Unraveling the mystery of cancer in antiquity
by Erik Ness
(MAMM, October 2000)
We are captivated by the mystery of long-ago bones. How else can we explain a 67 million-year-old dinosaur named Sue fetching $8.36 million at auction and national headlines at her unveiling? How else do we understand the popularity of the Fox Television special “Opening the Tombs of the Golden Mummies: Live!” or Hollywood’s decades-long fascination with the stumbling mummy?
We entertain such morbid spectacles because, ultimately, we are curious—sometimes fearfully so—about what the dead can tell us, especially about our own lives. Archeological specimens reveal countless stories to trained eyes, stories about life and death. There are tens of thousands of skeletal remains lodged in academic coffers, and thousands of mummies. If you apply too much sympathy or watch too many horror movies, it’s a grisly spectacle, but for paleopathologists—people who study disease in antiquity—it is a cryptic pageant studded with clues.
This small core of academics is a cross between Indiana Jones and TV’s Quincy, the medical examiner. They have helped solve centuries-old murders and mapped the ancient grip of diseases such as syphilis and tuberculosis. An even smaller cadre has bent its shoulder to the problem of cancer.
And while the pathology report on a 3,000-year-old corpse is of little immediate concern to the modern cancer patient, medical anthropologist Marc Micozzi, MD, PhD, director of the College of Physicians in Philadelphia, the nation’s oldest medical society, argues that reading the archeological record helps to focus contemporary debates about cancer in society. As he wrote in the August 1991 issue of the Archives of Pathology and Laboratory Medicine, “Understanding changes in the occurrence and rates of diseases through history is important for a fuller understanding of whether cancer is truly a disease of modern society or whether it may be regarded as part of human heritage from earliest times.”
THE INVESTIGATION BEGINS…
It’s the ultimate cold case: no crime scene, no witnesses, no material evidence. More than likely tomb robbers, insects and inclement weather got there first. And once a specimen is removed from the sheltering ground, anything but the most delicate care is likely to harm it. Clear those hurdles, and the investigation begins: “When we look at skeletal materials from prehistory, the first thing we do is determine whether that skeleton is human, if it’s male or female, how old it is, and if we can tell from the associated artifacts how old that skeleton really is,” says Leslie Eisenberg, North American editor of the International Journal of Osteoarcheology. “After that, those of us interested in studying disease will look at changes to the bone—infectious changes, metabolic changes and other kinds including cancerous ones —because many of the diseases we wrestle with today have a long history in antiquity.”
Cancer, or at least a disease that could well have been cancer, crops up repeatedly in ancient art and texts from the beginning of recorded history. Translations of Egyptian medical papyri dating as far back as 3000 B.C. spoke of tumors. Herodotus and Hippocrates, founding figures of history and medicine, both mention cancer, and the second century A.D. Greek physician Galen set a somewhat primitive standard of care for breast cancer—excision and cauterization—that would linger into the Renaissance.
Among these possible early reports of cancers, those of the breast seem particularly common—a function, no doubt, of the breast’s anatomical prominence. In the days before autopsies, cancer of the colon, lung or kidney were not as likely to be seen as diseases of a particular organ.
But all these reports must be read with the understanding that cancer was a biological mystery. Because nobody really knew what cancer was, recorded symptoms were likely to be insufficient for the modern clinician to confirm the diagnosis. Was it breast cancer or inflammatory mastitis? Was a reported tumor malignant?
Finding physical evidence fell to the archeologists. In 1774 in Germany, E.J.C. Esper, a German naturalist, reported a bone cancer in the femur of a Pleistocene epoch cave bear. In 1824 one Augustus Bozzi Granville, a well-traveled English physician with eclectic research interests, reported in great detail his autopsy of an Egyptian mummy secured for the equivalent of $4 in the vicinity of Thebes. After writing numerous pages on bandages and “racial” characteristics, he reported in a few paragraphs on an ovarian cyst: “The disease which appears to have destroyed her was ovarian dropsy attended with structural derangement of the uterine system generally.”
As medicine evolved into a science over the next century, these and other assertions about the antiquity of cancer gained credence. Before we ever really understood how cancer did its damage, it became axiomatic that it was nothing new under the sun.
Yet as pathologists refined their craft, they revisited many of their earlier paleo-diagnoses and found them to be in error. In fact, today, scientists are less convinced that the Egyptian mummy from Thebes died of ovarian cancer. “We don’t know whether it was malignant or not,” says Arthur Aufderheide, MD, professor of pathology at the University of Minnesota, Duluth School of Medicine. “It didn’t show any evidence of going beyond the cyst.”
In 1991, in the Archives of Pathology and Laboratory Medicine, Dr. Micozzi set up a long string of these diagnoses of cancer in antiquity and knocked them down again. For example, the references to cancer in Egyptian papyri were partially due to Victorian-era translations by Egyptologists with no medical training, while the bear had merely suffered a broken bone. Micozzi ultimately concluded, “Those cancers that are common in the modern industrialized world have left no traces of their existence in prehistory and early human civilizations.”
