The Emperor Must Die Published July 7, 2015 By Col. Kevin Murphy 436th Medical Group commander DOVER AIR FORCE BASE, DEL. -- Last month I read The Emperor of All Maladies: A Biography of Cancer by Sidhartha Mukherjee. Mukherjee weaves his experience as an oncologist and cancer researcher into the history, treatment and prevention of cancer going as far back as 2500 B.C. While the historical accounts of diagnosis and treatment were fascinating, the role of prevention was the critical piece. Any discussion of something abnormal must first start with what is normal. Normal body cells grow, divide and die each and every day. This cell division leads to growth in early life and replacement of dying cells or injury repair as an adult. Cancer, on the other hand, is caused by abnormal division growing out of control and often leading to invasion of normal surrounding tissues. Damage to DNA appears to play a critical role in determining which cells become cancer cells. When DNA is damaged in a normal cell, the cell either repairs the DNA or the cell dies. In a cancer cell, the DNA damage does not lead to cell death and the cell continues to make identical defective cells, cancer cells. Damaged DNA can be inherited, occur as a result of a mistake in replication or be induced by environmental factors such as smoking or sun exposure. The American Cancer Society estimates that there will be 3.9 million new cases of cancer this year and just over 600,000 cancer-related deaths. History The first reference to tumors comes from Imhotep, an ancient Egyptian surgeon, in 2500 B.C. Imhotep wrote about a number of medical conditions ranging from broken bones and abscesses to tumors. His diagnosis and treatment for each was carefully documented in great detail. Imhotep's despair and frustration at not being able to treat tumors is evident in his indicated therapy - "There is none." Around 400 B.C. Hippocrates used the word karkinos, Greek for crab, to describe tumor masses with radiating blood vessels that resembled a crab and its legs. Some 500 years later Galen, the highest medical authority for more than 1,000 years, attributed tumors to an internal overdose of black bile. Like Hippocrates, he felt that invasive tumors were "best left untreated, since patients live longer that way." Writing in Latin, karkinos translated to cancer. Outside of the examples above, early medical history has few references to cancer and there are several explanations for this absence. Cancer is an age-related disease. The risk of breast cancer for a 30-year old woman is 1 in 400, at 70 years of age the risk grows to 1 in 9. Simply stated, people usually succumbed to other diseases such as cholera, small pox and plague before cancer had a chance to present. Cancer incidence saw a sharp uptick in the nineteenth and twentieth centuries. Some of this can be attributed to an increase in the average lifespan, but environmental factors and changes in lifestyle also played a role. In 1900, tuberculosis was the most common cause of death, while cancer ranked seventh. Between 1900 and 1916, cancer related deaths grew by 29.8 percent and became the send leading cause of death behind heart disease. It's no coincidence that per capita consumption of cigarettes rose from 54 in 1900 to 675 in 1918. Per capita consumption continued to climb and reached its peak of 4,345 in 1963. During this period, lung cancer death rates skyrocketed from 2.7 per 100,000 to 75.6 per 100,000. If you thought the lung cancer statistics were sobering, the rate of skin cancer cases is even more astonishing. Today, about 2.2 million people per year are diagnosed with skin cancer - squamous cell, basal cell and melanoma. Over the past three decades, more people have been diagnosed with skin cancer that all other cancers combined. To put this in perspective, between 40 and 50 percent of Americans who live to the age of 65 will have either basal cell or squamous cell carcinoma, while one person dies of melanoma every 57 minutes. Treatment The advent of anesthesia in 1846 led to an explosion in surgical approaches in the treatment of cancer and ushered in "the century of the surgeon". At Johns Hopkins, Dr. William Halsted advanced the radical mastectomy for the treatment of breast cancer, a procedure that would remain in vogue for the next 80 years. Ground breaking research by Dr. Bernard Fisher in the 60s and 70s called into question the need for radical mastectomies and his research conclusively proved that a less-invasive lumpectomy surgery was just as effective as the radical mastectomy. In 1896, a 21-year old Chicago medical student, Emil Grubbe hypothesized that recently discovered X-rays could be used to kill