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FILE NAME Kent KNT DATE 1950 June 20 DOC KNT101 DOCUMENT DESCRIPTION Journal Article - Cancer of the Lung Consideration of Incidence and Etiology - New York Medicine NEW YORK MEDICINE Official Publication of the Medical Society of the County of New York CANCER OF THE LUNG CONSIDERATION OF INCIDENCE AND ETIOLOGY ETIOLOGY 4 4 q By WILLIAM L. WATSON M.D. ae teebaab fe Introduction Every specialist naturally con- Besides the fresh concept of lung cancer siders his professional work to be valuable and brought about by Dr. Graham's pioneer pneu- important There seems however to be valid monectomy in 1933 cancer of the lung war- reason for giving serious consideration to the rants attention at this time because the inci problem of lung cancer Perhaps the subject dence of this highly fatal form of cancer is warrants considered attention because it has so LSoe recently 1933 been brought from the ranks of hopeless new growth into the family of cur- most certainly increasing at a startling rate The time has arrived perhaps when we should not mince words with the public or our col- able cancers Its very newness in this respect leagues internes and students because the facts suggests the need for searching discussion of seem to indicate clearly that cancer of the lung the problem which in turn may well lead to a is a much more common disease today than it method of diagnosis for this disease while it is was twenty years ago yet its beginning phase The need for prompt Incidence There are numerous possible ex diagnosis becomes more compelling when we are planations for the increased incidence of this made aware that acceptable almost routine deadly disease First of all there is an increased surgical management of the disease is already awareness of cancer in general on the part of at hand and an insignificant operative mortality the public and the medical profession Also and an appreciable five year salvage rate can the prominent symptomatology of cancer of the reasonably be assured the patient and his phy- ling has been well publicized The antibiotics sieran penicillin and aureomycin undoubtedly have * Presented at the March 27 County of Society the Thoracic New of * Attend Thoracic Surgical 1950 meeting of the Medical York Service Memorial Hospital Associate Professor of Singery Bellevue Medical Center New York Universityon played an important role in more frequent and more accurate diagnosis of cancer of the lung In the past pneumonia in elderly males was a NEW YORK MEDICINE 15 common cause of death and undoubtedly many of those called pneumonias were cases of pneumonitis secondary to bronchogenic cancer Nevertheless the death certificate classed the death as one due to pneumonia Nowadays the antibiotics do a great deal to relieve this pneumonitis Fewer patients die of the inflammatory complications of cancer of the long in its early stages at least and therefore many of them receive further clinical investi- Section of the American Cancer Society reveals a summary of the lung cancer deaths in the United States during the year 1947. There were 14,666 deaths and this represents due to cancer of a death rate per the lung hundred thousand of 10.2 More than twelve per cent of all male cancer deaths and 3.2 per cent of all female cancer deaths can be charged to cancer of the lung 7.7 per cent of all cancer deaths 1947 gatio which leads to an accurate diagnosis of cancer of the lung I should estimate that bet- ter than 75 per cent of the patients now coming us with cancer of the lung have had a pre- cious clinical diagnosis of vinus pneumonia FIGURE I RESPIRATORY 60 SYSTEM CANCER DEATH DEATH RATES BY United oan States : 1933 and 1946 ue uneeee Tote AGE j This * . diagnosis has often been sub- x! by ~ a ! Nt stant ard competent radiographic studies 10,00 N of the chest Of course a called atypical 10 ,0 0 api PER | pneumonia in patient over forty years of age PER PER : : RATE which recurs or fails to resolve should be viewed with considerable suspicion RATE ol cor DEATH DEATH DEATH - ee, we : DEATH ' Perhaps Perhaps the increase in life expectancy brings : | ! alr! into the lung cancer age a considerable number 20 2 > " 20 ee 30 40 ou 50 Wake 60 - -- 