ONE-ON-ONE
- March 2001
by Ed G. Lane ‘Cancer is
Not a Taboo Word Anymore’
Smoking accounts for 30 percent of all cancer deaths,
says oncologist
 |
Philip
A. DeSimone, M.D.
Philip A. DeSimone, M.D. is Chief of the Division
of Hematology/Oncology for the Department of
Internal Medicine at the University of Kentucky
College of Medicine. From 1984 until his
retirement from the position last year, he served
as chief of medical service for the Department of
Veterans Affairs Medical Center in Lexington. He
served as a principal investigator for the
Southeastern Cancer Study Group from 1979-1984. A
New Hampshire native, he attained his medical
degree at the University of Vermont, two
administrative certifications at the Harvard
School of Public Health, and completed his
internal medicine internship and residency at UK
Medical Center. He has taught in the UK College
of Medicine since 1974, serving in a score of
academically appointed leadership positions
during his tenure. From 1968 to 1970, he was a
captain and combat flight surgeon in the U.S.
Army, serving for one year in Vietnam. |
Ed Lane: Recent data compiled by the American Cancer
Society in 1998 indicate that Kentucky has the third
highest cancer incidence rate in the United States. To
what do you attribute Kentucky’s high cancer rate?
Philip
DeSimone: Cigarette smoking is the number one cause.
Kentucky has the highest rates of teenage smokers.
Thirty percent of all Kentuckians still smoke.
EL: How does
smoking contribute to cancer rates and is there anything
an individual can do to drastically lower the chance of
contracting lung cancer?
PD: At
the turn of the last century, lung cancer was an
unheard of disease. It wasn’t until after World
War I and specifically during World War II when
cigarette smoking increased. Statistically, you
started seeing a rise in lung cancer that was
directly related to cigarette smoking. Women smokers
increased during the 60s. If you look at the two
curves for lung cancer, men’s and women’s
are at different times but at the same incline. Men
are beginning to stop smoking. Women are almost
beginning to stop – but not quite. Cigarette
smoking has significantly increased lung cancer.
Reducing smoking will substantially reduce lung
cancer rates in the future.
EL:
Nationally, lung cancer mortality rates are about 23
times higher for current male smokers and 13 times higher
for current female smokers. Approximately half of all
continuing smokers die prematurely from smoking and lose
an average of 20 to 25 years of life expectancy. How does
having the highest rate of smoking impact cancer
incidence in Kentucky?
PD: We
have a high incidence of lung cancer in Kentucky
– around 18 percent of all Kentucky cancer
cases. Obviously, reducing life expectancy 20 to 25
years is bad. The Netherlands did a study – if
cancer of the lung was eliminated, what would happen
to spending on medical care? For the first ten –
maybe fifteen – years after everybody stopped
smoking, costs would go down. But as these people
lived longer and remained in the population, medical
costs would increase and continue to escalate because
an older population needed ongoing medical
treatments. What’s good for society may not be
the best for the individual and vice versa.
EL: How do
genetics figure into lung cancer?
PD: A
person can have an incidence of lung cancer if he/she
smokes. If there is a family history of lung cancer,
then you increase that by two more times because of
genetics. If someone has lung disease – chronic
bronchitis or something similar – that
multiplies by four more times the chance of cancer.
EL: In
addition to causing 87 percent of lung cancers, what
other cancers are associated with smoking?
PD:
Bladder, mouth, throat, neck and esophageal cancers.
EL: How does
smoking cause cancers at other sites?
PD: When
you light up a cigarette, 2,000 chemicals are being
produced. You’re sucking in 2,000 chemicals that
go everywhere in your body. One of the things we know
about bladder cancer is that these chemicals are
actually in the urine and stay against the bladder.
The chemicals probably cause a chronic irritation.
Our bodies have a repair mechanism. If your body has
chronic irritation from smoking, it will have chronic
repair going on all the time. As you age, it’s
likely this repair mechanism will go haywire.
EL: Are there
areas in Kentucky where cancer incidence rates are
higher?
PD: I
conducted a study back in the late ‘70s and
looked at what cities had the highest admissions for
cancer. One was Ashland – the third highest. The
second was Morehead, and the first was Paducah. So I
went back to find out what was going on in those
areas: In Paducah, which was the highest, it is
what’s showing up now – radioactivity
that’s been pushed around; Maxey Flats, which is
now closed, was in the Morehead area; and industry
located in Ashland involved a lot of steel, coke
production, and using asbestos. Those were the three
areas in Kentucky with high patient admissions for
cancer.
EL: Based on
your 30 years in the cancer field, please comment
generally on how income and education affect cancer
rates.
