CHAPTER 6
HEALTHY ADULTS

Goal:  To improve the health of adults,
    and,  by 1990,  to reduce deaths
   among people ages 25 to 64 by at
    least 25 percent, to fewer than
    400 per 100,000.

  The contrast is sharp.  For an infant at birth,
life expectancy since 1900 has increased 26 years.
But today for a man at age 45 the expectancy is only
five years greater than it was in 1900.

  On the one hand, preventive measures have been
successful in reducing infant and childhood deaths
from what were the major threats in those years, the
acute  contagious diseases.   On the other hand,
treatment measures, even though increasingly sophis-
ticated, have been far less successful against what
are the prime threats for adults:   the chronic
diseases, often of insidious onset, slowly progres-
sive, ultimately devastating.

  Only recently have we gained significant in-
sights into the causes and many risk factors in-
volved in the chronic diseases--and into tangible,
applicable  preventive measures.   Although   those
measures are different and the results may be less
inznediately dramatic than was the case for the acute
childhood diseases, we already have reason for opti-
mism in what has been happening very recently to
adult mortality trends.

  In 1970, the death rate for adults aged 25 to 64
was even higher  than  in 1960 - 657 per 100,000,  up
from 640.

  Since then, however,  there has been an annual
average decrease of 2.6 percent in the death rate

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for adults.  By 1976, the rate had dropped to 555.
And data for 1977 show a further 2.7 percent
decrease to 540 (Figure 6-A).

  More than one-third of all deaths among the 100
million American adults have been due to cardiovas-
cular diseases, principally coronary artery (heart)
disease and stroke (Figure 6-C).  And it is deaths
from those causes which have been declining and
accounting for most of the drop in mortality rate.

  There is every reason to believe that the down-
ward trend not only can be maintained but acceler-
ated with increased efforts on behalf of such pre-
ventive measures as high blood pressure detection
and control,  reduction of smoking, prudent diet,
increased exercise and fitness, and better stress
management.

  A reduction in cancer deaths should also be
achievable--to a worthwhile,   even  if necessarily
more limited, extent in the near future.

  One reason for slower progress against cancer is
that by the time malignancy becomes apparent, many
years have gone into its development.  In a sense,
any  currently  appearing   cancer   reflects  past
history--perhaps, for example, 35 years of smoking
in a 55-year-old patient with lung cancer.   There-
fore, it will take years for modifications of cancer
risk factors to be expressed in marked reductions in
cancer mortality.

  A second reason  is that declining rates for
certain   cancers  will   be more  than  offset by
increases in  occupational   and  smoking-related
malignancies  because of already-established adverse
effects.  The net result will be a small, gradual
rise for the next few years  in the age-adjusted
death rate for cancer.

  Prevention efforts--to reduce exposure to can-
cer-inducing agents and to foster more early detec-
tion and prompt treatment--need to be instituted now
to reverse the trend.

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              FIGURE 6-A
DEATH RATES FOR AGES 25-94 YEARS: UNITED STATES,
       SELECTED YEARS 19ML1977

90
60

70

60

50

40

30

3                      1

1900    1910     1920     1930     1940     1950    1960     1970     1980

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        FIGURE 6-B
DEATH RATES FOR AGES 25-94 YEARS:
  SELECTED COUNTRIES, 1975

-

I

Umted
states

Sweden

England
and
W&S

Japan       Chile

NOTE  me moi: recent year Of ddfd lo, Chile 1s 1971

Sources~ United States, National Center for Health Statistics, Divismn of Vita Statistics;
     other countries, United Nations.

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              FIGURE 6-C
MAJOR CAUSES OF DEATH FOR AGES 26-64 YEARS:
        UNITED STATES, 1976

Heart
disease

Cancer     Stroke

Cirrhosis
of hver

All other
accldentr

Motor
veh&
accidents

Hornlade

0 Whne
m All other

Source: Based on data from the National Center for Health StatlstIcs. Dwsion of Vital Statistics.

6-5


Subgoal:  Reducing Heart Attacks and Strokes

  In 1977, heart disease was responsible for over

700,000 deaths--the leading cause of death for men
after age 40.  And although women, up to menopause,
have about one-third the heart disease rate of men,
their heart attack incidence thereafter increases,
begins to approach the male rate by age 70, and
virtually equals it by age 85.

   Heart disease not  only produces fatal heart
attacks;  it is also the greatest cause of permanent
disability claims  among  workers  under 65, and
responsible for more  days of hospitalization than
any other single disorder.  And it is the principal
cause of  limited activity for some 2.5 million
Americans under age 65.

