CANCER, INC. 350/Madison Avenue New York, N. Y. THERE is a rift in the black cloud of fear and ignorance which has long prevented frank discussion of cancer. Through this gap, knowledge gained by new types of research, im- proved treatment and organized education is pouring like powerful sunlight to bring vigorous activity and hope. The power behind that heartening light is the aroused interest of men and women like yourself who have come to realize that they have an all-important part to play in gaining a final victory against an enemy which kills approximately 150,000 of our citizens each year. Cancer is peculiarly a personal problem. It cannot be checked or controlled by scientists or medical men alone. In its conquest every man and woman has a place to fill and a duty to perform. The story of man's increasingly successful fight against cancer has lately become an .inspiring one. It stretches over the centuries with a strange, sinister quality of uninformed Clarence C. Little, $c.D., Managing Director of the American Society for the Control of Cancer, Inc., and Director of the Roscoe B. Jackson Memorial Laboratory, Bar Harbor, Maine, is author of Civilization Against Cancer, Farrar & Rinehart, 1939. Copyright, 1939, by the Public Alfairs Committee, Incorporated --A nonprofit, cducatiorlal organization--

THE FIGHT OH CANCER fear which makes it unique. Man has had to be patient how- ever; for until the last forty years, there was almost no prog- ress. Since the beginning of the twentieth century, however, CANCER DEATHS IN WOMEN BY AGES AG[S 0.4 5.14 H~L$ 28O 15.24 i 517 conditions have changed, and today tens of thousands of lives -formerly doomed-are being saved. In this pamphlet will be presented some of the high lights of this story of progress. Naturally, much must be omitted, but there remain many thrilling events, the full meaning of which time will emphasize. Recognition of Cancer Successful treatment of cancer rests upon accurate and THE FIGHT ON CANCER prolnpt recognition of the type and location of the cancer which is to be treated. The most skillful specialists, who have seen thousands ol cancer cases, can, by inspection, do a reasonably good job or" recognizing cancer where it is advanced and where it is located on the outside of the body. Even the best of them, however, cannot distinguish by mere inspection early cancer or the nature of internal masses or lesions. There is only one sure way to make certain of cancer, and that is through microscopic examination of the suspected tissue by a trained specialist. This fact is generally admitted today, bat tfiere still re- main altogether too many institutions and individuals who maintain that early or internal cancer can be diagnosed by inspection or by some other unproved method. The ignorance of the public has allowed this wrong point of view to persist and has nourished one of the most da~gcr- ous elements in the whole cancer problem; namely, quacks. Cancer Quacks The history of quackery in cancer is a long and evil one. It includes the story of men and women who are out-and- out crooks and also of those who honestly but mistakenly be- lieve that they have a successful "cure." The effect on the patient is the same in both cases and may be snnuned up as misinformation, disillusionment, expense, and death. Mr. Smith, with a sore on his lip, reports to Dr. Hokum, a quack, who examines him superficially and annouuces that he has cancer. Mr. Smith naturally is worried. Dr. Hokum, however, calms him by promising a "cure" and usually agrees upon or receives a fixed fee in advance. If Mr. Smith is cured we can all be sure that the condition was ~lot cancer, bat he, believing that it was, goes back to his friends bringi~g word of Dr. Hokum's "miraculous" skill. The news spreads and new patients appear. If, however, Mr. Smith did have a cancer, he may show temporary improvement coupled with a more optimistic mental attitude, but sooner or later he gets worse and eveutually dies. At that point Dr. Hokum attrib- utes his death to the fact that Mr. Smith previously has been

THE FIGHT ON CANCER unsuccessfully treated with surgery or X rays, or to some other hidden cause. Surgery, X rays, and RadiumMThe Only Approved Treat- ments The fact is that surgery, X rays, and radium, either singly or in combination, are the only forms o[ cancer treatment accepted by organized medicine as of proved value. This attitude is amply justified not only by the failure of other types of treatment, but by the outstanding success of these methods. There are several ways in which this success can be demon- strated. Using the records of established medical men, the American College of Surgeons, a great national organization, has collected facts on over 29,000 cancer cases in which the patient has lived [or five years or more following an opera- tion or radiation. Such cases are oflicially accepted as clinical "cures" because few cases that remain well for