Chapter 5

Cancer
Looking Back

The history of cancer is as old as the

history of humankind. Tumors are described
in ancient E f,'Yptian writings such as the
Ebers papyrus, the Smith papyrus and the
Petri e papyrus, all of which date to approxi-
mately 1600 Be. Ideas about the causes of
cancer origin ated in Greece, with some of
the earliest writings ascribed to Hippocrates.
Hippoc rates was the first to introduce the
term ., carcinoma " derived from karkil10s (crab) .
He proposed that cancer was a disease
caused by an excess of black bile (alrabilis) ,
and classified tumors as malignant ulcers and
The Smith pllpyms deep-seated o r occul t tumors. [n the second century, the
IlIJJlT(>x. 1600 BC. famous R.om:llJ doctor Galen cod ified the H ip pocratic
theory, proposing that an excess of a body " humor" caused
ca nce r. Galen was the fi rst to use the term "sarcoma" for
fleshy tumors and co m ended that IIlflammation occurred
when the "humor" flowed to any part of the body.

It wasn't until 1800 th at the Frenchma n M arie Francois

Xav ier ll ichat proposed that cancer, rather than swollen
and inflamed tissue, was instead an overgrowth of cellular
tissue. In 1830, after the invention of the mIcroscope, cells
were identifled as the fundamental unit in tumor tissue.
In 1858, RudolfVirchow, the German pathologist and
founde r of cellu lar pathology, first ex pressed the theory
that every cell originates from another cell, a maxim that
became the foundation for the modern cellular approach
to cancer.

Early in the 20th century, health care advo cates began to

!\1llrie FfIlllcois recognize cance r as a significant problem for society. The
Xavier Bir/lill American Society for the Control of Cancer (ASCC)
was formed in 1913, prompted by the American M edical
Association and the American College of Surgeons. Its goa !
H4 M,le'fonc, C.h,'pl<r5 CJnrcr·Looklllf: 1J.1<k . ' ~'."_.~ 1_ " •
. . '''". . . . . - L'~'.~~_~ _"

was to educate the American public about cancer and help

de-stigmatize the disease. ill 1937, Congress established the
National Cance r institute, and in 1945, the ASCC became
know n as the American Cancer Society.

AnllC>UlllCmcllt of thc Natiollal Call(er Ills tillite on AU,<!ust 6, 1937. First NCI dirr(lor
Dr. Carl Kll.'ogt1in
Until the 20th century, few cance r patients had any chance ( 1938-1943).
for long~tt~ r m survival. By the 19305, about one in four
patie nts lived five years post~diagtlosis. During the 19405,
cancer cbimed 75,000 Jives a year in the United States; and
by 1970, cancer had become the nation's second~le a ding
cause of death. Fears that cancer was contagIOus discour-
aged public discussion, as did the idea that callcer tlllght
be inherited. A major step in changing public perceptions
about cancer occurred ttl 1971 when President R ichard
Nixon signed the National Cancer Act, which has been
referred to as the "War on Cance r."

This legislation mobilized the country's tesources to fight

cancer by accelerating basic research and its ttanslation to
treatment. Accordtng to D r. Vincent T. DeVita, one of the
country's leading cancer authorities and later the director
of the National Cancer Institute, "The National Cancer Act
of 1971 was a turning point in the long bitter struggle to
defeat the disease."The mandate that was stated in the act
itself was '"to support basic research and applicat ions of the
results of basic research to reduce the incidence, mortality
and morbidity from cancer."

The Nation al C:mccr Act resulted from the intcllSe

lobbyin g of the late philanthropist Mary Lasker, who
lived in New York City, and th e unflaggIng support of
Texas Senator Ralph W. Yarborough, who spearheaded the
legislative effort in Congress. Mrs. Lasker was a patron and
advocate of medical research all cancer, heart disease and
blindness. As a volllllteer leader of the American Cance r
SocIety in the 19405, she persollJlly raised the first million
dollars the society invested in C:1l1cer resc:1rch. Mrs. Lasker's
passioll;'Lte interest in medicine W:1S fueled in part by the
illnesses of pt'ople around her and by her concern for her
OWll health; she had pJinful ear infections repeatedly dur-

ing her childh ood . At the same time, Senator Yarborough

sought to l1l:1ke the conquest of cancer a national priority.
He led :1 group of medical experts, cancer advocates and
business leaders who explored the issue; the group became
commonly known as the "Yarborough COlllmission."The
Yarborough Report became the blueprint for the National
Cancer Act.

Lasker and Yarborough argued that government was spend-

illg $410 per person per year on defense compa red with
just 89 cents per pe rsoll for cance r research, yet the disease
h:!d killed 330,000 Americans in 1970 alone, Together,
they fought to increase government expenditures in ca nce r
research and tre:l.tment, an unprecedented lobbying effort
dl:!t became remarkably successful. Th e resulting National
Cancer Act of 1971 established as a nat ional priority t he
go:!l of conquering cance r and strengthened the National
Cancer Institute's ability to lead the national cancer
program.

[n his May 11 remarks about the 1971 Act, President

N ixon exp lained his rationale for gra nting special presi-
dent ial interest to the cancer-cure progr:!lIl: " I have as ked
Congress to establish a cancer-c ure program withill th e
Natiol1allnstitlltcs of Hea lth , where it CJn take the full est
;'L(lvalltagc of other wide-ranging research. At the same
time, it is imponatH th:u this p rogram be identified as
one of our hi ghest prioriti es and t hat its potential fo r
reli ev ing human suffering not be compro mised by th e
familiar dange rs of bureaucracy and red tape. For this
reason , I am askin g C ong ress to g ive the can ce r-c ure
program independent budgetary status and to make its
director responsible directly to th e president. This effort
needs the full weight and support of th e presidency to
see to it that it moves toward its goal as expediti o usly
as possibl e."

The governm ent directed its actions in the fi ght against

cancer throu gh th e National C ance r Institute. After the
Nati o nal Ca ncer Act passed, rh e N:ltional Ca ncer Institute
becam e part o f th e Public Health Service with special
ind ependent authority w ithm the National Institutes o f
H ealth (N IH ). On ce housed at NIH . the N atio nal Can ce r
Institute greatly expanded Its auth o rities and resources .
~ Since t 971, research fun ds have grown from less
than S 1 million annually to nearly $5 billio n . The res ultin g
,
mobi lization of resources granted under th e 1971 National Sin ce 197 1,
Cancer Act laid th e foundation fo r buildin g th e unparal - research fund s
leled research infrastructure and enterp rise that exi sts have g rown
today, including a nationa l network of ca ncer centers that from less than
condu ct cuttin g-edge research and deliver state-of- the- art $ 1 million
clini cal ca re. Th e centers support a stron g core o f can cer annuall y to
research , co mmunity-based can cer- preventio n programs, nearly $5 billion.
and trainin g and co ntinuing educat ion programs for health
care professio nals. Th e centers also support cllIli cal trials
that offer pati ents access to new therapies.

