PREVENTIVE
MEDICINE
4, loti-
1 I4 ( 1975)
SPECIAL ARTICLE
School
Preventive
Oncology
MICHAEL
B. SHIMKIN
of Medicine. University of California, San Diego, Sun Diego. California
This is the right time to propose a new specialty, Preventive Oncology. It is no secret that in the United States preventive medicine has been talked about much more than practiced. It has no financial base, and it falls in the crack between public health and medicine. Some of us had hoped that preventive medicine could come of age under the Regional Medical Program, but that idea wound up on the shoals. Preventive oncology can assume a leadership position for preventive medicine if it is developed as an integral yet identified component of the network of cancer centers that is being established under the National Cancer Plan. It would be my fervent hope that, under the flag of cancer, the plans would include not only other diseases but would be oriented to health rather than to disease. Since the objectives are broader than cancer, let us postpone creating an American Society of Preventive Oncology, or issuing an American Journal of Preventive Oncology, although perhaps we need both. Preventive oncology, and all preventive medicine, is not yet another clinical specialty. It involves different types of practitioners, and different practitionerpeople relationships than those appropriate for the clinical branches of medicine. The usual clinical patient is someone who hurts, or suspects he or she might hurt. Such a patient comes to a physician for help, and the roles of supplicant and grantor, or of consumer and provider, are immediate and obvious. In preventive medicine, there are no patients, but individuals, with different sets of motivations and anticipations. People, in general, simply are not patients most of the time. To attract their attention and to motivate them to carry out recommendations said to be good for them require different techniques than are effective among the sick. Health education as it is practiced at present is not an exciting topic for the nonsick. Diagnostic procedures that are acceptable by a patient, may be completely unacceptable, for reasons of time, expense or discomfort, by an individual who feels well. And, finally, most of the practices and procedures used in preventive medicine are too simple and easy (otherwise they would not belong under preventive medicine) for highly trained physicians. Clinical medicine is essentially a panic service; preventive medicine should be ’ Modified Workshop workshop
from a Paper Presented on Persons at High Risk was held at Key Biscayne,
at the National of Cancer: An FL, December I06
Copyright All rightJ
@ 1975 by Academic of repmduction in my
Press, Inc. form reserved.
Cancer Institute-American Approach to Cancer Etiology 9-12, 1974.
Cancer Society and Control. The
SPECIAL
ARTICLE:
PREVENTIVE
ONCOLOGY
107
a maintenance service. A sharp division between the two is neither possible nor desirable. Nevertheless, preventive medicine has its own clientele and techniques for which it needs its own practitioners and facilities. It cannot be practiced as a part-time adjunct of clinical medicine, yet it must be in close conjunction with clinical medicine. A somewhat different pattern of relationships, or contracts, is required between client and practitioner in preventive medicine than in clinical medicine, and between preventive and clinical medicine than between clinical branches. Preventive oncology has three tasks: (A) The acquisition and validation of knowledge regarding prevention through research and field trials. (B) The transmission of such knowledge, through education, which also requires research and validation. (C) The use of knowledge, through development of motivation and compliance with health practices and procedures. Again this task requires research, and the feedback of validation. The prevention of cancer (2) is essentially of two types: The prevention of occurrence (primary prevention), and the prevention of the consequences and sequelae of the disease or its precursors (secondary prevention). Information regarding primary prevention is obtained usually through epidemiologic research, which may go through the stages of description, analysis, and experimentation. Table 1 summarizes our sparse knowledge regarding etiologic factors in cancer (IO). Additional knowledge must be sought, but, for the practice of prevention, that must also include validation. Thus, it is not sufficient to find a relationship between an environmental factor and an increased risk to some form of cancer. Further studies are necessary to validate that the withdrawal of the factor indeed reduces the risk of cancer. Secondary prevention entails the definition and identification of high-risk groups and groups with precursor stages of disease (Table 1). There is, of course, no sharp break between primary and secondary prevention, nor between precursors and “early” stages of a disease. Thus, a woman who starts her sexual life early and continues intensive sexual activity increases her risk of cervical cancer; cervical dysplasia is a precursor of clinical cancer and in situ carcinoma of the cervix is still our best example of biologically early cancer. In this continuum, intervention is preferable between dysplasia and morphological malignancy, through the use of cytologic techniques. Two research areas in preventive oncology seem imperative but are conspicuous by their absence in the present cancer center plans. The first would encompass the study of the natural history and effect of treatment on the so-called premalignant lesions. We have but fuzzy knowledge of the actual quantitative risk of invasive cancer in patients with leukoplakia, with keratoses, and with polyps. Cohort studies are necessary to yield this information. The second area is the study of the value of various intervention procedures suggested against cancer and its precursors. The model for this is the evaluation of X-ray mammography for breast cancer detection, performed at the Health Insurance Plan