cancer cells. He put his theory to the test and found X-rays to be successful at killing small localized cancers, but had no effect on tumors that had already metastasized. Further research validated his success and led to increased use of radiation therapy in conjunction with therapy. In 1933, Dr. Evarts Graham performed the first pneumonectomy (removal of an entire lung) to save a patient diagnosed with lung cancer. Ironically Dr. Graham, a lifelong smoker, died of lung cancer in 1957. Dr. (Lt Col) Stewart Alexander studied the effects of mustard gas on soldiers in 1943 and discovered that the gas stopped rapidly dividing cells and theorized it could be used to suppress the growth of cancer cells. Animal studies proved him correct and the first human treatments began in 1945, ushering in the age of chemotherapy. Today's combination of radiation therapy, chemotherapy and minimally invasive surgery have significantly improved outcomes, quality of life and survivability rates. Prevention and Early Detection Advanced diagnostic tools have enabled earlier detection which in-turn has led to earlier intervention and greater survivability rates. That said, an ounce of prevention is worth a pound of cure. So, what can you do to prevent the most common forms of cancer? Here are some tips. Skin cancer- Avoid tanning beds and cover up with clothing, including a wide-brimmed hat and UV-blocking sunglasses. Use a broad spectrum (UVA/UVB) sunscreen with an APF of 15 or higher, SPF 30 or higher for extended outdoor activity. Apply sunscreen 30 minutes prior to going outdoors and reapply frequently, every 2 hours, to maximize the effectiveness of the sunscreen. Examine your skin from head-to-toe once a month and follow the skin cancer ABCDEs - Asymmetry (draw a line through the center of a mole and both halves should resemble each other), Border (borders should be smooth), Color (should be a single shade), Diameter (should be smaller than the diameter of a pencil eraser), and Evolving (note any changes in size, shape, color or elevation). More information can be found at the following link - http://www.skincancer.org/skin-cancer-information. Lung cancer- Smoking is the single greatest cause of lung cancer. If you are a smoker and would like to quit smoking, the Medical Group has several resources to assist you. Health Promotion, formerly the HAWC, offers one on one tobacco cessation counseling, access to the "Freedom Quitline" which is sponsored by the Air Force and University of Tennessee, and direct provider counseling for nicotine replacement therapy (NRT). For these programs please contact the Health Promotion staff at 677-FRED. You can also call 430-7633 to schedule an appointment with Dr. Frazier, the Internal Behavioral Health Consultant, in the family clinic for assistance with stopping tobacco use and maintaining abstinence. Breast cancer- Women between the ages of 20 and 40, should perform monthly self-breast exams and have a clinical breast exam every three years. Women 40 and over should also perform monthly self-breast exams and have a clinical breast exam annually. Mammograms are also recommended annually for women ages 40 and over. Colon cancer- diets high in vegetables, fruits, and whole grains have been linked with a decreased risk of colorectal cancer. Being physically active and maintaining a healthy weight has also been linked to a lower risk of colon cancer. Regular screening with a colonoscopy, beginning at age 50, is recommended for men and women. Those with a family history of colon cancer or other risk factors may need a colonoscopy at an earlier age and should check with their doctor. Cervical cancer- nearly all cervical cancers are linked to the human papilloma virus (HPV). Two vaccines are available to protect against certain HPV infections and the American Cancer Society recommends routine vaccination for boys and girls at 12 years of age, or as early as 9 years of age in extenuating circumstances. Women should start getting Pap smears at age 21. Women age 21-29 should get routine pap smears every 3yrs. Women over the age of 30 should have routine pap smears every 5 years with additional HPV testing. If a woman has an abnormal pap, it is imperative for her to follow up with her Gyn provider. Significant advances in diagnosis and treatment have drastically reduced the number of cancer related deaths and enhanced the quality of life for cancer patients. But, there will still be 3.6 million new cases this year and more than 600,000 will die as a result of cancer. Following the preventive tips above will significantly increase your chances of having a cancer-free life. Now, take these preventive weapons and kill the Emperor.