Tobacco Documents Online

Page ;APTEA 4 A CLINICAL AEVIBN OF 493 QATIENT3 QF LdHG CANCEA (197G-:980) 34 .1 Materials 35 .2 Sex and age distribution 36 .3 Ristologic types 39 .4 Clinical features 43 .5 Chest radiological patterns 47 .R libreoptic bronchoecopic patterns 49 .7 Cigarette smoking (A) Cigarette smoking and lung cancer 53 (8) Cigarette smoking pattern in our patients 57 .8 Survivals in untreated, inoperable disesse 62 ,.9 Conclusion 68 :HAPTaIt 5 A P2.ANN$D RQTR08PBCTIVS CLiNICAL sTS3DY OP 603 pATISNTB OF LUIiG CAIVCER (1961- 19s4) a8 S.1 Yaterials - 3.2 8ex and Rge distribution 70 5.3 gistologic types 73 5.4 Clinical features 77 565 Chest radiological patterns 80 5.6 Pibreoptio bronchoacopio patterne sZ 5.7 Cigarette smoking pattern 86 6.8 Conclusion 83 sV----

CHAPTfiIt 0 BPPSC2+ OP CHBld0T1cBtiAPF ON SURVIVAL ~ A STUDY Or T13RZE COitBINATION CRS1dOTH8RAPY 3CK5u8S IN 139 PATIENTS XTTLi INOPERABLE LUNG CANCSR (1979- 1984) 6.1 iaa11 ce11 carcino+sa - ILACC chemotherany 97 (A) patienta and srethoda 97 (g) Results 102 (C) Discussion 202 6.2 •Ron-sraall cell lung ca.ncer 109 (A) KACC ohemotherapy 1. Patients and Methods 109 2. Results 112 (8) Two !AY ehemotherapy schemes ia bronchial adoaocarcinoma 119 1. Patients and ltethocls 120 2. Result^ 121 (C) Discussion 132 8.3 Conclusion 135 CHAPT6R 7 CABE-C4NTROL STU33Y OF'PA3SIVE SMOKING, uDaos2249 8TOV8 OSAOa XND HOtiE INCEN3E Bt1RKING IN RELATtON TO LUNG CANCER IN ItON-SMO1CTR PBKALES (1981-1994) 7.1 (A) Introduction Passive smoking (8) (C) Kerosene stove Incense burning ooorin8 at hosae 7.2 Fatients and methods 7.3 Reaults 7.4 Diecussion 7.5 Conclusion 95 136 137 137 138 130 140 143 143 156 CliAPTSR a D2RECTIONB POR FOTVRL* STtJDIES 157 8.1 tnidemiolosioal studies (A) Ya 8on8 KonQ (8) In collaboration with Guangzb,ow (Canton) zii

8.2 Pathologic studi.s: (A) Cliaico-Pathologlc study 161 (B) 8carring (tuberculoua) and lung cancer 161 8.3 1loat determinants t (A) ltistocomDatibility (HLA) antitea• and lung 184 cancer (8) Aryl Hydrocarbon HydroxYlae• (AFIlI) inducibility tod lung aa.sacar 1135 8.4 , Bpilo:gue 167 SSPS#tSNCfi3 169 ~ ~ _ r~xiii CJ

In HonB 7Con8, lung cancer is the commonest lethal malignant disease in both males s,ad females. This thesis represented the first sd.jor oliaiasl study of lung cancer (197fl- 19i4) in the local C'hinese poQulation. The patients were those sdmitted to the IIniversity De9artment of Medicine, Queen ldary 8ospital, Eon; B:onQ, and a11 bad histologically or cytolo8ica11y proven lung cancar. Ristolo8ical typin8 was based on the Torld Seaith Orsanization Classitication (19$1), wl.th 4 major types of lung canoer, naM41;y_. (1) squamous cell carcinoma (SQ), (Z) smLll cell carcinoma (9X), (3) adeaooaroinoms (iD), #.nd (4) large cell careinoma (U). prereQuisite Zor,a ollnicai s=uay oz iunQ oancer is aGOurate cell, typin=. ?~ Yy • pha0e-one stl2dr was to assess ; :. - • . - , .. ,-. !t . . .. _ . . . • coliaborately with the Departmsnt oi Qatholoty.the osll typing __- accuracy of cytodis8nosio (broncboscopio and sputum) in our , . . _ . X . . ._ • :~... ... . . - . _ .... . . . , hospital• In s"tive-yezr study period (1978-1983) in E73 patients. for both broachoscoptc and sDutum cytologic cell typins, accuracy wzs highest in $Q and 89 (7Q-100x), toilow.d by AD (so-aQ!.). That of LA was IDuoh lower (( 97x), bct the number OS patients Was amall. The aext phase is collection of clinical data base by a ell.nical review o2 493 patients admitted from 1978 to 1980. The atale to lemais sex ratio vas low (1.87:1), reflecting the ~ ~ ~