Cancer: From Fatal to Treatable

E.uly in th e 20th ce ntury, th e only curabl e can ce rs were
small and locali zed e nough to be completely removed
by surge ry. [n 1896 , a German physics professor, Wilhelm
Conrad R oe ntge n , prese nted a rem arkabl e lecture titled ,
" C oncerning a N ew Kind of Ray." He called It the " X-
ray," with " X " being th e algebraic symbo l fo r an unknown
q uantity. Wo rldwidc excitement about Roentgc n '5 di scov-
ery arose immedi ately. Within months, systems were being
devised to lise X- rays fo r dia gnosis; and within three years,
radiation began to be used in th e treatm ent of ca ncer.
R adiation was also used after surgery to control small
Willo r g rowth s that were no t surg ica lly removed, In 1901, Pr'!ieSS()f
Roentge n received the first Nobel Pri ze awarded in physics . Wilh elm C. RoclIf.'olel1
 HI/;ell/ recrir1illj.! (1/1 X-ray ill II ROC,IIj.!CII fill' apparatus, 1920.

It wasn't until 1956 th:H the cure of metastatic can cer

became possible. when Dr. Min Chiu Li. who worked at
Dr. Mill C/rill Li, NIH, discovered a cure for choriocarcinoma, a cancer that
firs/ /() (11((' (1 fO(/li originates in tro ph obb stic ce lls of the placenta (afterbirth).
of /IIe/IlSIa/;( ((llIcrr. Along with othe r n1:ljor research advances, Li demonstrated
that systemic chemotherapy coul d result in the cure of a
w idely metastatic malignant disease.

By the mid-20th cetltury, scientists beg,lTl to acqui re th e

resou rces needed to begin ex haustive research on chem ic:!l
and biologica l problems presented by cancer. One of these
resources was the discovery of t he exact chemical structure
of DNA by Drs.J:!llIes W:!tson :!nd Fr:!ncis Cnck in 1953

An t'l/rly p/w/<J,((ra/J/r oj Drs.JalUes WII/s<m mul Frauds Cri(/.:.

in Cambridge, En gland. This discovery made it possible for
scientists to understand bow genes worked and how they
could be damaged by mutations. As tht, understanding of
DNA and genes increased , sc ientists determined that it
was the damage to DNA by che micals and radiation or
the introduction of new DNA sequences by viruses that
o ft en led to the development of cancer. Sc ientists also dis-
cove red that defective genes might be inherited. Offering
cons iderable promise for early screening, these findings on
DNA mu tation and defective-gene heredity made possible
the identification of people who had a highe r probability of
developing cancer.

Although a cure for cancer has yet to be found, 33 yea rs

after the U.S. government declared wa( on cancer, advances
in ca nce r biology, cance r treatm ent and prevention have
dramatically improved treatment . survival and quality of
life for people with can cer. The development and usc of
chemothe rapy drugs have resulted in the successful treat-
ment of many people with cancer. Advances in technology
make it possible to aim radiation more precisely than in
the past. New surgical procedures allow for marc complete
removal of many tumors. And a better understallding of the
role of environment and lifestyle on cancer development
(che mi cals, nutrition, physical act ivity, smoking, stln and
exposure) has led to more effective education about pre-
ven tion. As the former director of the National Cance r
Institute, P...ichard Klausner, MD, said in an interview with
Time magazine, ... "We may not know how to cu re
ca nce r yet, but we do know what we need to do to get
,
there. And that's very exci ting." "We may not
know how to
Cancer incidence rates dropped 0 .5 percent per year III cure cance r yet,
t he last decade of the 20th century (1991-200 I), while but we do know
death rates from all cancers combin ed dropped 1.1 percent what we need to
pc r yea r from 1993 to 2001 according to the Annual do to get there.
R.eport to the Nation on the Status of Cancer, 1975-2001 " And that's very
This report indicates that death rates for I 1 of the [Op 15 exciting."
cance rs ill men decreased 1.5 percent per year from 1993-
200 1, while death rates for eight of the top 15 cance rs in
women decreased by 0.8 percent per year from 1992- 2001.
In addition, for men large gains in cancer survival rates
(more than 10 percent) were seen in cancers of the pros-
tate, colon and kidney and non-Hodgkin's lymphoma,
melanoll1a and leukemia. At the same time, childhood
 I
callcers showed SOllle of the largest improvements in cancer
survival during the past 20 yea rs, with 311 absolute survival
rate increase of 20 percent in boys and 13 percent in girls.
III fact, the current five -year survival rate of over 75 percent
confirms the substantial progress made since the early
1970s, when childhood can cers were nearly always fatal.
This has been a remarkable accomplishment.

Observes John Seffrin. PhD, chief executive office r of the

American Cancer Society:" Advances in Ollr understanding
of cancer biology have taugh t us that cancer is not a single

, disease that will bc conque red with l single 'mag ic bullet'

cure as was believed 30 years ago. ~ Today, we know
that cancer is far more complex, representing hundreds of
"Today, we know
diseases, each requiring specialized appro3ches to treatment.
t hat cance r is far Since its inception, the national cancer program has reaped
more complex, rema rkable returns, revolutionizing the way wc prevent,
representing diagnose and treat cancer. We have seen a decline in death
hundreds of ratt:s for many cancers, and more people arc surviving thall
diseases, each ever befo re. We have also dramatically improved quality of
requiring special- life for people with can cer." c
ized approaches
to treatment."