a five-year period will recur. The success of surgery, radium, or X rays is directly related to the stage which the cancer has reached when it is treated. The sooner the cancer is detected and treated, the greater the chance of cure. This is shown by the chart on pages 16 and 17 using varied but representative types of cancer. These results are strik- ing. They form the cornerstone of the educational campaign against cancer which will be described later. Concer Clinics As our knowledge of cancer increased, it became clear that in many cases the most successful handling of the patient came only after one or more conferences between surgeons, radiologists, pathologists, iuternists, and other specialists. The need of microscopic study of tumor tissue and the growing frequency of combined use of X rays and surgery, or for choosing wisely between them, form the main reasons why such group activity is an all-important development in the fight against cancer. So true is this that the American College of Surgeons THE FIGHT ON CANCER regularly maintains a staff of medical men who advise anti assist in the establishment of cancer clinics. These men also regularly inspect and certify for official approval clinics that are already established. The growth in the number of these clinics has beeu a definite indication of progress in the treatment of cancer. In places where the greatest advance in the control of cancer has been made, the clinic idea is accepted as a basic principle. The combined use of surgery and irradiation, to which reference has been made, is becotning much more geucral and has given surprisingly good results which are better than might have been expected had surgery or irradiation alone been used. GENERAL FACTS ABOUT CANCER THE reason why group judgment is useful in diagnosing and treating cancer is that the word "cancer" is used to include many different types and degrees of abnormal growth. Since a lump or swelling usually is formed when tissue becomes cancerous, cancers are included, for descriptive pur- poses, in a great grOUp called tumors. A tumor is a mass of new tissue which persists and grows independently o~ its surrounding structures. There are two types--benign and malignant. Benign tumors are usually surrounded by some sort of limiting capsule or structure. They do not invade the ad- jacent tissue. Malignant tumors are usually irregular in shape. They invade surrounding tissues and have no clearly defined boundary. To all malignant tumors the name of cancer is applied. In its early stages cancer is usually confined to a small area. This [act accounts for the relatively greater success of treatments at such stages. As cancer progresses, it extends its growth from its original point of origin and also gives off living bits of itself, which may be transmitted to distant parts of the body by the blood or by the colorless body fluid known as lymph. Often these transferred bits of the original tumor

THE FIGHT ON CANCER lodge in vital and inaccessible parts of the body and there start a secondary growth of the same malignant type as the original mass. The analogy of the spread of fire is helpful in describing the growth of cancer. Early cancer may be compared with a small fire, localized and capable of being easily extinguished. Late cancer is like a widespread conflagration, out of con- trol and, therefore, difficult or impossible to extinguish. There is a further parallel between fire and cancer in that when a coullagration occurs, sparks may leave the main blaze and settle elsewhere, starting a secondary fire. In very much the same way, bits of a rapidly growing cancer may leave the main mass aud settle elsewhere in the body to start secondary cancerous growths. Cancer Is Not Catching A natural question from anyone reading of the rapid spread of cancer in the body would be: "Is cancer catching?" The answer is "No." For decades many efforts have been made in laboratories to find a germ or germs responsible for cancer. They have not bcen successful. There is no evidence that cancer can be "caught" by any person working with patients afflicted with the disease. Had such an evcnt been possible, cancer would have destroyed the human race long before now. What Is Cancer? It is natnral to ask what cancer is, since it is not a disease of the ordinary type. The answer is somewhat startling. Cancer is merely the uncontrolled growth of one or more cells or tissues of our body. In order to understand ~lae origin and nature of cancer, it will be necessary to describe briefly a series of events experi- enced by every human being since man first appeared. Each and every one of us started his individual existence as a tiny, fertilized egg cell in the body of his mother. At that stage we were each of us too small to be identified by the naked eye. THE FIGHT ON CANCER The word "cell" is used to describe the smallest living unit capable of independent existence among higher animals