Lung cancer - almost unknown before 1900 - kills millions of people every year. Virtually all these deaths could have been prevented.
By JUDY SIEGEL-ITZKOVICHsmoking 88(photo credit: )
If you went to a medical library and searched through 19th century texts, you would find almost no references to lung cancer. By 1900, the number of cases in the entire medical literature had reached a grand total of 100.
Yet by the 1970s, this kind of tumor had moved from one of the rarest to the number one malignant killer, causing 30% of all cancer deaths in the Western world. Over 1.2 million people around the world died of lung cancer last year. Between 90 and 95% of lung cancers are the direct result of smoking or being exposed to another's tobacco toxins, with a tiny minority caused by radon, asbestos exposure and still-unknown influences. Half of all smokers - and there are currently 1.3 billion - will die from tobacco use, their lives shortened by an average of 10 years.
Before the smoky 20th century dawned, tobacco was used only by "gentlemen" in cigars. Cigarettes - originally sweepings collected from cigar factory floors - were smoked only by the very poor. Newly emerging cigarette companies gave their product free to millions of American soldiers in World War I, and when the lucky survivors returned home from the battlefield, large numbers were hooked. Since there is a two- or three-decade lag between the first cigarette puffed and a diagnosis of lung cancer, doctors didn't see an epidemic of it until the 1930s, but the link was soon discovered. Large statistical studies in England and the US half a century ago proved without doubt that cigarette smoking is the primary cause of lung cancer.
IN THE following decades, along with the campaign for women's rights, females were also targeted by tobacco ad campaigns, and became almost as addicted as men; their newly won "equality" was marked by nearly equal rates of this disease.
Every year, almost twice as many American women die from lung cancer as from breast cancer.
But the tobacco companies continue to knowingly slaughter their customers, seeking to replace those who die with gullible young substitutes.
Conferences on lung cancer, such as that held earlier this month at Jerusalem's Shaare Zedek Medical Center, would be almost unnecessary if cigarettes, cigars, hookahs and other nicotine "delivery systems" had not been invented. And if those cursed leaves had never been cultivated, the dedicated cadre of oncologists, surgeons, pulmonologists and other experts who devote their energy to extending the lives of lung cancer patients by maybe a few months could spend their time fighting other types of malignancies.
"Don't start smoking and quit if you already do!" was the primary message of the Shaare Zedek experts to the audience at the conference, organized with support by Roche Pharmaceuticals-Israel. But for those long-time-smoking lung cancer patients in the auditorium, it was too late. With their deep, gruff voices from smoke-irritated vocal cords, and breathlessness from lobes of lungs removed with their tumors, several of those who asked questions clearly had been hit by the disease.
Yet despite ads in Hebrew-language Jerusalem weeklies of the free event for cancer patients and their families, the 350-seat hospital auditorium was less than a quarter filled. The fact that there were relatively few people, said Shaare Zedek director-general Prof. Jonathan Halevy, "illustrates the problem of lack of awareness. Lung cancer is a big problem."
SHAARE ZEDEK oncology department head Prof. Alberto Gavizon said the rate of lung cancer diagnosis will increase in the years ahead, with an equal threat to men and women. "Early diagnosis is important, as the more advanced it is, the more deadly."
Hospital pneumologist Dr. Gabriel Izbicki added that there are 4,000 chemicals and 50 known carcinogens in every cigarette. A short list includes formaldahyde, lead, benzene, DDT, cadmium, ammonia, cyanide, arsenic, carbon monoxide and acetone. Besides causing lung cancer, smoking also ages skin, creates nicotine stains on teeth and fingers, causes the dreaded shortness-of-breath disease named emphysema, hypertension, heart disease, bladder and esophageal cancer and stroke.
"One million Israelis smoke - or about 28% of the adult population. In addition, 11% of 10th and 11th graders smoke regularly. The age of onset has gone down to seventh grade," continued Izbicki.
The initial symptoms of lung cancer are not specific. They include a cough that doesn't go away, tiredness, breathlessness and lack of appetite. Those who complain of such symptoms are sent for a chest X-ray. If a suspicious shadow appears, they are referred for a computerized tomography (CT) scan and then bronchosocopy to take a biopsy. The diagnosis is thus confirmed. A positron emission tomography (PET) scan of the whole body is often performed to see if the cancer has spread, and more biopsies may be taken from the lungs and lymph glands to determine the best treatment and prognosis, Izbicki continued.
TREATMENT may include surgical removal of one or more lobes of lung, radiotherapy and/or chemotherapy (oral or intravenous). If the cancer has spread beyond the lungs to the lymph glands and other organs, chemotherapy and/or radiation are usually the preferred treatment, with surgery sometimes performed. Lasers may be used to relieve breathing difficulty in the bronchi, but that doesn't solve the problem.
