	The Internet has revolutionized how information is disseminated and goods are transferred, which has had a profound effect on the medical world. While the Internet is a valuable resource, its largely unregulated terrain allows a Website maintained by an individual selling an unproven health product, such as a “novel cancer treatment” from his or her garage, whether in the United States or abroad, to appear as legitimate as the Website of an esteemed medical organization, such as the American Cancer Society. On the Web, individuals can make modest or extraordinary claims of medical utility without proof or by fabricating data to sell their potentially dangerous products, such as electronic cigarettes, with few if any ramifications.

	Electronic cigarettes, also known as e-cigarettes, are battery-powered devices that resemble cigarettes and are designed to deliver a measured amount of nicotine to the user, along with a variety of other pleasurable chemicals, if desired. These chemicals, described as “flavorings,” include offerings such as chocolate and bubble gum, which may be appealing to teenagers and even younger children (

). Although e-cigarettes have been available since 2003, they have been gaining popularity over the past few years. It is estimated that there are currently 300,000 e-cigarette users and that 1 million people have tried them 

(http://en.wikipedia.org/wiki/Electronic_cigarettes

	On the Internet, e-cigarettes have been marketed as a method for smoking cessation, and an online survey revealed that users thought they were a healthy alternative to smoking traditional cigarettes; however, the FDA has not approved these devices for this purpose. In an interesting twist, e-cigarettes have also been touted as a workaround to the “smoke-free” zones because individuals are not restricted from using these devices in such areas.

	In 2009, the FDA attempted to halt the importation and sale of e-cigarettes in the United States after an analysis of a large number of seized shipments found these devices to contain ethylene glycol, a chemical used in antifreeze, as well as a variety of other 

. The actual content of nicotine also varied within the same type of device, suggesting a user would not know the relative amount of inhaled nicotine from one “cigarette” to the next, and those that were claimed to be nicotine-free often were not. Unfortunately, the FDA’s effort to control these potentially dangerous devices has recently been thwarted. Judge Richard J. Leon of Federal District Court in Washington granted a temporary injunction against the FDA’s attempt to block the importation of e-cigarettes from China, saying the FDA overstepped its authority and noted these devices to be “the functional equivalent of traditional cigarettes,” rather than a combination drug-device that should be subject to more stringent regulation (

	The inability of the FDA to prevent the sale and distribution of these completely unregulated devices is particularly worrisome and noteworthy when one considers Congress recently granted the agency historic oversight of the tobacco industry, an effort specifically designed to enhance the public’s health and welfare (

). Judge Leon noted that while the FDA won’t be able to prevent these products from being imported, its new tobacco division will be able to regulate the marketing claims made by e-cigarette manufacturers in the same way that traditional tobacco products will be regulated (

). Given the current climate, it is highly doubtful that regulatory authorities will be able to prevent these types of potentially dangerous products from reaching an unsuspecting public. It is also reasonable to assume that individuals using the Internet for personal gain will continue to use this inexpensive and efficient vehicle to sell their hazardous wares.

	Medical professionals can play an essential role in safeguarding the public from dangerous devices such as e-cigarettes by educating their patients and the public on the potential dangers associated with unregulated health- related products sold via the Internet. One strategy is to remind patients that if they hear a health-related claim, discover a medical product on the Internet that appears to be “too good to be true,” or they are considering consuming one of these unregulated products, to fi rst discuss this decision with a medical professional so that they can be certain that this is the “right thing” for them to do. 

Maurie Markman, MD, is editor-in-chief of Oncology Net Guide and Vice President of Clinical Research for University of Texas MD Anderson Cancer Center in Houston, Texas. 

Articles

ONCNG Oncology

The Internet has revolutionized how information is disseminated and goods are transferred, which has had a profound effect on the medical world.