30 of patients susceptible to this disease and one Service monterte Store ( 1993 Woot AGE Stat at ie of the 12-194 States 1946 10:49 should therefore expect an actual increase in the number of its victims Prolonged exposure to factors of chronic irritation such as smoking dust city gas fumes and industrial factors TABLE I 21. CANCER DEATHS AND DEATH DEATH RATES BY AGE SEX AND SITE United States Cancer of Lung and Bronchus International List Nos 47 and 47 4 also may play a part in the increased incidence BOTH SEXES MALE FEMALE of this disease Improved methods of diagnosis due to rou- Percent Number of all of | Cancer | Death Deaths | Deaths Role | Percent Number of all Concert |DeathsConcert Deaths Mole Concert Death Concert Parcent Number | of all af Female || Deaths Cancer Death Role Deathe tine chest ray studies extension of hospitali- ALL AGES 14,666 77 | 10.2 11,546 12.3 16 | 3.120 32 : 4 zation easily available bronchoscopy the recog- nition of specialists trained in thoracic diseases routine bronchial extology studies together with public knowledge of the possible significance of chronic cough blood spitting and so forth Percent cancer deaths of the lung and branchus in specified group of all cancer deaths in that group ** Rotes are the number of deaths in specified group per 100,000 estimated ews midyear population of that group including the armed forces overseas Source Vital Statistice of the United States 1947 Statistical Research Section Medical and Scientific Dept. American Cancer Soc all may prove to be factors in explaining the rapid increase in the number of patients coming to us with cancer of the lung Coupled with the foregoing generalizations is the important factor of better cancer teaching at the medical school level Fig 1 compiled from the mortality statistics of 1933 and the vital statistics of the United States of 1946 reveals a very sharp rise in respiratory system cancer in the thirteen year period following the first surgical care of cancer of the lung Table compiled by the Statistical Research Now if the foregoing reasons are used to explain the increased incidence of cancer of the lung it should be equally valid to use these data to show an increase in the other common types of cancer But from fig 11 we see that from 1933 to 1946 the incidence of cancer of the lung in males has shown a sharp increase in rate without a corresponding increase in the mumber of cancers of the stomach pros- tate bladder skin esophagus and so forth Fig HI illustrates the fact that cancer of the lung in females has increased in relation to 16 JUNE 20 1950 malignant disease of the ovary breast uterus and stomach FITURE II WHITE " MALE CANCER DEATH RATES United States 1933-1946 =~ BY SITE Pa ee Stumoch Stumoch Stumoch Stumoch 24 i | ye | v6 POPULATION Prostate . POPULATION POPULATION POPULATION coerce partie POPULATION Interlines ee POPULATION C+ Interlines wr pie---7 i Ve Lung & Bronchys 100,000 100,000 100,000 100,000 1 PP PPEERR L_~ ae a . oe Rectum | Liver RATE RATE | fo - _ Bladder oS a inal Pancreas a7 Pancreas "724 aJeone 2 FONE oe oe 4 = 7 ; aNShinae i 3 : Esophagus , . 1 1833 rn 1937 n n 1 1 1 A 1942 1942 YEAR Standardized for age on the 1940 United States population FIGURE HI WHITE FEMALE CANCER DEATH RATES BY United States, 194196 46 SITE a ta . ena Slemach ey POPULATION ooo POPULATION POULATION Inteclines 10.0 PER RATE Meee wen Overy eo Pencrees Lung B Branchus | glander t ~ - en in et anand a a ae fa : ... if _ ie eer Cees a 1967 1967 ee Se 1937 1967 1946 YEAR Standardised for oga on the 1940 United States population In at least two large medical centers in the United States it is now reported that cancer of the lung is a more common disease than cancer of the stomach so that in these two in- stitutions at least a relative increase in the frequency of cancer of the lung seems to have taken place The figures at Memorial Hospital clearly substantiate these reports as shown in fig IV indicating the relative incidence of cancer of the lung cases admitted to Memorial Hospital in relation to cancer of the stomach and cancer of the prostate From 1926 to 1933 Figure IV NO OF CASES INCIDENCE MEMORIAL HOSPITAL HOSPITAL - CANCER OF STOM STA OMCACHH - PROS 1926-1949 1926-1949 