  Stroke,  in 1977,  led to nearly 183,000 deaths,
almost 10 percent of the total mortality for the
year.   Although  some 250,000 Americans survive
strokes each year, many remain disabled by paraly-
sis,  speech difficulties, and memory loss.  Nearly
10 percent of nursing home admissions in people
under 65 are because of strokes.

  Although most stroke deaths (about 85 percent)
occur in people over 65, early deaths are not uncom-
mon,  particularly among blacks who, between ages
25 and 64, have a stroke death rate almost 2.5 times
that of whites.

   But we are  now beginning  to see a welcome
decline in death rates for both heart disease and
strokes.

  For heart disease, the death rate, which had
been increasing rapidly after 1940 began to level
off in the early 1960s and, between 1968 and 1977,
fell by 22 percent.  For stroke, the death rate, de-
clining gradually over the last two decades, dipped
more sharply, falling off 32 percent, between 1968
and 1977.

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  Behind both diseases lies the process of athe-
roclerosis in which critical arteries become nar-
rowed by fatty deposits.  Beginning silently, even
as early as the first decade of life, atheroscle-
rosis  gradually thickens  the walls of affected
arteries with "plaques"'  which usually consist of a
core of cholesterol and fats.  The wall thickening
progressively narrows artery diameter, reducing the
amount of oxygen-carrying blood reaching the heart,
brain or other parts of the body.

  Manifestations do not usually appear until the
disease process is well advanced and blood flow
considerably reduced.  Chest pain (angina pectoris)
may appear when excitement,  physical effort, or
exposure to cold increases the heart's requirements
for oxygen beyond the level that can be supplied by
the impaired blood flow.  Angina may be a forerunner
of eventual heart attack--but heart attacks, fre-
quently fatal, can occur suddenly, without warning,
when an already narrowed coronary artery serving the
heart is further blocked, completely shutting off
flow to an area of the heart muscle.

  A stroke occurs when the blood and oxygen supply
to the brain is severely reduced. The mechanism can
be similar to that of a heart attack--further block-
ing of an artery supplying brain tissue, usually an
artery already compromised by atherosclerosis.  Most
strokes are of this type.  A stroke may also occur
when an artery ruptures in the brain and the hemor-
rhaging destroys brain tissue.

Risk Factors for Heart Disease and Stroke

  The importance of risk factors is not in ques-
tion.  Each individually is clearly linked to in-
creased likelihood of heart disease or stroke--and
in combination they multiply the likelihood.   What
only remains  uncertain is the precise extent to
which risk can be decreased by modifying the risk
factors.

Smoking. syo;; the late 194Os, research ,",I;
consistently      that cigarette  smokers

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nearly twice the heart disease death rate of non-
smokers.    The   difference is   much  greater in
individuals under 65.

  Substances in cigarette smoke which may be
hazardous to the heart include nicotine and carbon
monoxide.

  Risk is proportional  to the amount of smoke
inhaled   and   the   number of  cigarettes   smoked.
Smokers of more than one pack a day are three times
more likely to experience a heart attack than
non-smokers (Figure 6-D).  Pipe and cigar smokers
have only slightly higher rates of coronary heart
disease than non-smokers.

  Hypertension..  High blood pressure contributes
to heart disease by putting an added burden on the
heart which must pump against the increased pressure
in the arteries and it also seems to be a factor in
the thickening of artery walls.  Hypertension in-
creases risk of stroke by promoting the atheroscle-
rotic process in arteries supplying the brain--and
by contributing to the rupture of relatively fragile
brain vessels.

  A blood pressure measurement consistently over
140 systolic (the pressure when the heart contracts)
and 90 diastolic (the pressure when the heart re-
laxes between beats) is usually considered abnormal.
And people with pressures exceeding 160/95 are con-
sidered to have hypertension which would benefit
from treatment.   About 35 million Americans have
pressures above 160/95.

  A study in Framingham, Massachusetts, has shown
that men aged 45 to 64 who have pressures of above
160/95 have two to three times the coronary heart
disease rate of those with pressures under 140/90.
Among people with systolic pressures above 160,
strokes are three times as frequent as among those
with systolic pressures under 140.

  The high incidence of stroke deaths at younger
ages among blacks is probably due in large measure

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           FIGURE 60
           FIGURE 60
AGE-ADJUSTED RATES OF FIRST HEART AITACK
AGE-ADJUSTED RATES OF FIRST HEART AITACK
  BY SMOKING STATUS FOR WHITE MALES
  BY SMOKING STATUS FOR WHITE MALES
   AGES 30-59 YEARS: UNITED STATES
   AGES 30-59 YEARS: UNITED STATES

200

150

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to the increased prevalence and severity of hyper-
tension which occurs in black Americans for reasons
not yet clear.