TABLE SOME
FACTORS
Stomach
Tobacco Alcohol Nutritional deficiency Alcohol Tobacco Nutritional deficiency Stricture (lye) 9
Colorectum
Diet
Liver
Alcohol ?Nutritional deficiency ?AtIatoxin Tobacco AlcohoI Tobacco Air pohhtion Occupational inhalation of chromate, asbestos, nickel, uranium. etc. Tobacco Schistosoma hematobium Occupational: aniline dye products Actinic radiation Ionizing radiation Arsenic Petroleum, tar products Bum scars Ionizing radiation ?Phenylbutazone ?Benzol ?Alkylat.ing agents Immunosuppression
Esophagus
Larynx Lung
Urinary bladder
Skin (incl. genitalia)
Leukemia (myelocytic) Lymphoma Thyroid Bone Testis Uterine cervix Endometrium Breast
1
TO OCCURRENCES
OF NEOPLASIA
Causative or predisposing factors ___~ Endogenous Exogenous
Site ______ Mouth and pharynx
RELATED
Ionizing radiation Iodine deficiency Ionizing radiation (radium) ?Mumps orchitis Early sex intercourse Promiscuity ?Uncircumcised partner ?Diet Ionizing radiation ?Diet
“Premaligna states or lesi
Phunmer-Vinson syndrome (sideropenia)
Leukoplakia -
Sideropenia Tylosis
?Dysplasia
Achlorhydria Pernicious anemia Familial (multiple polyposis) Ulcerative colitis Gardner’s syndrome Hemochromatosis Cirrhosis
Family history
?Tryptophan metabolism abnormality
Atrophic gastr Polyp ? Leukoplakia Cytologic atypl Bronchial aden Leukoplakia Papilloma
Fair complexion Xeroderma pigmentosum
Senile keratosi! Arsenical kerat Leukoplakia
Mongolism Bloom syndrome Fanconi syndrome
Myeloproliferdt states (preleukemia)
Agammaglobuhnemia Wiskott-Aldrich syndrome Family history Paget’s disease Fibrous dysplasia Osteochondroma Cryptorchidism
Endocrine: obesity, infertility, diabetes ?Ovarian hyperfunction Nulhparity Family history Endocrine: obesity, diabetes
3 ?Adenoma -
? Leukoplakia Cytologic dyspl: Cytologic atypie ?Hyperplasia Intraductile papilloma Chronic cystic disease
SPECIAL
ARTICLE:
PREVENTIVE
ONCOLOGY
109
of New York. (9) We simply must have quantitative data from which we can draw conclusions regarding cost-benefit ratios, acceptance by the public, and similar mundane but essential matters. The determination of cost should not obscure value, but these considerations are complementary. We must know the value and the cost of what we are selling! In regard to education, its purpose is to spread accurate information about cancer, and to discourage misinformation. Education should also include emphasis upon motivating the recipient to take the action implied in his education. We must be sure that the products we purvey are correct, and identify the areas of ignorance. We must clarify the thinking of teachers who continue to confuse “early” and “small” cancers. The term “early” is a misnomer for most situations regarding cancer, since we seldom have a measure of the time the lesion has existed. The size and extent of the lesion at first discovery by the patient or the physician do not measure the growth rate unless observed over time. “Late” also suggests that the prognosis in many cancers is related more closely to clinical delay than the facts support, and connotes guilt for the delay. A recent paper on patient delay in cancer (4) used delay itself as the endpoint, rather than the effect of such delay, if any, on outcome. A flurry of letters objecting to this was heartening (12). To reiterate for emphasis: Delay, from symptoms or signs to treatment, is meaningful only if it affects the outcome. Otherwise, reduction in delay merely lengthens the period of worry and expense. How we educate in health is a field of special expertise. There has been disenchantment in hardware aids to education, and in ex cathedra spoon-feeding by professors. I suspect that the elements that will survive include an early start of education, group participation, and peer and leadership examples. And no phony information, please! One approach to the evaluation of education in cancer would be to analyze the stage distribution and outcome of cancer among physicians and other health personnel, as compared to appropriate patients without such medical background. Does a medical education motivate “earlier” reference for treatment of colorectal cancer? If it does not, a rigorous reappraisal of some of our educational concepts would be in order. The negative effect of too much education is not unknown. The next component necessary for the development of preventive oncology is a facility staffed by men and women trained in preventive medical methodology (5) where the simpler predictive and screening procedures would be performed. This would include a history and an abbreviated physical, blood pressure, urinalysis, blood sample for the laboratory, an electrocardiogram, hematest on a fecal sample, and X-ray mammography and vaginal smear for women. A “check-up” physical, carried out by paramedical personnel, must be considered as a screening procedure, with those identified as abnormal being channeled immediately to appropriate medical clinics. It must be admitted that cold analyses of the benefits of multiphasic screening are not exactly heartening in their conclusions (6). With few exceptions, we lack data on the quantitative value and the cost of most procedures that are usually included in multiphasic screening. However, it is evident that in most settings
