News News according to Cody. At the Mayo Clinic, women who received the drug received 1/10 that dosage, or about 1,000 mg. So, while a study of women who received DES at the Mayo Clinic found that the mothers and sons had no increased risk over the control group, the study may not apply to women who received higher doses.
Conference Planned An April 22 conference sponsored by NCI, the National Institute of Environmental Health Sciences, the National Institute of Child Health and Human Development, and the Office of Research on Women's Health will foster collaboration, review existing data on the longterm effects of DES exposure, encourage new research efforts, and assess the needs of the DES registries, according to NCI's Ruthann Giusti, M.D., the conference organizer. —By Cori Vanchieri
Second Wave? "Before DES, clear cell cancer, though very rare, was something that happened to women in their 60s and 70s," said Pat Cody, program director at DES Action of Oakland, Calif. "Will there be a second wave?" she asked. Also, although no direct extrapolations can be made, studies have shown female mice who were exposed to DES in utero got breast cancer in their middle ages at much higher rates than a control group. A major concern over the applicability of current data is the geographic differences in how the drug was prescribed. Administration varied by both dosage and time of delivery. In one part of the country, the average woman on DES got the drug for 7 months with gradually increasing dosages every 2 weeks. The total she received over that time period was about 12,046 mg, 566
Central European Countries Find Communism Was No Bloc To Cancer Decades of authoritarian government gave Central Europeans heavy industrialization, restricted travel, limited food choices, and free centralized health care. The cancer rates in these countries are a reflection of this unique amalgam of cultural and economic factors. According to a report by researchers at the International Agency for Research on Cancer, former Eastern bloc countries (Czechoslovakia, Hungary, Poland, and former East Germany) are going to need facilities and manpower to diagnose and treat about 60% more cancer patients in the year 2000 than they had in 1975. This projected increase in patients would be due mainly to the aging population, but statistics show that overall cancer rates are also increasing.
Cancer Rates
Dr. Kenneth Nolfcr
Czechoslovakia, Hungary, and Poland have higher overall mortality rates for most cancers compared with the United States and even some Western European countries. World Health Organization statistics for 1986-1988 show that these former Eastern bloc countries have overall cancer mortality rates for men of 200 to 235 cases per 100,000 (age adjusted to the world standard) compared to 163 cases in the United States. The very high rates for men make up the biggest difference between East and West, while the differences in rates for women are less extreme. For women there are between 107 and 130 cancer deaths per 100,000 in Central Europe versus 109 in the United States. Journal of the National Cancer Institute
Downloaded from http://jnci.oxfordjournals.org/ at New York University on May 13, 2015
trols run by Ted Colton, Sc.D., of Boston University School of Public Health. Since the 20-year point of follow-up of these women, divergence in risk between the exposed women and controls has been increasing. A new review of these same cases found an additional 127 breast cancers—a 64% increase over 6 or 7 years. An increased risk has not been found for any gynecological cancer other than clear-cell adenocarcinoma of the vagina, according to Colton. Researchers are watching carefully, as the daughters and sons reach their 40s, to see if rates of cancers usually found in older adults, such as prostate, cervical, and breast will show up early or at higher rates in this group. There is concern that the time of greatest health risk from DES has not yet appeared. Will DES sons, who are just approaching their 40s, develop higher rates of prostate cancer at an earlier age than the average man?
News News government to raise cigarette prices, which were controlled by the state. The state refused. "It was one of the few pleasures that were available... food, alcohol, and cigarettes," explained Joerg Poetzsch, Ph.D., an epidemiologist from the former Central Institute of Cancer Research in Berlin, and a visiting scientist at the U.S. National Cancer Institute.
Upward Trend Heavy Smoking Up Assessment of the trends indicates that there have been increases in specific cancer rates over the past 10 years. 'The incidence rates in former East Germany are quite similar to those in other European countries," said Detlev Ganten, M.D., Ph.D., of the Max Delbrueck Center for Molecular Medicine in Berlin. There are a variety of opinions on these statistics. Ganten, for example, believes there is no support for the projection that there will be 60% more cancer patients in the year 2000. Also, factors such as early detection, lifespan of the population, and availability or acceptance of treatments, could
Dr. Detlev Ganten
Vol. 84, No. 8, April 15, 1992
»...«* This is the first in a series of News articles to focus on worldwide cancer rates and risks.
alter the validity and outcome of predictions like IARC's. But as in the United States, trends still show some increases in cancer rates.