I I

• Canc~r_inc,de"cc ,",lie' and c.ncer_de"h ""e$ nc '"e."""d as ,he Ilumber of ca'cl

or dead" per 100.000 peopk pcr ynr .nd .re .g~-.dJus'ed '''' ,he 2000 U.S. ,un d.rd
population. When. C.llcer a!T~c" ouly one gender - ror ex.mplc.pro"". c.ncn -
,h,," 'he "umber,s pcr 100.000 persons of 'hot gender.
Case Study
Screening Tools for Cancer Detection
Identi fying cancer in its earliest stage, it is w idely
accepted, leads to improved diagnosis, less radical treat-
ment, dec reased mortality and lowe r health care costs .
Today, the hea lth care community is for tu nate to have
a variety of screening tools available to identify cancers
in their initial stage. Wh ile these screening methods are
not perfect, their use has made early detection, treat-
ment and even preven tion possible, especiaUy in foul'
of the mOSt common cancers: cerv ical, breast, prostate
and colon.

Screening for Cervical Cancer

Cervical cancer occurs in the uterine cervix of fema les.
It is often preceded by cervical dysplasia, a preca ncerous
condition caused by the IlIImall papillomavinls (H PV)
and is characte rized by a change of cervical cells that
can be detected by a Papanicolaou smear and confirmed
by biopsy. The Pa panicolaou smear is a microscopic
examination of cel ls taken from the cervix. Th is test was
firs t proposed in 1923 by D r. George PapanicolaoLl to
diagnose ute rine cance r. His proposal was not well re-
Dr. Georxe Papalliw/aou
ceived by his colleagues, who argued that the diagnostic
first proposed Tile "Pap
method was useless. Un deterred, in 1928 Papanico laou smcm" ill 1923.
delivered a lecture called "New Cancer Diagnosis"
at the R ace Betterment Conference in Battle Creek,
Mi chigan, descnbing morc fu lly the tec hnique that
came to be known as the " Pap smea r."The medical
profession still paid no attention to his work. H is paper,
" Th e D iagnostic Value of Vagi nal Smears It1 Ca rcinom a
of the Uterus," did not appear in the Americall jormJaI
of Obstelri{s and GYllecology until 1941. In 1942, he pub-
lished the technique for scail11ng, which he Iud devel-
o ped in his Cornell laboratory; it came to be known as
the Papanicolaou stain . In 1954, Papanicolaou published Pal! smear /edmique
his Alias of Exfoliative Cytology, and this time his pee rs oj lakiIJX cells from tile
Immediately accepted the monumental work, nearly cervix.
 30 years afte r his first lecture on the topic. In 1957 the
American Cancer Society urged women to demand chat
Pap tests be included in the if anllual physicals and,
further, ea rmarked 25 percent of its annual budget for
training Pap test technicians and funding Papani colaou 's
conti nu ed research. Yet it was Ilot until 1988 tbat the
American College of Obstetrics and Gynecology rec-
ommended an annual Pap smear to all women w ho
are sexuall y active or have reached 18 years of age.
, ~Th e inciden ce of cervical cancer, once a major
cause of death in U.S. women, has markedly decreased
The incidence of
due almost enti rely to the advent of the Papanicolaou
cervical cancer
smear. In fact, between 1955 and 1992 the number of
has markedly
cervical cancer deaths in the United States dropped by
decreased due
74 percent. T he death rate from cervical canc er contin-
almost entirely to
ues to decline by about twO percent a year.
the advent of the
Papanicolaou Detecring cervical can cer in irs early stages is lifesaving,
smear. as su rvival of can cer of the cervix depends heavily
on stage at diagnosis. Unfortun:ltely, elderly, African-
American and low-in come women are less likely to
have regular Pap tests. Similarly, cervical cance r deaths
are higher in populations around the world where

American Cancer Society Cervical Cancer Detection Gu idelines

Test Ag' Frequt:llcy
St~rt 3 YCJr' .ft", first
Yearly wnh conventio nal Pap tCSt or .... very 2 Y"'" wnh
,,,,,illal im"rcon"e but
liqUId- based Pap test.
no lot", than 21
After 3 normal resnhs in a row. screening can b" ewry 2 - 3
Pap t~-St O\".... r30 years. An ,Iternative is a Pap test plus HPV DNA trSlttlg .nd
cO",""lIIion.1 or liquid-based cytology ew,ry 3 Y"~TS. ~

Owr 70 After J uomlal l'ap sme:lrs in a row withiu th .... past to

y,., .... womcn Inay choose to stop scTecning.'
Not spccified l);$CUSS wuh hc~hh en" prov;d"r.

• Doctors ""y ,uggest , wom,,, be SCT<"c,,~d mort· of"" If she h.s CcTl,,,, mk r.ctors. such oS H1V mfecllon or. wc,k
"",,,,,ne '~·"e"'.
t Women wnh • h,story of ,e,viul ..... "CCT. DES c~po,u ..... or who h,,'c • weak ;nnnunc '1""'''' ,hould C""''''"e >creening
., 10ng.1 thq' ore III ,uson.b)y good he,hh .
women do not have routine Pap tests. In fact, cervical
cancer is the m:lJor cause of ca nce r deaths in wome n
in many developing countries. Th ese cases are lIsually
diagnosed at an invasive late stage, rather than as pre-
cance rs or early ca nce rs.

R ecognizing th e impressive value of the Pap smear as

a screenin g tool for ea rly detection of cervical cancer,
Co ng ress passed th e Breast and CervicJ\ Can cer Mor-
tality Prevention Act of 1990. This act authorized cervi-
cal ca ncer screenin g services for underserved women,
including o lder women, wom en w ith low incomes and
women of r:a cial and ethnic minority groups . In sho rt ,
when cervical c:aJ1 cer is found early and treated, it bas
proved to be highly curable. Most deaths from cerv ica l
c:ancer cou ld be :avoided, th erefo re, if women h:ave regu-
lar check ups with the P:ap test .

Screening for Breast Cancer

Breast can cer is any type of cancerous growth in the
bre:ast tissue. It is frequently di:agnosed, second only to
skin c:a ll cer diagnosis in women, and is the second lead-
ing cause of c:ancer death among women in the United
St:ates. In 2001, :abou t 192,200 new cases of invasive
breast c:a ll cer were di:agnosed and 40,200 women d ied of
the di sease. T he incide nce of breast cancer has increased
in recent years, and mu ch of th e increase can be attrib-
lIted to the detection of smaller, earlier-stage cance rs in
asymptomatic women using mammography screenin g. In
co ntrast to th e increased detection of breast ca ncer, dea th
rates decreased ann ually between 1990 and 2001 by 2.3 JH RI of cnu(eroU$
percent per year. This decline in breast cancer mortali ty brrils/ /;$511(.
has been attributed to mammography screenin g and to
improvements in breast cancer treatment.