110
MICHAEL
B. SHIMKIN
TABLE 2 CHANCE IN 100,000 OF DYING DURING NEXT IO YRS US 1968 [DATA
FROM
GELLER
Age
20 -.1810 4070 670 1690
.-White Black White Black
male male female female
-
(S)]
-.--
30
40
50
60
2220 6730 1240 3730
5490 12,220 3050 7490
14,290 23,000 6920 14,350
31,840 44,350 15,810 32,320
-
the comparisons are not between groups getting the multiphasing screening versus groups not getting the procedures. The latter are also covered by some medical service scheme, and get many of the same procedures when considered indicated. Certainly, convenience and cost in time should be considered as well as the more usual indices of beneficial medical effects. It is neither economical nor medically sound to separate tests for cancer from test for hypertension, diabetes, or habits that may be hazardous to that individual. At this point we extend from cancer to the totality of risks that threaten health and life. The topic now is preventive medicine. Risk to life is the easiest risk to measure. The insurance companies have been making good money on this measure for many decades. Table 2 summarizes the total risk of mortality in four major groups that compose our population, expressed in IO-year periods. These are condensed from the Geller tables (3), based on 1968 data. It shows the advantages of the female sex and white skin. Table 3 indicates the major causes of death among white males, and Table 4, TABLE WHITE
MALE:
CHANCE
3
IN 100,000 [DATA FROM
OF DYING GELLER
20
30
DURING
NEXT 10 YEARS
(3)]
.---.---All causes Arteriosclerotic heart disease Cancer of lung Stroke Auto accidents Cirrhosis Emphysema Suicide Pneumonia Cancer of colorectum Accidents Homicide
----~2220 310 47 64 376 86
1810 22
II
I
24 762
I
III V
I57 28
III
200 45
II IV
228 I08
IV V
174 I07
40 I IV II III v
5498 1861 291 209 339 304 62 253 I14 88
URoman numerals indicate relative importance in each age group.
50 I II III v IV
14,290 5874 IO40 666 373 567 319 324 297 303
60
I III II IV v
31,840 13.759 2165 2270 400 649 I I64 337 722 747
SPECIAL
ARTICLE:
PREVENTIVE TABLE
WHITE FEMALE: CHANCE
FROM
20 All causes Arteriosclerotic heart disease Stroke Cancer of breast Cancer of colorectum Auto accidents Cirrhosis Cancer of lung Pneumonia Suicide Homicide
GELLER
DURING
8
v
IV
23 9
IV II
I
170 8
I
21 59 28
III
NEXT
40
1240 62 73 100
I III II
119 51
V IV
34 94 29
10 YEARS
(3)]
30
670
V II III
4
100,000 OF DYING
IN [DATA
111
ONCOLOGY
3050 355 200 351 95 127 167 99 69 126
50 I III II IV V
6920 1483 498 678 289 148 273 237 146 129
60 I II III IV V
15,810 5448 1566 839 639 204 256 325 314
a Roman numerals indicate relative importance in each age group.
among white females. The relative risks for each age group are indicated in roman numerals, as well as the absolute risks for lo-year periods. In the younger age group, the violent nature of our society is profiled. Accidents, suicide and homicide rank above all diseases. In older age groups, many of the diseases are self-induced. Lung cancer, the top neoplastic killer of men, and creeping up on the list for women, has cigarette smoking as its primary cause. Cirrhosis of the liver is alcohol-induced in 90% of our population. Traditional curative medicine is certainly not the answer to these societal lifestyle problems. As we learned, reduction in gasoline supplies and speed limits saved more lives on our highways than could have been achieved by erecting and staffing first-aid stations on every crossroad of the nation. Automobile, alcohol and arms make a particularly fatal triad. Lewis Robbins has devised a systematic assay and guidance scheme that he calls prospective medicine (7,8). Table 5 shows one step in the process, in which a 40-year-old man, with a 5.5% chance of dying during the next 10 years on the basis of general age-sex-race risks, is analyzed for the risks relative to the first cause of anticipated death, arteriosclerotic heart disease, which accounts for one-third of the total risk. There are at least six defined risk-factors that are listed and to which rough numerical values can be given as they affect the risk. Thus, elevated blood pressure carries increased risk; it can be reduced by treatment. Other factors can be reduced only by changes in life-style, such as smoking. The importance of the analysis is that something can be done about many of the factors. Studies to obtain improved estimates of risk should have high priority for situations in which such data are dubious or crude. Causes of mortality are the most obvious and most dramatic threats. With some disease entities we are also beginning to measure the cost in terms of inca-
112
MICHAEL
B. SHIMKIN
TABLE White male Rank 1
Age 40
Cause of death
No.
%
Arteriosclerotic heart disease
1.877
33.8
D Source: Robbins and Hall (3.
