The elephant in the examination room
It seems to me that people go to see their doctor with a specific complaint for one of two reasons; they’re annoyed or they’re worried.
Annoyance is the simpler of the two and can often go something like, “Doctor I’ve had this bloody cough for two months and you need to give me something to make it stop.” Find a solution and the patient goes home happy.
When someone is worried, however, it often isn’t directly stated and the underlying fear needs to be teased out a bit. A doctor can start to wonder if reason two might be lurking about if the patient is a bit vague, seems to be skirting around the issue, or if we ask ourselves, “Why exactly is this person here?” I find that the clinical visit won’t be satisfying for anyone unless these worries are addressed. In my training as a resident in family medicine I’ve made a specific intention to explore these concerns with patients, and have noticed a very striking pattern. When you really get into it, and across a huge range of symptoms (headaches, stomach upset, joint pain, skin changes, you name it), the vast majority of the time the worry is, you guessed it, cancer.
This collective concern is really quite valid. Who among us doesn’t personally know several people who have been diagnosed with cancer, or died from it? And probably each of us holds one or two of those “bad luck” or “uncanny” cancer stories. Like, “She was diagnosed with breast cancer at age 27! Healthy lifestyle, no family history… what a shame.” Or something like, “Yeah, he never smoked a day in his life, but still, lung cancer.”
The official stats support our fears even more strongly. According to the Canadian Cancer Society , 40% of women and 45% of men will develop cancer in their lifetimes, and fully one quarter of Canadians will die from cancer. According to the BC Cancer agency statistics, there were 3017 men diagnosed with cancer in British Columbia in 1970, as compared with the 9954 who were diagnosed in 2005.
In discussions I’ve had with other medical professionals on this topic, it’s common to hear the theory that this increase in prevalence is simply due to our improved diagnostic technology and ability to detect cancer more sensitively. Cancer has always been there, we just couldn’t see it. The other common explanation is that we’re all living longer and well, you’ve got to get something sometime. At first blush these answers seem reasonable enough; but a deeper investigation into the topic shows them to be dangerously untrue, even a potential block against our coming to grips with the health realities that surround us. One important source we can turn to is Devra Davis’s excellent book The Secret History of the War on Cancer. In it Davis addresses this very issue:
"An aging population does not explain why five times more men and women get brain cancer in America than Japan. Nor do we understand why rates of testicular cancer in men under age forty have risen 50% in one decade in most industrial nations, why women of Generation X are getting twice as much breast cancer as their grandmothers did, or why young black women get and die from breast cancer in greater numbers then their white counterparts".
She also points to a marked increase in childhood cancers as evidence of a true, and startling, increase in cancer prevalence in our day.
So what’s happening in our way of living that has created this profound shift in our health? Why do we hear so much in the media about what happens once we get cancer, and so little about how to prevent it? And most importantly what can we be doing to protect our families and ourselves from receiving a devastating cancer diagnosis?
How did this happen to me?: Cancer’s tipping point
In my first year of medical school I volunteered at a unique clinic located in Vancouver, Canada called InspireHealth. They are practicing evidence-based integrated cancer care, are supported by the provincial government (generally rather conservative in such matters) and are expanding. They’re improving quality of life (and emerging data suggests survival as well) in their patients by addressing their whole person needs, and going far beyond the conventional chemical cocktails that the latest studies are recommending.
During an open information session one afternoon, a newly diagnosed patient asked the physician an extremely common question, “What did I do to get cancer?” Her response remains the most concise and clear description of cancer development I have heard to date. She explained that our individual genetics create a pre-disposition, a potential, for developing cancer. Layer on top of that our individual life choices (whether we smoke, exercise, eat processed foods, etc), and other more subtle qualities of our being (stress, depression, lack of connectedness). Now put that whole dynamic system in the context of a society and environment that is profoundly toxic in many ways, and you can appreciate that it doesn’t take much to tip over into profound imbalance and cellular dysregulation, or, cancer.
Okay, so let’s flesh these factors out a bit.
Bad genes, bad luck?