Electronic Cigarettes: Another Potentially Dangerous Product Sold on the Internet

, scientists have constructed a complete genetic map for two types of cancer: small cell lung cancer and malignant melanoma. The melanoma DNA came from a 45-year-old man, and the lung cancer cells were sampled from a 55-year-old man. The research team compared the genetic sequence of the diseased cells with that of healthy cells from the same patients, documenting all genetic mutations. In the lung cancer cells, researchers identified 23,000 mutations, most attributable to chemicals in cigarette smoke known to adhere to and deform DNA. According to the investigators, a typical smoker would acquire one mutation for every 15 cigarettes smoked, or approximately one mutation per pack of cigarettes. The melanoma DNA contained 33,000 mutations, the majority of which arose from ultraviolent exposure via direct sunlight. Both projects were completed by British geneticists from 

 in Cambridge, a member of the International Cancer Genome Consortium (

	Professor Mike Stratton, who co-led the research team, said it took a few months to sequence each genome. The team decided to focus on these two cancers because of their established environmental causes. Data suggested that the underlying process of cancer development was underway long before the disease was detectable. “We have been able to explore deep into the past of each tumor, uncovering with remarkable clarity the imprints of these environmental mutagens on DNA, which occurred years before the tumor became apparent,” said

	The majority of mutations in the two cancers appeared to be passenger mutations, described as inconsequential or harmless. Only two mutations in the lung cancer DNA and three in the melanoma DNA were identified conclusively as driver (or somatic) mutations. “All cancers carry both driver mutations, which are cancer genes and which contribute to cancer development, and passenger mutations, which have essentially just been carried along for the ride. At the moment, it is not known in this or any other cancer how many driving mutations there are,” he said, but added that it would not be far-fetched to speculate that there are 5 to 10 driver mutations in each cancer. Professor Stratton predicted the actual number would become clearer over the next 5 to 10 years, after additional cancer genomes have been sequenced in their entirety.

	“Other cancer cases of the same type—in this case, melanoma and lung cancer&mdash;will likely have some of the same genes carrying driver mutations but equally will probably have some different cancer genes with driver mutations,” Professor Stratton said. Noting that passenger mutations are randomly distributed, he said “one would expect these to be different in every cancer.”

	Another interesting observation from the studies is evidence of the genome’s attempt to “defend itself against the damage wreaked by the chemicals in cigarette smoke or the damage from ultraviolet radiation,” said Professor Stratton. “Our cells fight back furiously to repair the damage, but frequently lose that fight.”

	When Gregor Mendel, an Augustinian priest and scientist born in the Austrian Empire, performed his experiments with pea plants in the mid- 1800s, scientists could see only the evidence of genes at work but not the genes themselves. It would be nearly a century before British biophysicist and chemist Rosalind Franklin captured the first clear image of genetic material—DNA&mdash; using a technique called X-ray diffraction. Franklin’s photograph and preliminary data assisted Francis Harry Compton Crick and James D. Watson in developing an accurate double helix model of the genetic molecule in 1953, for which they later won the Nobel Prize in physics.

, a collaboration of international scientists at universities and research centers, released a nearly complete map of humankind’s genetic makeup. Finished 2 years ahead of schedule, the 13-year project estimated that the human genome contains anywhere from 20,000 to 25,000 genes. Deciphering the genome has transformed the practice of medicine, leading to innumerable medical breakthroughs. In no discipline has this been more evident than oncology, with many recent advances closely trailing discoveries in genetics and molecular biology.

	At ASCO’s annual meeting in May 2009, renowned geneticist Burt Vogelstein, MD, director of Ludwig Center at Johns Hopkins, described how he sees the human genome. “I look at the human genome as simply a series of books, an encyclopedia, where each gene is a page containing about 1500 As, Cs, Ds, or Gs, and each book is 1000 pages, which means it contains 1000 genes,” he said. “There are, of course, 46 books—23 from the mother and 23 from the father.” He then explained how cancer fits into the picture. “Of these 40,000 pages, there are only 44 with typographical errors; [there are] 11 missing pages and 8 duplicated pages. That’s really not very much,” he said. “If you were to make an encyclopedia and only had this many typos in it, you’d be pretty satisfied.” This “more than 99.9%” commonality between malignant and normal cells, however, is what makes cancer so much harder to treat than bacterial infections, he said.

	Decoding the genomes of various cancer types has become a research priority. In 2008, several of the world’s top geneticists united to establish the International Cancer Genome Consortium (ICGC), with the aim of identifying the genetic roots of 50 major cancer types. The ICGC works to coordinate cancer genome sequencing across the globe, standardizing procedures and facilitating data sharing in the hopes that this will lead to rapid advances in prevention, detection, and treatment.