5” Total risk: 5560 Prognostic characteristics Blood pressure systolic 200 180 160 140 120 Diastolic 106 100 94 88 82 Cholesterol level 280 220 180 Diabetic Yes Controlled No Exercise habits Sedentary work and leisure Some activity work or leisure Moderate exercise Vigorous exercise Family history of ASHD Both parents died before 60 One parent died before 60 Neither, if now under 60 Neither, if now over 60 Smoking habits: Cigarettes daily average 4 pack or more Under t pack Cigars or pipe Stopped smoking within 10 yr Nonsmoker or stopped 10 yr Weight 75% Overweight 50% Overweight 15% Overweight 10% Underweight
Factor
3.2 2.2 1.4 .8 .4 3.7 2.0 1.3 .8 .4 I.5 1.0 .5 3.0 2.5 1.0
2.5 1.0 .6 .5 1.4 1.2 1.0
.9
1.5 1.1 1.0
.7 .5 2.5 1.5 1.0 .8
SPECIAL
ARTICLE:
PREVENTIVE
113
ONCOLOGY
pacitation. We are still very far from objective approaches to the ultimate, the measure of the quality of life, but that day will come. We return to the practitioners of preventive medicine and their clients, the public. This public service may well save medicine as well as improve the health of the people. Canada has recognized (11) that there can be no unlimited spending for personal health services and that the legitimate way of controlling such demand is through education and health maintenance. This makes medical as well as fiscal sense. Our main threats to life are now based primarily on lifestyles and habits. Advice on healthy habits does not require highly specialized physicians or expensive hospital centers. We should broaden health maintenance by teaching body awareness, including self-examinations and examinations of one’s children or each other in conjugal or other pairings. Women’s Lib has shown what can be done in this regard (I). It needs some tidying up, but the approach is useful. It is a legitimate concern for the preventive medicine units I am visualizing. Let us now designate them as Preventories. It is in the Preventories that health education, health surveillance and multiphasic screening would come together, where self-examinations and examinations of one’s partners would be taught, where premarital and prenatal advice and guidance would be offered, all summarized in a neat packet for the individual as well as for any central record keeping. If automobiles have records placed on the door to indicate the date for the next lube job, a human machine deserves no less. Another important role of Preventories in health scheme of the future is that they are natural units for community health action. Here would be one of the groups which could discuss community health matters such as air pollution, water supplies, and industrial incursions. The social contract between the members of a Preventory and its professional staff would be different from one that is more appropriate between patients and doctors. The ideal, of course, is a full partnership with each, in turn, acting as a messenger into the community. The relationship of Preventories with clinical centers must be intimate. There is no point in picking up incipient disease if nothing can be or is done about it. There is also a serious limitation of the system if the fiscal arrangements of the Preventory are separated from the clinical center. Here we are in that sticky area of unresolved national policy regarding national health insurance and health TABLE REQUIREMENTS
FOR HEALTH
Money Available Acceptable Accountable
6
SYSTEM:
THE
Men
A,M,
MATRIX
Mater3
114
MICHAEL
B. SHIMKIN
maintenance organizations, not to mention professional services review organizations. I assume that we accept the national consensus that medical care of all people is a right and no longer a privilege. All segments of the medical care system would profit from inclusion of preventive medicine in the plans. The payoffs would be better health and better health-educated people. We have now gone from preventive oncology to preventive medicine, to Preventories, and thence to health maintenance for the population. For all these plans, the A3M3 matrix, as indicated in Table 6, has to be fulfilled. Money, Men (including women, of course) and Materiel have to be, in turn, available, acceptable and accountable to the public. The people of the United States deserve no less than a health system that fulfills these characteristics. REFERENCES 1. Boston Woman’s Health Book Collective, “Our Bodies Our Selves.” Simon and Schuster, New York, 1971. 2. Breslow, L. The Prevention of Cancer, in “Cancer” (R. W. Raven, Ed.), Vol. 6, pp. 464-493. Buttenvorths, London, 1959. 3. Geller, H. “Probability Tables of Deaths in the Next Ten Years From Specific Causes.” Methodist Hospital Graduate Medical Center, Indianapolis, IN, 1972. 4. Hackett, T. P., Cassem, N. H. and Raker, J. W. Patient delay cancer. N. Eng. J. Med. 289, 14-20 ( 1973). 5. Martin, P. L. Cervical cancer. Use of a nonphysician health team for screening procedures. Cnl$ Med. 110, 463-467 (1969). 6. McKeown, T. ef al. “Screening in Medical Care.” Oxford University Press, London, 1968. 7. Robbins, L. C. and Hall, J. H. “How To Practice Prospective Medicine.” Slaymaker Enterprises, Indianapolis, IN, 1970. 8. Sadusk, J. F., Jr. and Robbins, L. C. Proposal for health-hazard appraisal in comprehensive health care. J. Amer. Med. Assoc. 203, 1108-l II2 (1968). 9. Shapiro, S., Strax, P., and Venet. L. Evaluation of the role of periodic breast screening in reducing the mortality from breast cancer. J. Amer. Med. Assoc. 215, l777- 1785 (197 I). IO. Shimkin, M. B., Primary prevention of cancer, in “Cancer Medicine” (J. F. Holland and E. Frei III, EXs.), pp. 382-390. Lea and Febiger, Philadelphia, PA, 1973. 11. Somers, A. R. Recharting national health priorities: A new Canadian perspective. N. Engl. J. Med. 291.4 15-4 I6 ( 1974). 12. Vietzke, W. M. el al. Implications of delay in cancer. (Letters) 14. Eng. J. Med. 289, 810-81 I (1973).