Mammography is one of several screeni ng tools for

detecti ng early breast ca ncer. Screen ing mammograms
are simp ly X-rays of each breast. The breast is placed
between two imaging plates for a few seconds while the
X -rays are taken. In addition to mammograms, other
screeni ng tests used to detect breast ca nce r are clini cal
 breast exams and breast seIr-exams. A clinical breast ex-
am is an exa m done by a health professional to feel for
lumps and look for changes in the size or shape of the

, breasts. A breast self-exam is an exam done by a woman

herself. .. PhysIcians recommend th:lt women do
brc:lsc self-exams once a month starting in their 20s,
Physicians
about a week after the ir periods e nd. In the same way,
recommend that
between the ages or20 and 39, every woman should
every woman
have a clini cal breast exam every three years, and after
do a breast
age 40 every woman should have a clinical breast exam
self-exam once
each year. Although aboLlt 15 percent of tumors felt by
a month, about
clinical breast exam C:lIll1ot be seen by regular mamlllO-
a week after her
graphi c screening, mammograms often detect tumors
period ends.
before they can be felt in clini cal breast exams o r breast
self-exams; they can also identify tiny specks of calcium
(microcalcifications) that could be an early sign of
cance r. Therefore, a high-quality mammogram with a
clin ical breast exam is th e most effective way to detect
breast cancer early.

Several large studi es conducted around the world sho'w

that breast cancer screening w ith mammograms reduces

, the number of deaths from breast cancer for women

aged 40 to 69, especially those over age 50. ~ H aving
annllal mammograms provides a 20 percent to 30 per-
Having annual
cent reduction in the breast cancer mort;llity rate for
mammograms
women 50 years old and older. However, m:lIllmography
provides a 20
is not without controversy. Cost-effectiveness estimates
percent to 30
of mammography screening - based on methodology,
percent reduction
population and inte rval - vary widely; it is estimated
in the breast
that breast cancer screening CO${S $3,400 to more than
cancer mortali ty
S83,000 per life-year saved. Howeve r, many experts and
rate for women
health care advocates believe that mammography offers
50 years ol d and
the potential for significant benefits in additio n to mor-
older.
tality reduction, including early diagnosis, less aggressive
therapy and improved cosmetic results.

Some of the most important contributions toward

awareness of breast cancer screenin g in th e United
States came 111 1974. At that time, three women in
the public eye were banling cancer at the same time:
Betty Ford, Susan G . Komen and R ose Kushne r. W hen
Betty Ford was first diagnosed, breast cancer was rarely
diSClissed in public and little was known about the dis-
ease. Th e first lady was the fir st high-profile American
woman co publicly discuss he r breast cancer, and she
gall1ed legions of adm irers for the candor with w hi ch
she faced her disease, as well as for he r support of breast
cance r awareness, screen in g and researc h.

Susan G. Komen, also battling breast cancer, asked her

sister Nancy before she died CO promise that she would Former firsl lady
do whateve r she cou ld to help other women facin g Belly Ford ill '19 74.
breast ca nce r. In 1982, Nancy Brinker established the
Susan G. Kome n B reast Cancer Fou ndation based on
that promise. Since the n, the Komen Fou ndation has
been instrumental in changing the way peop le think
about breast cancer by inspirin g a nationwide move-
ment and rallying m illi ons CO the cause. Since its incep-
tion, the Komen Fou ndation has raised S450 million
for breast cance r research and communi ty olltreach
programs; a majori ty of these proceeds come from the
popular Kom en R ace for the Cure Series, which
draws 1.4 millio n people eac h yea r.
Jo urnalist Rose Kushn er's discovery in June 1974 o f
a breast lump that proved co be cancerO liS cha nged her
life. Finding that there was little in formation available
for the ge nera l publ ic, she researched the to pi c in med-
ical and tec hnical publications and kept no tes as she
underwent lumpectomy and reconstru ctive surger y. An
article based on her experience appeared in Til e Wash-
il/gtoll Post and was syndicated in hundreds of newspa-
pers. H er book Breast Cal/cer: A Persol/al History an d
Rose Kushner i'J 1986.
lllvesligatil/e Report (1975) was revised and reprinted
twice, as were Wh y Me? (1977) and Altematil/cs (1984).
For her books and numero us articles about breast can-
cer, Rose Kushn er received the Medal of Honor (1987)
and the Courage Award (1988) fro m th e American
Cance r Society. She fou nded th e Breast Cancer Adviso-
ry Ce nter in 1975 to provide infor mation and support
for breast cancer patients and has fre quen tly testified
before Congress on healch and cancer topics.
r m,~

l;;~
I

Amer ican Ca ncer Society Breast Cancer Detection Guide li nes [\

Test Age Frequency 1\
0l'no,,~1. Women should be wid aoom be""fit, ,nd humanon,
I':'",
Br~aSI "'If_cum
O\'er 20 of USE. They ,houl,1 know how thtl' bH'ms (,-d normally and
(USE) 'j
"'p<lrt ony differences !O d'CIT he,lIh core profeSSional.

20-39 I'HI of a pCrI(xhc hahh "x,m. pn.. fcrably cv,'ry 3 yean.

Chn;c.1 b .....l'l "'<Jill I',
0"".40 I'Jrt of J p\'rimhc h",ldl ""oUl.preferably '-'c'Y ycu.

V,'arly. connn"",!: for :u lonl: os a woman IS '"

M"unlognlll O"cr 40
1;00<1 hc,hh '*

• Wom."" ",,,used rI$~ (f.""ly )m\ory. genetic \"",klley. p'" bro." canccr) ,hould <>I~ wllh Iheir doc"'>T' .bout the
ben"r,u .nd hlll'uuo"" of """"Il """''''ognphy sc reenlll!; c,rI,,'r, 1"'-"'1; .ddmot,.1 leSl. (sneh .. breast nhnsound. ,
Mill ) or havn,!; mo,," f''''l''c", n,m,.

Screenin g for Pro state C an cer

Prostate can ce r is th e seco nd leadin g cause of can cer "
death in men , exceeded on ly by lung cance r. It aCCountS
for 29 perce nt of all male can ce rs and 11 perce nt of
mal e cancer- related dea ths. Modern meth ods of detec-
ti o n and treatme nt mea n that prostate cancers are now
detected earli er and treated more effe ctively, leadi ng
to decreases in death rates in rece nt years. T he most
comm o n sc reenin g methods are testing the amount
of prostate-specifi c antigen (PSA) in th e blood and
a dig ital rectal exami nation (DRE).

