A Survey Study on Medicinal Plants and Mushrooms Use in Treatment of Cancer by Patients at The Istanbul University Institute of Oncology
Yıl 2020,
Cilt: 3 Sayı: 2, 51 - 60, 10.07.2020
Hüseyin Onur Tuncay
,
Miraç Ekici
Büşra Teke
,
Emine Akalın
Öz
Objective: Medicinal herbs are commonly used as complementary or prophylaxis in common illness, as well as in diseases such as cancer, where the disease is severe. In order to determine the use of plants and mushrooms among cancer patients, a survey was conducted with 100 cancer patients who are receiving treatment at polyclinics at the Istanbul University Institute of Oncology. Material and Methods: The questionnaires were conducted face to face with the patients and the results were evaluated in computer. Results: According to the survey results, only 24 of 100 patients were found to use the plants and mushrooms for treatment, to reduce the side effects of the treatment or to feel better. As a result, it was determined that a total of 17 different plants and 1 mushroom were used. The mechanism of action, side effects, and warnings of these plants and mushrooms on cancer treatment have been investigated. With this study, it was determined how the patients obtained the plants and mushrooms, how the age, gender or socioeconomic status affect the plants and mushrooms used and what kind of feedback the patients give about their experience. Conclusion: The fact that the plants and mushrooms are not supplied by pharmacies, the application of herbal treatments with the advice of people under the title "expert" and "reliable" cause many problems. The survey study yielded promising results about the use of plants and mushrooms by cancer patients in Turkey. Similar studies are expected to be conducted in more clinics.
Teşekkür
Thanks to Fatma Betül Aydın for her contributions.
Kaynakça
- 1. Faydaoglu E, Sürücüoglu MS. History of the Use of Medical and Aromatic Plants and their Economic Importance Kastamonu Üniversitesi Orman Fakültesi Dergisi 2011;11(1): 52-67.
- 2. Riddle MJ. Dioscorides on pharmacy and medicine. Austin: University of Texas Press; 1985.
- 3. Engel LW, Straus SE. Development of therapeutics: opportunities within complementary and alternative medicine. Nat Rev Drug Discov 2002;1(3):229-37.
- 4. Falzon CC, Balabanova A. Phytotherapy An Introduction to Herbal Medicine. Prim Care 2017;44(2):217-27.
- 5. Fürst R, Zündorf I. Evidence-based phytotherapy in Europe: Where do we stand? Planta Med. 2015:81(12-13):962-7.
- 6. Çetin O. The Use of Complementary and Alternative Medicine in Eskisehir. SosyoEkonomi 2007;6(6): 89-106. (article in Turkish with an abstract in English)
- 7. Kav S, Hanoglu Z, Algıer L. Use of Complementary and Alternative Medicine by Cancer Patients in Turkey: A Literature Review. UHOD 2008;28(4):32-8.
- 8. Başgöl Ş, Aslan E. Complementary and Alternative Medicines In Gynecologic Cancers: The Evidence-Based Approach. YBÜ Sağlık Bilimleri Fakültesi Hemşirelik E-Dergisi 2014;2(3):51-62.
- 9. Yıldırım Y, Tinar S, Yorgun S, Toz E, Kaya B, Sonmez S, et al. The use of complementary and alternative medicine (CAM) therapies by Turkish women with gynecological cancer. Eur J Gynaecol Oncol 2006;27(1):81-5.
- 10. Shukla M, Jaiswal S, Sharma A, Srivastava PK, Arya A, Dwivedi AK, et al. A combination of complexation and self-nanoemulsifying drug delivery system for enhancing oral bioavailability and anticancer efficacy of curcumin. Drug Dev Ind Pharm 2016;43(5):847-61.
- 11. Nagpal M, Sood S. Role of curcumin in systemic and oral health: An overview. J Nat Sci Biol Med 2013;4(1):3-7.
- 12. Fetrow CW, Avila JR, editors. Professional’s handbook of complementary and alternative medicine. Springhouse, PA: Springhouse; 1999.
- 13. Mohammadi A, Mansoori B, Aghapour M, Baradaran B. Urtica dioica dichloromethane extract induce apoptosis from intrinsic pathway on human prostate cancer cells (PC3). Cell Mol Biol 2016;62(3):78-83.