PD:
Usually people with higher incomes are better
educated. In the early ‘90s we used to think
that people who didn’t smoke were better
educated. Now that trend is reversing. Many of the
people who do smoke – college students –
are well educated. It is still suspected that if
you’re not well educated, you just tend to do
what your mother and father did. This factor has a
lot to do with higher levels of smoking in eastern
Kentucky. Many eastern Kentuckians don’t really
believe that cigarette smoking causes cancer. For
this reason, educating about the dangers of smoking
is paramount and will allow the general public to
make decisions based on the facts.
EL: With
regard to diet, will more fiber, less fat impact cancer
incidence rates?
PD: There
are theories about fiber and fat. The latest study of
nurses was conducted to see if fiber and low fat
helped affect cancer rates. The study evaluated the
differences in the diets of nurses and concluded that
the incidence of colon cancer was not related to the
amount of fiber or fat you had in your diet. That was
only a 10-year study.
During
the depression, everybody’s diet changed. There
was much more fiber in people’s diets since
there was not enough meat. There was no change in the
incidence of colon cancer then, and that was a very
long period of time. Studies about how diet affects
cancer will probably have to be greater than a
20-year period.
EL: How does
UV radiation affect cancer rates in Kentucky?
PD: Sun
is a known cause of skin cancer – melanoma.
Galveston and El Paso are on the same latitude. The
incidence of melanoma in El Paso is about 20 times
less than it is in Galveston. The difference is that
there is no beach in El Paso. The temperature in El
Paso remains the same but people tend to keep their
clothes on to protect themselves from the sun. The
people in Galveston take their clothes off and go to
the beach. Persons who, during the first five years
of their lives, are exposed to the sun (if you had
major burns as a young kid) will have a higher
incidence of melanoma. Kentucky is a place where
there is no beach and sunburns are low, so melanoma
rates are average.
EL: What are
some key factors that relate to reducing cancer incidence
and mortality?
PD:
Don’t smoke. Smoking accounts for at least 30
percent of all cancer deaths and is a major cause of
heart disease. I have a list of 101 causes of cancer.
One is too much sex. You can actually get cervical
carcinoma from that. Another is not enough sex. So
nuns have a higher incidence of ovarian cancer. The
wrong kind of sex. Aids patients have an increased
incidence of rectal carcinoma. From just sex alone
– there’s too much, not enough or the wrong
kind. There are three different ideologies you have
to deal with. Each one of these plays a role. Which
one has the greatest role? What can you do the most
about? Well, have safe sex in moderation. The next
best thing is screening for cancer. Early detection
has the best survival. The thing that stops cancer is
cancer prevention – stopping smoking and maybe
changing your diet.
EL: How do
today’s medical students differ from those a
generation earlier?
PD:
Vastly different. They come in with a bigger
knowledge database. For instance, DNA. When I was a
college student, DNA was first noted so it was a big
deal. Now everybody knows about DNA so the database
is huge, and the computer makes the information more
accessible. Medical students start out knowing a lot
more than students a generation ago.
Over the
years, cancer education has changed. It’s no
longer a mystery disorder. It’s a primary
disease we teach. We teach doctors about hospice.
Initially, doctors didn’t like the concept of
hospice. It was a strange concept to have some person
taking care of your dying patient. All that is
finished.
Cancer is
not a taboo word anymore. It’s wide open. People
use it all the time. So that is what has really
changed. Doctors are much more educated about cancer
and how to deal with cancer. Doctors are better at
treating cancer because they have been taught the
realities of cancer.
EL: In your
capacity as a medical oncologist, how do you emotionally
deal with terminally ill patients?
PD:
Frankly, I try to discuss it as much as I can. I will
say, “You’re dying. What can we do to help
you?” Or I tell them, “There are a couple
of things you need to ask me. I’ll give you some
time to think about it, but I’m going to come
back and talk to you if you don’t ask these
questions.”
EL: If a
member of your family were terminally ill, at what point
do you feel it is appropriate to candidly discuss the
situation with them? Do you need to tell them there is a
certain amount of time left?
PD: My
father died of cancer. I had a difficult time with
it. He died in 1977. I learned a lot from his death.
My father
had very little cancer, and when he died all of his
cancer had been treated. He didn’t have any
viable cancer. But he died within four months of his
diagnosis. He was told the word “cancer”
and that was it – he was going to die. Knowing
what I went through with him, I try to bring this up
early on with patients. You need to live or you
don’t. It’s up to you on how you want to
deal with cancer.
Cancer
patients have a better chance to communicate with
their family members because they have a longer time
to talk about their illness. It’s different from
someone who dies of a heart attack. Often, people
need the time to talk about how they feel about their
family members. Cancer gives people a chance to do
that.
