Pathologists, and surgical pathologists in particular, are in the business of frequently giving bad news to their clinician counterparts, and by extension to the patients they serve. Cancer remains a big deal, tissue diagnosis the gold standard needed to commence treatment and that’s where the pathologist comes in. The news that I often bring from the microscope is often bad; it’s cancer, or worse, it’s an especially aggressive form of cancer, or that the cancer has spread and is incurable.
And here at Duke, and in my own practice, it’s usually about lung cancer.
Clinicians aren’t usually surprised at the pathologist’s finding; lung cancer is not a subtle disease, nor is it uncommon. We see a ton of it at the Medical Center, involving folks from all walks of life, most of whom share the common bond of being smokers or ex-smokers. And if you follow this sort of thing, November is National Lung Cancer Awareness Month. No, there’s no Race for the Cure, no celebrity spokesman to put a face on lung cancer and you don’t get a bracelet. Lung cancer and its victims lack social currency, and it remains the poor relation among malignancies, its research underfunded in proportion to the magnitude and severity of the problems it causes.
It’s hard to frame a discussion of lung cancer without mentioning smoking, its principal cause. Back in the day, cigarettes were once touted as healthful reducers of stress, and a sign of glamour and suave sophistication. One could pretty much smoke where one pleased. The smokers among my grade school teachers were relegated to the noisome recesses of the teachers’ lounge, but a number of my college professors stalked about the classroom, cigarette in hand, as did a number of attending physicians during rounds in the hospital when I was a medical student. There were dedicated smoking rows in aircraft, and when the lights came on at the end of the show in movie theaters or in concert halls and sports arenas, it was usually to illuminate a dense and acrid fog of cigarette smoke.
Non-smoking areas of bars and restaurants were unheard of. The Surgeon General’s Advisory Committee 1964 report on smoking and health, concluding that cigarette smoking causes cancers of the lung and larynx in men and women, added scientific validity to the fledgling public health crusade against tobacco, beginning with health warnings on cigarette packages and the banning of cigarette advertising in the broadcast media.
The tobacco industry fought this strenuously and was quick to pounce on cigarette smoking as a means of rebellious empowerment for women and exercising one’s civil liberties. The Women’s Movement of the late 1960s and 1970s saw the targeting of young women as a vast market for tobacco products by the industry, and with this came the creation of cigarette brands intended solely for women.
And therein lies tragedy.
Previously responsible for a miniscule amount of cancer deaths in women, the creation of the contemporary young woman smoker has resulted in lung cancer’s emergence as the leading cause of cancer deaths in both sexes, more than breast, colon, prostate and all the remaining cancers of other solid organs combined. This remains true today. The lack of outrage and silence on this from groups advocating women’s rights has always puzzled and bothered me.
The Centers for Disease Control and Prevention currently estimates 46 million Americans, nearly 21 percent of the population older than 18, currently smoke cigarettes, with the highest rates among those who live below the poverty level. Nothing seems to spark a debate like plans to ban cigarette smoking in restaurants, bars and other public establishments. Cigarettes are legal products for adults to use—who’s the government to say where we can smoke? No one is forced to pass time in a smoky bar, argue some civil libertarians. Second-hand smoke is noxious and carcinogenic, and there is no absolute right to smoke anywhere you please and the cost of caring for tobacco-related disease as smoking slowly kills you is bankrupting us to boot, argue public health officials.
Regardless, workplace and public area smoking bans have been associated with greatly reduced prevalence in smoking: California’s aggressive anti-smoking campaigns and bans on smoking have been accompanied by a fall in smoking prevalence from 22.7 percent in 1988 to 13.8 percent in 2007. I don’t ever see a prohibition on tobacco and given the history of problems spawned by former prohibition on alcohol and the current disastrous prohibition on illicit drugs, this is probably a good thing. Lung cancer awareness can be distilled down to just a few points. If you choose to smoke, you stand a good chance of getting lung cancer. If you get lung cancer, there’s a good chance of it killing you. Public tobacco consumption abatement programs reduce the prevalence of smoking, and the most highly lethal form of cancer is paradoxically among the most preventable. Lung cancer lacks its Lance Armstrong, but it’s not exactly an unknown malady in Hollywood or in the sports and entertainment world, claiming the lives of John Wayne, Paul Newman, Walt Disney, Joe DiMaggio and Ayn Rand, with many others dying of tobacco-associated aerodigestive tract cancers. Should there be even more draconian measures to curb tobacco consumption? You decide.
In the meantime I have a stack of slides here by my microscope that’s about two feet thick. Inside there is bound to be bad news.
Dr. Thomas Sporn is an associate professor in the Department of Pathology. His column runs every other Friday.
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