Combination of Factors Jan A. Steffen, M.D., of the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology in Warsaw summed that "mortality from cancer has been increasing very rapidly in Poland for the last three decades as a result of a very unfavorable combination of demographic, lifestyle, and environmental factors." Lung cancer rates in Central Europe— especially in males—are much more a product of cigarette smoking than any other factor. And Central Europeans smoke in great numbers. Within central Europe, Poland rates the highest in cigarette consumption at about 3,200 cigarettes per person per year. The no-smoking policies that are so all-encompassing in the United States and some Western European countries are simply not acceptable in Central Europe. Surveys during the 1980s showed that the cost of cigarettes would be a deterrent for children in East Germany to start smoking. Cancer advocates asked the
In addition, the consumption of cigarettes is relatively high and is not decreasing rapidly. Poetzsch explained that in former East Germany, there are decreasing numbers of people who smoke, but the proportion of heavy smokers is rising. Therefore, overall cigarette consumption is fairly steady. Some of the blame is given to the recent importation of Western cigarettes. Smokers who may have quit are often enticed to try the new brands. Central Europe is one area where the worldwide decreases in stomach cancer rates are occurring only recently and rather slowly. Rates for this cancer remain much higher here than in the west—even Western Europe. Stomach cancer is the second most common cancer in Poland, whereas it ranks no higher than 10th in incidence among white Americans. Reasons for this west to east phenomenon are not widely understood, although researchers frequently cite improved food preservation techniques as a critical factor. Cancers of the breast, prostate, endometrium, and colon follow a reverse continuum, with Poland's initially lower rates of these cancers now beginning to rise (/Nail Cancer Inst 84:313-320, 1992). While these cancers in some cases are attributed to higher fat, lower fiber diets (which are also a sign of growing affluence), matters of culture and NEWS 567
Downloaded from http://jnci.oxfordjournals.org/ at New York University on May 13, 2015
In former East Germany and Czechoslovakia, cancer registries have provided good incidence data since 1968, but statisticians discount the reliability of the mortality data. In 1987, East Germany had overall age-adjusted incidence rates of 247 per 100,000 men and 197 per 100,000 women. Czechoslovakian rates were 351 and 247, respectively.
News News preference, availability and affordability of specific foods are also important.
No Change Foreseen
health care has its advantages, but early detection programs were not one of them. In East Germany, the most effective screening is for cervical cancer, but its success was not due to cancer concern. "If women wanted to be on the birth control pill, they had to see a physician every year," explained Poetzsch. "The doctor visit was made to get the pill, but the cancer screening took place at the same time."
No Results In Czechoslovakia, the picture is similar. "The large cancer control program initiated with great glory in 1976 had, until now, unsatisfactory or no results," said Plesko. For example, cervical cancer death rates are decreasing only very slowly, and many cases of this and other cancers are diagnosed at advanced stages. In Poland, the same is true. "In a considerable percentage of cases, the diagnosis of cancer is made at such an
Uranium Miners There is more agreement about the risks of certain occupational exposures. In former East Germany, for example, a study of lung cancer rates throughout the country showed that men who worked in uranium mines had the highest risk of the disease. "Most of the sources and the extent of exposure to carcinogenic chemicals in industry were identified and assessed only recently," said Steffen, who added that occupational risk will remain a major concern in Poland. "A large proportion of the workforce is still employed in traditional heavy and chemical industries." Cancer mortality rates can also reflect availability and effectiveness of health care within a country. Free, centralized 568
Or. Joerg Poetzsch
Journal of the National Cancer Institute
Downloaded from http://jnci.oxfordjournals.org/ at New York University on May 13, 2015
'The high prices of vegetables and fruits in combination with increasing inflation and inadequate education do not indicate that there will be any change in diet in Czechoslovakia in the near future," said Ivan Plesko, M.D., Dr. Sc, of the Cancer Research Institute of the Slovak Academy of Science in Bratislava, Czechoslovakia. Plesko explains that, in parts of the country, the intake of food varies greatly from season to season, including an extremely low intake of fresh fruits and vegetables, especially in the winter. The story is similar throughout Central Europe. "[Before reunification with West Germany] there was little available in the store," explained Poetzsch. "In the winter there were apples, and maybe at Christmas, an orange." Farmers have traditionally had better access to vegetables and fruits than city
dwellers—perhaps one of the reasons there are regional differences in cancer rates within some countries. City dwellers tend to smoke more, as well. But there are also occupational factors. Poland's Steffen said, "It seems likely that workplace or environmental exposures to carcinogens contribute to these regional differences." Throughout Central Europe, factories that were in production 24 hours a day for economic reasons were also producing constant streams of smoke and dust. With the change in governments, many of these factories no longer produce goods or pollution round the clock, but their presence continues to be felt. The need for pollution control is undeniable, but researchers say its role as a cancer risk factor is unclear and perhaps may be overestimated. "Pollution in the environment is really a very important problem," explained Plesko, "but cancer is not the best argument in this field. In the etiology of cancer, pollution can hardly be compared with tobacco."