- 14. Chrubasik JE, Roufogalis BD, Wagner H, Chrubasik SA. A comprehensive review on nettle effect and efficacy profiles, Part I: Herba urticae. Phytomedicine 2007;14(6):423-35.
- 15. World Health Organization. WHO Monographs on Selected Medicinal Plants Volume 2, World Health Organization. Geneva: World Health Organization; 2002.
- 16. Ameri A. Ganoderic Acid in the Treatment of Prostate Cancer. Jundishapur J Nat Pharm Prod 2012;7(3):85-6.
- 17. Wasser SP. Reishi or Ling Zhi (Ganoderma lucidum). Encyclopedia of Dietary Supplements 2005;1:603-2
- 18. Suganuma M, Saha A, Fujiki H. New cancer treatment strategy using combination of green tea catechins and anticancer drugs. Cancer Sci 2011;102(2):317-23.
- 19. Schönthal AH. Adverse effects of concentrated green tea extracts. Mol Nutr Food Res 2011;55(6):874–85.
- 20. Braun L, Cohen M, editors. Herbs and Natural Supplements Volume 2: An Evidence-Based Guide. Australia: Elsevier Health Sciences; 2015.
- 21. Vasanthi HR, Mukherjee S, Das DK. Potential health benefits of broccolichemico-biological overview. Mini-Rev Med Chem 2009;9(6):749-59.
- 22. Kruger CL. Generally Recognized As Safe (Gras) otification for the Use of Aqueous Broccoli Seed Extract Powder in Food. U.S. Food Drug Administration. Office of Food Additive Safety: 2013 July. Report No: 496.
- 23. El-Ashmawy NE, Khedr NF, El-Bahrawy HA, Abo Mansour HE. Ginger extract adjuvant to doxorubicin in mammary carcinoma: study of some molecular mechanisms. Eur J Nutr 2018;57(3):981-89.
- 24. Altman RD, Marcussen KC. Effects of a Ginger Extract on Knee Pain in Patients with Osteoarthritis. Arthritis Rheum 2001;44(11):2531-8.
- 25. Blumenthal M, Busse WR, Goldberg A, Gruenwald J, Hall T, Riggins W, Rister RS, editors. German Commission E Monographs: Therapeutic Monographs on Medicinal Plants. Austin, Texas: American Botanical Council; 1998.p.135-136.
- 26. Bourgou S, Bellila A, Falleh H, Ksouri R, Marzouk B. Phenolic composition and biological activities of Tunisian Nigella sativa L. shoots and roots. C R Biol 2008;331(1):48-55.
- 27. Ali BH, Blunden G. Pharmacological and toxicological properties of Nigella sativa. Phytother Res 2003;17(4):299-305.
- 28. El-Obeid A, Al-Harbi S, Al-Jomah N, Hassib A. Herbal melanin modulates tumor necrosis factor alpha (TNF-alpha), interleukin 6 (IL-6) and vascular endothelial growth factor (VEGF) production. Phytomedicine 2006;13(5):324-33.
- 29. Sung B, Chung HY, Kim N. Role of Apigenin in Cancer Prevention via the Induction of Apoptosis and Autophagy. J Cancer Prev 2016;21(4):216-26.
- 30. Andres C, Chen WC, Darsow U, Mempel M, Ollert M, Ring J. Anaphylactic Reaction to Camomile Tea. Allergol Int 2009;58(1):135-6.
- 31. Kijima I, Phung S, Hur G, Kwok SL, Chen S. Grape seed extract is an aromatase inhibitor and a suppressor of aromatase expression. Cancer Res 2006;66(11):5960-7.
- 32. Miccadei S, Di venere D, Cardinali A, Romano F, Durazzo A, Foddai MS, et al. Antioxidative and apoptotic properties polyphenolic extracts from edible part of artichoke (Cynara scolymus L.) on cultured rat hepatocytes and on human hepatoma cells. Nutr Cancer 2008;60(2):276-83.
- 33. Englisch W, Beckers C, Unkauf M, Ruepp M, Zinserling V. Efficacy of Artichoke dry extract in patients with hyperlipoproteinemia. Arzneimittelforschung 2000;50(3):260-5.
- 34. Lorusso G, Vannini N, Sogno I, Generoso L, Garbisa S, Noonan DM, et al. Mechanisms of Hyperforin as an anti-angiogenic angioprevention agent. Eur J Cancer 2009;45(8):1474-84.