Prostate ca ncer sc ree nin g was first imple mented in

th e 1970s w ith th e use of the D I"t.E . H owever, O R E
oftcn detcc ts di sease in pati ents w hose prostate can cer
has alread y spread to oth er o rgans. Th e developm ent
and appli cati on of PSA for early detection and screen-
in g h:ls led many patie nts to be dia gnosed at an earlier
stage than with O I<"'E scree nin g alo ne. PSA was first
used ex perim entally in 1979 to moni to r pati ents after
prostate ca nce r trea tment as a measure of di sease recur-
rence and / or progression. Beginnin g in 1989 , som e evi-
de nce of its valu e in detecti ng early prosta te can cer in
Ille n wit h no symptoms or signs of prostate di sease was

I,
I.:
reported. Moreover, the pr incipal strengths of the PSA
test are its super ior sensitivity, reasonabl e cost and hi gh
patient acceptance.
Since the use of e:lrly- detection tests for prostate cancer
became relatively common in 1990, the prostate ca ncer
death rue has dropped . It has been suggested that de-
clines in mortality rates in ce rtain comm unities reflect
th e be nefit of PSA scree nin g. ~ Over the past 20 ,
years, the su rvival rate for prostate cancer has increased
Over the past
from 67 percent to 97 perce nt. Am ong men diagnosed
20 years, the
with prostate cancer, 98 pe rcent survive at least 5 yea rs,
survival rate for
84 percent survive at least 10 years, and 56 percent
prostate cancer
surv ive at least 15 years. Of th e men whose prostate
has increased
cancers have already spread to dista nt parts of the body
from 67 percent
at the ti me of diagnosis, 34 perce nt will survive at least
to 97 percent.
5 years.

In 1992, the Am erican Cancer Society publi shed

a recom me ndation that men over 50 years of age
be tested ann ually by D R E and PSA; later, it was
modi fi ed to recom me nd that men d isc uss PSA testin g
with their p hysicians and m ake an inform ed decision
about wheth er to be tested. In recent years, however,
the PSA test has met with controversy. In September
2004, Dr. T homas Stamey, a professor of urology at
Stanford University who ch amp ioned th e test in
1987 as a tool for prostate ca ncer detection , published
a scientifi c paper statin g £lady that " the PSA era is over."

American Cancer Society Prostate Cancer Detecti on Gu idelines

Test Age Frequency

Should b<' offcred ye~rly (alont: w,th ,n(ormation
O ver 50
Digi tal rccI.I eXam
on b<'ncfit) ,nd I,nutations) to mcn with ~t ic3St ~
(.vent:c ris k)
(DR.E) and pmsmc_ 10-year hf,' cxp~..:m":y.
spec ific .ntigen (I'SA)
Owr50 Ycorly (. Iong wnh II,fortllJuon on potemi.1
blood ,esl
(high risk *) risks and limitations) .

• Defined ., Af"c.n-Amcncon ",en or tho,~ with a strong ('111ily hIStory (on" Or ",orc .ffcClcd fi .. t-dc!l'""c .<"1",,'<'"
such ' s (.,het< or broth,· ... d"gno,ed with prosP tc unC~T "' .n e.rly .g<». M en "' c~cn higher risk. dn" to ",ul"pk
first-degrec reb",",! .IT"c<cd "' .n e.rly .ge. could beg'" lesting 01 oge 40. Depcnding <.." the rcsull, of d,e inm.llcst,
no (n"he, ,,,,,ins migh' b~ nceded umil age 4S.
 Essentially, Stamey wrote that he realized ove r the years
that high PSA levels are merely indicators of prostate
e nlargement, not prostate cancer. Since then. many
doctors an d scientists have weighed in, with some
taking Stamey's side and others questioning his findings.
Howeve r, the America n Cancer Society contin ues co
recommend that men 50 years and ol der who have at
least 10 yea rs life expecta ncy with average risk be tested
annually with PSA and ORE. Although PSA testing
ll1:ly lead to needless biopsies that remove part of the
prostate tissue to make the diagnosis, all men should
be made aware of the limitatio ns and benefits of early
detection of prostate cancer.

Screening for Colon Cancer

, Colon cancer, a disease in which cancerous
cel ls for111 in the tissues of th e colon , is the third IllOst
Colon ca ncer ...
co mmon can cer in rh<.': United States and the second
is the third mOs t
leading ca lise of cancer death. It is ge nerally accepted
cO lllmon can cer
that most colon ca ncers develop from polyps, non-
in the United
cancerous growths in th e colon, which can progress to
States and the
cance r. Screening reduces colon cancer morbidity and
second leading
mortality by both diagnosing the disease at a marc
cause of cancer
favorable stage and preven ting disease by removing
death.
precancerous It'sions. There are four COllllllon scree nin g
tests for colorcctal ca nce r that may be used alone or in
combination: fecal occult blood test (FOBT), flexib le
sigmoidost.:Opy, double-contrast bari um ene ma (DC BE)
and colo noscopy.

FOBT is designed to detect blood in the stool , which

may come from either a cancer or, more common ly,
latge polyps (greater than two centimeters). A positive
FOBT is the trigger for a diagnostic work-up of the
entire colon with DCBE or colonoscopy to identify the
source of bleeding. A sigmoidoscopy allows for direct
visualization by th e physician of the distal bowel (bowel
at the f.1rthest distance), and it is more sensitive and
speCific for adenocarci nomas and polyps than the
FOBT. DC13E is a se ries of X-rays of th e colon :lI1d
rectum taken after tbe patient is given an enema,
fol lowed by an injection of air. T he barium outlines
the intestines on the X~rays, allowing nuny abnormal
growths to be visibl e.

The most successfu l screening tool for detecting colon

cancer, the colon oscopy, has the added benefit of total
bowel visualization plus th e abil ity to remove adenomas.
A study published in 2000 in the JOl/mal oj rile American
Medical A ssociarioll by Lindsay Frazier, MD of H arvard's
Brigham and Women's H ospital, fOllnd that ~ there 'I'
would be significancly fewe r dea th s from colorectal
.. .there woul d
cancer if a sin gle colonoscopy was performed during
be significantly
a pe rson's lifetim e. T he find ings were co ntained in a
fewe r deaths
cost~ effectiveness ana lysis of 22 screening methods for
from colol'ec tal
colon cance r.
cancer if a sin gle
U nfortunately, findings from the National H ealth colon oscopy was
Interview Survey, administered by the Cente rs for performed dur-
Disease Control and Preventio n (CDC), indicate that in IIlg a person's
2000 o nl y 45 percent of men and 41 percent of women lifetime.
aged 50 ycars or oldc r had undergone a sigmoidoscopy
or colonoscopy within the previolls 10 years or had
used an FOBT home test kit with in the preceding year.
Due to the low use of these screeni ng tools, only 38
perce nt of colon ca ncers are fo und in an early stage.

