Chapter 1

Cancer Is Preventable

Cancer Facts

Primary and Secondary Prevention

The Importance of Early Detection

Life is not merely to be alive, but to be well.

Martial, first-century Roman epigrammatist

A recent Gallup poll found that 6 out of 10 Americans surveyed believed they would develop cancer in their lifetime, when in reality the actual odds are only about half that. Maybe you count yourself among that group. For so long, the origins and mechanisms of cancer were so enigmatic, and the treatments so harsh, that the disease assumed an aura of dread and terrible capriciousness. Only recently has the public become aware that cancer is gradually yielding up its secrets, including the secrets of prevention. But the barrage of information is so confusing and seemingly contradictory that it leaves people feeling uncertain what to do -- and doubtful that anything they can do will make a difference anyway.

Nothing could be further from the truth. It is estimated that most men and women can reduce their odds of getting cancer by half. This book will show you how.

To be sure, cancer is a devastating disease, one that currently claims over half a million American lives each year. Despite advances in research that have enabled us to chip away steadily at the mortality rate, the incidence continues to climb. It is projected that by the year 2000, cancer will surpass heart disease as America's number-one killer.

As longtime physicians at New York City's Memorial Sloan-Kettering Cancer Center, designated a comprehensive cancer center by the National Cancer Institute, we've seen firsthand the agony this disease inflicts on patients and loved ones. Even the many success stories contain their share of heartbreak, for cancer treatment can be a grueling ordeal that depletes finances and severely strains even the closest of families.

But the biggest tragedy by far is that most of the cancer cases we see daily could have been prevented. Only 10 percent to 15 percent of all cancers are of obscure or completely unknown origin, which includes factors of heredity, environmental radioactivity and other environmental hazards. As you can see from the above table, many cancers are caused by our own behavior, something we each have the power to control.

With this in mind, consider the following:

* Each year 165,000 Americans die from cancers brought on by tobacco use. The vast majority of those premature deaths could be avoided. The same is true of the 17,000 cancer deaths attributed to excessive alcohol use.

* Reducing fat consumption to 20 percent of total calories and increasing fiber intake to 25 to 30 grams a day, levels recommended by a number of authorities on cancer nutrition, could prevent more than 150,000 cancer fatalities per year.

* Safe sunning habits could slash the incidence of melanoma and other skin cancers by 90 percent, saving more than 8,000 lives annually.

HOW TO USE THIS BOOK

Why, then, do people often feel helpless to avert cancer? One reason may be that information on prevention is extremely fragmented. Visit your local library or book store, and you'll likely find a few rifles on breast cancer prevention, others on preventing prostate cancer, and some on diet as it relates to cancer. But the vast majority of cancer books are intended specifically for cancer patients.

It was recognizing the need for a clear, concise, comprehensive book outlining preventive action against cancer that inspired us to write Cancer Free. In it we will explain step by step how to design your personal, practical and surprisingly simple cancer prevention program, using the guidelines developed by physicians at Memorial Sloan-Kettering. We'll also decipher for you the latest research on the relationship between cancer and nutrition, genetics, exercise -- minus the scientific jargon that tends to confuse rather than enlighten -- and explain what these studies mean to you.

Part One provides a basic understanding of cancer: what it is, how and why it occurs, and how it is detected and treated. Part Two, The Building Blocks of a Cancer Prevention Program, is devoted to what we call primary prevention: identifying, then modifying or eliminating those environmental and lifestyle risk factors that can cause cancer. In these chapters you'll learn:

* How to draw your family tree, a valuable tool in determining your inherited cancer risk and the steps you must take to reduce it.

* The dangers of tobacco and other substances, and proven methods for quitting smoking.

* How to follow a low-fat, high-fiber diet with relative ease, with a week's sample menus to get you started.

* Steps for protecting yourself and your family from carcinogens (cancer-causing agents) commonly found at home and on the job.

* How stress and emotions may influence cancer, and techniques for reducing stress.

* The benefits of physical activity, which may lower cancer risk.

Does practicing cancer prevention require revamping your entire way of life? Only if you're a beer-swilling, fat-consuming, chain-smoking couch potato who exercises nothing other than your TV-remote-control trigger finger and hasn't seen a doctor since the days of house calls. Chances are that you already practice some preventive measures, but you need to develop a comprehensive game plan. These lifestyle recommendations apply to everyone, regardless of individual risk of developing cancer. In addition, they offer protection against heart disease, diabetes, emphysema and other deadly disorders, and in general help to promote vital, active, healthy living.