When we look at genetics, it’s important to remember that genes represent a blueprint, a model for the production of proteins, which go on to determine the function of cells and tissues. Some of us are born with a genetic code that predisposes us to certain cancers. However, only a few cancers are purely genetic. Certain types of colon cancer qualify, and there is one important genetic mutation that causes devastating breast and ovarian cancer in 80% of women born with it. Of course your physician will always ask you about a family history of cancer, as a positive family history does statistically increase your risk.
The vast majority of the time though, genes are only a small part of the picture, something in the range of 5-10 percent (1). In fact, there’s new and startling research that shows that even those of us born with unlucky genes may be able to do something about it. Several studies are now showing that dietary and other lifestyle interventions can actually change the expression of genes. In a 2008 study led by Dr. Dean Ornish, men with a diagnosis of prostate cancer had their RNA (a form of genetic coding) tested before and after an intensive lifestyle modification program. They found that the program modified more than five hundred genes in the prostate – those that were protective against cancer were stimulated, and the harmful genes were suppressed (2). For those of you who, like me, have had training in biology and accepted the status quo that genes are static and unchanging, this research is seriously mind blowing.
Lifestyle choices: What’s the impact of smoking, moving and eating?
The importance of our individual lifestyle choices in cancer development is news to no one. Some large epidemiological studies (such as the HALE study) show a 60% reduction in cancer mortality among those who adopted a healthier lifestyle, and other large studies suggest that fully 40% of all cancers could be prevented by simple changes in diet and physical activity. Of course, “healthy lifestyle” is pretty vague terminology and it might be useful to break this down just a bit.
It is time to quit.
Smokers have a 20 to 30 times increased risk of cancer, and this is by no means limited to lung cancer. They are also at risk of cervical cancer, and cancers of the stomach, esophagus, mouth, and neck. Unfortunately, conventional cigarettes are exquisitely designed to create and maintain addiction. The amount of nicotine included in each, the chemicals added to adjust burning time, the size and length and smell of them all work to encourage users to have about one per hour, or one pack (usually 25 cigarettes) per day. Quitting smoking is no easy feat – as any smoker will tell you - and most folks will try several times before being successful.
Move your body, run from cancer.
No brainer, right? A sedentary lifestyle increases your risk of cancer, especially if you’re overweight to boot. Adipose tissue (or fat) stores many carcinogenic compounds, and some suggest that exercise has a directly “de-toxifying” effect. Also exercise seems to reduce excess hormone levels (such as estrogen and testosterone) that are implicated in some cancers (breast, uterine, prostate). Exercise reduces pro-inflammatory compounds, and also reduces blood sugars, which in turn decreases tissue inflammation and tumor growth (3). There are countless guidelines out there as to how much exercise we should be getting and what types, but it seems to me that it’s being made too complicated. Moving your physical body around at least several times a week is a mandatory part of being a human on the planet. Nuff said. Thankfully, being active feels great and improves sleep and mood, so evolution has given us some incentive for getting off the couch, or away from the computer desk, as it were.
Starve cancer, feed life.
Now let’s move to diet. T. Colin Campbell is a professor at Cornell University who helps us to understand the relationship between diet and cancer. He hypothesizes that the initiation of a cancer depends mostly on genes and environmental toxins. But whether or not that seed of a cancer goes on to develop, progress and cause disease (or promotion) depends on the local environment in the tissues surrounding the early cancer. He’s found that dietary factors are very powerful in this process and can act as promoters or anti-promoters.
There are so many components to an individual or culture’s diet that it can be difficult to isolate out the offensive bits. This is the detective work of epidemiology – to look for patterns and make deductions about the origins and progression of disease. There are few components of our diet that by themselves cause cancer – there has been a remarkable decrease in rates of stomach cancers now that we have better refrigeration of foods and fewer nitrates – and generally it’s understood to be a combination of many factors.
That being said, it is becoming increasingly clear that our “Western” diet is particularly implicated in promoting cancer development (4). In his book Anticancer: A New Way of Life, Dr. David Servan-Schreiber goes as far as to call our Western diet fertilizer for cancer growth! Strong words, with serious implications.
Some aspects of our western diet that seem to pre-dispose to cancer development are the addition of large quantities of highly refined sugar, changes in farming and animal raising to highly centralized industrial processing, and an exposure to a large number of new chemical products and additives (5).