T here is a clear need to Illcrease awareness an d promote

the use of colorecral cancer screening examinatio ns at
regular intervals . In \985, President Ronald Reagan
was diagnosed with colon cancer, and the surrounding
publicity raised awareness of screening. Sin ce the
dea th from colon ca ncer in 1998 of Katie Couric's
42~year~old husband, Jay Monahan , the popular televi~
sion "Today Show" co~hos t has devoted much of her
professional and personal life to raising awareness of
the disease. R esearch completed by the Unive rsity of
Michigan fou nd that awa reness efforts had increased
colon oscopy rates by 20 percent due to what the
researchers called "The Comic Effect."
 Currently, CDC and partner organizations are seeking
to in crease the use of screening tests for colon cancer.
For example, CDC and the Centers for Medi ca re &
Medicaid Services have created and imp lemented
"Sc reen for Life," a multimedia campai gn promoting
colorectal cance r screening. CDC has also developed
a training program for health care prov id ers, titled A
Call to Aaioll, design ed to increase their awaren ess of
and knowledge -abollt preve ntion and ea rl y detection
of colorectal ca ncer. Th e Am erican Cancer Society has
launched an ambi ti ous public awareness campaign to
help conSUillers understand their co lon can cer risk and
encourage them to di sc uss testing options with their
doctors. 0

Ameri ca n C ancer Society Colorcccal Cancer D etec tion Guidelin es

Test Age Frequency

F~CJI Ocell I! bload Ic'S( (FO lln

oc Ow, 50 Yc'ariy
F<'c~1 Illl""mochc"nCll ICS' (F in

Flex,ble s,s,no,do!co!,y Owr 50 Ewry 5 ycars

FOllT Or FIT
Ye.rly,
.nd 0 ''1:,50
Ewry 5 YClrs '
ilcxlble "o:mOLdoscopy

Colono$Col'Y 0"",50 Ewry 10 yc,'rs

Double -co lllr:l" b.1rtll'"

0"", 50 E"cry 5 )'c,rs
cm'"" (DeBE)

• Combmed ("<ling" I'n:fe,n:d ,we' el1hcr FO BT o r FIT. 0' nexlbk SIgmOIdoscopy every 5 YClrs, alollc, Pt'ople who .rr
'1 ",o,k'J'c or lIigh "S~ l;,r colo'ec!.1 c,nrt', .1I0"ld I>lk wuh. d""", ,bout a d,fj'e,eU1 [cmllg schedule .
100

Vignette
Skin Cancer and Sunblock/SPF Products
Sk in cancer is the 111 0St common type of cancer in the United States.
In the past, the public did not perceive exposure to the sun, whethe r
through purpose fu l sun tanning or through work outdoo rs, as dan ger-
OLLS. H owever, morc tha n one million cases of basal cell o r squam ous

cell cancer afe diagnosed ann ually.

Skill cancer is a largely preventable disease if Slln protective practices
arc used co nsistently. Interestingl y, it was only in 1978 that sun expo-
sure was first linked to skin cancer through research. [n 1986, a study
presented by Dr. Robert Stern, Chief of Dermatology at the Beth
Israel Hospital in Boston, found that using sun protection f.1Ctor
SPF 15 sunsc reen regularly during the firs t 18 yea rs of life - when
80 percent of lifetime SUIl exposure occurs - might reduce by 78
perCent a person's lifetime r isk of developing nonmeianoma ski n
can cer. SPF m easures a sunscreen's ability to absorb UVB rays and
ge ne rally indi cates how much longer an individual can stay in tbe
su n before burning. After the release of this study, a young c hild's
sunbur ned shoulders and face, once seen as cute, were viewed as
dangerolls, and promoting the use of sunscreen became an integrJI
part of skin ca ncer prevention programs.
Who invented sunscreen is not exactly cl ear, but this much is
known. In the early 19305, a young chemist in South Australia,
H.A. Milton l3Iake, experimented in a kitchen with some frien ds
to produce a sun burn cream. The University of Adelaide tested the
product, gave It a thumbs up, and Hamilton Laboratories was born.
In 1936, a French scientist named Eugene Schuell e r, the founder
of L'Oreal, ltlvented the first SUllscreen, according to his company's
Web si te. During World War II , airman and future pharmacist Den-
j amin Green developed a sun-protective formula for soldiers. Later,
in 1944, Green invented a sUlltan cream called "Copperrone Suntan
Cream " in his Miami Beach kitchen. In 1945, he added "Coppertone
Suntan Oil" to the lin e, promoted by the slogan " D on't be a pale
face."

In 1972, the Coppenone brand introduced the SPF system in t he

U.S., but the FDA did nO[ revise its sunscreen regulations until 1993
to state that sunscreens with a high SPF were effective in stopping
UVD penetration that might calise Skill ca ncer. In additi on to using
sunscreen products, sun-safety awareness campaigns have reinforced
other preventive measures, such as avo iding the sun between 11 a.m.
and 3 p.m. and wearing sun-p rotective clothing. c
 Looking Ahead
Genomic Research and Medicine

In 1990, the United States Department of Ene rgy and the

National Institutes of Health founded the Hum:l11 Genome
Project,:l.Il international collaborative research program. Its
goal was the complete mapping and sequencing of all the
genes of human beings, and remarkably thIs goa l was ful-
filled only a decade later in June 2000. In April 2003, with
a high-quality, "finished " sequence completed, the findings
on human genomes were made available to researchers and
the public. Since then, the medical industry has continued
to build upon the Human Genome Project's findings CO
further understanding of ge netic contriburiollS to human
health. Specifically, medical professionals from all specialties
arc turning their attention to investigating the role that
genes play in health and disease.

