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Relationship of Smoking to Carcinoma
191
Relationship of Smoking to Carcinoma A-foderator: Dil~cussant:
Arthur M. Olsen, M.D. Alton Ochsner, f.l.D.
Dr. Ochsner: My interest in this subject began in 193~. I had seen only one case of cancer of the lung durmg my four years in medical school. At that time, this disease was so rare that the whole student body of Washington University was called to see it. I did not see another case until 1936. I had gone to Tulane University as Professor of Surgery in 1927, and in 1936 I saw nine men with cancer of the lung in a period of six months. Suddenly an epidemic had appeared to occur. All these patients had one thing in common. They were all men who had begun smoking during the first World War and had smoked excessively. At that time, I had the temerity to suggest that there might be a causal relationship between smoking and cancer of the lung. Because I had had no experience with the disease, I thought that it might be controlled if we could make an early diagnosis. With time, however, and after having seen more than 4,000 cases of cancer of the lung, I have become convinced that it is, as was brought out this morning, a hopeless disease. The five-year survival rate when the diagnosis of cancer of the lung is made is only about 6 per cent. The reason for this almost hopeless prognosis is the early angio-invasive character of the lesion. Several years ago, Dr. Hurst Hatch, Director of our Pulmonary Physiology Laboratory, conceived an idea based on the premise that a vein draining a viscus with carcinoma contains a higher incidence of neoplastic cells than does the systemic circulation. We know that is a valid concept because blood from the portal vein of patients with carcinoma of the colon contains a higher percentage of neoplastic cells than blood in the systemic circulation. The patient with carcinoma of the lung should have a high incidence of neoplastic cells in the peripheral arterial circulation. Therefore, about five years ago, Dr. Hatch and Dr. Guillermo Carrera, Head of our Department of Pathology, began doing cytologic studies on the peripheral arterial blood on all patients going through the Pulmonary Physiology Laboratory. They found no neoplastic cells in patients with benign lesions of the lung; there were no false positive results. Of those with proved carcinoma of the lung, 40 per cent had neoplastic cells in their peripheral arterial blood. These observations have not changed our treatment at all because I am convinced that the blood is tumoricidal, and although the potentiality for DIS. CHEST, VOL. 54, NO.3, SEPTEMBER 1968
metastasis exists, I believe that this should not change our thinking. I would question Dr. Hom's statement that a patient with carcinoma of the lung does not have to stop smoking. We can salvage about 6 per cent of these patients. I have had five patients who have survived longer than five years, and these are the five, I think, who have not stopped smoking and the only patients in whom a recurrent lesion or a new lesion developed. We can all agree that carcinoma of the lung, epidermoid carcinoma, is caused by tobacco and largely, cigarette smoking. Dr. Oscar Auerba~h ha~ proved this conclusively. Other carcinomas are caused by tobacco, and the tobacco does not necessarily have to be lighted because a large number of people in the south still use snuff. The snuff is put between the cheek and jaw. A vicious type of cancer results from this practice. Although some have speculated that the cancer might be due to the paper used to wrap the tobacco for cigarettes, snuff has no paper and it causes cancer. It is the carcinogens in the tobacco that cause cancer. Carcinoma of the tongue, lips, and larynx are also caused by tobacco, which can be cigar or pipe tobacco as well as cigarette tobacco. Cigarette smoking is the culprit in cancer of the lungs because the cigarette smoker inhales. The cigar and pipe smoker usually does not inhale unless he has been a heavy cigarette smoker and switches to a pipe. Also to be considered in regard to carcinoma of the lips, tongue, esophagus, and larynx is the added factor of alcoholic consumption. Apparently, the nutrititonal disturbance resulting from excessive consumption of alcohol added to the carcinogenic effect of the tobacco tars is of importance. The incidences of carcinoma of the esophagus and bladder are increasing, and usually patients with these conditions use tobacco. The incidence of cancer of the bladder is definitely higher in people who use tobacco. When cancer is produced in animals by applying a carcinogen to the cutaneous surface, not only will cancer develop at the site of application of the tar, but it will develop in the bladder in a very high percentage of them. The probable reason for this is that the carcinogen is absorbed into the blood stream and is excreted in the urine, and the urinary bladder mucosa is particularly susceptible to malignant change. Dr. Oscar Auerbach made the statement that a patient who has an epidermoid or undifferentiated carcinoma is a smoker. He has never seen a patient with one of these carcinomas who was not a smoker. 23
Relationship of Smoking to Carcinoma A-foderator: Dil~cussant:
Arthur M. Olsen, M.D. Alton Ochsner, f.l.D.