and man. The fertilized egg cell possesses one of life's most general but least understood characteristics; namely, that of being able to form, of its own substance, two "daughter cells" which remain attached to one another and which can repeat the process of "cell division." By this process the number of cells of which we are com- posed increased with truly nfiraculous speed. Various types of tissues and organs, each with a definite structure and nse, developed. In nine short months we had changed from a microscopic speck to a baby ready for birth. The number of cells of which we were composed had increased from one to billions. During our stay within our mothers' bodies, the rate of growth was almost unbelievably rapid. After birth we continued to ~ow rapidly. We are all aware of the great increase in size and of the further development which occurs in infants during their first year. Remarkable as this is, however, it is infinitely less rapid than was the rate of growth before birth. We had already begun to "slow down." The slowing process continued, for, although each suc- cessive year we increased in actual size, we did so at a steadily decreasing rate of speed. Finally, as adults, we reached a balance and we stopped growing. The experience of becoming an adult is, therefore, one in which natural "brakes" are being silently and effec- tively applied to our tendency to grow. The possibility thereafter exists biologically for the reap- pearance at some time of a local center of rapidly growing cells which reaches perhaps the rate o~ growth of the whole body at birth or soon thereafter. Such a center of rapid, local ~owth occurring in a bal- anced body produces a tumor and, if relatively unconfined, a cancer. In its early stages, then, the tissue oE a tumor or cancer is vigorous and free from any "disease" in the ordinary sense of the word. It is impossible for ~he early s~ages of cancer ~o

THE FIGHT ON CANCER THE FIGHT ON CANCER 9 AGE AND CANCER PROPORTION OF DEATHS FROM CANCER BY AGE GROUPS 10-19 12.4M 30-39 50"$9I I i i iilii i i ill S IiitlIIIIIII 14.8~)1 ,PeW symbol represents one per cent of total deaths kill, and because the tissue forming the cancer is actually a part of the individual it is not recognized as being a foreign body. How Does Late Cancer Kill? Death due to cancer is not referable to any one cause in all cases. Many times it is largely a mechanical matter, as in the obstruction of some vital passageway by the rapidly grow- ing cancer mass. At other times, the cancer may grow to such a size that the blood vessels which bring it food cannot suffice to nourish all of it. Parts of the cancer then deteriorate, die, and cause blood poisoning. The reason that cancer kills is that it occurs in a body where capacity to feed, house, and support an area of unre- stricted growth is limited. For this reason the final outcome of untreated cancer is always fatal. Age and Cancer People of all ages are not equally likely to get cancer. Nor is the kind of cancer the same for all ages. The reports published by the United States Bureau of the Census for 1936 show that in that year 1't2,538 people of known ages died of cancer in the Uifited States. The ages o[ the victims are shown in the chart on the opposite page. It is clear why many people think of cancer as a disease of middle and old age. The parts of the body most likely to be attacked by cancer may be seen in the following table: Nztraber Per cent Lip 764 0.56 Tongue 1,097 0.81 Mouth 620 0.46 .law 950 0.70 Pharynx 912 0.68 Esophagus 2,386 1.77 Stomach, duodenum 27,241 20.31 In testine 15,634 11.45 Rectum, anus 7,325 5.47 Liver 10,425 7.77 Pancreas 4,440 3.3i

10 THE FIGHT ON CANCER Number Per cent Lungs and other respiratory organs 6,840 5.10 Uterus 16,280 12.14 Breast 13,708 10.29~ Male genito-urinary 12,356 9.91 Skin 3,404 2.53 Kidneys 2,075 1.54 Bladder 4,653 3.46 Brain 1,284 0.95 Bones 1,976 1.47 134,370 From the reports of the Census Bureau we can obtain further interesting and important facts. Taking the total number of cancer deaths at a single age period as 100 per cent, we can calculate what proportion of that total occurs in different sites. When this is done certain very siguificant facts becolne evident. The nine commonest sites for cancer at each succes- sive age period can be tabulated in order of frequency as follows: ,4ge 0-9 I0.19 ~0-~9 80-89 .~0.~9 50.59 1. Kidney Bones Digcs.* Diges.* Diges.° l)iges.* 2. Diges.* Brain Uterus Uterus Uterus Uterus 3. Bones Diges.¢ Lung Breast Breast Breast Brain Lnng Brain Lung Lung Lung ~: IAIng Kidney Bones Brain Mouth Mouth 6. Mouth Mouth Breast Bones Kidney Kidney 7. Skin Skin Mouth Mouth Brain Bones 8. Breast Breast Kidney Kidney Bones Skin 9. Uterus Uterus Skin Skin Skin Brain 60-69 70-79 80-89 90- Diges.* Dige~.* Digcs.* Diges.