Cancer

Cancer is our second leading cause of death. It sounds strange, but you could say that's a mark of progress. Cancer mostly strikes older people, and more of us are living long enough to get it. Just a few generations ago many children died from measles and other childhood diseases. Women often died in childbirth. Without antibiotics, we had few tools to fight infections.

Now it's not a child with a fever or an infected wound that strikes fear into our hearts. It's cancer. That's no wonder, but U.S. cancer death rates continue to go down, lately by about 2% a year. Improved awareness, screening for some cancers and better treatments have all helped.

We also have more options for people who are dying of cancer. They can fight it with all the treatments we have, and get help dealing with the side effects. Or they may choose hospice care, which provides the highest possible quality of life for the patient and their caregivers. It's now widely available, and Medicare covers it.

What factors influence my risk of getting cancer? How can I reduce my risk?
Some risk factors are beyond your control:

• Growing older Cancer risk goes up with age. Most cancers are in people over 65. You can't stop those birthdays from coming around.
• Family history of cancer Melanoma and cancers of the breast, ovary, prostate, and colon sometimes run in families. Discuss your family health history with your provider. Ask if there are screening tests you should start early, or lifestyle changes or preventive treatments you should consider.

You have some control over other risk factors:

• Tobacco It's not just lung cancer; smoking increases your risk of cancers of the bladder, lung, kidney, pancreas, cervix, mouth, larynx, throat and esophagus. Even one cigarette a day counts. Nicotine is very addictive, but new drugs make it easier to quit. Avoid secondhand smoke, too.
• Sunlight Some sun, but not too much, is probably the best when it comes to cancer prevention. Too much sun can lead to skin cancer. You know the drill for that--use sunscreen, cover up, and stay out of the midday sun. Avoid tanning booths; use a sunless tanning lotion if you want a bronze glow. But a bit of sun (10-15 minutes for fair-skinned people, up to 45 minutes for those with dark skin) a few days a week during the summer months is a good idea to increase your body's reserves of vitamin D. People who have high blood levels of vitamin D have lower rates of many types of cancer.
• X-rays and CT scans Getting a look inside your body can be a big help in diagnosing illness, but these tests expose you to radiation. This exposure from scans is linked to small increases in cancers of the parts of the body that were X-rayed or scanned. There's very little radiation used for mammograms and bone scans, but a lot more for CT scans. Don't bug your provider for tests that aren't indicated. And don't get "preventive" whole body scans when you don't have symptoms. Only get the tests you need.
• Radon This radioactive gas comes from soil and rocks in some areas. Inhaling the gas increases your risk of lung cancer. Check with your local health department if you're not sure whether your home is at risk.
• Chemicals and other substances Over 80,000 chemicals are registered for commercial use in the U.S. Most have never been tested to see if they're toxic to adults, let alone to developing fetuses and children. But some are known to increase the risk of cancers of many types. For example, exposure to arsenic, asbestos, PAHs (polyaromatic hydrocarbons), and chromium can cause lung cancer. Benzene is a known cause of leukemia. Exposure to the pesticide methyl bromide has been linked to prostate and other types of cancer. People who work with toxic chemicals are at highest risk, but anyone who is exposed runs some risk. Be sure to follow instructions and safety tips on containers to avoid or reduce contact with any known harmful substance (including pesticides, used engine oil, paint, solvents, and other chemicals). And use common sense with all chemicals, since many have never been tested. Avoid breathing fumes or getting them on your skin. And do your best to limit your exposure to air pollution from traffic, factories, coal-power plants, incinerators, gas stations, oil refineries or diesel exhaust. Air pollution contains many toxins. You can learn about some of the most common cancer-causing chemicals at a government site, Tox Town.
• Some viruses and bacteria We've identified some infections that increase the risk of cancer. There's now a vaccine for young girls that can stop infection from specific HPV viruses that increase cervical cancer risk. Hepatitis B and C infections increase the risk of liver cancer. We have a vaccine that protects against hepatitis B, but none for hepatitis C. Human T-cell leukemia virus type I can cause leukemia and lymphoma. You can protect yourself from hepatitis B, hepatitis C, Human T-cell leukemia virus type I or HIV infection by avoiding unprotected sex or sharing needles. If you have stomach ulcers, ask your provider whether you should be tested for H. pylori, bacteria that cause ulcers and can increase the chances of stomach cancer.
• Certain hormones Hormone therapy for symptoms of menopause may slightly increase breast cancer risk.
• Alcohol Having more than two drinks a day for many years increases the chance of cancers of the mouth, throat, esophagus, larynx, liver, and breast. The more you drink, the higher the risk--and it's even higher if you also smoke. Limit yourself to 1 drink a day for women, 2 for men.
• Poor diet, lack of physical activity, or being overweight People who have a poor diet, are inactive or overweight may have more risk of several types of cancer. For example, a high-fat diet increases the risk of cancers of the colon, uterus, and prostate. Lack of physical activity and being overweight are risk factors for cancers of the breast, colon, esophagus, kidney, and uterus. Eat plenty of fruits, vegetables, whole-grain breads and cereals, and exercise.