- 35. Linde K, Knuppel L. Large-scale observational studies of hypericum extracts in patients with depressive disorders: a systematic review. Phytomedicine 2005;12(1–2):148-57.
- 36. Jiménez S, Gascon S, Luquin A, Laguna M, Ancin-Azpilicueta C, Rodriguez-Yoldi MJ. Rosa canina extracts have antiproliferative and antioxidant effects on caco-2 human colon cancer. PloS one 2016;11(7):e0159136.
- 37. Chrubasik E, Rougofalis BD, Müller-Ladner U, Chrubasik S. Systematic review on the Rosa canina effect and efficacy profiles. Phytother Res 2008;22(6):725-33.
- 38. Merghoub N, Btaouri H, Benbacer L, Gmouh S, Trentesaux C, Brassart B, et al. Inula Viscosa Extracts Induces Telomere Shortening and Apoptosis in Cancer Cells and Overcome Drug Resistance. Nutr Cancer 2016;68(1):131-43.
- 39. Zeggwagh NA, Quahidi ML, Lemhadri A, Eddouks M. Study of hypoglycaemic and hypolipidemic effects of Inula viscosa L. aqueous extract in normal and diabetic rats. J Ethnopharmacol 2006;108(2):223-7.
- 40. Güneş H, Alper M, Çelikoğlu N. Anticancer effect of the fruit and seed extracts of Momordica charantia L. (Cucurbitaceae) on human cancer cell lines. Trop J Pharm Res 2019;18(10):2057-65.
- 41. Basch E, Gabardi S, Ulbricht C. Bitter melon (Momordica charantia): a review of efficacy and safety. Am J Health-Syst Pharm 2003;60(4):356-9.
- 42. Sui JQ, Xie KP, Zou W, Xie MJ. Emodin inhibits breast cancer cell proliferation through the ERαMAPK/ Akt-cyclin D1/Bcl2 signaling pathway. Asian Pac J Cancer Prev 2014;15(15):6247-51.
- 43. Malik MA, Bhat SA, Fatima B, Ahmad SB, Sidiqui S, Shrivastava P. Rheum emodi as valuable medicinal plant. IJGMP 2016;5(4):35-44.
- 44. Mohammed FA, Elkady AI, Syed FQ, Mirza MB, Hakeem KR, Alkarim S. Anethum graveolens (dill) - A medicinal herb induces apoptosis and cell cycle arrest in HepG2 cell line. J Ethnopharmacol 2018;219:15–22.
- 45. Kwon HK, Jeon WK, Hwang JS, Lee GG, So JS, Park JS, et al. Cinnamon extract suppresses tumor progression by modulating angiogenesis and the effector function of CD8+ T cells. Cancer Lett 2009;278(2):174-82.
- 46. Chevallier A. Encyclopedia of Herbal Medicine: 550 Herbs and Remedies for Common Ailments. Third ed. Dorling New York, USA: Kindersley Book; 2016.
- 47. Zhu XX, Ding YH, Wu Y, Qian LY, Zou H, He Q. Silibinin: a potential old drug for cancer therapy. Expert Rev Clin Pharmacol 2016;9(10):1323-30.
- 48. El-Kamary SS, Shardell MD, Adel-Hamid M, Ismail S, El-Ateek M, Metwally M, et al. A randomized controlled trial to assess the safety and efficacy of silymarin on symptoms, signs and biomarkers of acute hepatitis. Phytomedicine 2009;16(5):391-400.
- 49. Stewart BW, Wild CP. World Cancer Report. Lyon: IARC; 2014.
