ApA Proactive Approach to Cancers
by Alf Adler, M.D.

The American Cancer Society (ACS) estimates that more than 192,000 women in this country were diagnosed with breast cancer in the year 2001.  In addition, 80,300 women were diagnosed with a gynecologic cancer that same year.  Some of these cancers are preventable, some are not.  In those that are not preventable, early diagnosis and treatment dramatically increases the odds of survival.  Women need to understand their own risk factors in order to take a proactive approach to prevention, early detection and treatment.

Cancers of women are divided into those that involve the reproductive tract (vulva, vagina, cervix, uterus, fallopian tubes and ovaries) and those that involve the breast.  The former cancers are known as gynecologic cancers.

The most common of the gynecologic cancers is uterine or uterus cancer, also known as endometrial cancer. The endometrium is the lining of the uterus.  ACS estimates that 38,300 women were diagnosed with uterine cancer in 2001.  Risk factors include the following:  never having been pregnant, starting her period at a very early age, and entering the menopause at a late age.  The average age of menopause is 51-52.  The common denominator for these risk factors is estrogen, which is one of the main female sex hormones.  The other sex hormone is progesterone.  A shift towards more estrogen and less progesterone increases the risk of endometrial cancer.

Ovarian cancer shares many of the risk factors seen with endometrial cancer such as early menstruation (before age 12), late menopause (after age 51-52), no pregnancies, a family history of breast cancer, and possibly the use of hormonal replacement therapy (still a controversial risk factor).  Symptoms are very non-specific, meaning that these symptoms are applicable to many other pelvic or gastrointestinal conditions, the majority of which are benign or non-cancer conditions such as swelling of the abdomen, bloating, increased gas, abdominal pain and rarely, indigestion.  Pelvic pain, irregular bleeding or postmenopausal bleeding, pain with intercourse, pelvic pressure, and leg pain are some other symptoms, again of a very non-specific origin.

Cervical cancer is one of those preventable cancers, if only we could get all women in this country to see their gynecologist or primary care physician on a regular basis for pap smears.  The ACS estimates that there were 12,900 cases of cervical cancer in 2001, and 2,100 cases of vaginal cancer.  Both share the risk factor of HPV infections or Human Papilloma Virus.  Some can cause genital warts, while others can cause microscopic changes in the vagina or cervix that can lead to benign inflammation of the tissue, precancerous changes and even cancer.  We believe many of these can be transmitted from one person to another through sexual contact.  Other modes of transmission are possible, but none that have been identified at this time.  In addition to HPV, smoking is a risk factor, as well as other immune compromising infections such as HIV.  Prior exposure to DES, a hormone prescribed to women from 1940-1971 to prevent miscarriages is also known to increase the risk of vaginal or cervical cancer in 1 out of every 1000 women born to women (their mothers) exposed to DES (diethylstilbestrol).  African-American women have a rate of cervical cancer that is twice the national averages.  Hispanic and Native American women also have higher rates than those found in other populations. 

Breast cancers have similar risk factors to those of uterus and ovary cancers.  Aging in the greatest risk factor.  Having a first-degree relative with breast cancer such as a mother, sister or even a daughter increases the risk.  Early periods, or late menopause, no children or having the first child after the age of 30, obesity, high fat diet, personal history of breast cancer, inherited mutations in breast cancer related genes (BRCA1, BRCA2) are other factors. 

Almost 80% of women with breast cancer in our country are older than 50 at the time of diagnosis.  75% of all women with breast cancer have no family history.  The inherited genes mentioned earlier account for only 5% of all breast cancers.  However, if you have a first-degree relative with breast cancer, especially if it occurred prior to menopause, or if her breast cancer occurred in both breasts, your risk is higher.  This next generation of women with that higher risk can develop breast cancer in their 30’s; therefore, genetic testing for the BRCA1 or 2 genes would be imperative. 

Breast cancer may present with a “lump” or mass in the breast or underarm (axillary) region, nipple discharge especially if bloody, nipple dimpling or retraction, skin dimpling or retraction.  Pain is rarely associated with breast cancer.  Lives can be saved when these cancers are detected early.

What to do?  An annual exam is critical.  It should include a thyroid exam, listening to the heart and lungs, breast exam, pelvic exam, frequently a rectal exam, and a pap smear.  Tumor markers for ovarian cancer (CA-125) and ultrasound are not very helpful in the early diagnosis of these malignancies.  Pelvic exam is the best protection that we have available at this time in diagnosing ovarian cancer.

Regular pap smears can actually prevent cervical cancer and at times vaginal cancer by detecting precancerous changes.  Currently, the ACS recommends that young women start having regular pap smears when they become sexually active or at 21, whichever comes first.  If a woman has had 3 normal pap smears in a row, the ACS recommends pap smears every 3 years.  As gynecologists, we still believe that yearly visits will provide women with the optimal protection since it allows for examination of other organ systems such as the thyroid, heart, lungs, breasts and the external and internal reproductive organs.

Mammography is recommended on a yearly basis after the age of 40.  If you are at high risk you need to discuss having mammograms done at an earlier age with your provider.  Breast self exams should be done on a monthly basis, after the period is over. Many breast cancers are detected by women at the time of their own self breast exam. 

What else can we do?  Well, many risk factors require a lifestyle change.  These are what we call modifiable factors such as weight loss, exercise, proper nutrition and diet.  Also consider the use of supplements with antioxidants, minerals and vitamins.

Protect yourself against HPV infections.  Have your partner use proper barrier protection such as condoms if you’re unsure of whether or not he may have HPV.  HPV can be asymptomatic.  50% of sexually active individuals in this country have HPV or have been exposed in the past.

Stop smoking - it will lower your risk of cervical and vaginal cancers.  Smokers are twice as likely to get cervical cancer.  

It’s time to take charge, to be in control, and to view health proactively.  Know your risk factors.  Alter those that you can control.  Maintain a healthy lifestyle.  Prevention, when possible is key.  Early detection for other conditions is also of the utmost importance, and it can save lives.