Discoveries Magazine

Cedars-Sinai

The Early Bird

The Early Bird

Today’s screening methods are increasingly effective at catching cancer in time to manage the disease, and lifestyle changes can help prevent it from developing in the first place. If we know prevention and early detection are so vital, why, then, is this potentially lifesaving tune so often tuned out?

One morning in August 2009, 53-year-old Satik Khanbabaian walked into her gynecologist’s office, sat down calmly across her desk, and made an unusual request: “I told her, ‘Take my breasts away. Take my ovaries away.’” Her mother, Nora Nazarian, had died of breast cancer a few months earlier at the age of 71, and Satik was determined not to follow the same path.

Instead of surgery, however, Satik’s doctor wisely suggested that she first consider other prevention measures. She soon met with Ora Karp Gordon, MD, director of Genetics for the Wasserman Breast Cancer Risk Reduction Program at Cedars-Sinai, and together they came up with an aggressive prevention plan based on her health and family history (a maternal aunt had also died of advanced breast cancer). The approach included getting annual mammograms and breast MRIs, plus regular blood tests for ovarian cancer and mouth swabs that checked for cancer susceptibility genes.

Satik didn’t stop there. Keeping cancer at bay is now part of her daily routine. Never a big fan of blueberries, she added them to her diet along with scads of other fruits and vegetables. “So many berries,” she says, laughing. Then came the regular walks—two-and-a-half miles every day— around her Woodland Hills neighborhood. To reduce stress, she listens to an inspirational radio talk show and tries not to worry when her house gets a little messy. “I used to drive myself crazy about it,” she says. “Now I say, ‘I can vacuum tomorrow.’”

The idea is simple yet powerful: We as individuals may be able to prevent many forms of cancer by taking steps very much within our control. Prevention covers a wide spectrum, from screenings and genetic testing to diet and lifestyle changes to tackling the disease at the cellular level before malignant tumors develop. Prevention is crucial to fending off the disease or making it more manageable, yet some of the most basic cancer prevention messages remain largely ignored. Could it be that our best bet against cancer—and the key to eradicating the disease—is improving and rethinking cancer prevention methods?

The American Cancer Society estimates that one-third of the more than 500,000 cancer-related deaths in 2011 in the United States could be attributed to poor diet and physical inactivity, while another third is caused by the use of tobacco products. Yet according to the American Institute of Cancer Research, about 40 percent of Americans remain unaware that they can take steps to reduce their cancer risk.

“There are clear-cut things that you can do, like having a colonoscopy and removing a pre-malignant polyp,” says Edward Phillips, MD. “Then there are the indirect things, like taking aspirin to reduce your chance of getting polyps, cutting alcohol intake, and improving your body weight to reduce the risk of breast cancer.” But the risks associated with ignoring such indirect steps are subtle. “They aren’t tangible to most people,” says Dr. Phillips, who is the director of the Sharon Osbourne Colon Cancer Program and the Wasserman Breast Cancer Risk Reduction Program, and co-director of the Saul and Joyce Brandman Breast Center—A Project of Women’s Guild at the Samuel Oschin Comprehensive Cancer Institute.

Cynthia Stein, MD, a sports medicine physician at Children’s Hospital Boston and co-author of The Handbook of Cancer Risk Assessment and Prevention, believes that unawareness rates could be even higher. “The attention to prevention waxes and wanes because the messages stay essentially the same,” she says. “Everybody knows they should maintain a healthy weight. Everybody knows they should not smoke and should be exercising.” Physicians can keep repeating the message, but eventually people stop paying attention, she notes.

risk-management

Many longstanding assumptions about the effectiveness of vitamins or antioxidants in cancer prevention, however, ultimately have not stood up to scrutiny. Results that were promising in the lab did not carry over when tested on a larger scale. The inconsistent messages are confusing. There is no single sound bite.

While tobacco-control programs and policies have had a huge impact—preventing a remarkable 795,000 lung cancer deaths between 1975 and 2000, according to a 2012 National Cancer Institute report—other prevention efforts in areas such as obesity continue to fall short.

“We live in a fast-fix society,” notes Adrienne Youdim, MD, medical director of the Cedars-Sinai Weight Loss Center, who specializes in obesity and preventive medicine. “So it’s a lot easier for patients to decide to take a pill to reduce their risk, for example, than prevent cancer through long-term strategies like dietary change and exercise.”