	Historically, complete genome sequencing has been prohibitively expensive outside of the research center. In 2007, Dr Watson’s genome was sequenced for nearly $1 million and presented to him on DVDs. By last year, the cost of genome sequencing had dropped to approximately $100,000 per patient. Then, in November 2009, the startup company

 that it had whittled the cost down to an all-time low of $5000 per genome. Several companies are now racing to develop a method that will allow the human genome to be sequenced for a relatively modest $1000, which would allow almost anyone to have his or her genome sequenced. Complete Genomics says it hopes to perform complete genome sequences for at least 10,000 patients in 2010.

	Professor Stratton said he believes this will soon lead to changes at the practice level in oncology. “Within a decade, we believe that improvements in the technology and reduction in the costs of DNA sequencing will mean that whole cancer genome sequencing to produce comprehensive catalogues of somatic mutations like the ones seen in the two cancers we have just published will become part of the routine diagnostic repertoire of tests for patients with cancer,” he said. The researchers at Sanger also believe that data from their studies and future sequencing of additional tumor types will lead to the development of new targeted therapies, furthering the effort to personalize care for patients with cancer.

	Dr Vogelstein shares Professor Stratton’s belief that continued mapping of cancer genomes will open up opportunities for new therapies, particularly in immunotherapy. “In a few years, when cancers become much easier to sequence,” he told the audience at ASCO, “one can determine the sequence of all genes in a cancer...and make a vaccine based on that particular tumor’s mutated gene and its ability to be recognized by the immune system.”

	The next project for Professor Stratton’s team is mapping 1500 breast tumors, funded by a multimillion-dollar grant from the ICGC. Based on preliminary data from 24 tumors, which Professor Stratton described as “astounding,” he said he believes they will find that breast cancer consists of more tumor categories than previously thought. “The genetic architecture suggests that we’re probably going to be dealing with at least 5 to 10 different animals,” he said.

	The ICGC has also funded what it describes as “the largest and most ambitious biomedical research project since the Human Genome Project” by a group of researchers at the German Cancer Research Center and four other cancer institutions in Heidelberg. In early 2010, the centers will begin analyzing 300 tumor samples from various types of pediatric brain tumors and 500 samples from common adult brain tumors in an effort to identify some of the causes of these malignancies. 

For the first time, scientists have constructed a complete genetic map for two types of cancer: small cell lung cancer and malignant melanoma. 

Mapping The Cancer Genome

	Radon is an invisible, odorless, and tasteless radioactive gas that is released into the air or dissolves into groundwater as uranium in rocks or soil decays. It was classified as a human carcinogen in 1988 by the International Agency for

on Cancer, but the ill health effects of this invisible killer had been observed for centuries in Europe. Today, radon is known to be the second leading cause of lung cancer overall and the leading cause of lung cancer in nonsmokers in the United States. The risk of lung cancer is greatest in smokers exposed to radon, with the majority of the estimated 15,000 to 22,000 

 deaths occurring in these individuals annually.

 have examined whether a link may also exist between leukemia and indoor radon exposure, especially in pediatric patients, but most have failed to establish such a correlation; however, a recently published epidemiological

of childhood leukemia in Denmark that included 2400 patients and 6697 controls between 1968 and 1994 found a weak but statistically significant correlation between residential radon exposure and acute childhood lymphoblastic leukemia. Studies examining possible links between radon exposure and stomach cancer, cardiovascular diseases, multiple sclerosis, and a host of other maladies have also been undertaken, yielding mixed results.

	To increase the public’s awareness of radon’s health risks, promote radon testing and mitigation, and advance the use of radon-resistant new construction practices, the US Environmental Protection Agency (EPA) has designated January as National Radon Action Month. The 

 estimates that one in every 15 homes nationwide has a radon level at or above the recommended action level of 4 picocuries per liter (pCi/L) of air, which according to 

articles from 2008 is a level that has “about the same risk for cancer as smoking a half a pack of cigarettes per day” and delivers the same amount of radiation per year as receiving more than 200 chest 

. Unless you are buying or selling a home, when radon testing may be mandatory, you may not know if the radon levels in your home are in the danger zone. Many kits are readily available to help you to determine your home’s radon levels, and if they are found to be elevated, there are various mitigation strategies that can be explored, some for nominal cost. We explore radon testing, how to locate a radon mitigation professional, and describe some of the online resources that can help you safeguard your home from this insidious carcinogen.