- 50. NCI (National Cancer Institute) Age and Cancer Risk. serial online 2015 April (cited 2020 April 20) Available from: https://www.cancer.gov/ about-cancer/causes-prevention/risk/age
İstanbul Üniversitesi Onkoloji Enstitüsü’nde Hastalar Tarafından Kanser Tedavisinde Kullanılan Tıbbi Bitkiler ve Mantarlar Üzerine Bir Anket Çalışması
Yıl 2020,
Cilt: 3 Sayı: 2, 51 - 60, 10.07.2020
Hüseyin Onur Tuncay
,
Miraç Ekici
Büşra Teke
,
Emine Akalın
Öz
Amaç: Bitkiler ve mantarlar, tamamlayıcı veya koruyucu olarak basit hastalıklarda kullanıldığı gibi kanser gibi tedavisi ağır olan hastalıklarda da yaygın olarak kullanılmaktadır. Kanser hastaları arasında bitki ve mantar kullanımını belirlemek amacıyla İstanbul Üniversitesi Onkoloji Enstitüsü’nde polikliniklerde tedavi gören 100 kanser hastası ile bir anket çalışması yapılmıştır. Gereç ve Yöntem: Anketler hastalarla yüz yüze gerçekleştirilmiş ve sonuçlar bilgisayar ortamında değerlendirilmiştir. Bulgular: Anket sonuçlarına göre, 100 hastanın sadece 24’ünün bitki ve mantarları tedavi edici, tedavinin yan etkilerini azaltıcı veya daha iyi hissetmek için kullandığı saptanmıştır. Anket sonucunda toplam 17 farklı bitki ve 1 mantarın kullanıldığı tespit edilmiştir. Bu bitki ve mantarların kanser tedavisi üzerindeki etki mekanizması, yan etkileri ve uyarıları araştırılmıştır. Bu çalışma ile kanser hastalarının bitki ve mantarları nasıl temin ettikleri, yaş, cinsiyet veya sosyoekonomik durumun bitki ve mantar kullanımını nasıl etkilediği, kullanılan bitki veya mantardan yarar veya zarar nedeniyle ne tür geri bildirimler alındığı belirlenmiştir. Sonuç: Bitkilerin ve mantarların eczanelerden tedarik edilmemesi, "uzman" ve "güvenilir" başlığı altındaki kişilerin tavsiyesi ile bitkisel tedavilerin uygulanması birçok soruna neden olmaktadır. Yapılan anket çalışması, Türkiye'de kanser hastalarının bitki ve mantar kullanımına ilişkin fikir oluşturması açısından umut verici sonuçlar vermiştir. Gelecekte yapılacak benzer çalışmalar ile kanser tedavisi almakta olan hastaların bitki ve mantar kullanımlarının öğrenilmesi ve hastanın bir bütün olarak ele alınarak bu konuda eğitim almış uzmanların tavsiye vermeleri ümit edilmektedir.
Kaynakça
- 1. Faydaoglu E, Sürücüoglu MS. History of the Use of Medical and Aromatic Plants and their Economic Importance Kastamonu Üniversitesi Orman Fakültesi Dergisi 2011;11(1): 52-67.
- 2. Riddle MJ. Dioscorides on pharmacy and medicine. Austin: University of Texas Press; 1985.
- 3. Engel LW, Straus SE. Development of therapeutics: opportunities within complementary and alternative medicine. Nat Rev Drug Discov 2002;1(3):229-37.
- 4. Falzon CC, Balabanova A. Phytotherapy An Introduction to Herbal Medicine. Prim Care 2017;44(2):217-27.
- 5. Fürst R, Zündorf I. Evidence-based phytotherapy in Europe: Where do we stand? Planta Med. 2015:81(12-13):962-7.
- 6. Çetin O. The Use of Complementary and Alternative Medicine in Eskisehir. SosyoEkonomi 2007;6(6): 89-106. (article in Turkish with an abstract in English)
- 7. Kav S, Hanoglu Z, Algıer L. Use of Complementary and Alternative Medicine by Cancer Patients in Turkey: A Literature Review. UHOD 2008;28(4):32-8.
- 8. Başgöl Ş, Aslan E. Complementary and Alternative Medicines In Gynecologic Cancers: The Evidence-Based Approach. YBÜ Sağlık Bilimleri Fakültesi Hemşirelik E-Dergisi 2014;2(3):51-62.
- 9. Yıldırım Y, Tinar S, Yorgun S, Toz E, Kaya B, Sonmez S, et al. The use of complementary and alternative medicine (CAM) therapies by Turkish women with gynecological cancer. Eur J Gynaecol Oncol 2006;27(1):81-5.
- 10. Shukla M, Jaiswal S, Sharma A, Srivastava PK, Arya A, Dwivedi AK, et al. A combination of complexation and self-nanoemulsifying drug delivery system for enhancing oral bioavailability and anticancer efficacy of curcumin. Drug Dev Ind Pharm 2016;43(5):847-61.
- 11. Nagpal M, Sood S. Role of curcumin in systemic and oral health: An overview. J Nat Sci Biol Med 2013;4(1):3-7.