(,l) ..-.Cliaical •datn w.re coiiected from 503 pati.nts upon : 1981 to 1994 high incidenee of lung cancer In women In Hoag Xong. In s.n, SQ was the predominant cell type (44'1), followed by AD (23'l), 814 (13%) and LA (?%), but In women, the preponderaace of AD (44%; SQ 31%; 81C 10%; LA 2%) is notasorthy. Cigarstts smoking waa a nsjor tactor In •8Q and ali. The relative risk ot lung oancer in smokers was 6.4 to 10.7 for SQ and 8g, but was not sisaiiicant with AD or LA (( 1.e). SQ and 8g, b4ing smoking-related, showed features ot a centraliy located tumour. Our AD, contrary to classiosl tsaching, also showed clinical, radiological and broacriAScopic teatures of a oentrally situated tumour. A tbres-Vart study was thea carried out In parallel from . ..:diaQnosis from January 1981 to April 1884. The fiadings of the ~~ __ __ .. .. ..'-at^Yti: P...~... ~ . . ~ . . . .. c . - .. / ' , r.view study were confirmed. The male to temaie ratio`rras loN ; A history of cigarstte smoking was strongly associated with SQ and 8k. The relative risk of lung canoer In smokers was 5.S with SQ aad 21 with SM In men, and 10.5 with SQ and 33.9 with aK in women, but not excessive with AD aad LA (l to Z.1). In women, AD was the predominant ceil tTpe (56x), and 48% of all cases and 83% ot AD were life-long aon-smolcers. Again, AD showed features of a predominantly centrally situated tnmour. . . N C"7 W ('!J N ZV ~ tV

(2) That our AD, usuallr in tioa-smoker iemales and centrally eituated, was intriguing. A case-0optrol study ot 183 temale patients and 185 female controls was carried out to compare their exposure to three common environm.ntai, inhaled r wv1' nr U.rnrann ntrnrn tw..s .i home incense burning. Analysis for non-smokers showed that kerosene stove and incense burning were not aontributory iactors (p > 0.06). Passive siaoking was also not shown to be associated with AD~oi the central type, but may contribute to AD of the peripheral tFD+ (p. ( 0.05). ( 3) ' - The uedian survival ol our ' ~ • ~ ~' ' •„ paLisats.witli uatreaEed, •;_ " _ i ± _.inoperable diseaae was poor,"_beiAS i month f_or srm`~all:aeli cancsr au.`.~`# : ~tj ... and 3 5 taonths to aan ll ll ~ . r -ama ce canoerv~e studied tbe Y ..w t ~ _ ~s: . ~. - . . ~. .~ ,~.. _ ... - .._ ,....,. i .. . . ~.. ~. . .. e~ r~ . ...~~ _. 'ti : ettect ot tAree combination chemotherapy sohir4es...nisurvi'val o! ~~ these patieaLs. ; 2n,'-43 patients oo small cell:carciaoma, : YACC ` -..- . (metnotrexste, adriamycin, cyoiophosDriamide and CCNU)'-__ chemotherapy was eStective (21% oomDlete and 53% partial response), and sizniticnntly improved overall patients survival (aaedian survival 50 weoks). In no;n-sraall cell canoers, horever, YACC cbemotberapy (in 42 patients) and luAM/Fiik sch.mes (Futra2ulJS-Fluorouracil, adriamycin, tnitoraycin-C, in 44 patients of adeaocarcinoma), were inett.ctive. Although partial response occurred in 3-Z73 of patients, there Mas no overall ~7 . ;.;. survival benezit. - - rJ Sv CJ M W

4 With a oore nor solia data bese,. oollat>orative studios are being initieted, iaciuding CitY-ride eQidemSoloQica2 studier, clinico-Dstboloeio studies, and studies of host determinants.

families, and should theretore be rr-ezunined." C. Tnoen_, ee Burnins a 8em^ - snrain8 of Chinese inoense at 9 temDies in worshiy ot idols or sods, a ooimnoa scene in tourists books, is part of the traditional Chinese owtoans stiil practised in lton8 toot. Burning of iaasnse at home, either for ancestor worshiD (traditioaal Chinese ttlial yiet7) or Qeity worship, is also co=on s2ooaF the large aoa-Christiaa looal , poyulation. Chinese iacense smoks has bssn shown to contain oarcinorens, (dchoantal i Oibbard, 1807) but to-date, oo studi.s ha.e bsen uad.rtaken to examine its rslation to lua8 cancer. ' GiVen that (1) ia IIonB xona, home iocsnse burning is oommon, (2) . : ~. ~ ' . .N _ . _ . . . . _ . . . . . - . . . that ~aany adait women in long Zon` are honsswi.ss who spenQ most F~ ~:..x..~Yk ..+•'"i' . .!', . .. . .. . ' .. .. . , . .. . . . S tbeir tiw at hooae iahaii iac.nse amok~ whioh ooat i ouciao~eas,sh"'(S) that song Zoa= is o*ererowded with ~oaay ~ .`ramilits 1i.ina irl bousss/tlats of area 400 to aoo saQars seetlr ' ' ' ' oaiy,4.fiieh. sould taerease the inhaled doss os_ aay Poteatial ~ . c.. ~ 4 t' "inhaled caroiaosea"_.nrssent ia a sM&11 home ars; it is concei.aale that inoeaso smoke might well be importaat in the sen,.sis o!' lung cancer in our women who do not smoke. A study was thersfore carried out to esaraine wliether passive smoking, kerosene sto.e cooking and incsase burning at home are likely cattsatiwe ta0tors ia ltta= oanesr in aon-smokin= rhinese wonen. This Zorms Part C of the 19a2-188d lung caacer