Annual screening, genetic testing, and early detection offer the best chance for successful treatment. Colon cancer, in particular, is largely preventable with regular colonoscopies. Unfortunately, too few people get the recommended screenings. The Centers for Disease Control and Prevention and the National Cancer Institute found that only 59 percent of men and women between the ages of 50 and 74 were screened in 2010, far short of the national goal of 71 percent.

“People need to be educated about symptoms and listen to their bodies,” says Sharon Osbourne. The celebrity talk-show host—who was diagnosed and treated for colon cancer in 2002 after a routine colonoscopy revealed a cancerous polyp—has become a vocal proponent of early detection. The Sharon Osbourne Colon Cancer Program at Cedars-Sinai supports prevention by funding programs that train physicians and nonphysicians in the latest screening recommendations, early warning signs, and risk-reduction behaviors, in addition to helping patients who are undergoing treatment.

Osbourne stresses that individuals who have any concerns “need to make an appointment to see their doctor. They can’t be afraid or simply put it off. It’s just too important.” Cost is often a key issue when it comes to screening. Breast cancer and colorectal cancer screening rates for persons living in the United States for less than 10 years have declined since 2008, and many of those known to be underserved, such as the uninsured and individuals without access to healthcare, continue to be screened less often than recommended.

With that in mind, doctors at the Wasserman Breast Cancer Risk Reduction Program recently introduced a cost-saving risk-assessment tool that makes it possible to look for multiple risk factors in women all at once. For women with a personal and family history of cancer, genetic testing is often recommended. Traditional genetic tests look for one gene at a time: One test will scan for breast cancer genes; a different one will be needed for colon cancer. The process is costly and time-consuming. “With our new system, for the cost of one test,” Dr. Gordon says, “we’ll be able to look at 15 to 20 genes at one time.”

Sometimes, getting even high-risk patients to agree to an assessment is a challenge, perhaps because they fear the worst and feel helpless against a seemingly incurable disease. “We have to remind patients that the earlier we identify the disease, the better our chances of defeating it,” says Beth Y. Karlan, MD, director of the Women’s Cancer Program at the Samuel Oschin Comprehensive Cancer Institute and the Gilda Radner Hereditary Cancer Program.

Founded in 1991, the Gilda Radner Program enrolls individuals who have been tested for BRCA mutations and collects epidemiologic, demographic, and psychosocial information to begin addressing questions regarding lifestyle, diet, exercise, smoking, stress, hormones, and other factors that may influence cancer risk.

It also gives individuals the opportunity to participate in investigational cancer screening studies aimed at early detection. Because the Gilda Radner Program has tracked a large group of high-risk women over a very long period of time, it has helped shape national guidelines for cancer screening and prophylactic surgery recommendations for this segment of the population.

“There is still much to be learned about the various modalities for detecting early-stage ovarian cancer—but until a cure for the disease is found, early detection is our best defense,” says Dr. Karlan.

While effective cancer prevention relies on improving patient outreach and responsiveness, a new approach to prevention may hinge on understanding how cancer cells behave in order to develop treatments that prevent tumors from developing or spreading in the first place.

Vaccination is another approach to prevention that is being developed worldwide. Inhibiting cancer with the prick of a needle did not seem possible a few years ago. Now vaccines have emerged as a formidable asset in preventing the deadly disease. In 2010, the U.S. Food and Drug Administration approved two types of preventive vaccines: one against the hepatitis B virus, which can result in liver cancer, and one against human papillomavirus (HPV) types 16 and 18, responsible for the majority of cervical cancers.

Although new discoveries in cancer treatment are still more likely to grab headlines, observers agree that prevention efforts have escalated nationwide. The Obama administration’s 2010 Patient Protection and Affordable Care Act includes a prevention and wellness initiative that requires all health plans to provide coverage for preventive benefits, such as colonoscopies, and allocates funding for Community Transformation Grants, which aim to reduce chronic disease by promoting healthy lifestyles at the neighborhood level.

At Cedars-Sinai, doctors envision a comprehensive program that coordinates prevention efforts within the Medical Center. According to Dr. Phillips, such a program will have a profound effect on communication—ultimately linking dozens of separate divisions, from the Colorectal Cancer Center and the Women’s Guild Lung Institute to the Heart Institute and Diabetes Outpatient Treatment and Education Center.

In the meantime, Satik Khanbabaian will continue with her daily walks and careful food choices, doing everything in her power to fight the breast cancer that took her beloved mother. “I am trying to do whatever I can,” she says. “I am determined to avert this disease, against all odds.”

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