Radiology Prof. Irit Hadas explained that routine frontal and side-view X-rays are not very sensitive; a white shadow may be a sign of a tumor or a benign growth. The best way to diagnose lung cancer is by CT, which in seconds can present up to 64 slices for each rotation.
"It is very exact, but at thousands of shekels per scan, it is very expensive. They emit a lot more radiation than X-rays, which cost less than NIS 100 each. And there are not many of these multi-million-dollar scanners, so we can't use them for screening. The most advanced CT scans can present 3-D images of the inside of the body, showing only the blood vessels," she said. "One can even see only the lungs as if they were outside the body, without the covering layer, or a virtual bronchoscopy, as if we were traveling inside the bronchi looking for a tumor."
There are, however, low-radiation CT scanners that produce less-clear images than those used for diagnostics, and they are used for screening. In 1993, an American research team began to screen seemingly healthy, asymptomatic people over 40 - smokers who were thus at high risk for lung cancer. Of the 30,000 scanned, nearly 500 were found to have lung cancer, but most were in stage 1. Some 300 underwent surgery, and 88% survived for a decade. The researchers concluded that low-radiation CT scans are recommended for such people. But obviously people should avoid the risk and not smoke or be exposed to others' smoke, said Hadas.
Shaare Zedek cardiothoracic surgery department's Dr. Maher Deeb noted that unlike the eyes, kidneys, arms and legs, the lungs are not symmetrical. "There are three lobes on the right and two lobes on the left. They also have different functions. If there is a tumor, we prefer to preserve what we can. There is a lymphatic drain in the lungs and lymph nodes around the trachea. But most patients arrive for surgery when the tumor is quite large." He said that chest surgery to remove lungs has been performed for 70 years. "It was first done by a doctor in St. Louis, who removed the cancerous lung lobe of a smoking colleague. But the surgeon," noted Deeb with irony, "also a smoker with lung cancer, died before his patient did."
Keyhole surgery (laparoscopy) is also used today to remove lung lobes without breaking the patient's ribs. Since many patients are inoperable, "30 to 40% of our work is supportive and not surgery. There are computerized devices that release programmed doses of painkillers, and the patient can give himself an extra dose if needed."
Seventy percent of those with stage 1 lung cancer survive for five years, while in the more advanced stage 2 that is limited to the lung, between 38% and 55% survive that long, said hospital oncologist Dr. Maya Gips. When it's stage 3 and the cancer can't be removed completely but there are no metastases, only 7% to 25% survive five years, while in stage 4 when it has metastasized to many parts of the body, there is only a 1% chance of living that long. The cure rate for advanced cancer is very low, and since most patients are diagnosed at stage 3 or 4, only 15% of all lung cancer patients live for five years or more after diagnosis. It's very sad, as nearly all lung cancer is preventible."
But even if the cancer is in the first two stages, she continued, there may be invisible cancer cells. "They are not visible in a CT scan or blood test, and can't be seen by the surgeon. But the disease comes back as a hidden disease in 30% of cases." Preventive chemotherapy can increase the survival rate, but it isn't easy. Using chemotherapy to kill invisible floating cancer cells is a new concept introduced in the past two years," said Gips. "It can raise the survival rate in 4% to 15% of patients, but we don't give it to all patients, and it is for only four months." If chemotherapy is given to stage 2 patients before surgery, she said, it can shrink the tumor and make surgery easier. But chemo has side effects, and not all patients can stand this treatment."
Another recent development is the giving of a "cocktail" of several types of chemotherapy, each with a different type of action, to produce a synergistic effect. But such a cocktail also can have multiple side effects.
BIOLOGICAL CANCER treatments focus on the molecular differences in cancer cells compared to healthy cells. "Such biological drugs are selective, like guided missiles, so they harm healthy cells less. But they also have side effects, even though less intense than chemotherapy."
Among the biological weapons is Tarceva, a pill that is not in the basket of health services, and Avastin, which is registered for treating colorectal cancer but not lung cancer.
"Tarceva can be used to lengthen life and improve quality of life, but it is not a cure, and there are side effects. Avastin is an antibody that fights the uncontrolled formation of blood vessels [angiogenesis] feeding the tumor. It can starve tumors so they may shrink. But Avastin has been shown to extend life only by an average of two months."
Dear smokers: If you have gotten this far, you must have realized that the "pleasure" you get from tobacco is not worth the almost inevitable suffering. Don't smoke near anyone, as passive smoking is just as deadly. Quit, with help from your doctor or a health-fund cessation course. Be a good example and encourage your relatives and friends not to get hooked.
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