  Cholesterol.  Premature heart disease is unequi-
vocally associated with elevated blood cholesterol
levels.  Stroke risk, too,  is increased by elevated
serum cholesterol,  although the association is not
as strong as for heart disease.

  For American men, the average cholesterol level
is about 220 mg/dl (milligrams of cholesterol in a
deciliter of blood).   Heart attacks are five times
as frequent in men--and women--aged 35 to 44 who
have cholesterol levels above 265 as among those
with levels below 220.  In general,  the lower one's
blood cholesterol the less the likelihood of heart
disease;  the higher the cholesterol  level, the
greater the risk.

  It is cholesterol deposited from the blood which
goes into atherosclerotic plaques. And cholesterol-
carrier substances  in the blood,  called lipopro-
teins, have recently been found to play an important
role in  atherosclerotic disease.  One type--low-
density lipoproteins (LDL)--appears to accelerate
cholesterol deposition in artery walls.   However,
another  type--high-density  lipoproteins  (HAL)--
appears not to hasten the process, and may even be
protective.

  Current research suggests that measuring HDL and
LDL levels may be a more accurate means of predict-
ing risk for atherosclerosis and heart attack than
measuring serum cholesterol  alone.   Factors like
exercise and perhaps even simple dietary modifica-
tions may increase the ratio of HDL to LDL and
thereby possibly protect against heart disease.

  Direct evidence from animal studies supports the
linkage of atherosclerosis with high levels of fats
(particularly saturated) and cholesterol in the diet.

  Diabetes.  Diabetes is a fourth important risk
factor for cardiovascular disease.   Diabetics have

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more severe atherosclerosis,  twice as many heart
attacks,  and about twice as many strokes as non-
diabetics of the same age. For diabetic women, the
risk of  atherosclerotic disease is five times
greater than for other women.

  Diabetics are also more likely to be hyperten-
sive and overweight.  Control of blood pressure and
elimination of smoking are especially important for
them since these risk factors still further heighten
their premature death rate.

  Other  risk factors.   Although they may be
somewhat less important in their effects than the
four major risk factors just  noted,  other risk
factors   for   coronary   heart   disease   include
overweight,   physical   inactivity,   personality
patterns which are related to stress,  genetic
predisposition, and oral contraceptive use.

  Even a moderate excess of weight may be asso-
ciated with increased levels of very low-density
lipoproteins  in the blood and with high blood
pressure and high blood sugar.   Still undetermined
is   whether  physical   inactivity--which  may be
associated with excess weight and elevated blood
cholesterol,  sugar,  and blood pressure levels--
independently increases the risk of premature heart
attack or stroke.

  All people face ordinary stresses of life and
work.   Some,  however,  invoke additional, extraor-
dinary  stresses.   Typically, they are extremely
ambitious,  competitive,  and  impatient,  and some
studies indicate that they are at higher risk of
coronary heart disease.

  In some families, early heart attacks--before
age 50--affect several closely related members,
leading to the belief that a genetic predisposition
to heart disease may exist.  Hypertension, diabetes,
and serum cholesterol abnormalities are,  in some
cases,  known to be hereditary, but other genetic
factors adding to heart disease risk have yet to be
identified.  Children of parents who have had heart

6-11


attacks before age 50 can be tested for relatively
rare hereditary fat metabolism disorders.  For most
people,  however  any contribution  to risk made by
genetic  conditions is  exacerbated by cigarette
smoking,  poor dietary habits, and other behavior
that members of a family often share in common.

  Some drugs may increase risk.   A substantial
increase  has been noted in women who use oral
contraceptives or estrogen replacements, and who may
have other risk associations.  For example, women
aged 40 to 44 who both use oral contraceptives and
smoke have about 10 times the risk of death from
heart attack as women who do neither.

Subgoal:  Reducing Death from Cancer

  Cancer, the disease most feared by Americans and

developed by one in four, claimed nearly 390,000
lives in 1977, making  it the second most common
cause of death.  More than a third of deaths occur
in the middle years  (ages 35 to 64) of life.
Although far more frequent among adults, cancer also
occurs in children.

  The most comnon fatal cancers are leukemia,
kidney and nervous system malignancies in children;
lung,  intestine and breast cancer in adults; and
cancer of the intestine, lung, prostate and uterus
in older Americans.   Almost half of all cancer
fatalities  in the United States are from three
varieties:  lung, large intestine, and breast.