Are cancer screening tests always a good idea? My provider says there are pros and cons. Isn't it always better to catch cancer early?
With some tests for certain age groups, it's a no-brainer. But it's not so simple with others. For example:

For an adult with average risk, there's no doubt that screening for colon cancer starting at age 50 saves lives. Colon cancer is very treatable at an early stage, and screening can even catch growths before they become cancer. If you get a traditional colonoscopy (not the virtual kind), they can remove anything suspicious during the screening and check it for cancer later. There are risks, but the benefits are greater. Many people are squeamish about getting a colonoscopy, but it's well worth the hassle.

But aging changes the equation. By age 76, the benefits for the average person aren't so clear. We can't be sure it's worth the risks. And by age 85, experts say that the possible risks are greater than the benefits. The preparation, the anesthesia, and the screening are harder on older bodies. So is treatment if they turn out to have cancer.

Thanks to the Pap smear screening test for cervical cancer, since the 1930's, 80% fewer women die from this cancer. The test finds precancerous growths that can be removed. It's recommended every 1-3 years for women who've been sexually active. After age 65 women whose recent Pap smears have been normal don't need further screening. Some providers end screening sooner for very low-risk women.

Women over 50 benefit from regular mammograms to screen for breast cancer. Some experts recommend mammograms starting at 40, but the evidence that this saves lives isn't as strong.

The value of prostate cancer screening (the PSA blood test) is still being debated. We don't have solid proof that the PSA tests starting at age 50 save men's lives. Screening has led to a lot more diagnoses of prostate cancer, and surgery for it. Many experts think that we're overtreating a cancer that is both common and very slow growing.

Men with prostate cancer may never develop symptoms. Most men who have it die of something else. Of course, there are cases where it's deadly. The question is whether it's worth it for many men to have such a serious surgery to prevent far fewer deadly cancers. Erectile dysfunction and incontinence are common side effects that may affect the quality of the rest of a man's life.

Is it worth it to have the surgery? Would it be better to skip the PSA test and not be faced with these questions? That's a personal decision that each man should make with his provider.

Here are some issues to discuss with your provider when you're deciding whether to have a screening test:

• Is there good proof that this screening test saves lives?
• How reliable is the screening test? Does it produce many false positive or false negative results?
• What are the risks, if any?
• What are the recommended age ranges for this test?
• What are the treatment options if I have that kind of cancer?
• If I wouldn't want the treatment, is there reason to get the test?

What are my chances of surviving if I get cancer?
Better and better, especially for patients in the U.S. Cancer is detected earlier and treated more aggressively here than in other countries. Many factors like your age, general health and especially the stage of the cancer (whether it has spread) affect your odds. Here are average 5-year survival rates for many types of cancer in people diagnosed around 1996. They're broken down by the stage of the cancer at the time of diagnosis. Since treatment has improved since 1996, survival rates for people diagnosed today are higher for many cancers.