• Uterus Breast Skin Skin Breast Uterus Breast Breast Lung Mouth Moulh Mouth Mouth Skin Uterus lllerllS Skin l.tlng Lung Lutlg Kidney Kidney Kidney Bones Bones Bones Bones Kidney Brain Brain Brain Braiu (Italics indicate periods of greatest prevalence o1" each type of cancer in relation to other types. Thus in sectiou 40-49, there is not more cancer of the breast than of the digestive organs, but it is more prevalent in these years in rela- tion to other cancer than at other times.) It will be seen that at different ages there is considerable shifting in the relative importance of different types of cancer. It is, however, clear that cancer of the digestive organs is the most important type throughout most of the life span. Cancer Among Men and Women Men and women are affected quite differently by cancer. Digestive tracts and intestines. THE FIGHT ON CANCER I1 Thus among white people in the United States, the number of deaths in the year 1934 from cancer affecting different parts of the body was as follows: WHERE CANCER STRIKES DEATH EROM CANCER IN VARIOUS PARTS OF THE BODY I | "'°"' I & MOUTH • IIHIIIIIII111 | | Ill | Iltl Iitliiiiii .,,,,. IIIIIIIIIII & ANUS Illllllll ,-. I-"-t111111111111 III" "°"" "" • SUPRARtNAL$ • • ~'~ & BLA~DEI ~ ~ II "' II I '" t III II I l,,0.~I"~llllllllllll II Each symbol represents |,000 deoths In a few cases persistent irritation is believed to play an important role. This is true of the lip, tongue, anti month. The excessive use of tobacco is, of course, more common among men than among women. It is also believed that the greater exposure of the skin, including the lips, to the sun and wind, which farmers and sailors undergo, makes for greater cancer risk. The more common nse of tobacco by men is also blamed by some for the frequency of lung cancer in that sex. The recent increase of this type of cancer among women is at- tributed to the increased number of women who today iuhale tobacco smoke. It is impossible to say how accurate these opinions are.

12 THE FIGHT ON GANGER But they are useful in introducing the general topic of chronic irritation. Chronic Irritation and Cancer The various tissues of our body possess to a remarkable degree the ability to resist the harmful effects of physical or chemical agents that tend to upset their proper function. When, however, such irritants are frequently or continuously applied, there are limits beyond which the body cannot go without developing growth of new tissue in an attempt to correct the situation. And there is always a possibility that this new growth will get out of control and become cancer- OUS. For this reason there are certain general rules that can profitably be followed by anyone who wishes to avoid such irritation. Mouth, lip, and tongue. Follow the well-known habits of oral hygiene, keeping teeth, gums, tongue, and mouth clean. Exercise proper dental care, having the dentist correct any jagged teeth or ill-fitting plate that might chafe or exert pres- sure on the tongue, the inside of the Inouth, or the gums. Throat. Avoid eating too hot food. Stomach. Avoid food or drink that causes any digestive distress. The exact procedure to be followed in this case will naturally vary with the individual. Intestine and Rectum. Establish habits of bowel regularity. Do not allow hemorrhoids (piles) to continue without being corrected. Breast. Avoid confining, chafing, or irritating.clothing, brassieres, or corsets. Uterus. See to it that any injuries or tears received during childbirth have prompt and adequate medical or surgical treatment. Skin. Keep the skin clean and protected from too much exposure to sun and wind. These rules do not form a guarantee against cancer. But they are valuable as general health measures and certainly cut down the chance of local irritation which often forms the site on which cancer develops. Among other preventable cancers are those which have a THE FIGHT ON CANCER 1:3 definite relation to certain occupations. Among tile groups frequently affected are .chimney sweeps, tar workers, dye workers, workers with luminous paints, and mule spinners. In each of these occupations proper protection of the workers can avoid unnecessary contact with irritating substances which otherwise may prove extremely harmful. Signs and Symptoms Which May Mean Cancer We should ahvays keep in mind that the chances for suc- cess in the treatment of cancer are greatly increased by early diagnosis. This, in turn, is possible only when a persou is alert and aware of the signs or symptoms that may mean that a cancerous or precancerous condition is present. The signs and symptoms are relatively easy to remember. They are, at times, so inti~nate that they can be recognized only by the person affected. Consult Your Doctor At Once for . . . Mouth, lip, and tongue. Any sore that does not heal within ten days to two weeks. Any hunp or local thickening. On the tongue persistent white areas, especially in the case of smok- ers. Throat. Dilficulty in swallowing or hoarseness lastiug for more than two weeks, which calmot be explained by a cold or other