- 12. Fetrow CW, Avila JR, editors. Professional’s handbook of complementary and alternative medicine. Springhouse, PA: Springhouse; 1999.
- 13. Mohammadi A, Mansoori B, Aghapour M, Baradaran B. Urtica dioica dichloromethane extract induce apoptosis from intrinsic pathway on human prostate cancer cells (PC3). Cell Mol Biol 2016;62(3):78-83.
- 14. Chrubasik JE, Roufogalis BD, Wagner H, Chrubasik SA. A comprehensive review on nettle effect and efficacy profiles, Part I: Herba urticae. Phytomedicine 2007;14(6):423-35.
- 15. World Health Organization. WHO Monographs on Selected Medicinal Plants Volume 2, World Health Organization. Geneva: World Health Organization; 2002.
- 16. Ameri A. Ganoderic Acid in the Treatment of Prostate Cancer. Jundishapur J Nat Pharm Prod 2012;7(3):85-6.
- 17. Wasser SP. Reishi or Ling Zhi (Ganoderma lucidum). Encyclopedia of Dietary Supplements 2005;1:603-2
- 18. Suganuma M, Saha A, Fujiki H. New cancer treatment strategy using combination of green tea catechins and anticancer drugs. Cancer Sci 2011;102(2):317-23.
- 19. Schönthal AH. Adverse effects of concentrated green tea extracts. Mol Nutr Food Res 2011;55(6):874–85.
- 20. Braun L, Cohen M, editors. Herbs and Natural Supplements Volume 2: An Evidence-Based Guide. Australia: Elsevier Health Sciences; 2015.
- 21. Vasanthi HR, Mukherjee S, Das DK. Potential health benefits of broccolichemico-biological overview. Mini-Rev Med Chem 2009;9(6):749-59.
- 22. Kruger CL. Generally Recognized As Safe (Gras) otification for the Use of Aqueous Broccoli Seed Extract Powder in Food. U.S. Food Drug Administration. Office of Food Additive Safety: 2013 July. Report No: 496.
- 23. El-Ashmawy NE, Khedr NF, El-Bahrawy HA, Abo Mansour HE. Ginger extract adjuvant to doxorubicin in mammary carcinoma: study of some molecular mechanisms. Eur J Nutr 2018;57(3):981-89.
- 24. Altman RD, Marcussen KC. Effects of a Ginger Extract on Knee Pain in Patients with Osteoarthritis. Arthritis Rheum 2001;44(11):2531-8.
- 25. Blumenthal M, Busse WR, Goldberg A, Gruenwald J, Hall T, Riggins W, Rister RS, editors. German Commission E Monographs: Therapeutic Monographs on Medicinal Plants. Austin, Texas: American Botanical Council; 1998.p.135-136.
- 26. Bourgou S, Bellila A, Falleh H, Ksouri R, Marzouk B. Phenolic composition and biological activities of Tunisian Nigella sativa L. shoots and roots. C R Biol 2008;331(1):48-55.
- 27. Ali BH, Blunden G. Pharmacological and toxicological properties of Nigella sativa. Phytother Res 2003;17(4):299-305.
- 28. El-Obeid A, Al-Harbi S, Al-Jomah N, Hassib A. Herbal melanin modulates tumor necrosis factor alpha (TNF-alpha), interleukin 6 (IL-6) and vascular endothelial growth factor (VEGF) production. Phytomedicine 2006;13(5):324-33.
- 29. Sung B, Chung HY, Kim N. Role of Apigenin in Cancer Prevention via the Induction of Apoptosis and Autophagy. J Cancer Prev 2016;21(4):216-26.
- 30. Andres C, Chen WC, Darsow U, Mempel M, Ollert M, Ring J. Anaphylactic Reaction to Camomile Tea. Allergol Int 2009;58(1):135-6.
- 31. Kijima I, Phung S, Hur G, Kwok SL, Chen S. Grape seed extract is an aromatase inhibitor and a suppressor of aromatase expression. Cancer Res 2006;66(11):5960-7.
- 32. Miccadei S, Di venere D, Cardinali A, Romano F, Durazzo A, Foddai MS, et al. Antioxidative and apoptotic properties polyphenolic extracts from edible part of artichoke (Cynara scolymus L.) on cultured rat hepatocytes and on human hepatoma cells. Nutr Cancer 2008;60(2):276-83.