  All cancers are similar in apparently occurring
when body cells begin to multiply without the usual
internal restraints.  The malignant cells push the
normal out of the way, spread out, and even migrate
to distant parts of the body.

  The process can be relatively quick, as in some
forms of leukemia.  But for the most common types,
including breast cancer, it is believed that 10, 15,
even 25 years may pass before all of the steps in
the biological chain of events leading to cancer are
completed.  Once they are,  varying lengths of time

6-12


may elapse before enough cancerous cells accumulate
to be recognized.

  Cancer is not a single disease but rather a
group of diseases occurring worldwide in man and all
other marrrnalian species.  Each type has its own rate
of occurrence and often tends to affect certain pop-
ulation groups sharing particular characteristics.

  Sex, race,  and other hereditary factors as well
as geographic, age,  and occupational differences--
when added to differences in habits and exposure to
certain substances--provide clues to the origin, and
prevention,  of many human cancers.  Many types of
malignancies are not necessarily fatal.  Some grow
very slowly and rarely spread; others can be halted
by prompt medical intervention.

  Although much remains to be learned about cancer
development,  extensive research has established that
in some cases something identifiable is responsible
for changing the behavior of cells and stimulating
their uncontrolled growth. A single cancer-inducing
(carcinogenic) agent such as radiation may trigger
this response.  While in rare instances cancer may
follow a single large exposure, usually it is due to
repeated low-dose exposures.

  Most carcinogens seem to have their major effect
in specific parts of the body, often related to
their mode of entry and their sites of activation,
destruction and exit from the body.  But cancer in
any one site may result from combined effects of
several agents or several events.  And variations in
the body's internal chemical environment or genetic
predisposition also play a role in determining the
response to potentially cancer-provoking stimuli.

  While the number of cancer victims has increased
dramatically in the past 40 years, much of the
increase is due to population growth.  When changes
in the size and age composition of the American
population are  taken into consideration, overall
cancer death rates have increased only slightly for
men since 1937 and have actually decreased slightly
for women.

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  Also changed over the past several decades have
been the patterns of cancer types and incidences for
men and women (Figures 6-E and 6-F) and for whites
and other races.  Men have more cancer of the lung,
intestines, bladder and stomach than women and have
higher overall cancer  death rate--l63 per 100,000
versus 137 per 100,000 for women.  Whites intend to
have higher  rates than others of cancer of the
breast, intestines,  and bladder, but lower rates of
cancer of the prostate, cervix, and stomach.

  Cancer differences can be noted from one country
to another.  Compared to Japan, the United States
has more cancer of the breast but less cancer of the
stomach.  Such variations in cancer types and death
rates may be due to differences in hereditary,
environmental and behavioral factors and/or use of
early detection measures.  The tendency of people
who migrate to assume the cancer patterns of their
new home provides some clues to cancer causes.

Risk Factors for Cancers

  Among influences which have been identified as
potential  contributors to cancer development are
cigarette smoking,  alcohol,  certain dietary pat-
terns,  radiation,  sunlight,  occupational  hazards,
water and air pollutants, and heridity and predis-
posing medical conditions.

  Smoking.  Cigarette smoking is responsible for
more cancer and more cancer deaths than any other
known agent.  Not only do smokers have about 10
times the frequency of lung cancer; they also have
three to five times as much cancer of the oral
cavity, more than three times as much cancer of the
larynx,  and more than twice as much urinary bladder
cancer as non-smokers.

  Cigar  and pipe smokers have lower malignancy
rates than cigarette smokers except for cancers of
mouth and lip for which their risk is approximately
the same.  The fewer cigarettes smoked, the less the
risk.  The risk also may be lower for smokers of
filtered or low tar and nicotine cigarettes but

6-14


FIGURE 6E

AGE-ADJUSTED CANCER INCIDENCE RATES BY SITE
FDR MALES: UNITED STATES, SELECTED YEARS, 1947-1979

100
80

60

40

20

70 :
1945

I        I        I        I

FIGURE 6F

AGE-ADJUSTED CANCER INCIDENCE RATES BY StTE
FOR FEMALES: UNITED STATES, SELECTED YEARS, 1947-1976

1KI
80                                .*#a,
   k"l'llll~`~l~lllllllll#lllll~,~l,,l,~,,,,,,,,,,,,~,,,,,,,,,,~,~~l~`~    -8reast
60

NOTE  All rates 1`1 age-ad,"rtea to tne 1960 United staler pOp"latlOn

Source:  Data for 1947.1948 are from the Second National Cancer Survey; for 1969.1971 from the
  Third NatIonal Cancer Survev; and for 1973-1976, from the Surveillance, Epidem'iologv, and
    End Results ISEER) Program, National Cancer Institute.