5-YEAR SURVIVAL RATES
(% of people who hadn't died from the diagnosed cancer within 5 years)

I just found out that I have late-stage cancer and I'm considering my options. What is the difference between aggressive treatment, palliative care, and hospice care?
People who want to do everything possible to either cure or slow down cancer seek the most aggressive treatment available. That's usually chemotherapy, surgery or radiation (often a combination). They're willing to deal with the side effects and complications, no matter how unpleasant they may be.

They can get palliative care at the same time. The goal of palliative care is to relieve the pain, symptoms and stress of any serious illness, and to improve the quality of life. Palliative care patients may be on the road to full recovery, coping with a chronic illness, or dying.

Some people with terminal illness continue aggressive care until they die--with or without palliative care. But other people choose hospice care. It's for people who are no longer seeking a cure, and who are likely to die in 6 months or less. Their treatment is meant to relieve symptoms, especially pain, and involves practical, emotional and spiritual care as well as medical care. Hospice patients may get care at home or in nursing homes, hospital hospice units or inpatient hospice centers. A typical hospice care team might include a physician, nurse, home health aide, social worker, chaplain, counselor and trained volunteers. They work with the patient's caregivers and loved ones as well as the dying person. Medicare covers hospice care.

If a dying person is still suffering despite all treatments to relieve pain and other symptoms, palliative sedation is an option. They're given enough sedative drugs to slip into an unconscious state while the disease takes its course. It is not meant to hasten death.

These are big decisions. You'll probably want more information from your provider. You can get suggestions about questions to ask in our article Maximizing Your Health Care in the Cover Story Archives. Another article there, Decisions at the End of Life, provides more information that may help you take charge of your treatment.

Does stress cause cancer? How about personality style?
Despite what many books and Web sites will tell you, studies have not found any link between the worst stressful life events and cancer risk. People who have survived concentration camps and other horrid events like the death of a child don't get cancer any more often than others do.

There are books and Web sites that will tell you all about the so-called cancer personality. They say that caretakers, people who take care of others but suppress their own "toxic emotions" are more apt to get cancer. They say that extroverted people who express themselves freely are unlikely to get cancer. It may sound true or likely. But the data for this is not only missing, it's contradicted by science. Studies have found no link between a trait called neuroticism (the tendency to worry and be anxious and moody) and cancer risk. And extroverted people are just as apt to get cancer as anyone else is.

Do alternative medicine treatments help cancer patients?
Alternative medicine doesn't cure cancer, but some alternative treatments can enhance treatment and help cancer patients cope.

• Mind-body therapies like relaxation training, yoga, support groups and other methods to lower stress can help patients cope with having cancer.
• Acupuncture may help with pain, and with nausea and vomiting from chemotherapy.
• Cancer patients should not take supplements without talking with their providers first. Many supplements, including St. John's wort, vitamin C and high-dose vitamin A, can worsen cancer or interfere with chemotherapy.

Isn't it essential that cancer patients have a positive attitude for treatment to work?
The answer may surprise you. Many different studies have found that mental outlook doesn't affect survival. People who felt hopeless, anxious or depressed lived as long as people determined to fight. Those who freely expressed their feelings die as often as those who didn't.

This is important because well-meaning friends and family often try to pressure cancer patients into being "positive." They tell them "you'll beat this" right up to the end. A positive attitude has many benefits, including making loved ones more comfortable. But it doesn't make patients live longer. And cancer patients have plenty of reason to feel fear, grief, fatigue and sadness as well as hope and determination. In fact, one of the reasons that many cancer patients benefit from support groups is that they can express "negative" as well as "positive" feelings freely. If you have a loved one with cancer, the most caring thing to do is to accept whatever they feel and the decisions they make.