News News Television's News Doctors: How They Operate Bob Arnot, M.D., of CBS News, shares the TV airwaves with other reporter-physicians such as Dean Edell, M.D., James "Red" Duke, M.D., (who both have their television broadcasts widely syndicated), and Timothy Johnson, M.D. who is seen regularly on ABC's 20120. As a reporter who is also physician, Amot is aware of his responsibility to report medical news accurately to the viewer.
Doctor First "First and foremost, I am a physician," said Amot. "My patients are our viewers." In effect, Arnot sees himself as a physician who represents the rights and needs of the patient, not the health industry.
Leveled Off In Czechoslovakia, childhood cancer mortality rates are decreasing and overall incidence for the disease has been stable. Plesko explained that until 1965 the mortality rates and life expectancies in the country were similar to western European norms—but since then they have leveled off while western rates dropped. "The reaction of statistical indicators of health to the political andrelatedchanges is rather slow," explained Plesko. The initial influences of socialism began in 1948, but health changes were not seen for 20 years. The current changes in government should help toreversethe trend. —By Kara Smigel Vol. 84, No. 8, April 15, 1992
Johnson agreed: "Clearly, I too am a doctor first and my first responsibility is the well-being of the patient." To Johnson that means not violating patients' rights or privacy for the sake of a story, or breaking a journal's embargo and reporting the news before physicians can study the research first hand. "Medicine is big news," Arnot said. "One out of every four news stories on CBS 60 Minutes concerns medicine." And medical journalism is being covered by more and more by physicians. A 1990 Gallup Poll of 100 television news directors said they prefer physicians over general assignment reporters to deliver today's medical news because they believed them to be more qualified and credible. At present there are between 250300 physicians in the country currently engaged in the business of making broadcast news. In 1983, the National Association of Physician Broadcasters was formed and now has a membership of some 250 physicians who are engaged at least part time in some aspect of broadcasting news.
AMA Training
Dr. Bob Arnot
Every year the American Medical Association sponsors a workshop for physicians on broadcast journalism. Physicians pay $650 to $900 to learn the latest "on-camera skills, including how to use a teleprompter, wardrobe and makeup, writing and editing, and how to get started on cable news," said Jill Stewart, the AMA coordinator for the program. The American Medical Writers Association also sponsored an all-day workNEWS 569
Downloaded from http://jnci.oxfordjournals.org/ at New York University on May 13, 2015
advanced stage that it precludes treatment for cure," said Steffen. Part of this problem may be due to the stigma of cancer in these countries. Many patients are never told they have cancer, mainly because the physicians are concerned that this knowledge would do far more harm psychologically than good. Discussions of early detection of such a dreaded disease is difficult, at best. "Public education on cancer is unsatisfactory," says Plesko. "For the majority of the population this term is terrible and cancer is considered to be an inevitably fatal disease." But programs to improve early detection, cancer awareness programs, and quality of statistical data, coupled with campaigns to stop smoking and reduce occupational hazards have been under way. The lifting of travel restrictions has enabled many researchers to visit and collaborate with researchers around the world. In Poland, where smoking is the highest in Europe, the percentage of male smokers decreased by about 8% total from 1982 to 1987. Overall, the number of smokers in the 25 to 34 year age range dropped 15% over that time period.