6-15


evidence is limited and risk is still much higher
than for non-smokers.

  Smoking also can multiply--in some cases many-
fold--the risks associated with other carcinogenic
agents.  Heavy alcohol use,  associated with esopha-
geal cancer,  has a greatly intensified effect when
combined with cigarette smoking. People exposed to
carcinogens on the job may have much greater risk if
they also smoke.  The combination, for example, of
occupational  exposure to asbestos and cigarettes
increases lung cancer risk 90 times.

  Alcohol.  Higher rates of cancer of the larynx,
oral cavity,  and liver as well as of the esophagus
occur among people consuming large amounts of alco-
hol.  Whether the nutritional deficiencies sometimes
associated with heavy drinking increase suscepti-
bility to the effects of alcohol, tobacco, and other
carcinogens,  or whether alcohol itself causes the
damage is yet unknown.  Contaminants that accumulate
during manufacture of most alcoholic beverages may
be the harmful agents, rather than alcohol itself.

  Diet.  A role in cancer development has been
prop= for components of diet--and for some
methods of food preparation such as pickling and
charcoal broiling.

  Some of the information about dietary causes is
based on animal studies and may have limited rele-
vance to man.  Other information comes from compar-
isons of human cancer rates in different countries
and among migrants from one country to another.

  The typical American diet includes foods con-
taining many substances added to enhance taste,
improve  color,  and retard spoilage--as  well as
residues  of food packaging materials, materials
added to animal feed, and other chemicals.

  Some of these additives may actually help pre-
vent cancers--notably antioxidants and those that
prevent growth of molds which can produce car-
cinogens such as aflatoxin--but others may have

6-16


carcinogenic potential.   Studies thus far have not
been conclusive.   But,  because  the number  and
amounts of additives were much less 30 to 40 years
ago,  and because malignancy can take that long to
develop,  careful scrutiny of the health effects of
substances added to food is important.

  Variation in rates of cancers (which differ
greatly from  country to country) may relate to
differences in diet.

  For example, people in Japan eat much less beef
and total fat and more salt and pickled foods than
Americans; they have much lower rates of breast and
colon/rectum cancers, but higher rates of stomach
cancer.   These  differences   cannot  be entirely
genetic.

  Among Japanese immigrating to the United States,
rates for breast and colorectal cancers tend to in-
crease while those for stomach cancer decline as
eating habits become more like those here.   Such
trends are also found among imnigrants from other
countries.   But the precise relationship between
dietary differences and various cancers is still not
known.

  Radiation.  A connection between exposure to
radiation and cancer has been recognized ever since
malignancies appeared in scientists and technicians
who received large doses in their work with radium
and early x-ray devices.

  More recently,  increased risk of cancer has been
associated with radiation used for some diagnostic
and therapeutic purposes.  Because no radiation dose
may be so small as to be risk-free and exposures are
cumulative, some health professionals, while valuing
x-ray procedures,  have been working to reduce pa-
tient exposures.   Much more can be done in this
regard.

  Other sources of low-level radiation to which
the American population is exposed include those
related to natural background radiation,  nuclear
weapons fallout, and nuclear energy.

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  Sunlight.  Sunlight can cause skin cancer--and
does among some people receiving large exposure,
particularly outdoor workers.  Americans living in
the South and Southwest have much higher skin cancer
rates than those in northern states.  People with
darker complexions are at lower risk.   Protective
clothing  and sun  lotions containing PABA (para-
aminobenzoic acid) or other compounds that screen
out harmful rays can help to prevent skin cancer,
and premature aging of the skin.

  Occupational exposure.  Each year in the United
States about 1,000 new chemicals are produced in
commercial quantities.   American workers are thus
exposed to an ever-increasing number of materials
that may have cancer-causing potential.

  More than 200 years ago, an association between
occupation and a specific cancer was recognized in
the higher incidence of cancer of the scrotum among
chimney sweeps.  Since then,  many substances have
been found to produce cancer among workers in a wide
variety of industries.

  Occupational exposures can cause cancers which
are rare in the general population--and, in the case
of some exposures,  can increase the incidence of a
number of cornnon types.

  Working with asbestos without appropriate pro-
tection, for example,  increases the incidence of the
rare malignancy, mesothelioma, as well as of lung
cancer.   And,  plastics workers exposed to vinyl
chloride are at 200 times greater risk for liver
cancer, four times greater risk for brain cancer,
and two times greater risk for lung cancer than the
general population.