MEDICINE
4, loti-
1 I4 ( 1975)
SPECIAL ARTICLE
School
Preventive
Oncology
MICHAEL
B. SHIMKIN
of Medicine. University of California, San Diego, Sun Diego. California
This is the right time to propose a new specialty, Preventive Oncology. It is no secret that in the United States preventive medicine has been talked about much more than practiced. It has no financial base, and it falls in the crack between public health and medicine. Some of us had hoped that preventive medicine could come of age under the Regional Medical Program, but that idea wound up on the shoals. Preventive oncology can assume a leadership position for preventive medicine if it is developed as an integral yet identified component of the network of cancer centers that is being established under the National Cancer Plan. It would be my fervent hope that, under the flag of cancer, the plans would include not only other diseases but would be oriented to health rather than to disease. Since the objectives are broader than cancer, let us postpone creating an American Society of Preventive Oncology, or issuing an American Journal of Preventive Oncology, although perhaps we need both. Preventive oncology, and all preventive medicine, is not yet another clinical specialty. It involves different types of practitioners, and different practitionerpeople relationships than those appropriate for the clinical branches of medicine. The usual clinical patient is someone who hurts, or suspects he or she might hurt. Such a patient comes to a physician for help, and the roles of supplicant and grantor, or of consumer and provider, are immediate and obvious. In preventive medicine, there are no patients, but individuals, with different sets of motivations and anticipations. People, in general, simply are not patients most of the time. To attract their attention and to motivate them to carry out recommendations said to be good for them require different techniques than are effective among the sick. Health education as it is practiced at present is not an exciting topic for the nonsick. Diagnostic procedures that are acceptable by a patient, may be completely unacceptable, for reasons of time, expense or discomfort, by an individual who feels well. And, finally, most of the practices and procedures used in preventive medicine are too simple and easy (otherwise they would not belong under preventive medicine) for highly trained physicians. Clinical medicine is essentially a panic service; preventive medicine should be ’ Modified Workshop workshop
from a Paper Presented on Persons at High Risk was held at Key Biscayne,
at the National of Cancer: An FL, December I06
Copyright All rightJ
@ 1975 by Academic of repmduction in my
Press, Inc. form reserved.
Cancer Institute-American Approach to Cancer Etiology 9-12, 1974.
Cancer Society and Control. The
SPECIAL
ARTICLE:
PREVENTIVE
ONCOLOGY
107
a maintenance service. A sharp division between the two is neither possible nor desirable. Nevertheless, preventive medicine has its own clientele and techniques for which it needs its own practitioners and facilities. It cannot be practiced as a part-time adjunct of clinical medicine, yet it must be in close conjunction with clinical medicine. A somewhat different pattern of relationships, or contracts, is required between client and practitioner in preventive medicine than in clinical medicine, and between preventive and clinical medicine than between clinical branches. Preventive oncology has three tasks: (A) The acquisition and validation of knowledge regarding prevention through research and field trials. (B) The transmission of such knowledge, through education, which also requires research and validation. (C) The use of knowledge, through development of motivation and compliance with health practices and procedures. Again this task requires research, and the feedback of validation. The prevention of cancer (2) is essentially of two types: The prevention of occurrence (primary prevention), and the prevention of the consequences and sequelae of the disease or its precursors (secondary prevention). Information regarding primary prevention is obtained usually through epidemiologic research, which may go through the stages of description, analysis, and experimentation. Table 1 summarizes our sparse knowledge regarding etiologic factors in cancer (IO). Additional knowledge must be sought, but, for the practice of prevention, that must also include validation. Thus, it is not sufficient to find a relationship between an environmental factor and an increased risk to some form of cancer. Further studies are necessary to validate that the withdrawal of the factor indeed reduces the risk of cancer. Secondary prevention entails the definition and identification of high-risk groups and groups with precursor stages of disease (Table 1). There is, of course, no sharp break between primary and secondary prevention, nor between precursors and “early” stages of a disease. Thus, a woman who starts her sexual life early and continues intensive sexual activity increases her risk of cervical cancer; cervical dysplasia is a precursor of clinical cancer and in situ carcinoma of the cervix is still our best example of biologically early cancer. In this continuum, intervention is preferable between dysplasia and morphological malignancy, through the use of cytologic techniques. Two research areas in preventive oncology seem imperative but are conspicuous by their absence in the present cancer center plans. The first would encompass the study of the natural history and effect of treatment on the so-called premalignant lesions. We have but fuzzy knowledge of the actual quantitative risk of invasive cancer in patients with leukoplakia, with keratoses, and with polyps. Cohort studies are necessary to yield this information. The second area is the study of the value of various intervention procedures suggested against cancer and its precursors. The model for this is the evaluation of X-ray mammography for breast cancer detection, performed at the Health Insurance Plan