, Knowledge of rhl.' human gt:nOlTle is being used to prevent

and control cancer. ~ U tilizing ncw genetic informa-
tion, scientists have found the mutations in genes or gro ups
Utilizing new of genes that causc many cancers . Scientists have found
genetic informa- that diseases such as breast cancer and colon cancer also
tion, scientists haw hereditary forms. This knowledge enables health ca re
have found the and public health professionals to help people they identify
mmatiOlls in as at risk for developing a cance r, first by studying their
ge nes or groups genes and then by developin g customized prevention or
of genes that treatment programs t hat usc ph:l.rlllaceurical ur therapeutic
cause many approaches.
cancers.
Cancer Gene Identification
Cancer gent:tics sl.,t:ks to discover how genolllic informa-
tion can be used to identify cancer-predisposin g genes.
Identification of cance r-susceptibility genes is illlponam
because it will help physicians to make mon.' mfonlH;:d
medical decisions in order to restore normal life expcct:l.11-
cy of people :l.t a genetic:l.lly increased risk for C:l.nccr. 111
addition, understanding the mechanisms of ca ncer g rowth
in inherited cancers will offer insights into eom111on cancer
developlllent.

As genes that might cause cancer are idemified, it becomes

possible to screen for cance r genes throllgh genetic tests.
~
-: - ;- '. .', ." •• /,-;:-~', ;., )0'''''':' .,'" ,.~
.... _.• { h,p"-" (on,",r L""k"'t:Ah~ad .' : ~.... - '" ~;:.,~.~ ~- ...
_ _~ ._ " ~' _ .. ',uno ,,, •• _•• < .,' &II.M" >.11 '-.'

The American Society of Clinical Oncology recommends

Cillt genetic testing be offered l1l1der the following condi-
tions .
• The individual has a personal or family history of a
ge netic cancer risk.
• R esu hs will help diagnose the can cer or influence the
medical care of a patient or family member.

[n gene ti c testing, an :l.ffected family member sho uld he

tested first for the presence or absence of a specific muta-
tion. If no mutation is found, unaffected f:1mily members
need not be offered genetic testing. On the odler hand,
if a mutation is detected in 311 affected individual, then
immediate f:1mily members should be tested for the pres-
ence or absence of the same mutatioll. If the mutation is
not founel. the genes carried by the affected relative do
not increase the risk in the unaffected relative. However,
these unaffected relatives can stil l develop cancer late r in
hfe, although the risk IS usually much less than the risk
for the mutation carriers .

The opportunity of identifying individuals in :l preclinical

state th rough genetic tests and initiating preventive the rapy
promises to avert disease treatment costs and suffering. In
addition, advances in laboratory tec hnology and in the
identification of cancer-susceptibi lity genes such as I3R-
CA 1, BR CA2 and MSH2 will soon make it possible to test
large segments of the population for cancer ri sk. However,
the expansion of genetic testing poses other kinds of r isks
~ medical, personal, psychosocial and economic. Publi c
health professionals and medical ethi cists will debate how
to balance this potentially useful genetic information with
the dangcrs of privacy invasion, insurance dcnials and
cmp loym en t isslies.

Pharmacogenomics
Genomic-sequence information can be used to design
highly targeted pharmaceutical therapies. Phannaceutical
genolllics or "pha rll1:lcogenomics" has cvolved as the study
of how an individual's genetic inheritance affec ts the body's
response to drugs. This area of study holds the promise that
drugs might one day be tailored for individuals and adapted
to each person's own genetic makeup. Understanding an
individual's genetic makeup is thought to be the key to
crea tin g pe rsonalized drugs that work safely and with
greater efficacy, although environment, diet, age, lifestyle
and state of health also greatly influence a person's response
to llll'dicines.

Pharrnacogenol11ics might also help to improve the side-

effcct pro(i]es of cancer-drug therapy. Although chemother-
apy is :m effect ive :md established treatillent, its toxicity i~
signifi cant. Infections, nallSe:l. vomitin g, ne rve pain. and
hair loss are COlllmon and can be an obstacle to complet-
ing a patient's recommended course of therapy. reducing
its effectiveness . As a result, scientists have begun using
the human ge nome sequence to design specific drugs that
maximize the rapeutic effects , inhibit malignallt-cell growth
:lnd decn.':lse d:l1ll:lge to ne:lrby he:llthy cells.

Gene Therapy
Gene therapy is :In appro:lch to tre:lting dise:lse tli:lt
eith er modifies the expressions of an individu:tl"s genes
or corrects :lhnorl1l:l1 genes. Th e concept of gene therapy
W:lS introduced in th e late 19705 after the dL'vclopmcnr
of rl'combin:lnt DNA tech nol ogy. [n 1990, Drs. Willi:llll
French Anderson, Mich:lel Ulaese and Kenllcth Culver,
researchers at the N:niOllal Institutes of H ealth, performed
th e first successful genc therapy in humans. The team
sllccessfully treated .l thell fO llT-ye:l r- old, Ashanthi DeSilva,
for :ldcllosinc deaminasc (ADA) deficiency,:I r:lre genetic
disease in which childre n :Ire born with scve rc ill1l1lul1o-

Frolll !tjl 10 r(~IH: D rs. Aliclllld 8/<1(,SI', Frl'lI(h I1l1dersoll (/Ild Kfllllflil
CII!J,Cf performfd Iht' firsl sll((eS~fll l ,J!t'IIf Iilemp)' ill hlllll(/IIS.
deficiency and are prone to repeated serious infections.

With tbe complete sequencing of the human genome,

sciemists have more resources to further develop gene
therapy. In particular, gene therapy representS a new field
of medicine that can potentially cure some forms of cancer.
All cancers have a genetic structure, triggered by ::lltcrcd
genes in cancer cells. and a different gene or set of genes
also controls the progressIOn of a cell from I10rmal to
malignant to invasive. Cur rently, researchers are studying
sever:al approaches to tre:ating cancer Llsing gene therapy.
Some :ap proaches target healthy cells to enh:ance their
abIlity to fight Cancer, while others target CanCer cells to
destroy them or prevent their growth.