	You can see if you live in a zone with potentially high radon concentrations by consulting the 

 radon concentrations have been observed in Iowa and southeastern Pennsylvania, but according to a report published by the World Health Organization (

) in 2009, “the majority of radon-induced lung cancers are caused by low and moderate radon concentrations rather than by high radon concentrations, because in general less people are exposed to high indoor radon concentrations”. If you discover that you live in an area with potentially high concentrations of radon, it is especially important to test your home for radon, but even if you live in an area predicted to have low levels (<2 pCi/L), you cannot guarantee that the levels in your home are in that range unless you test.

	Although you can have your home professionally tested for radon, using a do-it-yourself kit is easy and economical. Radon test kits can be found at many home improvement stores, through online 

 such as the Kansas State University National Radon Program Services at, and sometimes for free from local or county health departments or state radon programs.

	Several types of radon test kits are on the market, including short-term and long-term tests, radon water tests, and electronic radon detectors. With so many choices, it may be difficult to determine what you need. Short-term tests, which remain in your home from 2 to 90 days, are the most commonly used. These tests cost approximately $15 each, which includes laboratory analysis. The EPA recommends using two or more of these kits throughout the year to ensure accuracy of the readings because the absorptive material of these tests can react to temperature and humidity changes, especially during transit, which may affect their precision. Radon levels also vary daily, so using multiple tests throughout the year gives a more accurate assessment of your year-round mean radon level. If you would rather avoid the hassle of dealing with multiple short-term tests, you may opt to use a long-term radon test instead. Long-term tests cost between $25 and $45 and remain in your home for more than 90 days, with some remaining in your home for up to a year.

	While the risk of lung cancer from inhaling radon is far greater than the risk of gastric or other cancers from ingesting water containing radon, radon can be released into the air when using water for daily living activities such as showering, contributing to lung cancer risk. The risk of radon entering your home through water is generally low, unless your water is from a ground water source, such as a private well, or a public supply that uses ground water. If your water comes from a public supply, you should receive a Water Quality Consumer

	Confidence Report (CCR) every year from your city or township, which will include radon levels. To learn more about these reports and how to decipher them, you can visit 

 International. If you have a private well or want to confirm the radon results of your CCR, you can buy a radon water test kit. These tests generally cost between $25 and $40, which includes laboratory assessment. If you have any questions about radon in drinking water, you can contact the Safe Drinking Water Hotline at (800) 426-4791.

	A few years ago, the risk of radon leaking from granite countertops made mainstream news. Although most experts agree that the risk of radon being emitted from most granite countertops is extremely low, slabs emitting more than 4 pCi/L have been identified. In an interview with CBS in 2008, Stanley Liebert, quality assurance director at 

 Laboratories in Clifton, New York, noted that certain colors seem to pose a higher risk than others, with reds, pinks, and purples appearing to emit the highest levels. Other 

 have indicated that the exotic and striated granite varieties from Brazil and Namibia are the most suspect. Because uranium levels in granite are not measured or controlled, the only way to guarantee your granite countertop is not a radon hot zone is by testing it. A pack of seven tests can be purchased for $79.95 at 

, where you can also watch a video on how to use these tests.

	If you wish to continuously monitor your home for radon, as you may already be doing for carbon monoxide, you can opt to purchase an electronic radon detector instead. Currently, the Safety Siren Pro Series3 HS71512 Electronic Radon Gas Detector is the only radon gas detector designed specifically for use by homeowners. It is available through 

 for approximately $125. The Safety Siren Pro features a numeric LED display to show the level of radon gas in the air, and offers both a short-term reading that displays the average radon level over the past 7 days and a long-term reading that displays the average radon level since being powered-up or since the last reset within the past 5 years. If the long- term measurement reaches 4 pCi/L or greater, or if the short-term measures stays above 4 pCi/L for 30 consecutive days, an alarm will sound.