  Occupational exposures  also may interact with
other environmental hazards for a great multiplica-
tion of risk as in the case of cigarette-smoking
asbestos workers.

  Nor are hazards from industrial substances con-
fined by workplace boundaries. Toxic materials may

6-18


pollute air outside as well as inside a plant, en-
dangering nearby residents.  For example, angiosar-
coma, a rare liver cancer linked to vinyl chloride
exposure,  has been diagnosed among people living
near vinyl chloride polymerization and fabrication
plants.

  Moreover,  contaminants  carried home on work
shoes and clothes can threaten families.  Documented
cases of mesothelioma have been found among people
whose  only known exposure  to asbestos has been
through living in a home with an asbestos worker.

  Water pollution.  Potentially carcinogenic in-
dustrial and agricultural wastes--including chlor-
dane,  aldrin,  dieldrin,  and benzene--are found in
some rivers and lakes from which drinking water is
taken.  Although their concentrations in drinking
water usually have been much lower than those known
to pose substantial risk, such substances can accu-
mulate in water supplies and may become concentrated
in fish or shellfish.  Their increasing amounts--and
varieties--make updating  and enforcement of water
quality standards essential.

  Air pollution.  Air quality varies greatly from
place to place within the United States. Air pollu-
tion comes primarily from automobile exhausts, the
burning of fuels,  and industrial activities.  Pollu-
tants such as asbestos, beryllium, benzene, and
other synthetic organic chemicals are potential car-
cinogens,  and several studies suggest that higher
levels of air pollution may be associated with in-
creased lung cancer rates.  The extent of increase
has not yet been quantified but close monitoring of
air quality is clearly indicated.

  Heredity.  Some cancers tend to run in families.
Sisters daughters of women with breast cancer,
for example, are at higher risk for the disease.

  But families often share environmental condi-
tions  and behavioral  characteristics,  making it
difficult to determine how much of family clustering
of cancer is really the result of heredity.

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  The significance of a family history varies from
one type of cancer to another.  Overall, only one or
two percent of cancers are attributable primarily to
heredity;  in some rarer types, the percentage may be
higher.

  People with certain genetically-related condi-
tions have a higher cancer incidence and are prone
to develop malignancy earlier.  One example is the
predisposition of those with multiple intestinal
polyps to cancer of the colon.

Cancers at Specific Sites

  A great number of cancers and cancer deaths can
be prevented through two strategies:  limiting ex-
posure to cancer-causing substances, and early de-
tection and treatment before a cancer has spread.

  Lung and urinary bladder cancers are amenable to
the first strategy.  More than 80 percent of all
lung cancer  and up to 50 percent of all bladder
cancer could be prevented if people stopped smoking.
Skin cancer also  is largely preventable through
avoidance of excessive sun exposure.  Modifications
in  occupational   exposure  and diet may  help to
prevent other types of cancer.

  Once cancer develops,  many deaths can be pre-
vented by early detection and treatment.  For this,
screening procedures must identify accurately people
with cancer still in early enough stages to allow
effective treatment.  Available screening measures,
more widely applied, could probably prevent a third
or more of the deaths due to breast cancer in women
over 50, most deaths from cervical cancer, and many
of those due to prostate and rectal cancer.

  Lung.   Lung  cancer,  the most comnon lethal
malignancy in the United States, accounted for four
percent of total deaths and 25 percent of all cancer
deaths in 1977.  Approximately 80 percent of the
72,000 men and 23,000 women dying from lung cancer
did so as a result of cigarette smoking.  Early
identification techniques--such as chest x-rays and

6-20


sputum examination--generally do not discover lung
cancer before it has spread.   The elimination of
cigarette  smoking  and occupational  exposures to
carcinogenic substances is the best approach.

  Breast.  Affecting  nearly one in 13,  breast
cancer the most comTlon malignancy for American
women.  Although more frequent in older women, it
does not spare the young and, 28 percent of the
time, affects women under 50. Definitive prevention
by any simple means is not available--but risk of
death from breast cancer can be reduced substan-
tially by early diagnosis.

  Several  screening procedures are available--
self-examination  (most important), examination by
a physician,   and  mammography  (a type of  x-ray
screening).

