©August 2008

Leroy Sievers, an award-winning journalist, died on August 15, 2008, of colon cancer after writing a daily blog since mid-2006 entitled “My Cancer”.  He described the blog as “…a daily reminder that none of us walks this road alone.”  Mr. Sievers’ work provided unmeasureable benefits to cancer patients and potential cancer patients alike, which pretty much covers all of us.  By breaking down the barriers that create a sense of stark isolation for the cancer patient, this journalist was able to neutralize perhaps the most fearsome characteristic of the cancer diagnosis: cancer comes from within.  The entire community shares the burden of cancer by virtue of the fact that each one of us is made up of cells that might at any time begin to grow willy-nilly without regard to the usual cellular responsibilities.  Detection of these rebellious cells at the earliest possible point is one of the prime goals of cancer prevention and treatment.  We can focus on ovarian cancer to explore how partnerships with our health care providers can be best used to detect otherwise invisible cancers, and diminish the sense of isolation which so often darkens the skies of cancer patients.

Any cell of the body can potentially become cancerous, although some are more likely to do so than others.  When a cell becomes cancerous, it devotes all of it’s energy to reproducing itself.  This occurs because of a mutation in the cellular DNA which changes the instructions the cell receives. Thus, a cell which is normally instructed to behave like an ovary cell is advised to reproduce as fast as possible and forget about producing the usual chemicals and enzymes that are characteristic of ovaries.  It is the constant effort towards reproduction that is the distinguishing feature of a cancer cell.

Ovarian cancer presents problems because the ovary is a small organ suspended in the abdomen.  As many mothers can attest, a growth in the abdomen can become quite large before it causes enough problems in it’s neighborhood to become apparent to the owner.  As a result, ovarian tumors (growths) often grow without detection for years before causing symptoms.

Certain cancer cells will release abnormal chemicals which can be detected by a simple blood test.  This occurs because the defect that leads a cancer cell to grow abnormally also often alters the assembly line for chemical production.  Similarly, a pastry that is mass produced, like a Hostess Twinkie, cannot be expected to be equivalent to a muffin meticulously prepared by the loving hands of a grandmother.  The abnormal chemicals produced by cancer cells are called “markers,” because they can often be used to identify the presence of cancer or monitor the progress of cancer during treatment.

For ovarian cancer, one of these “abnormal” chemicals is called CA-125.  The problem with cancer markers is that they are actually often not truly “abnormal” chemicals, but instead are produced by normal cells in small amounts.  Thus, there are other conditions besides ovarian cancer that can explain elevations of CA-125 in some patients.  The question, then, is when do we measure a CA-125 in women, and if it is elevated, what should be done with the information?

The risk of ovarian cancer increases with age, especially after 50 years old.  Women who have never had children, women who are infertile or who have had their first child after age 30 at are increased risk for ovarian cancer.  The risk of ovarian cancer is increased for many women with a history of breast cancer, or a family history of breast, colorectal or ovarian cancer.  There have been several genes, such as the BRCA-1 and BRCA-2 genes, identified that predispose to ovarian cancer in some families.  Women with any of these risk factors should speak with their health care providers to determine if they are candidates for ovarian cancer screening.

The U.S. entity charged with the responsibility to develop and update recommendations for health screening of otherwise healthy people is the United States Preventive Services Task Force (USPSTF).  This group has found insufficient evidence to either support or oppose routine pelvic examination except for screening for cervical cancer, gonorrhea and chlamydia. Screening for these latter conditions is still recommended every three years between the age of 21 and 40 years depending upon the patient’s sexual activities and the recommendations of their health care provider.  After age 40, a pelvic examination should be obtained depending upon your health care provider’s advice.

Symptoms of ovarian cancer often include nothing more than vague bloating, abdominal enlargement, nausea, or pelvic pressure.  However, these symptoms are commonly caused by minor conditions unrelated to cancer.  To recognize when such symptoms warrant further evaluation, describe your symptoms carefully to your health care provider, and if your symptoms continue despite treatment, be sure to convey this fact.