Conference Planned An April 22 conference sponsored by NCI, the National Institute of Environmental Health Sciences, the National Institute of Child Health and Human Development, and the Office of Research on Women's Health will foster collaboration, review existing data on the longterm effects of DES exposure, encourage new research efforts, and assess the needs of the DES registries, according to NCI's Ruthann Giusti, M.D., the conference organizer. —By Cori Vanchieri
Second Wave? "Before DES, clear cell cancer, though very rare, was something that happened to women in their 60s and 70s," said Pat Cody, program director at DES Action of Oakland, Calif. "Will there be a second wave?" she asked. Also, although no direct extrapolations can be made, studies have shown female mice who were exposed to DES in utero got breast cancer in their middle ages at much higher rates than a control group. A major concern over the applicability of current data is the geographic differences in how the drug was prescribed. Administration varied by both dosage and time of delivery. In one part of the country, the average woman on DES got the drug for 7 months with gradually increasing dosages every 2 weeks. The total she received over that time period was about 12,046 mg, 566
Central European Countries Find Communism Was No Bloc To Cancer Decades of authoritarian government gave Central Europeans heavy industrialization, restricted travel, limited food choices, and free centralized health care. The cancer rates in these countries are a reflection of this unique amalgam of cultural and economic factors. According to a report by researchers at the International Agency for Research on Cancer, former Eastern bloc countries (Czechoslovakia, Hungary, Poland, and former East Germany) are going to need facilities and manpower to diagnose and treat about 60% more cancer patients in the year 2000 than they had in 1975. This projected increase in patients would be due mainly to the aging population, but statistics show that overall cancer rates are also increasing.
Cancer Rates
Dr. Kenneth Nolfcr
Czechoslovakia, Hungary, and Poland have higher overall mortality rates for most cancers compared with the United States and even some Western European countries. World Health Organization statistics for 1986-1988 show that these former Eastern bloc countries have overall cancer mortality rates for men of 200 to 235 cases per 100,000 (age adjusted to the world standard) compared to 163 cases in the United States. The very high rates for men make up the biggest difference between East and West, while the differences in rates for women are less extreme. For women there are between 107 and 130 cancer deaths per 100,000 in Central Europe versus 109 in the United States. Journal of the National Cancer Institute
Downloaded from http://jnci.oxfordjournals.org/ at New York University on May 13, 2015
trols run by Ted Colton, Sc.D., of Boston University School of Public Health. Since the 20-year point of follow-up of these women, divergence in risk between the exposed women and controls has been increasing. A new review of these same cases found an additional 127 breast cancers—a 64% increase over 6 or 7 years. An increased risk has not been found for any gynecological cancer other than clear-cell adenocarcinoma of the vagina, according to Colton. Researchers are watching carefully, as the daughters and sons reach their 40s, to see if rates of cancers usually found in older adults, such as prostate, cervical, and breast will show up early or at higher rates in this group. There is concern that the time of greatest health risk from DES has not yet appeared. Will DES sons, who are just approaching their 40s, develop higher rates of prostate cancer at an earlier age than the average man?
News News government to raise cigarette prices, which were controlled by the state. The state refused. "It was one of the few pleasures that were available... food, alcohol, and cigarettes," explained Joerg Poetzsch, Ph.D., an epidemiologist from the former Central Institute of Cancer Research in Berlin, and a visiting scientist at the U.S. National Cancer Institute.
Upward Trend Heavy Smoking Up Assessment of the trends indicates that there have been increases in specific cancer rates over the past 10 years. 'The incidence rates in former East Germany are quite similar to those in other European countries," said Detlev Ganten, M.D., Ph.D., of the Max Delbrueck Center for Molecular Medicine in Berlin. There are a variety of opinions on these statistics. Ganten, for example, believes there is no support for the projection that there will be 60% more cancer patients in the year 2000. Also, factors such as early detection, lifespan of the population, and availability or acceptance of treatments, could
Dr. Detlev Ganten
Vol. 84, No. 8, April 15, 1992
»...«* This is the first in a series of News articles to focus on worldwide cancer rates and risks.
alter the validity and outcome of predictions like IARC's. But as in the United States, trends still show some increases in cancer rates.