  Most breast cancers are first found by women
themselves rather than by physicians during routine
examinations.   Women should examine their breasts
once a month.  Particular care should be taken by
those with family histories of breast cancer.   For
women still menstruating, the best time is just
after the period.  Menopausal  and postmenopausal
women should choose a specific day of the month for
breast self-examination so they are less likely to
forget to do so.  Although a lump, abnormal dis-
charge, or size irregularity is usually a symptom of
benign  rather than malignant  breast disease, a
physician's  examination is essential when any of
these conditions is noted.

  Periodic examination by a physician, in combina-
tion with mammography,  increases the number of
cancers identified early, before their spread.

  Mammography may identify cancerous cell deposits
too small to be detected even by careful physical
examination.  Among women over 50, it can contribute
to reducing breast cancer death rates.

  Mammography does use x-rays which, particularly
in higher doses, may cause cancer, and frequent use

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of the procedure  carries  a risk which must be
weighed against potential benefits.  Each mammogram
may raise risk by a very small fraction.   It has
been estimated that if, for example, a woman has
five mammograms, her chance of ever developing
breast cancer would increase from 7.0 percent (no
mammograms) to 7.35 percent.

  Colon and rectum.   Cancers of the colon and
rectum, which make up 15 percent of all cancers and
are the second most common cause of death from
malignancy,  affect 100,000 Americans and lead to
50,000 deaths  annually.   They are  particularly
comTlon between ages 50 and 70.  Early indications
may include rectal bleeding and bowel habit changes.

  Premature death from colorectal cancers can
often be prevented by periodic medical examinations,
including use of instrument examination (sigmoidos-
copy or colonoscopy) when indicated, to detect early
disease amenable to treatment. People with family
histories of colorectal cancer have special need for
periodic examinations.

  People whose diet is relatively lacking in
fiber may have a higher incidence of colorectal
cancer.  The evidence that high fiber diets will
reduce the incidence is scanty at present, but such
diets are prudent and are likely to reduce the
chance of diverticulitis and hemorrhoidal disease.

  Prostate.   Prostate cancer incidence has been
increasing over the past 40 years, especially for
black men.  Four-fifths of cases occur after age
65.  Not enough is known about causes to permit a
strategy of prevention.

  The best available alternative is early detec-
tion   and  surgery.   Considering  improvements in
treatment over the last 15 years, the outlook is far
better when prostate cancer is still localized at
the time of diagnosis.  Rectal examination by a phy-
sician is the most reliable method of early detec-
tion and should be part of every physical exam for
men after 40.

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  Cervix.   Invasive cancer of the cervix affects
20,000 American women and causes over 7,500 deaths
annually.   Rates of   incidence   and   death   have
declined substantially since the early 1950s.

  Risk of cervical cancer seems to increase with a
multiplicity of sex partners,  early and frequent
sexual activity, and multiple childbirth.

  Although the reduction in incidence and death
rates began before such early detection measures as
the Pap (Papanicolaou) smear were widely used, these
measures are probably responsible for at least part
of the continuing decline.

  The Pap smear-- for  analysis of cells from the
cervix--has greater potential for reducing cancer
deaths than any other screening method now avail-
able.  Smears--which can detect cells with cancerous
potential before they become invasive--should be
taken at periodic intervals:  for three consecutive
years beginning at age 20, or at the beginning of
sexual activity;  then every three years until age
35, every five years to age 60, then again there-
after every three years.  The screening frequency
should be increased for women using oral contracep-
tives or estrogen therapy, and in those found to
have pelvic abnormalities.

  Urinary bladder.   Bladder cancer, relatively
comnon in men, led to an estimated 6,900 deaths in
1977.  About 40 percent of cases occur before age 65
and the malignancy is most common in heavy smokers
and individuals exposed to cancer-causing occupa-
tional chemicals.

  Blood in the urine is the most common early
sign--but it may also signify other conditions', some
of which are not serious.

  The key to prevention lies in reducing cigarette
smoking and exposure to carcinogens in the work-
place.  Many deaths may be prevented through early
detection and treatment.

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**********

  The pattern of cancer incidence has varied
widely--over  time,    across   national   boundaries,
within subgroups in the population.

  Only a small fraction of these differences can
be explained by heredity.  Environmental factors and
factors in individual behavior appear to be the
prime causes of most forms of cancer.

  Therefore,  many--perhaps   even  most--premature
deaths due to cancer should be preventable.

Other Important Problems

  Most notable among other problems posing threats
to the health of adults are accidents (which have
been considered in earlier chapters, and will be
again in  Chapter 9), alcohol abuse and mental
illness.  The latter two,  as well as periodontal
disease, deserve special comment here.

Alcohol Abuse

  It is difficult to overemphasize the profound
and pervasive influence of alcohol abuse as a cause
of death for Americans.