study. (soe Chapter 5, pp at?)• 7.Z ?atiQnts E Methods This is a case-coatrol study. Tuo aases woru all of the Chinose temale patients who wore adimitted to the OalvMrsity t>epe,rtment of Medicine, Qu.oA Mary Ho4pital, Roag RoaQ, bet.oon Jsnuary 19191 and April 1984, with blstologicallr and/or oytoloSioally confirmed o+troinoma of the lung of the tour major cell types (Types 1-4, 1t.H.0. Classitication, 1la1). - Great care .. .. .ar taken to exclude seoondary carcinoma of the lttag (seo pp 15 j.:. '_ 19) but othorriso all Chtneso Zsnale patisnts were iaoludedwith ;; o otY~er 'Com-irison p-tieat (oontrols)'~~~ ; ~ seleotion oriterta a ,~ c ,, ' Ort6opaidic` rards ~"~ `; ~ s wdre Chir~oso temule pa tients adAitted ` to ! ths . F 1~'~. sriod 19a2-2064 ; ooro ~ th rable ;~ ri t it l d Y ~ ~ pa ~ , e p u at ary, bip a ln Quera - y i....>:^ .. ..:-aF.<". ;~_, too lung `aaooer pati.uts ino sgo and .ooial ciass - both oases ~an4'" controls .ere!patisnts ot the thir4 olass Qeneraf.ards aaA +veru ~ " .. . - . :.. mostly trom the lower ianouw group. patienta rith pathologioal ,- tractupes due to s~aokiat-related Aalignaroia, and periphoral; : vasoular disonse-retated orthopaedio aonditions woro excluded. It is oonsidered that onr ortbopaodio oo4trols should not be biasert towards smokins-assooLsted diseases. Aii sasa• a+re interviewed by mysell, and the aontrols ~ by myseli or xLss Ciudy Ling, our toahoiciaa aW1 =esearah assistaat, who .as tralned tor this iqvestigatloo and thoroughly - 140 - CID I'-7 . W GJ FJ ~ 0'a U~

=amiliar with 1ocw1 cult+tre. The que+ttions oovored dialect grouD, oocupation, smoking habito, pusttvo smokins, domsstic cooking including keroso4e stove, and home incsnsc burning, ic form of a staACtardiwad du.stionaaire (Fig. Z.1). gor very ili pativats, or for pr.tients e$o spoke a dialect otber than . Cantonose or Hahlarin, arraagemont would then be made for their next-ol-kia to be iaterviewed witlr the patients as lnterpretor. :Attempts at quantitatioa Of petssivo smoking Aas been ~~ . .. . . ..J.:~w,lf.~ .... .. ... .. _ . .. :.. -: recogaiasd as 4iftiault (Royai College of physiclans, 1983; .~ ._ . . ._ . . . . : ~ . i> Yeiss •t al. 1g83).: aido+ttream smoke. to which the passive ``r amoker is •xposod, .is dilated by roore air to a vsrkabie extent. . ~: ,. . . . . .. ,_{ ~y- The -room air itself also oont;ains smokr.{~which has been iahaiea L?7}s .cw~L~ ~ . aad tbvn exbs1sd into the rir. t tmouat aad duration of smoke . - F ` ~xthk'ki a bitidtili ` , eposurs,--e smoers•,smonga,'sso aa veaaton Of . w=s otc. are all impdrtUnt varlables, 'aad the amount of the _ various components of tobsoco smoke brexthod by the non-stmoker from a smoky atmosphere are therefore extremely variable aad napredictable, anut there aro ao agrood •tandards for expressiaa the o+ttd4t of pollution of indoor atmosDheres by tobacco smoko. The sams problem applt.v to Quantitatioo Of ezposure to kerosone sto'vu eookins luoas and burning of iacense at home. I bad the opportuqity Of disoussiag thin with Bir Xiobard Doll during hxs visit to the University Depwrtment of Uedictao, iiang xong, in ~ •14t- Cj ' ~•. V.l ~ ,~