	If radon testing reveals a level of 4 pCi/L or more, it is important to fix your home to mitigate risk, but even levels between 2 pCi/L and 4 Ci/L pose some risk and may warrant a repair. Costs of radon mitigation generally average between $800 and $2500. A comprehensive

 of mitigation techniques is available. If you are handy, you may be able to tackle some of these repairs yourself, but because mitigation generally requires sealing basement foundations, concrete slab floors, or areas under crawl spaces, and installing ventilation or radon collection systems, these tasks may be best left to the professionals.

	To find a radon service professional in your area, you can visit 

and then select your state, which will pull up contact information for state radon programs and other organizations that can help you identify contractors in your area. You can also opt to contact one of the following privately-run National Radon Proficiency Programs, which provide accreditation and certification in radon testing and mitigation. Both organizations maintain a database of certified radon professionals on their Website:

National Environmental Health Association - National Radon Proficiency Program 

	If you prefer to tackle the radon problem yourself, you may consider purchasing 

Protecting Your Home from Radon: A Step by Step Manual for Radon Reduction

 by Douglas L. Kladder and colleagues before you get started. The book has a 5-star rating on Amazon based on two reviews. One reviewer commented, “[The book allows] a reasonably competent DIYer to design and install their own radon mitigation system. In addition, it covers the necessary safety precautions to take in the process.” The book can be purchased through Air-Chek for $29.95 by calling (800) AIR-CHEK. To view the book’s table of contents, visit 

www.radon.com/radon/radon_mitigation-book.html.

	January is a time for making resolutions to improve health, and while eating better and exercising are important, environmental health risks should not be overlooked. Radon exposure is a known risk factor for lung cancer, and more studies are showing that it may contribute to the development of other health issues as well, such as leukemia. Radon testing is inexpensive and easily performed, and mitigation costs are no greater than most other home improvements, but can have a considerable impact on health. As you know from treating patients with cancer, health is our most precious commodity, so don’t let radon rob you, your loved ones, or your patients and their families of it. Take action by testing your home and encouraging your patients to do the same.

Cover Story

Radon is an invisible, odorless, and tasteless radioactive gas that is released into the air or dissolves into groundwater as uranium in rocks or soil decays.

The Invisible Killer in Your Home: Understanding Radon, Testing, and Mitigation

	For faster manipulation of patient records and imaging, try Magic Mouse, Apple’s new multi-touch wireless mouse, which retails for approximately $65. Its content interaction technology matches the iPhone and iPod, with simple finger gestures controlling onscreen features. One- and two-finger motions allow scrolling, zooming, and swiping through Webpages or images. An internal chip differentiates between the various finger commands. Magic Mouse’s entire surface is a button, so users can click or double-click anywhere on the top shell. Its powerful laser tracking eliminates the need for a mousepad. With no mousepad and no cord, Magic Mouse frees your workspace from restrictive clutter. If you are interested in obtaining more information about the Magic Mouse, visit 

	With VoiceFactor voice-recognition technology, your computer recognizes the sound of your voice and instantly creates reports,e-mails, patient evaluations, prescriptions, spreadsheets, and more. The speech-to-text technology composes documents without typos at the speed of your voice. VoiceFactor consultants tailor packages to meet an individual practice’s needs. Continual support is offered through training videos, online and in-house training sessions, and a helpline. VoiceFactor packages also include Text Aloud Speech Technology, in which a voice reads text aloud from your monitor. Another feature, Voice Shortcuts, performs Web searches in response to your voice commands. Use the technology on the go with Bluetooth and other wireless devices. To check out these and other VoiceFactor products and applications, visit 

	In 2010, technology bling is coming to a store near you with the ORB

 is a ring that twists open into a Bluetooth headset. Designers Hybra Advance Technology, Inc and AbsolutelyNew are even releasing limited-edition models with decorative gemstones. The comfortable, noninvasive ORB rests outside the ear, using bone-conducting technology to deliver high- quality sound. All models come in multiple ring sizes and have class 2 Bluetooth range (approximately 30 ft). The deluxe edition offers voice-to-text technology and a display screen featuring caller ID and texts. ORB was named the Consumer Electronics Show (CES) 2010 Best of Innovation winner in the wireless handsets accessories category. Look for basic editions in January for $129.00 and deluxe models in April for $175.00. For more information, visit 