1926-1949 1926-1949 ee 200 e a we wee ' fi 150 125 | J / a LUNG | | 1 100 ! i 75 504 a y, J 92 ee STOMACH ! STOMACH a 251 251 H an we ee 1925 1930 1935 ibeeetetied 1940 | 23 sam ee PROSTATE PROSTATE PROSTATEPROSTATE : 1945 1949 a very small number of were seen at Memorial lung cancer patients Hospital but from 1935 to 1940 there was a sharp rise in the incidence and shortly after 1940 the admissions for cancer of the hung crossed the line for cancer of the stomach and went on to a precipitous rise in 1945 and continued through 1949 when a total of 193 patients with cancer of the lung were seen at Memorial Hospital It may be of significance that the increase starting in 1935 was more or less coincidental with Dr. Gra- ham's report of the first tomy for cancer of the vertical rise from 1945 successful pneumoneclung and the almost on coincides with the general introduction of the antibiotics peni cillin streptomycin and aureomycin Etiology Macklin in his monograph on this subject What Causes Primary Cancer of the Lung makes the statement that his data indicate the thesis that primary carcinoma of the NEW YORK MEDICINE 17 lung is due to chronic inflammatory changes in the lung amproved He further states that the role of chronic bronchitis as a causative igent in the production of pulmonary cancer has not been demonstrated He also believes that emphysema bronchiectasis asthma pul- monary abscess and so forth when found asso- ciated with cancer of the lung are probably of coincidental interest only Tuberculosis pneumonia and gassing have not been proved to be unequivocal factors in the inception of cancer of the lung CASES CASES 200 FIGURE V MEMORIAL HOSPITAL PATIENTS WITH LUNG CANCER -1926-49 lung have been reported Pneumoconiosis has been said to cause cancer of the lung and yet South African miners have a high incidence of pneumoconiosis but a comparatively low incidence of cancer of the hutg I have two brothers as patients each of whom worked thirty years or more in the anthracite coal mines one has cancer of the lung and the other has anthracosis and no cancer Tarred roads roentgen rays motor exhaust fumes and so forth have all been suggested as possible causes When we review all the theories on the cause of pulmonary cancer we find that not one supposed cause has been proved to be a real cause and that none of the alleged causes have been investigated with sufficient statistical accuracy to enable the observer to pass an opinion carrying any great weight Perhaps there is good reason to believe that there is no one cause for cancer of the lung but certainly there are additive factors which lead to the inception of cancer of the lung that is a number of etiological factors working together over a period of years probably result in the eventual incep- tion of cancer in sensitive tissues which have become altered due to the degenerative changes of age 1926 1930 1935 940 1945 1949 In this regard considerable interest has been evidenced in the recent past regarding the \ Occupational relation to primary cancer of significance of prolonged cigarette smoking as y the lung is difficult to prove and efforts along a possible factor in the inception of cancer of this line have for the most part been unsuccess- the lung Schrek in the January 1950 issue of i ful The sole exception to this rule being the Cancer Research discusses tobacco smoking as pulmonary cancer which occurs in the miners an etiological factor in cancer and concludes j of Schneeberg and Joachimstal in Bohemia the incidence of which is so high in comparison with that of cancer of the lung in other localities and so high in comparison with the incidence A relatively high percentage of cigarette smokers was found among the patients with cancer of the respiratory tract as compared to the control This positive correlation between the inci- among the neighbors of the victims who are not working in the mines that there seems to be little doubt that this occupation is strongly productive of cancer of the lung But even the effect of clase imbreeding and heredity have dence of cigarette smoking and incidence of cancer of the respiratory tract appeared to be both statistically and biologically significant There is strong circumstantial evidence