TABLE SOME
FACTORS
Stomach
Tobacco Alcohol Nutritional deficiency Alcohol Tobacco Nutritional deficiency Stricture (lye) 9
Colorectum
Diet
Liver
Alcohol ?Nutritional deficiency ?AtIatoxin Tobacco AlcohoI Tobacco Air pohhtion Occupational inhalation of chromate, asbestos, nickel, uranium. etc. Tobacco Schistosoma hematobium Occupational: aniline dye products Actinic radiation Ionizing radiation Arsenic Petroleum, tar products Bum scars Ionizing radiation ?Phenylbutazone ?Benzol ?Alkylat.ing agents Immunosuppression
Esophagus
Larynx Lung
Urinary bladder
Skin (incl. genitalia)
Leukemia (myelocytic) Lymphoma Thyroid Bone Testis Uterine cervix Endometrium Breast
1
TO OCCURRENCES
OF NEOPLASIA
Causative or predisposing factors ___~ Endogenous Exogenous
Site ______ Mouth and pharynx
RELATED
Ionizing radiation Iodine deficiency Ionizing radiation (radium) ?Mumps orchitis Early sex intercourse Promiscuity ?Uncircumcised partner ?Diet Ionizing radiation ?Diet
“Premaligna states or lesi
Phunmer-Vinson syndrome (sideropenia)
Leukoplakia -
Sideropenia Tylosis
?Dysplasia
Achlorhydria Pernicious anemia Familial (multiple polyposis) Ulcerative colitis Gardner’s syndrome Hemochromatosis Cirrhosis
Family history
?Tryptophan metabolism abnormality
Atrophic gastr Polyp ? Leukoplakia Cytologic atypl Bronchial aden Leukoplakia Papilloma
Fair complexion Xeroderma pigmentosum
Senile keratosi! Arsenical kerat Leukoplakia
Mongolism Bloom syndrome Fanconi syndrome
Myeloproliferdt states (preleukemia)
Agammaglobuhnemia Wiskott-Aldrich syndrome Family history Paget’s disease Fibrous dysplasia Osteochondroma Cryptorchidism
Endocrine: obesity, infertility, diabetes ?Ovarian hyperfunction Nulhparity Family history Endocrine: obesity, diabetes
3 ?Adenoma -
? Leukoplakia Cytologic dyspl: Cytologic atypie ?Hyperplasia Intraductile papilloma Chronic cystic disease
SPECIAL
ARTICLE:
PREVENTIVE
ONCOLOGY
109
of New York. (9) We simply must have quantitative data from which we can draw conclusions regarding cost-benefit ratios, acceptance by the public, and similar mundane but essential matters. The determination of cost should not obscure value, but these considerations are complementary. We must know the value and the cost of what we are selling! In regard to education, its purpose is to spread accurate information about cancer, and to discourage misinformation. Education should also include emphasis upon motivating the recipient to take the action implied in his education. We must be sure that the products we purvey are correct, and identify the areas of ignorance. We must clarify the thinking of teachers who continue to confuse “early” and “small” cancers. The term “early” is a misnomer for most situations regarding cancer, since we seldom have a measure of the time the lesion has existed. The size and extent of the lesion at first discovery by the patient or the physician do not measure the growth rate unless observed over time. “Late” also suggests that the prognosis in many cancers is related more closely to clinical delay than the facts support, and connotes guilt for the delay. A recent paper on patient delay in cancer (4) used delay itself as the endpoint, rather than the effect of such delay, if any, on outcome. A flurry of letters objecting to this was heartening (12). To reiterate for emphasis: Delay, from symptoms or signs to treatment, is meaningful only if it affects the outcome. Otherwise, reduction in delay merely lengthens the period of worry and expense. How we educate in health is a field of special expertise. There has been disenchantment in hardware aids to education, and in ex cathedra spoon-feeding by professors. I suspect that the elements that will survive include an early start of education, group participation, and peer and leadership examples. And no phony information, please! One approach to the evaluation of education in cancer would be to analyze the stage distribution and outcome of cancer among physicians and other health personnel, as compared to appropriate patients without such medical background. Does a medical education motivate “earlier” reference for treatment of colorectal cancer? If it does not, a rigorous reappraisal of some of our educational concepts would be in order. The negative effect of too much education is not unknown. The next component necessary for the development of preventive oncology is a facility staffed by men and women trained in preventive medical methodology (5) where the simpler predictive and screening procedures would be performed. This would include a history and an abbreviated physical, blood pressure, urinalysis, blood sample for the laboratory, an electrocardiogram, hematest on a fecal sample, and X-ray mammography and vaginal smear for women. A “check-up” physical, carried out by paramedical personnel, must be considered as a screening procedure, with those identified as abnormal being channeled immediately to appropriate medical clinics. It must be admitted that cold analyses of the benefits of multiphasic screening are not exactly heartening in their conclusions (6). With few exceptions, we lack data on the quantitative value and the cost of most procedures that are usually included in multiphasic screening. However, it is evident that in most settings