- 33. Englisch W, Beckers C, Unkauf M, Ruepp M, Zinserling V. Efficacy of Artichoke dry extract in patients with hyperlipoproteinemia. Arzneimittelforschung 2000;50(3):260-5.
- 34. Lorusso G, Vannini N, Sogno I, Generoso L, Garbisa S, Noonan DM, et al. Mechanisms of Hyperforin as an anti-angiogenic angioprevention agent. Eur J Cancer 2009;45(8):1474-84.
- 35. Linde K, Knuppel L. Large-scale observational studies of hypericum extracts in patients with depressive disorders: a systematic review. Phytomedicine 2005;12(1–2):148-57.
- 36. Jiménez S, Gascon S, Luquin A, Laguna M, Ancin-Azpilicueta C, Rodriguez-Yoldi MJ. Rosa canina extracts have antiproliferative and antioxidant effects on caco-2 human colon cancer. PloS one 2016;11(7):e0159136.
- 37. Chrubasik E, Rougofalis BD, Müller-Ladner U, Chrubasik S. Systematic review on the Rosa canina effect and efficacy profiles. Phytother Res 2008;22(6):725-33.
- 38. Merghoub N, Btaouri H, Benbacer L, Gmouh S, Trentesaux C, Brassart B, et al. Inula Viscosa Extracts Induces Telomere Shortening and Apoptosis in Cancer Cells and Overcome Drug Resistance. Nutr Cancer 2016;68(1):131-43.
- 39. Zeggwagh NA, Quahidi ML, Lemhadri A, Eddouks M. Study of hypoglycaemic and hypolipidemic effects of Inula viscosa L. aqueous extract in normal and diabetic rats. J Ethnopharmacol 2006;108(2):223-7.
- 40. Güneş H, Alper M, Çelikoğlu N. Anticancer effect of the fruit and seed extracts of Momordica charantia L. (Cucurbitaceae) on human cancer cell lines. Trop J Pharm Res 2019;18(10):2057-65.
- 41. Basch E, Gabardi S, Ulbricht C. Bitter melon (Momordica charantia): a review of efficacy and safety. Am J Health-Syst Pharm 2003;60(4):356-9.
- 42. Sui JQ, Xie KP, Zou W, Xie MJ. Emodin inhibits breast cancer cell proliferation through the ERαMAPK/ Akt-cyclin D1/Bcl2 signaling pathway. Asian Pac J Cancer Prev 2014;15(15):6247-51.
- 43. Malik MA, Bhat SA, Fatima B, Ahmad SB, Sidiqui S, Shrivastava P. Rheum emodi as valuable medicinal plant. IJGMP 2016;5(4):35-44.
- 44. Mohammed FA, Elkady AI, Syed FQ, Mirza MB, Hakeem KR, Alkarim S. Anethum graveolens (dill) - A medicinal herb induces apoptosis and cell cycle arrest in HepG2 cell line. J Ethnopharmacol 2018;219:15–22.
- 45. Kwon HK, Jeon WK, Hwang JS, Lee GG, So JS, Park JS, et al. Cinnamon extract suppresses tumor progression by modulating angiogenesis and the effector function of CD8+ T cells. Cancer Lett 2009;278(2):174-82.
- 46. Chevallier A. Encyclopedia of Herbal Medicine: 550 Herbs and Remedies for Common Ailments. Third ed. Dorling New York, USA: Kindersley Book; 2016.
- 47. Zhu XX, Ding YH, Wu Y, Qian LY, Zou H, He Q. Silibinin: a potential old drug for cancer therapy. Expert Rev Clin Pharmacol 2016;9(10):1323-30.
- 48. El-Kamary SS, Shardell MD, Adel-Hamid M, Ismail S, El-Ateek M, Metwally M, et al. A randomized controlled trial to assess the safety and efficacy of silymarin on symptoms, signs and biomarkers of acute hepatitis. Phytomedicine 2009;16(5):391-400.
- 49. Stewart BW, Wild CP. World Cancer Report. Lyon: IARC; 2014.
- 50. NCI (National Cancer Institute) Age and Cancer Risk. serial online 2015 April (cited 2020 April 20) Available from: https://www.cancer.gov/ about-cancer/causes-prevention/risk/age