that cigarette smoking was an etiological factor in cancer of not been exonerated as possible factors the respiratory tract Chromitum dust iron oxide in silica dust exposure to coal gas the air or coal tar on the skin and the preparation and sale of tobacco have all been brought forward as possible causes of cancer of the lung A few cases of asbestosis associated with primary cancer of the In the United States some recent publicity was given to this subject of smoking and cancer by Dr. Graham's group at St. Louis and al- though it was not mentioned one hundred or half of the cases studied came from Me- Continued on page 40 18 JUNE 20 1950 Continued from page 18 morial Hospital and the figure as first reported seemed to indicate that 97.5 per cent of our cases were heavy smokers and none of our pa- tients with cancer were smokers These figures were widely quoted but unfortunately they are inaccurate Tables H. III and IV show our figures on that series of 100 cases of cancer of the lung in relation to smoking Table 11 is of course open to criticism but it is the classification which we finally selected We decided to use three groups The first group the smokers the second group the moderate smokers or patients who smoked up to 20 cigarettes per day for twenty years or more with inhalation and the third group the heavy smokers chain smokers or the patients who smoked from 20 to 60 cigarettes per day for twenty or more years with inhalation We arbitrarily decided for purposes of comparison that one pipe was the equivalent of two and a half cigarettes and one cigar the equivalent of five cigarettes TABLE I MEMORIAL HOSPITAL SMOKING AND LUNG CANCER CLASSIFICATION 1. Non smokers H. Moderate smokers Up to 20 cigarettes per day for 20 years or more with inhala- tion III Heavy smokers 20 to 60 cigarettes per day for 20 or more years with inhalation ( pipe cigarettes 1 cigar 5 cigarettes In Table 111 for the Males we see that in Class 1 smokers in the Control Series cleven per cent of men did not smoke and in the Cancer Series five per cent of men did not smoke in Class II moderate smokers in the Control Series 70 per cent and in the Cancer Series 58 per cent But in Class III heavy smokers 19 per cent in the Control Series and 37 per cent or nearly twice the previous figure in the Cancer Series We think this latter figure is of considerable significance And as can be seen in Table IV for the Females 60 cent did not smoke in the Control Series and 58 per cent in the Cancer Series In Class II moderate smokers 37 per cent in the Control 40 JUNE 20 1950 Series and 25 per cent in the Cancer Series But when we come to Class I11 heavy smokers only three per cent of the Control Series of women were classed as heavy smokers but in the Cancer Series 17 per cent were heavy smokers TABLE III SMOKING AND LUNG CANCER MEMORIAL HOSPITAL MALES Control Class Class Non Smoker 2... Moderate Smoker % 70 Class Heavy Smoker .. % Cancer At, 587 3 37 7 TABLE JV MEMORIAL HOSPITAL SMOKING AND LUNG CANCER FEMALES Control Class Non Smoker .. 60 Class Moderate Smoker 37 Class Heavy Smoker .. % Ganeer 5807 259 17 SUMMARY It has been concluded from statistical studies that comparison of the smoking habits of victims of lung cancer with those of control cases obtained by careful questionnaire affords strong grounds for suspecting the carcinogenic possibilities of heavy chronic smoking But however strongly suggestive they cannot afford incontrovertible proof especially in the eyes of smokers themselves Chronic heavy cigarette smoking may very well be an additive factor in the causation of lung cancer in sensitive in- dividuals However the individual irritant it- self may not be as significant as the chronicity of the patient's exposure to that irritant In this respect I suppose we are witnessing a vast human experiment never before carried out by man namely what will be the long range re- sult on the human tissues and structures which come in contact with that chronic smoke stream But whether we indict cigarette smoking as a cause for cancer of the lung or whether we admit that we do not know the actual inciting cause of cancer of the lung the fact remains that the incidence of cancer of the lung has risen sharply since 1926