THE PROBLEM OF CANCER IN ANTIQUITY : BRIEF REVIEW OF 94 CASES

di Fornaciari Gino

Paleopatologia

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Susanna Gamba, Gino Fornaciari
Division of Paleopathology
Department of Oncology, Transplants and Advanced Technologies in Medicine
University of Pisa, Medical School

The general opinion about the occurrence of malignant tumors in antiquity was that they were nonexistent or extremely rare. Paleooncologists still strongly disagree about the prevalence of cancer in the past, sometimes almost reaching the point of denying their existence (1), other times admitting a very low prevalence compared to the present. Therefore, cancer seems to have been rare in the past and the calculated prevalence might be either real or it might only reflect an underdetection of cancer.
Some of the reasons given as an explanation for the rarity of cancer in antiquity are as follows : 1) the average life span was shorter (individuals died earlier and more frequently from injuries or infections rather than from a complication of the malignant tumor) ; 2) certain chemical substances or physical agents known to being cancer promoters were absent in the past ; 3) as far as primary soft tissue tumors are concerned, the tendency to spread to the bones is not always the same for all types of tumors ; 4) bone metastases appear first in the marrow cavity and the simple inspection of bones may fail to reveal inner growths which might instead become apparent, were recovered bones sistematically radiographed (2) ; 5) malignant tumors might have been scarcely reported in older literature also because anthropologists in charge, being not medically trained, simply did not look for tumors (3).

In order to assess the actual situation of cancer occurrence in the past, we reviewed all the cases of malignant tumors reported in literature, and found 28 cases in Egypt and Nubia, 40 in Europe, 19 in the Americas, and 7 in Asia (4-17).
The numbers given do not represent a real estimate of the occurrence of malignant tumors in the various regions of the world. They rather represent a quantification of the digging activity in one area more than in another.

In our review study, we found the first reference to the presence of a malignant tumor in Poland dating back to as early as the Neolithic Period (4000-2000 BC) and, since then, references to cancer follow down to the XIX century AD in Japan.
Unfortunately, direct diagnosis of malignant soft tissue tumors is exceptional in paleopathology. In fact, with the exception of primary bone tumors (which for that matter are rare in modern medical records as much as they are in archeological specimens [8]), the diagnosis is generally indirect, through osseous destruction by metastases. There follows a problem in the differential diagnosis of the specific types of osseous involvement. The most difficult differential diagnosis concerns the distinction between multiple myeloma and osteolytic metastases from carcinoma. Although osseous metastases from carcinoma are much more common than multiple myeloma (12), one cannot only rely on frequency data (20, 21).
For that matter, we collected and reviewed the 94 cases of malignant tumors. Among these, we found some cases of presumed multiple myelomas which diagnosis we dare consider absolutely uncertain but are unable to categorize otherwise : the absence of paleopathological specimens makes the accurate assessment of every single case impossible (18).


Our differentiation into specific types of malignant tumors yielded :
Osteosarcoma
8 cases       5 males (3 adult, 1 mature, 1 senile)
                  3 US (1 adult, 2 UA)
Carcinoma (metastases included)
64 cases     17 males (4 adults, 12 mature, 1 senile)
                  23 females (11 adult, 11 mature, 1UA)
                  24 US (1 adult, 1 senile, 21 UA)
Multiple myeloma
15 cases     3 males (1 adult, 1 mature, 1 UA)
                  3 females (1 adult, 2 mature)
                  9 US (2 adult, 7 UA)
Tumors of uncertain diagnosis
7 cases       4 males (4 adults)
                  2 females (1 adult, 1 UA)
                  1 US (1 UA)

The lack of an adequate number of ancient individuals over 60 years of age (the reason of which we reported previously) prompted us to limit our study to individuals within 60 years of age ; thus, in order to balance, we extended such limit when referring to modern population data as well.

These results show that carcinomas were rather frequent (68.0%) and sarcomas were rare (8.5%), showing a trend similar to the present. The very high percentage of multiple myelomas (16.0%) shows an unusual pattern concerning the age of prevalence, namely preferring the young-adult age, which contrasts with modern medical reports showing that multiple myeloma affects individuals in their 50s-60s ; again, we dare admit that some of these cases might have been misdiagnosed.
We believe that five cases of nasopharyngeal carcinoma detected in Egypt ad Nubia deserve separate mention. Nasopharyngeal carcinoma is relatively rare in Western developed countries (0.25%), while its incidence in certain regions of Africa (7.8%), Southeastern Asia (18%-20%) and Alaska is greater. The five cases in ancient Egyptians and Nubians show no significant sex preference ; the age distribution is shifted toward a younger period than would be expected according to the most recent incidence of carcinoma.
Four out of five cases date to the Byzantine and Christian Periods (300-1400 AD) which can be interpreted as an expression of the trend to increasing incidence of carcinoma. Environmental influences facilitating the development of nasopharyngeal carcinoma can be supplied by the Epstein-Barr virus. Also, it seems that short chain fatty acids are needed to act as promoters in addition to the viral infection ; this kind of fatty acids is contained both in plants of the Family Euphorbiacea (typical of warm climates) and is also produced by the nasal and oral flora secondary to poor hygiene (3, 19).

In our review, most cases of cancer are concentrated in the age range between 21 and 40 years, while modern medical records show that the highest incidence of cancer occurs beyond age 40 ; this might be explained taking into consideration that the modern life span has expanded compared to the past ; in addition, certain tumors have a tendency to develop and manifest themselves later in life, at an age when the same individual in the past might have already been dead from an infection or an injury. On the other hand, osteosarcoma is a tumor of the young and it is surprising (or maybe etiologically significant) that the prevalence in antiquity was not greater, although the survival of young individuals in the archeological record is not always good enough for observing diseases affecting this age group (2).
From our review, it can also be seen that the prevalence in males and females reaches 50%, as it occurs nowadays.

The rare completely studied skeletal series from Russia and Italy show a prevalence of cancer in the past up to 3.8%, which is very close to the contemporary 5.0%.
We agree that malignant tumors were certainly less frequent in antiquity, but this by no means implies that cancer did not exist at all.

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