The peaks in blood sugar that come with refined sugars or foods with a high “glycemic index” (think white flour foods) cause secretion of insulin as well as a compound called IGF (insulin-like growth factor). Both insulin and IGF support the growth of new cells, including cancer cells. They also both promote factors of inflammation, which stimulate cell growth and act as fertilizers for tumors. One study showed that of mice who had breast cancer cells implanted into them, 16 of 24 who were fed a high glycemic diet were dead after two and a half months, as compared to 1 of the 20 who were given a low glycemic diet. In another study, of two groups of women under 50, those with the highest IGF levels were seven times more likely to develop breast cancer than those with the lowest (6). Considering the fact that the average Canadian consumes 24 kg of sugar and 72 L of pop each year, and sugary, refined foods are being heavily marketed to our children, this is information we may want to start to take seriously.
Healthy bodies in a toxic world?
It seemed impossible to discuss the other two aspects of our diet I mentioned above – industrial farming and meat production, and chemical products we are consuming – without moving away from individual lifestyle choices to our broader society and environment.
Our centralized industrial food system uses vast amounts of chemicals, additives, preservatives, pesticides, fertilizers, and antibiotics and hormones in the case of meat, poultry and dairy production. One stat suggests that the average Canadian consumes 15 lbs of food additives per year (7)! What are the effects of these chemicals on our health, and particularly their role in cancer development?
Well if you ask the industries and companies involved, they'll certainly tell you that these chemicals have been tested for safety in humans, so eat up and enjoy. And certainly they have been tested for safety – and in many cases being labeled as “possible” or “probable” carcinogens, or the very comforting “unclassified” - but one at a time (8). Devra Davis, the epidemiologist mentioned above takes a shot at this principle, saying:
"The producers of these agents take comfort in the fact that any one of them, tested by itself, looks fairly benign by various measures of carcinogenic potency....still, it defies common sense and basic biology to assume that just because a single agent looks alright, we can safely encounter hundreds of such materials all at once".
There’s even some highly disturbing suggestions that there may be an additive, or “cocktail effect”, and that these chemicals can increase the toxicity of their neighbors while they’re all swimming around together in our bodies. There are studies being done now working to demonstrate this effect and the results are anything but reassuring (9).
There are strong movements afoot to challenge the status quo of conventional food production and decrease the burden of these chemicals in our diets and bodies (not to mention our soil, water and wildlife). Among them is a turn towards smaller farms, locally-sourced diets and alternate purchasing systems such as farmer's markets and CSA's (community supported agriculture). Most well known of these is a move towards organically grown foods. To give an idea of the impact of going organic, one small study at the University of Washington involving children looked at the difference between conventional and organic diets. For three days children ages 2-5 were given a diet of either organic (75 percent of food labeled as organic) or conventional food (75 percent not labeled as organic). The levels of pesticides in the kids who were given organic foods was one sixth of those on the conventional diet. For them, the level found was four times higher than the official safety limit.
Of course food is not the only place that these chemical show up. From our cleaning products, cosmetics, water bottles, kids toys, frying pans, cell phones, not to mention industrial and occupational exposures, the media seems rife with stories about how everything we touch just might be giving us cancer (10). It's hard to know what to do with such information! Some of us move to islands and hide, some get health-obsessive and drink wheatgrass or the latest most powerful “antioxidant” super-food eight times a day, and some of us, perhaps even most of us, listen with concern and attention, make a few small changes, and go quietly back to our lives as before.
Looking within: Stress, cancer and self-blame
The last element of cancer development I want to address has to do with that inner part of us, the part where stress, emotion, fear and isolation reside. You can think of it as the "mind" of the mind-body connection.
What does mind have to do with cancer development? Well what happens in our inner environment has a direct effect on our physiology... turns out that whole mind-body dualism thing never really had a leg to stand on. Examples of this relationship abound, and include everything from our friend the placebo effect, to the simple fact that your heart beats faster when you feel emotionally charged. Persistent feelings of helplessness or despair have been shown to increase levels of noradrenaline, the fight or flight hormone, and cortisol, the stress hormone. Both of these chemicals decrease immune function (our body’s innate mechanism to eliminate cancer) and increase inflammation (11).