The Fut ure of Genomics in Medicine

The genomic era is now a reality. Experts h:ave begllll to
underst:and the role of genetic factors in health and disease
and to use this knowledge in prevention, diagnosis and
treatment. The completion of the human genome sequence
is impacting public health. In furthering society's interest
in good public heal th, adv:a nces in medical :applications of
genomic research improve the conditions that ensure tlur
people can be heal thy. Researchers hope th:lt in the next
10 years, genetic tests for Ill any common conditions will
help alleviatc inherited risk and that by the year 2020
genc-based designer drugs will be avai lable for m:any con-
ditions. ~ Pe rhaps the most exciting prediction is that
cancer treatment will precisely targct the molecubr finger-
,
prints of particula r tumors, and genetic inform:ation will ... the most excit-
be used routinely to give patients more approp rilte drug ing prediction is
therapy, avo iding unnecessary side effects and increasing th:a t treatment
chances of cure. Neve rtheless, the ultimate use lnd inter- will precisely
prNltion o f genetic infor mation r:aiscs et hical, social, target th e molec-
psyc hological and political issues. Consequently, public ub r fingerprints
health and governmental aU [[lOrities need to improve the of particu lar
infrastructure capabilities that will be needed to widely tumors, and
implement genomics' medical applications. Public heal th ge netic informa-
:and government will also need to crelte regubtory policy tion will be Llsed
to give pa ti ents
to control the negative implications of gcnctic information,
co nfronting such issues :as pr ivacy, labor and insur:ancc more ap propriate
disuimination, ethics and psychological consequences drug therapy.
for affected families. among others.

jolm Srifri", PhD,
cilirj exrwliJle r~r tile
rlm('ri(illl C IIII(cr Sodery.
, current cancer patiems will survive long-tcrm,"' exp lains
" Tragic:ally, how-
ever, nowhere
near I 00 percent
of can cer patients
today will receive
state-of-the-:art
c:ancer care."
As Dr. Seffrin of the AmerIcan C:ancer Society points Oll t.
"The public. private and nonprofit secto rs must diligently
work together to ad vance groulldbreaking cancer research.
Prior investments in cancer research have laid the founda-
tion for a period of unparalleled sllccess."
However, currem funding constraints allow the National
Cancer IllStitme (NC I) to fund only 0111..' in five eligible
research projects, forcing the NC I to pass ovet many excit-
ing cancer research opportunities. With authorities granted
undet the 1971 National Cancer Act, the NC I director
develops a strategic plan for cancer research each year that
reflects the best thinking of cancer researchers, patients,
clinicians and other constituency groups. As Seffrin
explains, "The goal for the nation lllUSt be to provide
adequate fundi ng to explore the 1IIost prom ising opportu-
nities in cancer research as outlined in this plan. R.eJ1lark-
able achieveme nts slIc h as the mapping of the human
gellollll' make new and better cancer treatments inevi table
if we invt'Sl lIIore of Otlt health expenditures 011 research
and developme nt. Landmark discoveries such as cancer
vaccines, targeted therapies :and chernopreventiol1 are lead-
ing to a paradigm sbift in how cancer is treated and to
thousands of lives being saved every year."
Scffrin also bcliews it is critically important to bridge the
gap between scie nce and practical application. In aren as
where public health has united to drive delivery at the
community leve l, there have been impressive resu lts. "With
state-of-the-art cancer care, 67 percent to 80 percent of
SefTrin. ~ "Tragically, howcwr, nowhere near 100
percent of cancer patients today will receive stare-of-the-
art cancer care. In f.1ct, only about 60 percellt will receive
so-called 'standard care.' A cardinal principle of pu blic
health states that 'access to the me,lllS for dIe arrain mellt
:and preservation of health is a bas ic human right.' In
truth, however, full access to Ollr health care system and
to the best in cance r care is sometimes :lVailabk' only to
a privileged fcw."
To implement a comprehensive cancer control program.
according to ScfTrin, disparate Pl1blic health organ izations
should unite to deliver understandable and acti onable
cancer prevention :and treatment Information dl:lt increases
".; 1 ()(l M,J,'<t<lIl,·< ('harte, 5 c.l1\~'" lookul!.: Ah"ad ' .,:'
~ .. .' r • , ' , .', '

pat ie nts' hea lth lite racy. At th e sam e tim e, medi cal schools
should improve edu cation to e nhance deli ve ry of cancer
preve ntion , and early-d e tection servi ces, hosp itals and
trcatlllcnt ce nte rs should improve health records syste ms
to help coordinate prevention and sc reening efforts.
Finally, poli cy make rs shou ld require that all insure rs cove r
and reimburse for ev ide nce- based prevention and earl y-
d etec ti o n se rvices . 0

Ph o to cre dit s
1',l'c 83: Edw", Smnh P'pyrus. ~ourt<·,y urTh~ New York Andemy uf M"drcrll~
Lrbrary. O 2(J05 The ..... ktropohurl Mus~um or Art.
1"1:" 83: Marr~ Frdncois Xav,..r Urch", NJllonalLrbrJTY ofM,,<hcUl",
1'.lg" 84:Th,' W><h,nglon I'osl 1937. ~o"rt"'y The Nano",1 C.rKer IU'I"ute,
1" 1'(' !l4: Dr. Carl Vocgtlin. COU"l'S}' Th,' N,ltu " a1 Cancer I"mltll,'.
Page 85: Mary Lasker, CourtelY The Nation,,1 Library of Medicine.
1'., I'~ K6: l'ror"<su r Wdhdm C. RO"lU g,·n . U,'w" ,,,,,/CO RIJI S.
P"ge 87: Dr. Mill C hin Li. COUrtesy The NOIi"".1 Lib",ry of M,'dicntc.
1" 1:" 87: Early X_r:ty UlachUlc, 0 B"ltman,,/COIlBlS.
P,lgc 87: Drs.J,,,,e\ Wat~o" "",I Fran"s C",k, Q Ikmu',.,t / CORBIS.
1',11\" <){J: D r. G"urg" 1'3pa",colaon. C Bettma"n/COftUIS.
l',lf:" 90: I'~p S""·,. ,1l"'1r:t!"'''' 20()5 Foto"·arch.c",,,.
I'df.:" ')2: M ltl of c,,,ccmu, brca" l<'S"~, Q H ow.ud Sochurd:JCOftHl:o.,
1'.11'" 94: Iktt}' I:or<l. 1974. "oun,"y Llbr.. y of Congn'SS, l'"ms a"d l'hOt~fJph,
1)"'",uII ILC- U$Z62-5191JI.
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Ccmer.
l'al\c 103: D" <"tO" fro", ti,.. Nation,1 Il",rt. blood. and lung In,uHtI,..
o ~"'Jn SIClllb"'l'/COft BlS.
Page 10;': Dr. John SdTrin, CUUrt,· ,)' WI-IO / I'. Virm.