Discuss
the illness right away. The sooner the better. The
family needs to know. The family is paramount. The
family is the most important thing.
EL: Based on
a 1997 report from the National Cancer Institute, a
female born today has a one in eight chance of developing
breast cancer during her life. What can be done to reduce
breast cancer?
PD:
Deaths from cancer of the breast have not changed.
The incidence has not changed. If you look at the
death rates, they’re a pretty straight line. We
know more about breast cancer, we can probably make
better judgements, but the death rates are about the
same. The use of Tamoxefin has proven effective in
the prevention of cancer of the breast.
EL: In
looking at statistical data, the incidence of cancer in
adults starts accelerating around age 50 in just about
every category. With regard to screening, what should
people do at age 50?
PD:
Screening is important, but screening is expensive.
The incidence of cancer increases around 50 because
as we age, the body’s repair mechanism goes
haywire. The older you are the more frequently you
should check for cancer.
EL: What is
there to look for in the future treatment of cancer?
PD: Where
are we going in the future? Where are the latest
treatments going? These issues are very hard to
understand. The news media have the ability to
communicate the greatest and the best and the newest.
Our understanding of cancer is better. My
understanding of cancer is much better. But I
can’t predict the future.
Perhaps
we will be able to extend life expectancy to let the
average person live to be 120 or 150. Ultimately,
everyone is going to die. If you live longer
you’ll probably be living a life that’s
lonelier because someone is going to relegate you to
a nursing home to sit in some corner. Longevity can
diminish one’s quality of life.
EL: If
Governor Paul Patton appointed you to run a task force to
reduce cancer in Kentucky, what would be two or three
things you would target?
PD:
Educate, educate, educate. I would start in the sixth
grade – maybe sooner. I would take my
anti-smoking presentation to school kids and talk to
them about cancer and what it’s like to have
lung disease. First, bring a practical approach to
children; second, continue to educate people
throughout the time when the incidence of cancer is
highest. We know that if a doctor tells patients to
stop smoking, that’s better than if a layman
tells someone to stop smoking. That’s education
– and more education.
EL: If you
were a smoker and the incidence of lung cancer is 23
times greater for a smoker, what screening test should
you request?
PD:
Screening for lung cancer has not been effective.
Studies using chest x-rays fail to show long-term
benefits. CT scans of the chest may be more effective
but at a great cost. The major problem is truly
effective chemotherapyto treat the newly found lung
cancer.
EL: So if
you’re a smoker, you could say to yourself, “I
have a 23 times greater chance of getting cancer of the
lung than someone who doesn’t smoke, and I’m
probably going to reduce my life by 20 to 25 years.”
PD:
People make educated decisions. People who smoke know
the risks if they’re educated. The non-educated
ones are taking the risk, and they may have no idea
that they are at risk. If you can educate that group
of people, then everyone will know the risks
involved.
EL: About a
half million people die of cancer each year, but a little
over 700,000 die of heart disease. How is the treatment
of cardiovascular disease progressing?
PD:
Deaths from heart disease are going down. It has been
going down because people have been educated. Heart
disease is a disease that people can do something
about. They can change their diet, exercise more, and
stop smoking. A lot of people look at cancer and say,
“I can’t do anything. What can I do?”
Other than smoking there is not a whole lot to be
done – changing your diet and exercising can
help.
EL: If one
wants to become a doctor today, what kind of IQ and
attributes are required to be successful?
PD:
What’s important is being a good listener and
being empathetic with people. Doctors can make very
good decisions based on knowledge and how they feel
about the situation. The schools emphasize IQs. I
don’t think you need to be a genius to be a
doctor.
And you
have to have desire. And it has to be your own
desire, it can’t be someone else’s desire.
EL: Each day
when you get up in the morning, do you think about your
case load and consulting with your patients? Perhaps a
test came back and there’s bad news?
PD: Some
days, when I have to talk about death or bad test
results, that truly bothers me. I have a hard time
doing that. Sometimes I try to avoid it. It’s
not new to me, I do this a lot. But some days I know
if I’m going to have 25 patients in clinic, I
know I’ll be tired; I know it will drain me of
my strength.
EL: Has your
wife, Lois, helped you get through those kinds of days?
PD:
She’s a good listener. It’s up to me to
tell her how I feel. A lot of times I don’t say
anything. I’m not a very outgoing person. So
it’s up to me to talk to her. She’s a
marvelous listener, and I rely on her opinion. As I
get older, I’m able to communicate better with
her.
Ed G. Lane is
chief executive of Lane Consultants Inc. and publisher of
The Lane Report.
edlane@lanereport.com
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