It’s probably best to consider Micozzi’s argument in light of the history of anthropology generally, where broad conclusions are necessarily drawn from limited evidence. For example, until the recent advent of DNA analysis, dozens of books were written about the evolution of Homo sapiens over the last 5 million years—a flurry of scholarship derived from just a few baskets of bones. And while there is considerable room for interpretation and argument, increasingly sophisticated diagnostic tools and continued study have now led paleopathologists to the general conclusion that while cancer seems to stretch deep into history, it was probably not as prevalent as it is today.
Today’s cancer patient undergoes a barrage of tests in pursuit of a proper diagnosis—and even under these conditions doctors sometimes disagree on diagnosis and treatment. So how does a paleopathologist determine if someone who died so long ago had cancer?
Because bones are often the only tissue available, paleopathologists look for cancer’s fingerprints on the skeleton. Although primary bone cancers are rare, “there are many cancers that do affect the bones, and in pretty substantial and spectacular ways,” says Eisenberg of the International Journal of Osteoarcheology. Often a tumor may leave a smooth walled cavity in the bone. “It’s as if someone took a small ice cream scoop,” she says. “The bone was responding to something made of soft tissue pushing against it. Bone is dynamic, so when something impinges on bone, you’ll see it.”
Theoretically, we should see evidence of cancer, as two/thirds of all cancers can metastasize to bone, particularly the most common cancers: breast, lung, thyroid, kidney and prostate. What’s more, adds Donald J. Ortner, PhD, curator of anthropology at the Smithsonian National Museum of Natural History in Washington, DC, “in the absence of radical surgery, with the malignancy having taken its natural course, a [large number of] skeletal metastases should be expected.”
It’s not that easy, though. First, there is the age factor. We in the industrial West live about twice as long as people in prehistory, and modern epidemiological studies have shown that cancer is primarily a disease of aging. “Individuals who lived in antiquity usually died of other causes before secondary tumors could become a serious factor in morbidity and mortality,” wrote Ortner in his volume Identification of Pathological Conditions in Human Skeletal Remains (Smithsonian Institution Press, 1981).
“The response of the skeleton to cancer tends to be fairly nonspecific,” he explains further. “Different types of cancer can produce very similar types of lesions. Other things do affect the skeleton, but breast cancer perhaps is one of the easiest to diagnose. I do think there is good evidence of breast cancer going back several thousand years.”
He cites a Native American woman, most likely from 3000-1000 BC but possibly from as late as 800-1700 AD, excavated in Kentucky, with lesions in her skull, left femur, mandible, spine, shoulder, pelvis and ribs. Of course, there is a second opinion: “The skeletal lesions can easily be confused with other conditions like multiple myeloma [a cancer of the bone marrow], but the case that I’ve described, unlike myeloma, is more variable in terms of the size of the destructive lesions and does show evidence of some reactive bone repair at the margins, and that never occurs in myeloma,” he says. “And it’s in a female skeleton so I think that breast cancer is a plausible diagnosis in a specimen that’s quite old.” Ortner’s may not be the confidence level that a contemporary patient demands from her oncologist, but diagnosis, without even a complete skeleton, is challenging.
While most human remains from antiquity are bones, mummies provide additional clues about the health of our ancestors. In fiction and mythology, mummies have been long associated with the quest for immortality. And there is a curious evolutionary twist here, for cancer is, in fact, a problem of immortality, of cells that refuse to die.
Mummies are formed when—by accident or design—the body dries before it can decay. In ancient Egypt, where the body was thought to be a repository for the soul, embalming had advanced to a science: internal organs were surgically removed, salts and, sometimes, special ovens were employed for drying, and bitumen and spices were used as preservatives. Egyptian mummies are best known, but many other cultures have honored their dead with similar rituals. In Papua New Guinea, the dead were smoked over fires and then covered with a protective layer of mud. High in the Andes, the dry mountain air helped to freeze-dry Incan mummies.
What can we learn from tissue that has been preserved this way? In 1977, Michael Zimmerman, MD, PhD, of the University of Pennsylvania in Philadelphia, experimented with mummification techniques and found that tumors actually were preserved better than other tissue. “The virtual absence of malignancies in ancient tissues can only be interpreted as indicating their rarity or possible absence in antiquity” he concluded in an article for the journal Cancer.
The extensive mummy database of The University of Minnesota’s Aufderheide has not yielded answers for cancer, either. “We have very little data,” he says. “The soft tissue cancers that have been identified you can count on probably two hands. Even breast cancer: You would think out of 800 bodies I might find a breast cancer, but I haven’t. It just hasn’t been there.”