Combination of Factors Jan A. Steffen, M.D., of the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology in Warsaw summed that "mortality from cancer has been increasing very rapidly in Poland for the last three decades as a result of a very unfavorable combination of demographic, lifestyle, and environmental factors." Lung cancer rates in Central Europe— especially in males—are much more a product of cigarette smoking than any other factor. And Central Europeans smoke in great numbers. Within central Europe, Poland rates the highest in cigarette consumption at about 3,200 cigarettes per person per year. The no-smoking policies that are so all-encompassing in the United States and some Western European countries are simply not acceptable in Central Europe. Surveys during the 1980s showed that the cost of cigarettes would be a deterrent for children in East Germany to start smoking. Cancer advocates asked the
In addition, the consumption of cigarettes is relatively high and is not decreasing rapidly. Poetzsch explained that in former East Germany, there are decreasing numbers of people who smoke, but the proportion of heavy smokers is rising. Therefore, overall cigarette consumption is fairly steady. Some of the blame is given to the recent importation of Western cigarettes. Smokers who may have quit are often enticed to try the new brands. Central Europe is one area where the worldwide decreases in stomach cancer rates are occurring only recently and rather slowly. Rates for this cancer remain much higher here than in the west—even Western Europe. Stomach cancer is the second most common cancer in Poland, whereas it ranks no higher than 10th in incidence among white Americans. Reasons for this west to east phenomenon are not widely understood, although researchers frequently cite improved food preservation techniques as a critical factor. Cancers of the breast, prostate, endometrium, and colon follow a reverse continuum, with Poland's initially lower rates of these cancers now beginning to rise (/Nail Cancer Inst 84:313-320, 1992). While these cancers in some cases are attributed to higher fat, lower fiber diets (which are also a sign of growing affluence), matters of culture and NEWS 567
Downloaded from http://jnci.oxfordjournals.org/ at New York University on May 13, 2015
In former East Germany and Czechoslovakia, cancer registries have provided good incidence data since 1968, but statisticians discount the reliability of the mortality data. In 1987, East Germany had overall age-adjusted incidence rates of 247 per 100,000 men and 197 per 100,000 women. Czechoslovakian rates were 351 and 247, respectively.
News News preference, availability and affordability of specific foods are also important.
No Change Foreseen
health care has its advantages, but early detection programs were not one of them. In East Germany, the most effective screening is for cervical cancer, but its success was not due to cancer concern. "If women wanted to be on the birth control pill, they had to see a physician every year," explained Poetzsch. "The doctor visit was made to get the pill, but the cancer screening took place at the same time."
No Results In Czechoslovakia, the picture is similar. "The large cancer control program initiated with great glory in 1976 had, until now, unsatisfactory or no results," said Plesko. For example, cervical cancer death rates are decreasing only very slowly, and many cases of this and other cancers are diagnosed at advanced stages. In Poland, the same is true. "In a considerable percentage of cases, the diagnosis of cancer is made at such an
Uranium Miners There is more agreement about the risks of certain occupational exposures. In former East Germany, for example, a study of lung cancer rates throughout the country showed that men who worked in uranium mines had the highest risk of the disease. "Most of the sources and the extent of exposure to carcinogenic chemicals in industry were identified and assessed only recently," said Steffen, who added that occupational risk will remain a major concern in Poland. "A large proportion of the workforce is still employed in traditional heavy and chemical industries." Cancer mortality rates can also reflect availability and effectiveness of health care within a country. Free, centralized 568
Or. Joerg Poetzsch
Journal of the National Cancer Institute
Downloaded from http://jnci.oxfordjournals.org/ at New York University on May 13, 2015
'The high prices of vegetables and fruits in combination with increasing inflation and inadequate education do not indicate that there will be any change in diet in Czechoslovakia in the near future," said Ivan Plesko, M.D., Dr. Sc, of the Cancer Research Institute of the Slovak Academy of Science in Bratislava, Czechoslovakia. Plesko explains that, in parts of the country, the intake of food varies greatly from season to season, including an extremely low intake of fresh fruits and vegetables, especially in the winter. The story is similar throughout Central Europe. "[Before reunification with West Germany] there was little available in the store," explained Poetzsch. "In the winter there were apples, and maybe at Christmas, an orange." Farmers have traditionally had better access to vegetables and fruits than city
dwellers—perhaps one of the reasons there are regional differences in cancer rates within some countries. City dwellers tend to smoke more, as well. But there are also occupational factors. Poland's Steffen said, "It seems likely that workplace or environmental exposures to carcinogens contribute to these regional differences." Throughout Central Europe, factories that were in production 24 hours a day for economic reasons were also producing constant streams of smoke and dust. With the change in governments, many of these factories no longer produce goods or pollution round the clock, but their presence continues to be felt. The need for pollution control is undeniable, but researchers say its role as a cancer risk factor is unclear and perhaps may be overestimated. "Pollution in the environment is really a very important problem," explained Plesko, "but cancer is not the best argument in this field. In the etiology of cancer, pollution can hardly be compared with tobacco."