So our bodies do respond to our subtle, interior experience, and this response can either be helpful or harmful to our physical health. The effect is small however, and it needs to be stressed that no single psychological factor has ever been demonstrated capable of creating the seed of a cancer. It's a psychosomatic (meaning mind influences body) rather than a psychogenic effect (as in mind creates disease).
In our post-modern society many people are very aware of the mind-body connection, and this can sometimes be a detriment. One of the saddest moments in the care of people with cancer is to witness a process of self-blame, when patients ask, "What did I do to create this cancer?" Certainly we should all strive to live relatively peaceful, emotionally healthy, low stress lives, but do so because it feels better on the inside of that experience, and not because we're fearful of making ourselves sick.
Finding our way
We've seen that cancer development is a complex, multi-factorial process. Because of this, it’s difficult for researchers, scientists, and epidemiologists to prove beyond a shadow of doubt exactly why cancer rates are increasing so much, and exactly what is responsible. As a result, most of mainstream medicine focuses on frantic attempts to improve the diagnosis and treatment of cancer, more or less leaving behind the messy business of prevention.
I remember a conversation with my husband that highlighted this for me. We were listening to CBC radio about the latest walk, run, bike ride, or other fundraiser for the latest type of cancer receiving attention. It seemed shocking just how much we focus on what to do once we get cancer, rather than looking carefully, and critically, at what is going on in our culture and communities that might be implicated. And just to be clear, I have nothing against fundraisers for cancer, but it does seem like a little bit of madness that so few of us are raising the alarm bells as to what exactly is going on to create the ever-increasing need for these events.
So then, keeping all this in mind, what should we be doing to protect ourselves, our families and our communities from suffering from cancer?
A guide to preventing cancer
1. Get some physical exercise a few times a week.
Like I said, lots of guidelines available on this. In general more is better. A mix of cardiovascular (brisk walking, cycling, jogging, dancing, swimming… anything that raises your heart rate for a sustained period of time) and strengthening exercise (weights, isometrics, yoga) is ideal. I like yoga, some people like triathlons. Do something you enjoy, outdoors is great.
2. Eat food, mostly plants, not too much.
Okay this is a direct rip-off from Micheal Pollan’s food rules, but I love the simplicity of his recommendations. We can (and do) make ourselves crazy about food. As he explains, North America spends more time, research and money on nutrition than any other place in the world and has the most nutrition-related illness. I would wager that obsessing about food may well negate the benefits of healthy eating! That being said, some key points are to avoid sugar and high glycemic foods, and definitely avoid highly processed foods. There are reasons for changing our eating outside of improving our own health (as in water, soil, wildlife), and thankfully, what is good for our bodies is good for the planet. Check out these previous Beams articles about food and food choices.
3. Take Vitamin D.
Although we do produce this vitamin through sun exposure, nearly all of us in North America are Vitamin D deficient (the sun simply doesn’t get hot enough for long enough to produce enough for the whole year), and supplementation has been shown to have a role in cancer prevention. The Canadian Cancer Society recommends at least one thousand units a day for adults, I take two thousand.
4. See your doctor and get screened.
There are certain cancers that have well developed screening programs, including breast, cervical, and colon cancer. For women, get your pap smear done yearly, and mammograms after age 50. For men, check your testicles (testicular cancer affects men between ages 20 – 40), and get your prostate checked after age 50. For everyone, get screened for colon cancer after age 50. None of this is pleasant business, but it works, so get it done.
5. Be conscious of the chemicals you expose yourself to.
As mentioned above, it’s our accumulated exposure to many kinds of chemicals (as well as other exposures, such as radiation and electromagnetic fields) that negatively affects our health, so our best bet is to start to become aware of where these exposures may be coming from.
I mentioned organic food earlier in this essay, and this is a good place to start. If you aren’t prepared to go fully organic (for financial or other reasons), here is a guide to the top 12 worst offenders in terms of pesticide burden.
Are you using plastics in ways that can be avoided - as in re-usable water bottles, plastic rather than glass food containers, or children’s toys that could be replaced by natural or wooden ones?
