December, 2012


By Michael J. Katin, MD

2012 is rapidly coming to an end, and the threats to our profession are greater than ever. It was bad enough that we have had to deal with decreasing reimbursement, that we anticipate a growing number of working persons losing their medical insurance , that we have to have continuing concern over liability , and that we anticipate regulation spiraling out of control. Now the greatest potential menace to our practice of radiation oncology is starting to be recognized.

We are not alone. Throughout the ages, entire species , civilizations , and occupations have been severely impacted by changes beyond their control. Possibly our fate will not be as dramatic as it was for dinosaurs , the Olmecs , or for booksellers , but that shouldn't make us feel any more secure.

Developments that can initially be construed as favorable may turn out to have unexpected consequences. The Imperial German government decided to facilitate Lenin's return to Russia in 1917 with the expectation that this would result in Russia's withdrawal from the Great War, and, in fact, this occurred with the Treaty of Brest-Litovsk less than one year later. The consequences of the Bolshevik takeover of Russia have been felt for decades. Construction of the Three Gorges Dam in China had been first thought to be a major advance in promoting development in a large section of the country, but many innocent bystanders have been adversely affected

That notwithstanding it is difficult to complain about the recently observed phenomenon that may doom our specialty. Prior to the 1930's, stomach cancer was the leading cause of mortality from malignancy in the United States. The incidence started to decrease markedly. This did not adversely impact radiation oncologists, of whom there were very few in the 30's and 40's, and since the incidence of other malignancies, such as lung cancer, started to escalate.

Today, for a multitude of possible reasons, the incidence of cancer is decreasing. The Centers for Disease Control found that the incidence dropped 0.6% per year in men between 2004 and 2008 and 0.5% per year in women from 1998 through 2006. These were primarily in decreases from lung cancer, colorectal cancer, and breast cancer. Our colleagues in the United Kingdom will also find a decreasing patient volume, with decreased incidences in kidney, liver, melanoma, oral, uterine, and bladder cancer

Although some decreases can be attributed to specific preventive measures ( smoking cessation , colonoscopy ) there may be other factors going on. Certainly, obesity has been linked to increased incidence of several types of cancer , and it may be that improved nutritional goals will have a secondary effect in producing decreased risk of malignancy. Increased meaningful use applications, such as measuring BMI, will further call attention to the need for patients to maintain a healthy body weight .

What else could be contributing to the decrease in cancer incidence? There are many potential source of credit. Vitamin C, Vitamin E, selenium, and folic acid didn't seem to make a difference in the long run, but Vitamin D and even multivitamins in general have been identified as beneficial. Foods such as broccoli may be linked to decreased rates. Even okra has shown evidence of being beneficial . It's probably slightly more complicated, since the way foods are prepared and consumed may make a difference. Even Dr. Oz has gotten involved in this, meaning it must be .legitimate.

Besides diet, there are other factors that could be reducing cancer incidence. Aspirin may be hard on headaches and platelets, but also may be hard on cells trying to go bad. Now that millions of people in the United States are on statin drugs, it's reassuring to know that they may also help prevent cancer. When everyone is talking aspirin and statins and not dying of heart disease or cancer, the leading causes of death might be those related to overcrowding .

Finally, it appears that getting enough sleep will also protect you from cancer. Now that millions of people are unemployed or under-employed, it is easier than ever to get plenty of rest and avoid the risk factor of sleep deprivation. For those who are fortunate enough to have jobs, it would be best to choose those that are boring or at least get protection by indulging in appropriate entertainment.

Do we need to start closing down our treatment centers? Soon, but not quite yet.

Unfortunately, there may be new factors causing cancer to make up some of the difference. We are surrounded by chemicals with unknown potential to do harm. Diesel fuel , as might have already been suspected, has been associated with cancer risk, but we might not have suspected tapioca tea . . Last year, the Department of Health Services added six fairly common chemicals to the list of possible carcinogens. Drinking from disposable cups, even in quantities of 16 ounces or less, may be hazardous due to styrene. Working with formaldehyde probably has never been all that pleasant , but now has to be considered somewhat hazardous. In 2011 the Department of Health and Human Services added six fairly common chemicals (styrene, captafol , cobalt-tungsten carbide, inhalable glass wool fibers , o-nitrotoluene , and riddelline) to the list of possible carcinogens, and also strengthened warnings on formaldehyde and aristolochic acids.The American Chemistry Council has objected to this decision but time will tell how much risk there truly is.

What else may develop? Although cigarette smoking is rapidly decreasing, vaping is on the rise. The Tobacco Vapor Electronic Cigarette Association (yes, there is one!) predicts the market to quadruple from 2011 to 2014, with over 100 different brands. Can anything this clever also be this safe? Maybe not .

It would be wonderful to see cancer go the way of pellagra and scurvy, but, unfortunately, with all the traditional and new potential causes, there will probably still be many more patients needing treatment in the future. This can be a topic for the social media

Just don't use them yourselves.