direct cause. Stomach and intestino. Distress following eating, especially in those of middle age or older who have not been previously aware of such a condition. Sudden or marked loss of weight without any recognized cause. Distaste for meat. Alternate periods of constipation and diarrhea with no particular change in diet to account for it. In the case of the lower intestine or rectum, tile appearance of blood as a rectal discharge or in the stools. Breast. Any lump, lack of symmetry, persistent soreness of the breast, or colored discharge from the nipple. Uterus. Any irregular bleeding at any time during life. Skin. Any lump, or sore that does not heal in ten days to two weeks. Any mole, wart, or wen which develops tender- ness, changes its texture, or begins to grow. Many of these conditions will turn out not tO be cancer,

14 THE FIGHT ON CANCER but the difference between those that are early caucer and those that are not can only be determined by a careful physi- cal examination by a doctor. Generally such an examination should be checked by a microscopic examination. It is always best to play safe, for early cancer is often, if not usually, painless. This is important. RESEARCH IN CANCER CANCER research has changed greatly in the last thirty years. Formerly the meetiugs of the American Association for Cancer Research dealt chiefly with reports of interesting or unusual hospital cases. The attitude of those concerned was to wait for cancer to appear naturally before they began to study it. Human material was most commonly used. The work was carried on leisurely. Then with the discovery that mouse-cancer could be suc- cessfully transplanted into other mice, the idea of increasing deliberately the supply of cancer available for study began to grow. Immortality of Cancer Tile result was the discovery of what Dr. Leo Loeb has dramatically called the "immortality of cancer." Although the life span of the laboratory mouse seldom exceeds three years, it has been possible by successive transplantations of bits of a single mouse-cancer to keep the cancer growing with un- diminished vigor for forty years. There is no evidence that the cancer "ages" or slows down in its rate of growth. The possibility of producing an mrli~nited amount of cancer tissue fiom a bit of a mouse which, as an adult, weighed perhaps thirty grams, is certainly present. Unless infection due to carelessness is introduced, the life of cancer appears to be limitless. We are, therefore, dealing not with a sickly or diseased tissue, but with one which pos- sesses tremendous vigor and power of growth. Another great forward step was taken when it was found that repeated contact with certain chemicals, notably some of the derivatives of coal tar, irritates the tissues of rabbits or THE FIGHT ON CANCER mice and results in overgrowth of the affected area, fre- quently leading to cancer. The development of this line of research has been startling and extensive. Today perhaps fifty substances, most of wlfich can be made in the laboratory, can be used to cause cancer. This has opened up fields of research in both chemistry and biology that are still in their early stages. Genetics and Cancer Mice have proved to be almost ideal for experimental studies of cancer because in their short life they provide man with a sort of "shorthand version" of his own life history. A mouse a year old is roughly comparable to a man of forty. A mouse two years old is like a person of sixty-five or seventy. One can observe, in a three-year period, the whole span of life of one of these little animals. This saves a vast amount of time, especially as mice of certain strains are very prone to form cancer without artificial treatment of any sort. Perhaps thirty years ago studies of closely inbred animals showed that after fifteen or twenty generations of brother-to- sister or parent-to-offspring matings a very high degree of bio- logical uniformity is produced. Animals descended frown such an inbred line are as like one another as a pair of identical twins. If the continucd inbreeding is accompanied by the sclcc- tion of cancerous animals as parents, a strain can be produced in which 80 or 90 per cent of the offspring develop cancer. If, on the other hand, the selection is away from cancer, strains can be produced in which only 1 or 2 per cent develop cancer. The biologist has thus been provided with invalnable re- search material. Today this is being extensively used. The largest laboratory for this pnrpose is the Roscoe B. Jackson Memorial Laboratory at Bar Harbor, Maine. Here a colony of between 50,000 and 60,000 mice of some thirty inbred strains is used for experiments on cancer and allied subjects and for distribution to other research laboratories all over tile United States. The mice are individually identified and a complicated and accurate system of records follows them throughout their

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