For high risk individuals or patients with specific symptoms, your health care provider may advise you to obtain a CA-125 blood test.  At this time, this blood test is not used to screen the general population because it can lead to unnecessary tests and complications.  Rely upon your health care provider to help you determine if this test is appropriate for you, but provide the information necessary to make a well-considered decision.

We have more tools available to us to improve our health than any society before us.  The trick is to use these tools efficiently and effectively, and to participate in the decision by partnering with health care experts.  Doing so will not guarantee that we will avoid illness, but it will maximize our benefits and remind us that we are part of a larger family.

©July 2008

Disease prevention is a familiar battle cry of public health.  It is better to diminish the risk of disease before an assault begins than to wait for the first skirmishes to occur.  But there are several criteria that must be met for a particular test to effectively identify risk of illness, and thereby allow an opportunity to prevent disease.  Colon and rectal (“colorectal”) cancer prevention provides an excellent opportunity to explore the characteristics of screening tests that can make a difference.

The tests recommended for colorectal cancer prevention fall into two categories.  The “fecal tests” involve testing the bowel movements each year by collecting small smears of stool on a card or in a container.  There are several “fecal occult blood tests” (FOBT) available for this which test for the presence of otherwise invisible amounts of blood in the stool.  Each should be done carefully and in accordance with recommendations provided with the test.  There are also new fecal tests available that detect certain cancer markers in the stool, but these are more expensive.

The second category of testing includes examinations of the structure of the lower bowel (the colon) and rectum, most often with a scope called a colonoscope or sigmoidoscope.  Fourteen million annual colonoscopies are performed in this country.

Each person’s health care provider will recommend the test that is most appropriate for the individual based upon factors like family history, age and overall health.  In general and in accordance with American Cancer Society recommendations, colorectal cancer screening should begin at age 50 years.

For a preventive test to be effective, the disease you wish to prevent must be worthy of attention.  It makes little sense to mount a campaign to identify people at risk of developing hiccups.  Colorectal cancer is the second leading cause of cancer death and the third most common cancer in the United States, more than justifying the effort to screen for the disease.

Even though no test is perfect, a test that is used to screen the population for risk of disease must be acceptably accurate, without over-measurement or under-measurement.  In the case of colorectal cancer, the target being measured may be blood in the bowel movement, DNA in the bowel movement or physical abnormalities in the lining of the colon or rectum, called “polyps” (small lumps attached to the lining) or “ulcers” (shallow sores).

Even if the test is accurate, it must be capable of detecting disease risk at a time when steps can be taken to cure the patient.  In some cases, a colorectal cancer test may detect polyps or growths before they are cancerous, and in other cases they may detect growths that have already turned cancerous.  To be effective, a colorectal cancer test must detect cancers or pre-cancers at a time when surgical treatment of the condition, either via a scope or by traditional surgery, is curative.

The test must be affordable.  In an era when “affordable health care” sounds ever more like an oxymoron, there is little need to explain why affordability is a vital part of any health care recommendation.  Screening tests for colorectal cancer may be completely free, such as Fecal Occult Blood Testing at the annual Tuolumne County Health Fair, or screening may run up to as much as $6000 for a colonoscopy and biopsy.  An affordable method of screening should be available for every person, and ultimately saves in health care costs to the community.

Finally, people must be willing to undertake the test.  It is difficult to motivate the public to perform tests on three separate bowel movements when they prefer to deny any personal relationship to sewage whatsoever.  However, people become increasingly compliant with annual stool tests, colonoscopy or other screening modalities as they learn the value of colorectal cancer screening and hear of friends or relatives who have benefited from early detection.

Screening rates for risk of colorectal cancer by low income households in our area steadily decreased between 2001 and 2005, while colorectal cancer screening for the general population increased by almost 10%.  These kinds of trends contribute to the disparity in health between different economic segments of our community.  At least in regards to colorectal cancer prevention, screening tests are available that are effective and affordable.  Please spread the word that this simple test is worth your time: fecal occult blood tests will be available at the Tuolumne County Health Fair in October.