Is your diet heavy in processed foods that contain preservatives, additives and other refined products? Try making simple meals from whole foods a little more often, you’ll find it's worth the extra time.
Are there other sneaky ways that exposures show up in your life (such as cosmetics, cleaning products, kitchen equipment made with Teflon) that you could become aware of, and start to change? It’s in the long run that these changes will be beneficial.
6. Find some joy, and give yourself time to relax and be mindful.
Joy and laughter keep you healthy! Laughter enhances immune function and decreases stress hormones, and one large Norwegian study showed that folks with the most sense of humour were 35 % less likely to die during the seven years they were followed.
Stress reduction and relaxation soothe the chronic fight-or-flight physiology a lot of us are running around with and allow our bodies to heal and rejuvenate. Whether you relax by taking a long bath, going for a run, playing with your grandchildren, or practicing yoga it really is time to make this a priority in your life.
Mindfulness and meditation offer stress reduction as well as many other benefits, including connection to authenticity and purpose, and a sense of grounding as we navigate life’s inevitable challenges. Good for cancer prevention, good for life in general. (12)
7. If you do get cancer, get the right support.
When the author of the book Anticancer, Dr. David Servan-Schreiber, a psychiatrist and researcher who developed brain cancer and drew on his own experience and research to write his book, asked his oncologist soon after diagnosis what he could be doing differently, some vague guidance about healthy eating was all he received.
And this isn’t because his physician was cold or uncaring. Our system currently focuses on what it does well – detecting and diagnosing cancers early in their course, providing timely and often curative surgeries, and offering chemotherapy and radiation treatments. And we’re very fortunate to have this level of care.
However, there’s good evidence that shows that what you do in addition to conventional cancer treatment can affect your outcome and quality of life. Many of these things we’ve already addressed (exercise, eating whole foods) but there are specific anticancer foods and other supplements (such as melatonin to reduce side effects during chemotherapy) that have been shown to be very helpful. If you live in BC or other places in Canada, contact InspireHealth. Otherwise, I would strongly recommend Dr. Servan-Schreiber’s book Anticancer as an excellent resource (13).
8. Hold this all lightly, take a deep breath, and enjoy your day.
Prescriptive lists like this one sometimes make me tense.
That’s not what I hope for you, but rather that together we become aware of the trends happening around us, and bring more consciousness to what we could be doing differently. At the same time that I don’t think I could possibly over-emphasize how critical these actions are, I think it’s important to not take it too seriously either. Being fiercely committed to your own health and well being, and holding it lightly at the same time, is a dance and a challenge. I think we’re up for it.
A final word
As I’ve tried to show here, cancer development is a complex process, and there are many aspects of our lives that are increasingly putting us at risk. We are busy, and a lot of us are stressed, isolated, and disconnected from family and community. We live in a secular, consumer-driven culture and often lack the deep peace and meaning that comes from connection to spirit. We are addicted. We eat shitty food a lot of the time. We’re surrounded by industrial systems that privilege the bottom line, which as it turns out, doesn’t include our health.
As a physician, I feel called to offer a different perspective to the status quo. I have witnessed the devastating effect a cancer diagnosis has on patients and families. How it cuts short the future and leaves people winded and lost. We’re not doing nearly enough to prevent this devastation, and we're going about it the wrong way. We need a whole system, whole person view to understand the roots of cancer, and a whole lot of commitment and tenacity to start to change things.
Maybe all the sadness, scars and suffering that are coming from this frightening rise of cancer can serve as a critical wake-up call of sorts. We can make meaning from it, without believing that we deserve it. After all, the world needs something from each of us, and it’s hard to serve from a sick body.
I’ve been personally impacted by cancer in loved ones, as I know most of you have, and I feel a certain urgency to get this conversation going. I hope to hear from you here: about how cancer has affected you, if it freaks you out, or if you feel pissed off. Let’s get our thoughts and ideas out and get clear about what we need to be doing differently. After all we can’t prevent, or heal, something that we’re ignoring.
Reference and Endnotes
(1) "In Denmark, researchers have found the biological parents of more than a thousand children adopted at birth...the genes of biological parents who died of cancer before age 50 had no influence on an adoptee's risk of developing cancer. On the other hand, death from cancer before the age of 50 in an adoptive parent (who passes on habits but not genes) increases the rate of mortality from cancer five-fold among adoptees.” From Anticancer: A New Way of Life, by David Servan-Schreiber, pages 8-9.