We advocate a total approach to prevention. However, because readers may be more vulnerable to particular cancers, Part Three presents specific strategies to combat the major adult cancers:

* Prostate cancer

* Breast cancer

* Lung cancer

* Colorectal cancer (colon and rectum)

* Gynecologic cancers

* Stomach cancer

* Esophageal cancer (cancer of the esophagus)

* Skin cancers

These chapters on specific cancers incorporate the recommendations of a number of specialists at Memorial Sloan-Kettering. (Other, less common or less fatal forms of cancer, while not covered in detail, are referred to throughout as they relate to nutrition, smoking and other factors that can fasten cancer.) Besides offering suggestions for primary prevention, Part Three will describe in detail the screening procedures used to discover a cancerous or precancerous growth before a person shows symptoms.

We can't emphasize enough the importance of these tests, which comprise secondary prevention. Early detection can spell the difference between life and death or spare a patient rigorous treatment, as Adele H., a mother and grandmother from Long Island, will vouch. In 1991, during her annual gynecologic exam at Memorial Sloan-Kettering, Dr. William Hoskins, chief of the gynecology service, studied the 56-year-old woman's medical records and noted that she was due for a routine breast x-ray called a mammogram.

"He set up the appointment for that day," recalls Adele, "and the x-ray turned up something suspicious," even though Dr. Hoskins had been unable to feel anything when he'd examined her breasts. Subsequent laboratory analysis of a tissue sample taken from the area in question confirmed a tiny malignancy.

The cancer was caught so early that the breast surgeon was able to perform a lumpectomy, the least invasive surgical method for removing a breast tumor. Normally after a lumpectomy, patients are treated with radiation therapy or chemotherapy. "But the doctor told me that the cancer was so small," says Adele, "no further treatment was necessary."

According to the American Cancer Society and the National Cancer Institute, most cancers are about 90 percent curable if found early, when the disease is still localized, or confined to the original (primary) site, and has not yet invaded the tissues or spread to other organs:

Finally, Part Four looks ahead to the promising cancer-prevention methods of the future, while an appendix lists names, addresses and telephone numbers of organizations and institutions that provide informative free booklets and helpful referrals. We urge you to make use of these resources and to consult the glossary of terms at the end of each chapter.

Throughout Cancer Free you will meet a number of patients, like Adele, from Memorial Sloan-Kettering Cancer Center. For the sake of privacy, we've given each a pseudonym. But their experiences with cancer and its prevention are real.

Henry M., a vigorous 68-year-old attorney and avid golfer from New Jersey, is another living testament to the benefits of cancer screening. Ironically, the father of two used to avoid doctors the way moles shun sunlight.

"My philosophy on life was that I was the rock of Gibraltar," he says. He came in for a general checkup in 1977 only because a friend had insisted on making appointments for both of them. "Otherwise," Henry admits, "I probably wouldn't have gone. The last thing on my mind was that I might have any physical ailment of significance." But a routine test detected blood in the stool, a finding that eventually led to a diagnosis of early colon cancer. Fortunately the growth was localized and could be removed surgically.

"I was stunned, because I'd had no symptoms," Henry remembers. "Dr. Winawer told me, 'Your chance for a cure is excellent.' When I walked out into the hall, I must have looked somewhat dazed. I saw a priest there, who asked, 'What seems to be the problem?'

"I said, 'I was just told I have cancer and need an operation.'

"He said, 'Let me tell you something: I've been visiting patients for many years. In my experience, many times patients are told the outcome looks bleak, only to succeed; and some are told the outlook is good, and they don't make it.'"

Henry replied numbly, "Thank you, Father," and walked away.

"Little did the priest realize," he says, laughing, "I'd gotten the good news, that I would be all right. He thought I was on the other end."

Henry required no additional treatment. More than 15 years later, he visits Memorial Sloan-Kettering annually for a series of followup tests, boards an exercise treadmill every morning before work, and shuns his once favorite fried and fatty foods. "I said to myself, Now it's time to follow a straight course. I've got to do what I've got to do. And I will continue to do it." Henry's case raises an important point: that practicing cancer prevention is no less essential if you've had a brush with the disease, for cancer survivors are at the same risk as other members of the population.

A medical scare likewise compelled Brian D., a successful New York businessman, to give up tobacco after 30 years. "I'd had occasional girlfriends, dates and office mates try to get me to quit," he recalls. "But that wasn't useful."

Then in 1992 the 52-year-old divorced father of two went to his doctor complaining of general malaise. "I just felt like hell," he says. "I couldn't be more specific than that." A CT scan indicated an unusual growth on one lung. Although it turned out to be nothing more than scar tissue from earlier bouts of bronchitis, the scar was what it took to jolt Brian into action. "I said to myself, You are not going to smoke anymore." With the help of a nicotine patch to ease withdrawal, Brian quit in a matter of weeks.

Another patient of ours, Judith K., surely qualifies as a role model for conscientious cancer prevention. We first met her in 1981, when her elderly mother, Rose, was diagnosed with advanced colon cancer. Sadly, Rose died the following year. So had Judith's maternal grandmother at age 55, also from colon cancer. It was news to Judith, then 37, that her family history put her at increased risk for the disease.