News News Television's News Doctors: How They Operate Bob Arnot, M.D., of CBS News, shares the TV airwaves with other reporter-physicians such as Dean Edell, M.D., James "Red" Duke, M.D., (who both have their television broadcasts widely syndicated), and Timothy Johnson, M.D. who is seen regularly on ABC's 20120. As a reporter who is also physician, Amot is aware of his responsibility to report medical news accurately to the viewer.
Doctor First "First and foremost, I am a physician," said Amot. "My patients are our viewers." In effect, Arnot sees himself as a physician who represents the rights and needs of the patient, not the health industry.
Leveled Off In Czechoslovakia, childhood cancer mortality rates are decreasing and overall incidence for the disease has been stable. Plesko explained that until 1965 the mortality rates and life expectancies in the country were similar to western European norms—but since then they have leveled off while western rates dropped. "The reaction of statistical indicators of health to the political andrelatedchanges is rather slow," explained Plesko. The initial influences of socialism began in 1948, but health changes were not seen for 20 years. The current changes in government should help toreversethe trend. —By Kara Smigel Vol. 84, No. 8, April 15, 1992
Johnson agreed: "Clearly, I too am a doctor first and my first responsibility is the well-being of the patient." To Johnson that means not violating patients' rights or privacy for the sake of a story, or breaking a journal's embargo and reporting the news before physicians can study the research first hand. "Medicine is big news," Arnot said. "One out of every four news stories on CBS 60 Minutes concerns medicine." And medical journalism is being covered by more and more by physicians. A 1990 Gallup Poll of 100 television news directors said they prefer physicians over general assignment reporters to deliver today's medical news because they believed them to be more qualified and credible. At present there are between 250300 physicians in the country currently engaged in the business of making broadcast news. In 1983, the National Association of Physician Broadcasters was formed and now has a membership of some 250 physicians who are engaged at least part time in some aspect of broadcasting news.
AMA Training
Dr. Bob Arnot
Every year the American Medical Association sponsors a workshop for physicians on broadcast journalism. Physicians pay $650 to $900 to learn the latest "on-camera skills, including how to use a teleprompter, wardrobe and makeup, writing and editing, and how to get started on cable news," said Jill Stewart, the AMA coordinator for the program. The American Medical Writers Association also sponsored an all-day workNEWS 569
Downloaded from http://jnci.oxfordjournals.org/ at New York University on May 13, 2015
advanced stage that it precludes treatment for cure," said Steffen. Part of this problem may be due to the stigma of cancer in these countries. Many patients are never told they have cancer, mainly because the physicians are concerned that this knowledge would do far more harm psychologically than good. Discussions of early detection of such a dreaded disease is difficult, at best. "Public education on cancer is unsatisfactory," says Plesko. "For the majority of the population this term is terrible and cancer is considered to be an inevitably fatal disease." But programs to improve early detection, cancer awareness programs, and quality of statistical data, coupled with campaigns to stop smoking and reduce occupational hazards have been under way. The lifting of travel restrictions has enabled many researchers to visit and collaborate with researchers around the world. In Poland, where smoking is the highest in Europe, the percentage of male smokers decreased by about 8% total from 1982 to 1987. Overall, the number of smokers in the 25 to 34 year age range dropped 15% over that time period.