Dr. Ochsner: My interest in this subject began in 193~. I had seen only one case of cancer of the lung durmg my four years in medical school. At that time, this disease was so rare that the whole student body of Washington University was called to see it. I did not see another case until 1936. I had gone to Tulane University as Professor of Surgery in 1927, and in 1936 I saw nine men with cancer of the lung in a period of six months. Suddenly an epidemic had appeared to occur. All these patients had one thing in common. They were all men who had begun smoking during the first World War and had smoked excessively. At that time, I had the temerity to suggest that there might be a causal relationship between smoking and cancer of the lung. Because I had had no experience with the disease, I thought that it might be controlled if we could make an early diagnosis. With time, however, and after having seen more than 4,000 cases of cancer of the lung, I have become convinced that it is, as was brought out this morning, a hopeless disease. The five-year survival rate when the diagnosis of cancer of the lung is made is only about 6 per cent. The reason for this almost hopeless prognosis is the early angio-invasive character of the lesion. Several years ago, Dr. Hurst Hatch, Director of our Pulmonary Physiology Laboratory, conceived an idea based on the premise that a vein draining a viscus with carcinoma contains a higher incidence of neoplastic cells than does the systemic circulation. We know that is a valid concept because blood from the portal vein of patients with carcinoma of the colon contains a higher percentage of neoplastic cells than blood in the systemic circulation. The patient with carcinoma of the lung should have a high incidence of neoplastic cells in the peripheral arterial circulation. Therefore, about five years ago, Dr. Hatch and Dr. Guillermo Carrera, Head of our Department of Pathology, began doing cytologic studies on the peripheral arterial blood on all patients going through the Pulmonary Physiology Laboratory. They found no neoplastic cells in patients with benign lesions of the lung; there were no false positive results. Of those with proved carcinoma of the lung, 40 per cent had neoplastic cells in their peripheral arterial blood. These observations have not changed our treatment at all because I am convinced that the blood is tumoricidal, and although the potentiality for DIS. CHEST, VOL. 54, NO.3, SEPTEMBER 1968
metastasis exists, I believe that this should not change our thinking. I would question Dr. Hom's statement that a patient with carcinoma of the lung does not have to stop smoking. We can salvage about 6 per cent of these patients. I have had five patients who have survived longer than five years, and these are the five, I think, who have not stopped smoking and the only patients in whom a recurrent lesion or a new lesion developed. We can all agree that carcinoma of the lung, epidermoid carcinoma, is caused by tobacco and largely, cigarette smoking. Dr. Oscar Auerba~h ha~ proved this conclusively. Other carcinomas are caused by tobacco, and the tobacco does not necessarily have to be lighted because a large number of people in the south still use snuff. The snuff is put between the cheek and jaw. A vicious type of cancer results from this practice. Although some have speculated that the cancer might be due to the paper used to wrap the tobacco for cigarettes, snuff has no paper and it causes cancer. It is the carcinogens in the tobacco that cause cancer. Carcinoma of the tongue, lips, and larynx are also caused by tobacco, which can be cigar or pipe tobacco as well as cigarette tobacco. Cigarette smoking is the culprit in cancer of the lungs because the cigarette smoker inhales. The cigar and pipe smoker usually does not inhale unless he has been a heavy cigarette smoker and switches to a pipe. Also to be considered in regard to carcinoma of the lips, tongue, esophagus, and larynx is the added factor of alcoholic consumption. Apparently, the nutrititonal disturbance resulting from excessive consumption of alcohol added to the carcinogenic effect of the tobacco tars is of importance. The incidences of carcinoma of the esophagus and bladder are increasing, and usually patients with these conditions use tobacco. The incidence of cancer of the bladder is definitely higher in people who use tobacco. When cancer is produced in animals by applying a carcinogen to the cutaneous surface, not only will cancer develop at the site of application of the tar, but it will develop in the bladder in a very high percentage of them. The probable reason for this is that the carcinogen is absorbed into the blood stream and is excreted in the urine, and the urinary bladder mucosa is particularly susceptible to malignant change. Dr. Oscar Auerbach made the statement that a patient who has an epidermoid or undifferentiated carcinoma is a smoker. He has never seen a patient with one of these carcinomas who was not a smoker. 23