(2) Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Dean Ornish, et al. Proceedings of the National Academy of Science, 2008 http://www.pnas.org/content/105/24/8369
(4) "If the tumor's environment is deprived of the inflammatory factors needed for it's growth, it will not succeed in spreading. The fact is that these inflammatory factors, these fertilizers for cancer, are provided directly by our diet. Major dietary fertilizers are refined sugars, which drive up pro-inflammatory insulin and IGF, insufficient amounts of omega-3's and the corresponding excess of omega-6's, which change into inflammatory molecules; and growth hormones (present in meat and nonorganic dairy products), which also stimulate IGF. Conversely, diet may also furnish "anti-promoters," such as all the phytochemical components of some vegetables or particular fruits, which directly counter-balance inflammatory mechanisms.... When Richard Belieau [researcher and professor of biochemistry at the University of Montreal, with a special interest in nutrition to supplement cancer treatment for children] talks about the Western diet in light of these findings: "If I were asked to design a diet today that promoted the development of cancer to the maximum, I couldn't improve on our present diet!" From Anticancer, page 110.
(5) “The chronic diseases that kill most of us can be traced directly to the industrialization of our food. The rise of highly processed foods and refined grains; the use of chemicals to raise plants and animals in huge monocultures; the super-abundance of cheap calories of sugar and fat produced by modern agriculture and the narrowing of the biological diversity of the human diet to a tiny handful of staple crops, notably wheat, corn or soy. These changes have given us the western diet that we take for granted: lots of processed foods and meats, lots of added fat and sugar, lots of everything- except vegetables, fruits and grains”. Michael Pollan, Vancouver Sun.
(6) On sugar, IGF and breast cancer risk. http://www.ncbi.nlm.nih.gov/pubmed/9593409
(8) "WHO's international agency for research on cancer keeps a list of carcinogenic substances in the environment. In the past 30 years, it has tested nine hundred potential culprits (a tiny proportion of the over one hundred thousand substances released by industry since 1940, at a rate of several million tons per year). Among these ... only one has been recognized as non-carcinogenic. Ninety-five have been identified as "known carcinogens" .. Three hundred and seven are "probable" or "possible" carcinogens.. Four hundred and ninety-seven remain "unclassified" (which doesn't mean that they are safe, merely that their effects have not been sufficiently studied, often for lack of funding)... In many cases, these substances continue to be widely used. This is true of benzene, a known carcinogen found in gasoline, certain plastics, resins and glues, certain lubricants, dyes, detergents and pesticides." From Anticancer, pages 84-85.
(9) A highly critical report on this topic was presented to the European Parliament in 2008 by Professor Andreas Kortenkamp, head of the Centre for Toxicology at the University of London. It highlighted how different substances that seem inoffensive when studied separately and at low doses become quite toxic when combined. (http://www.env-health.org/spip.php?article792)
(10) cf. Slow Death by Rubber Duck for more on this topic; http://slowdeathbyrubberduck.com/
(11) “Persistent feelings of helplessness... Accompanied by changes in the secretion of noradrenaline (known as the fight or flight hormone) and cortisol, the "stress hormone." These hormones.. stimulate the inflammation factors needed to repair tissues. At the same time, these hormones are also fertilizer for cancerous tumors, latent or already established. From Anticancer page 47. http://www.ncbi.nlm.nih.gov/pubmed/15581732
(12) “Non-doing has nothing to do with being indolent or passive. Quite the contrary. It takes great courage and energy to cultivate non-doing, both in stillness and in activity. Nor is it easy to make a special time for non-doing and to keep at it in the face of everything in our lives which needs to be done.” Jon Kabat-Zinn http://www.wisebrain.org/papers/MedImmuneBrain.pdf
(13) As you can see, I have drawn heavily on Dr. Servan-Schreiber’s important contribution, Anticancer: A New Way of Life. Sadly he passed away in July of 2011 after his brave 20-year battle with brain cancer. I am deeply grateful for his courage and dedication.