Columns

Gadget Watch

	While family history and lifestyle factors affect cancer risk, environmental factors also play a considerable role. You will no doubt recall the movie 

, which recounted the story of a law firm file clerk uncovering the dumping of hexavalent chromium, also called chromium 6, into the groundwater supply of Hinkley, a small town in southern California, by Pacific Gas & Electric. This finding and subsequent lawsuit led to one of the largest toxic tort injury settlements in US history, with $333 million in settlements awarded to approximately 600 Hinkley residents suffering from ailments such as breast cancer, Hodgkin lymphoma, lung cancer, brain-stem cancer, gastrointestinal cancer, kidney and ovarian tumors, and a host of other maladies as a result of being exposed to chromium 6. While similar cases have surfaced throughout the United States, and stories of chemicals being leached into drinking water by corporate entities may receive considerable attention by the media, there are naturally occurring environmental risk factors for cancer, such as radon, that receive comparably little attention but affect far more households.

	The ill health effects of radon have long been observed in miners, but it was not known to be a health risk in the general population until the 1980s. Radon is now known to be the second leading cause of lung cancer, and it may contribute to the development of other cancers as well, yet the only time this environmental risk factor may be brought to anyone’s attention is during a real estate transaction. January is National Radon Action Month, as designated by the US Environmental Protection Agency, and our cover story, “The Invisible Killer in Your Home: Understanding Radon, Testing, and Mitigation”, provides an overview of radon, testing methods, and locating a mitigation professional, while outlining some online resources that can help keep you, your family, and your patients informed and safeguarded from this environmental health hazard. 

	Our second feature story, “Mapping the Cancer Genome”, reviews some of the findings that cancer genome sequencing has yielded, including how environmental and lifestyle factors can increase cancer risk. Recently, researchers from the Wellcome Trust Sanger Institute in Cambridge reported the results of their study published in Nature, which compared the genetic sequence of small cell lung cancer cells and melanoma cells with normal cells taken from the same individuals. Through this analysis, the researchers were able to identify thousands of mutations in the cancer cells, with almost all mutations in the small cell lung cancer and melanoma cells being traced back to smoking and ultraviolet exposure, respectively. The researchers estimate that a typical smoker may acquire one mutation for every pack of cigarettes smoked, and one may surmise that exposure to other environmental toxins, such as radon, could lead to additional mutations, as research has shown that lung cancer risk from radon is especially high in smokers. As more cancer cells are sequenced, which is being made possible by the dramatic drop in gene mapping costs, the effects of various carcinogens and the role of genetic factors will be better understood, which will also lead to more effective, personalized treatments.

	In our From the Editor column, Dr Markman discusses electronic cigarettes, which have become increasingly popular, with some individuals using them as an alternative to traditional cigarettes because they are perceived to be healthier. As Dr Markman points out, however, assessment of these cigarettes has shown that they may contain other known carcinogens, as this industry is largely unregulated. Further, because electronic cigarettes are relatively new, their ill health effects are not yet known; thus, patients expressing interest in using electronic cigarettes should be warned of their potential dangers.

 and would love to know what you think of it, or if you have any topics you would like to see covered in an upcoming issue. You can send an e-mail to the editor, Christina Loguidice, at 

While family history and lifestyle factors affect cancer risk, environmental factors also play a considerable role. You will no doubt recall the movie Erin Brockovich, which recounted the story of a law firm file clerk uncovering the dumping of hexavalent chromium, also called chromium 6, into the groundwater supply of Hinkley, a small town in southern California, by Pacific Gas & Electric.

January 2010

Electronic Cigarettes: Another Potentially Dangerous Product Sold on the Internet

Mapping The Cancer Genome

The Invisible Killer in Your Home: Understanding Radon, Testing, and Mitigation

Gadget Watch

Cancer Risk: Role of Environmental and Lifestyle Factors

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