That absence of cancer in Aufderheide’s database may be an artifact of epidemiology—in addition to shortened lifespans in antiquity, many of the mummies he has studied are children or adolescents, in whom cancer is rare. At some point, researchers hope to be able to take a suspected tumor and verify its diagnosis with DNA, much as criminal investigators match DNA evidence with a suspect. Aufderheide guesses it will be another decade or two before we understand the genetics of cancer well enough to arrive at reliable paleopathological diagnoses of malignancies through DNA testing. One ancient cancer—of the colon—has been identified so far using DNA, thanks to recent breakthroughs in understanding the genetic legacy of that disease.
“In the last decade we certainly have documented that cancers existed [in antiquity],” Aufderheide concludes. “The question is one of frequency. Using the current methods and given the available bodies for examination, I’m not sure we’re going to be able to answer that question for decades yet.”
A CONTEXT FOR DISEASE
If the evolving politics of cancer has taught us anything, it is that the diagnosis of cancer is meaningless without context. Disease is intertwined with our lives and can often tell us a great deal. For example, naseopharyngeal carcinoma is prevalent today in Africa and Asia relative to the industrial West. From archeological evidence, paleopathologists have concluded that the probable culprit is wood smoke. “That, of course, would be much more common in women because they cook and tend the fires,” Ortner says.
To fully appreciate cancer’s place in history, we should at least consider the overall health status of our ancestors. “It’s a very tricky thing to try to go from skeletal evidence to a statement about the general health of the people that you’re looking at,” Ortner cautions. “I think there is a tendency to make out people as being worse off perhaps than they were. But there’s no doubt that in comparison with what we enjoy today in terms of general health, in terms of longevity, there’s a big difference.”
Kimberle Gray agrees. In pursuit of a PhD in Bronze Age archeology at the University of Cincinnati, Gray analyzed the skeletons of 58 Bronze Age women (3000 BC-1020 BC) from Greece and Cyprus to assess their health status. Gray wanted to challenge a long-standing notion about female mortality in the ancient Mediterranean, where women died approximately five years earlier than men, essentially the reverse of the modern industrial world. The accepted explanation was the drains of pregnancy, childbirth and lactation. The only problem: “They haven’t even determined whether these women had given birth,” she says. “It’s ludicrous.”
In her examination, Gray saw no cancer and guesses that these women were likely consumed with the struggle for daily survival. Tremendous malnutrition marked their lives: misshapen pelvis, collapsed crania, scarred dental enamel. “We cannot consider the life experiences of these women solely as an outgrowth of their pregnancies … and lactation,” she concludes. “There are so many more generalized patterns that come first, and these seem to all point towards malnutrition and disease. We can’t just say pregnancy, childbirth, pregnancy, childbirth.”
Ironically, lactation and pregnancy are precisely what scientists are now focusing on as they try to understand the prevalence of breast cancer today. “One thing with breast cancer that’s incontrovertible is that to spend all those years not pregnant and not lactating is clearly a risk factor,” says Micozzi, who studied precisely this problem for his PhD. “These are major shifts in the biology of most women’s lives.”
One of our biggest questions is whether cancer is a modern disease. According to Ortner, strictly speaking, paleopathological evidence indicates that cancer has probably been with us all along. “Cancer is basically a disease of aging,” he argues. “It’s less common in bioarcheological skeletal samples because people didn’t live long.”
Of course, it is the unique distinction of human beings that we are no longer beholden solely to biological evolution; we have created a process of social evolution as well. As a result, we live long past our reproductive ages and meddle with our own and other people’s biology. “Our adoption of diets, physical inactivity and reproductive patterns … are at odds with our inherent biology,” writes Mel Greaves of the Institute of Cancer Research in London in a new book Cancer: The Evolutionary Legacy (Oxford University Press, 2000).
Women’s cancers, he argues, are driven by these conflicting dynamics: “The stark reality is that females of our species are burdened with a 5-million-year-old genetic program that anatomically and physiologically primes them for regular pregnancy and lactation. But then our rapid social development as a species has produced a schism between our socialized reproductive behavior and our evolutionary heritage—nature and nurture in conflict.” A number of epidemiological studies, ranging from an 18th century study of nuns to the ongoing Nurses’ Health Study, suggest that reproductive factors, such as age at first birth and at subsequent births, influence breast cancer risk.
Micozzi explains the increase in cancer rates by pointing to changes in behavioral patterns, as well as a damaged environment. “A lot of people think it’s because of the massive changes in our environment brought about by industrial technology,” he says. “Not only the whole pollution side of the story, and additives and chemicals and radiation, but simply changes in diet. If people want a clue as to what type of lifestyle puts you at risk for cancer, then obviously knowing about the past is important.”
The challenge now is how our culture adapts to the disease. For all the money we sink into research, Ortner speculates that the cultural responses are largely intuitive. “I think what happens is that societies are constantly experimenting with different diets, with different sorts of strategies for living. “The game that we can play now is that we can intervene. We can understand what’s going on. The more we know about disease the better off we are, because we can then [craft] different strategies for dealing with it, in a way that our ancestors couldn’t.”
Copyright 2005 by Erik Ness