110
MICHAEL
B. SHIMKIN
TABLE 2 CHANCE IN 100,000 OF DYING DURING NEXT IO YRS US 1968 [DATA
FROM
GELLER
Age
20 -.1810 4070 670 1690
.-White Black White Black
male male female female
-
(S)]
-.--
30
40
50
60
2220 6730 1240 3730
5490 12,220 3050 7490
14,290 23,000 6920 14,350
31,840 44,350 15,810 32,320
-
the comparisons are not between groups getting the multiphasing screening versus groups not getting the procedures. The latter are also covered by some medical service scheme, and get many of the same procedures when considered indicated. Certainly, convenience and cost in time should be considered as well as the more usual indices of beneficial medical effects. It is neither economical nor medically sound to separate tests for cancer from test for hypertension, diabetes, or habits that may be hazardous to that individual. At this point we extend from cancer to the totality of risks that threaten health and life. The topic now is preventive medicine. Risk to life is the easiest risk to measure. The insurance companies have been making good money on this measure for many decades. Table 2 summarizes the total risk of mortality in four major groups that compose our population, expressed in IO-year periods. These are condensed from the Geller tables (3), based on 1968 data. It shows the advantages of the female sex and white skin. Table 3 indicates the major causes of death among white males, and Table 4, TABLE WHITE
MALE:
CHANCE
3
IN 100,000 [DATA FROM
OF DYING GELLER
20
30
DURING
NEXT 10 YEARS
(3)]
.---.---All causes Arteriosclerotic heart disease Cancer of lung Stroke Auto accidents Cirrhosis Emphysema Suicide Pneumonia Cancer of colorectum Accidents Homicide
----~2220 310 47 64 376 86
1810 22
II
I
24 762
I
III V
I57 28
III
200 45
II IV
228 I08
IV V
174 I07
40 I IV II III v
5498 1861 291 209 339 304 62 253 I14 88
URoman numerals indicate relative importance in each age group.
50 I II III v IV
14,290 5874 IO40 666 373 567 319 324 297 303
60
I III II IV v
31,840 13.759 2165 2270 400 649 I I64 337 722 747
SPECIAL
ARTICLE:
PREVENTIVE TABLE
WHITE FEMALE: CHANCE
FROM
20 All causes Arteriosclerotic heart disease Stroke Cancer of breast Cancer of colorectum Auto accidents Cirrhosis Cancer of lung Pneumonia Suicide Homicide
GELLER
DURING
8
v
IV
23 9
IV II
I
170 8
I
21 59 28
III
NEXT
40
1240 62 73 100
I III II
119 51
V IV
34 94 29
10 YEARS
(3)]
30
670
V II III
4
100,000 OF DYING
IN [DATA
111
ONCOLOGY
3050 355 200 351 95 127 167 99 69 126
50 I III II IV V
6920 1483 498 678 289 148 273 237 146 129
60 I II III IV V
15,810 5448 1566 839 639 204 256 325 314
a Roman numerals indicate relative importance in each age group.
among white females. The relative risks for each age group are indicated in roman numerals, as well as the absolute risks for lo-year periods. In the younger age group, the violent nature of our society is profiled. Accidents, suicide and homicide rank above all diseases. In older age groups, many of the diseases are self-induced. Lung cancer, the top neoplastic killer of men, and creeping up on the list for women, has cigarette smoking as its primary cause. Cirrhosis of the liver is alcohol-induced in 90% of our population. Traditional curative medicine is certainly not the answer to these societal lifestyle problems. As we learned, reduction in gasoline supplies and speed limits saved more lives on our highways than could have been achieved by erecting and staffing first-aid stations on every crossroad of the nation. Automobile, alcohol and arms make a particularly fatal triad. Lewis Robbins has devised a systematic assay and guidance scheme that he calls prospective medicine (7,8). Table 5 shows one step in the process, in which a 40-year-old man, with a 5.5% chance of dying during the next 10 years on the basis of general age-sex-race risks, is analyzed for the risks relative to the first cause of anticipated death, arteriosclerotic heart disease, which accounts for one-third of the total risk. There are at least six defined risk-factors that are listed and to which rough numerical values can be given as they affect the risk. Thus, elevated blood pressure carries increased risk; it can be reduced by treatment. Other factors can be reduced only by changes in life-style, such as smoking. The importance of the analysis is that something can be done about many of the factors. Studies to obtain improved estimates of risk should have high priority for situations in which such data are dubious or crude. Causes of mortality are the most obvious and most dramatic threats. With some disease entities we are also beginning to measure the cost in terms of inca-
112
MICHAEL
B. SHIMKIN
TABLE White male Rank 1
Age 40
Cause of death
No.
%
Arteriosclerotic heart disease
1.877
33.8
D Source: Robbins and Hall (3.