"One of the nurses told me it could be hereditary and said, 'You should go for the colon cancer screening,'" she remembers. "She gave me Dr. Winawer's name and number, and I called immediately. He considered me to be at high risk of having colon cancer." She underwent her first colonoscopy shortly thereafter and has had the screening procedure repeated every three years.

In addition, the New Jersey mother of three gets tested annually for breast and gynecologic cancers. She notes with a laugh, "A nurse at work said she thought I was 'a fanatic.'" But Judith, a chemist for a major oil corporation, doesn't think of herself that way at all. "I have young children," she reflects. "I'm doing everything I can to make sure I live a long time. I don't know if I can beat the odds, but I feel like if I give it my best shot, if I do end up with a cancer, then at least I won't have any regrets."

Rather than living in fear of the disease, taking these precautions affords Judith peace of mind. It's a good feeling, she says, to know that you can exert a degree of control over your health. "You can't put your life in the hands of a doctor," she adds. "You really have to take responsibility for your own life."

CHANGING ATTITUDES

If only more men and women had the same attitude as Judith. But as Dr. Daniel Nixon of the American Cancer Society observes, "It's very difficult to get people to change their habits, which are hard to break. I think there's something about human nature where people may be fatalistic, on the one hand, but they're omnipotent-thinking, on the other: 'Cancer can't happen to me; therefore I'll go ahead and smoke and drink and eat fat.' There are many psychologic factors involved here that we don't understand."

In 1986 the National Cancer Institute issued a detailed report entitled "Cancer Control Objectives for the Nation: 1985-2000." Its goal: to halve the number of cancer deaths in the United States. To accomplish this would require trimming the average American's fat intake to less than 30 percent of total calories and increasing the fiber to 20 to 30 grams a day, and reducing the percentage of adult smokers to 15 percent.

As of 1994, how close were we? According to Dr. Peter Greenwald, director of cancer prevention and control for the National Cancer Institute, the 50 percent reduction is not yet in sight. But the figures he cites, while higher than we would like to see, represent progress nonetheless:

"We've seen the smoking rate drop since the nineteen sixties," he points out. From 30 percent at the time of the NCI report, "Now we're down to 25 percent of the adult population. In diet, we've seen some decrease in fat, from 40 percent of calories to 36 percent."

Both Dr. Greenwald and Dr. Nixon believe we may be entering an era of increased awareness of cancer prevention. The country simply can no longer afford not to take note, as the current healthcare crisis has made painfully dear. It is estimated that in addition to causing suffering and death, cancer costs the economy $104 billion annually. We believe that practicing cancer prevention, in addition to saving lives, will ultimately help keep medical costs down.

To do so entails changing our notions about the purpose of medicine. "Neither the medical profession nor the public has taken prevention completely seriously," comments Dr. Joseph Simone, Memorial Sloan-Kettering's physician-in-chief. "A lot of it's inertia, and a lot of it's vested interest. There are not well-oiled systems in place for undertaking preventive medicine strategies. We just haven't invested the time and energy into that as much as we have into taking care of the disease once it has happened."

Many people view their doctor as someone to be called upon only when something breaks down. Often, the same person who faithfully brings in his car for its yearly inspection will avoid going for a checkup as long as possible. We feel strongly that it is in everyone's best interest to view medicine as a complement to sustaining good health rather than solely a means for curing illness -- in other words, not just intervention, but prevention. We've long advocated this philosophy, presenting scientific papers and giving lectures on the subject both to medical professionals and the public. The growing acceptance of the importance of cancer prevention methods has us excited and optimistic that the ravages of cancer can be significantly reduced.

Can we guarantee readers that they will never contract cancer? Of course not. The disease's origins are still somewhat mysterious. Even "healthy" people -- nonsmoking, teetotaling, top physical specimens -- can get cancer. But we can show you ways to improve your odds. The encouraging news is that because cancer typically lurks in the human body for between 10 and 30 years before it is diagnosed, time is on your side.

Now let's get to work.

KEY WORDS

Carcinogen: Any agent in food or the environment that causes cancer.

Localized: A cancerous growth found only in the original (primary) site.

Primary prevention: Identifying, then modifying or eliminating dietary, environmental and lifestyle factors that can cause cancer, such as tobacco, fat consumption or exposure to asbestos.

Screening test: A procedure used for early detection of cancer or precancerous growths in people who have not yet developed symptoms.
Secondary prevention: Finding, identifying and eliminating a cancer or precancerous growth when it is still curable, through the use of screening examinations.

Copyright © 1995 by Sidney J. Winawer, Moshe Shike and G. S. Sharpe