There are an estimated 10 million problem
drinkers in the country.

  In 1977, more than 30,000 Americans died from
cirrhosis of the liver--and 95 percent of the deaths
were alcohol-related.

  Alcohol is a contributor to several of the lead-
ing causes of death from age 15 to age 70, with
direct responsibility for certain cancers of the
liver.

  It is a risk factor in various other cancers--
and, rarely, in diabetes.

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  It is an indirect cause in almost 150,000 deaths
annually from accidents, homicides, and suicides.

  Alcohol abuse also is a contributor to family
disruption,   child   and   spouse  abuse,   unwanted
pregnancy, rape, assault, other forms ofa;;olence,
job  instability,  economic  insecurity,      St111
other problems.

Drinking during pregnancy can cause abnormali-
ties in the fetus, leading to mental retardation and
other defects.  And special problems are presented
by the combined use of alcohol and sedatives.

  Chapter 10 will look in detail at the demography
of alcohol abuse in the United States and strategies
for its control.

Mental Health

  Mental illness is a substantial contributor to
disability and suffering for American adults.

  The President's Commission on Mental Health has
reported that three percent of the population--
nearly seven million people--sought treatment in
1975 by specialists in mental health and one to two
million were hospitalized for mental problems in
that year.

  In 1974, five percent of persons reporting limi-
tations on daily activities indicated mental and
nervous conditions to be the cause.  Surveys note a
large proportion of patients in the general medical
care  system have some emotional or psychiatric
problem.

  The Comnission's report also indicates that, at
any given time, up to 25 percent of the population
is estimated to be suffering from mild to moderate
depression, anxiety, or other emotional disorder.

  Depression and manic depressive disorders are
among the most severe types of mental  illness in
terms of prevalence, economic cost, and mortality.

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Of the 29,000 suicides recorded in the United States
each year, more than 80 percent are believed to be
precipitated by depressive illness.  Severe depres-
sion or manic excitability handicaps an estimated
two to four of every 100 adults at any given time.

  Consistent  relationships   have   been   observed
between mental disorders and factors such as sex,
social class, and place of residence.

  Women have highest  rates of manic-depressive
psychosis while men have relatively high rates of
personality disorders.  The incidence of psychiatric
disorders is highest among people with lowest levels
of income,  education,  and occupation.  People in
cities have higher rates of anxiety, mild depres-
sion,  phobias,  self-doubt and other symptoms of
personality disorders, with only manic depressive
psychosis apparently higher in rural areas.

  There is persuasive evidence that appropriate
treatment  at the onset of acute psychosis can
markedly influence its outcome.

Periodontal Disease

  Disturbingly comnon among adults--and costly and
difficult to  treat--periodontal   disease   affects
tissues supporting the teeth.

  It is most often caused by bacterial deposits
(plaque) on the teeth--and, in its most frequent
form, gingivitis, produ-es inflammation of the gums,
with redness, swelling, and easy bleeding tendencies.

  Gingivitis often progresses to a more severe and

destructive form of periodontal disease--periodon-
titis.  At this point, bone and ligaments supporting
the teeth are gradually destroyed and the teeth
loosen or "drift."

  In its most advanced form, the disease causes
loss of teeth--and is, in fact, the prime reason for
tooth loss after age 35.  A recent survey found that
more than 30 percent of Americans between ages 55

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and 64, and 45 percent of those 65 to 74, have lost
all of their natural teeth.

  Careful and thorough daily brushing and flossing
to remove bacterial plaque is effective in prevent-
ing and retarding progression of periodontal di-
sease.  Regular professional examination and treat-
ment to remove hard deposits that form on teeth,
correct predisposing factors,  and repair existing
damage are also  essential for control of this
disease.

**********

  Many  adult health problems  today--it bears
reemphasizing--can frequently be controlled by the
individual.  And the measures required are often not
particularly dramatic.

  An individual's risk of disease can be substan-
tially reduced (or increased) by a few simple per-
sonal decisions with respect to smoking, alcohol
use,  diet,  exercise,  seat belt use, and periodic
screening for major  diseases such as high blood
pressure and cancer.

  The potential exists to promote substantial
changes in the profile of disease and disability
among American adults.   But collective resources
will have to be mobilized to assist individuals
seeking to enhance their prospects for better
health, as well as to protect them from threats not
within their control.

  It is encouraging that many voluntary organiza-
tions, large businesses, and community agencies have
undertaken programs to help people adapt lifestyles
for a healthier life.  With a broad-based effort to
provide this kind of support, we can anticipate im-
pressive gains in the health of adults.

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