5” Total risk: 5560 Prognostic characteristics Blood pressure systolic 200 180 160 140 120 Diastolic 106 100 94 88 82 Cholesterol level 280 220 180 Diabetic Yes Controlled No Exercise habits Sedentary work and leisure Some activity work or leisure Moderate exercise Vigorous exercise Family history of ASHD Both parents died before 60 One parent died before 60 Neither, if now under 60 Neither, if now over 60 Smoking habits: Cigarettes daily average 4 pack or more Under t pack Cigars or pipe Stopped smoking within 10 yr Nonsmoker or stopped 10 yr Weight 75% Overweight 50% Overweight 15% Overweight 10% Underweight
Factor
3.2 2.2 1.4 .8 .4 3.7 2.0 1.3 .8 .4 I.5 1.0 .5 3.0 2.5 1.0
2.5 1.0 .6 .5 1.4 1.2 1.0
.9
1.5 1.1 1.0
.7 .5 2.5 1.5 1.0 .8
SPECIAL
ARTICLE:
PREVENTIVE
113
ONCOLOGY
pacitation. We are still very far from objective approaches to the ultimate, the measure of the quality of life, but that day will come. We return to the practitioners of preventive medicine and their clients, the public. This public service may well save medicine as well as improve the health of the people. Canada has recognized (11) that there can be no unlimited spending for personal health services and that the legitimate way of controlling such demand is through education and health maintenance. This makes medical as well as fiscal sense. Our main threats to life are now based primarily on lifestyles and habits. Advice on healthy habits does not require highly specialized physicians or expensive hospital centers. We should broaden health maintenance by teaching body awareness, including self-examinations and examinations of one’s children or each other in conjugal or other pairings. Women’s Lib has shown what can be done in this regard (I). It needs some tidying up, but the approach is useful. It is a legitimate concern for the preventive medicine units I am visualizing. Let us now designate them as Preventories. It is in the Preventories that health education, health surveillance and multiphasic screening would come together, where self-examinations and examinations of one’s partners would be taught, where premarital and prenatal advice and guidance would be offered, all summarized in a neat packet for the individual as well as for any central record keeping. If automobiles have records placed on the door to indicate the date for the next lube job, a human machine deserves no less. Another important role of Preventories in health scheme of the future is that they are natural units for community health action. Here would be one of the groups which could discuss community health matters such as air pollution, water supplies, and industrial incursions. The social contract between the members of a Preventory and its professional staff would be different from one that is more appropriate between patients and doctors. The ideal, of course, is a full partnership with each, in turn, acting as a messenger into the community. The relationship of Preventories with clinical centers must be intimate. There is no point in picking up incipient disease if nothing can be or is done about it. There is also a serious limitation of the system if the fiscal arrangements of the Preventory are separated from the clinical center. Here we are in that sticky area of unresolved national policy regarding national health insurance and health TABLE REQUIREMENTS
FOR HEALTH
Money Available Acceptable Accountable
6
SYSTEM:
THE
Men
A,M,
MATRIX
Mater3
114
MICHAEL
B. SHIMKIN
maintenance organizations, not to mention professional services review organizations. I assume that we accept the national consensus that medical care of all people is a right and no longer a privilege. All segments of the medical care system would profit from inclusion of preventive medicine in the plans. The payoffs would be better health and better health-educated people. We have now gone from preventive oncology to preventive medicine, to Preventories, and thence to health maintenance for the population. For all these plans, the A3M3 matrix, as indicated in Table 6, has to be fulfilled. Money, Men (including women, of course) and Materiel have to be, in turn, available, acceptable and accountable to the public. The people of the United States deserve no less than a health system that fulfills these characteristics. REFERENCES 1. Boston Woman’s Health Book Collective, “Our Bodies Our Selves.” Simon and Schuster, New York, 1971. 2. Breslow, L. The Prevention of Cancer, in “Cancer” (R. W. Raven, Ed.), Vol. 6, pp. 464-493. Buttenvorths, London, 1959. 3. Geller, H. “Probability Tables of Deaths in the Next Ten Years From Specific Causes.” Methodist Hospital Graduate Medical Center, Indianapolis, IN, 1972. 4. Hackett, T. P., Cassem, N. H. and Raker, J. W. Patient delay cancer. N. Eng. J. Med. 289, 14-20 ( 1973). 5. Martin, P. L. Cervical cancer. Use of a nonphysician health team for screening procedures. Cnl$ Med. 110, 463-467 (1969). 6. McKeown, T. ef al. “Screening in Medical Care.” Oxford University Press, London, 1968. 7. Robbins, L. C. and Hall, J. H. “How To Practice Prospective Medicine.” Slaymaker Enterprises, Indianapolis, IN, 1970. 8. Sadusk, J. F., Jr. and Robbins, L. C. Proposal for health-hazard appraisal in comprehensive health care. J. Amer. Med. Assoc. 203, 1108-l II2 (1968). 9. Shapiro, S., Strax, P., and Venet. L. Evaluation of the role of periodic breast screening in reducing the mortality from breast cancer. J. Amer. Med. Assoc. 215, l777- 1785 (197 I). IO. Shimkin, M. B., Primary prevention of cancer, in “Cancer Medicine” (J. F. Holland and E. Frei III, EXs.), pp. 382-390. Lea and Febiger, Philadelphia, PA, 1973. 11. Somers, A. R. Recharting national health priorities: A new Canadian perspective. N. Engl. J. Med. 291.4 15-4 I6 ( 1974). 12. Vietzke, W. M. el al. Implications of delay in cancer. (Letters) 14. Eng. J. Med. 289, 810-81 I (1973).
