Ruling Out Cancer
By L. William Lauro, MD
My wife’s oldest sister lives in a small town in the western United States. She is in her early fifties and has been in good health all of her life. She is a wonderful woman who, along with her husband, has raised a great family (seven children – six boys and one girl), has been a faithful and devoted member of the Church, an active member of the community, and is now suffering with terminal breast cancer. If anyone were deserving of a miracle it would be she. But, thus far, no miracle has been forthcoming.
My sister-in-law lives many miles from a medical center large enough to offer breast mammography. And so she has procrastinated driving the fifty miles or so to the big city to get her first mammogram. In addition to the inconvenience of driving the long distance to the medical center, she has also been just too busy to go get her test – busy raising her seven children, busy serving in the Church, busy sustaining her husband in his callings and activities (he has served as bishop of their ward, and as mayor of their town).
And besides, she has been in perfect health and has felt fine.
Yes, one day she would plan to travel to the big city and get a mammogram, but just not today. You see, it’s just not a priority right now (even though she was now almost fifty years old).
Then one day, while drying herself off after a shower, she noticed that one breast seemed a little harder than the other. Upon further inspection it also appeared to be a little bigger than her other breast. It’s probably just my imagination, she thought. Nothing to worry about.
But then a few days later she saw a TV program where Oprah was talking to a cancer expert about breast cancer signs (which she now realized she had) and how important it was to faithfully get one’s mammograms, starting at age 40.
So, a little concerned and a little worried, she finally went in for her first mammogram – at the age of 49. A week later she called me with fear and trembling in her voice: they had just told her that her mammogram was suspicious for cancer. They had scheduled a biopsy of her breast in a week, but she was scared and anxious and upset, and didn’t know how she was going to be able to wait a whole week to find out.
I immediately called a friend of mine who is a breast cancer surgeon here in Salt Lake City and he agreed to see her the next day in his office, with the thought that he could do the biopsy that evening.
My friend saw my sister-in-law as promised, but there would be no biopsy – her breast exam and mammogram were so obvious for advanced breast cancer that a biopsy was not even necessary. Surgery was no longer an option for treatment – she had waited too long before coming in for her first breast cancer screening.
No, my surgeon friend could do nothing for her – she was now off to the oncologist for chemo and radiation with the hope of prolonging, rather than saving, her life.
She was shocked and upset and devastated. Her life had been turned upside down in just a matter of days! The prior week her biggest worry had been what to cook for Sunday dinner – now she was asking questions about how long she would live, and whether she would be around for her only daughter’s graduation and wedding and first child and all those other events that a mother and daughter look forward to together.
And she was also asking those haunting questions for which there are no easy answers: Why didn’t I have my screening exams? Why wasn’t I more vigilant? Why did I wait so ling to go in? If only I had caught this earlier, I might have had a chance for a cure – and a life. But not now…
Did you know that cancer has now passed heart disease as the number one cause of death in the United States (except in the very most elderly)? We as a people have done a remarkable job at watching our cholesterol, stopping smoking, exercising more, and watching our weight, and the heart attack rate in this country is improving. But cancer still looms large on the horizon.
So what are we to do?
We must be vigilant, we must have our screening tests, and we must pay attention! And so here, below, I offer the most recent recommendations regarding the early detection of the major cancers.
Colon:
I had my first colonoscopy at age 47 (usually most people wait until age fifty to have their first test). But because one of my closest friends had just been diagnosed with advanced colon cancer at the time, and he was only 48, I decided to go in. My test was negative – thank heavens – but my dear friend died 18 months later from his colon cancer.
Did you know that despite all the publicity and efforts directed at colon cancer screening, only 30% of the population aged 50 and older has had a colonoscopy? Why so few?
Sure it’s a hassle taking the preparation to clean out the bowel, but it isn’t bad. You take some medicine the night before, and again the morning of the exam. You get some diarrhea but your bowel is nice and cleaned-out. Not a big deal. Then you go to the out-patient section of the hospital, they start an IV, give you a slug of IV Valium, knock you out, perform the test, and twenty minutes later they wake you up. All done. And – best of all – if you are free of polyps you are free of another colonoscopy for ten years! What a deal. And many insurance companies will cover the cost of the test. Ask your family doctor for his help in getting it arranged.
There are other accepted screening tests for colon cancer, but none are as accurate as colonoscopy. The fecal occult blood test (FOBT), a test performed on three consecutive days’ stool samples brought to the physician by the patient, is helpful but not foolproof. And, since most patients do not do the required three tests, they are even less accurate.
Sigmoidoscopy, another option, is easier and cheaper than colonoscopy, but only looks at the first 18 inches of the 72-inch-long colon. Helpful, but not good enough in my opinion.
So, if you are 50 or older, my advice is to get a colonoscopy. And if you have certain risk factors, such as a first-degree relative with colon cancer or adenomatous polyps (“pre-cancerous” lesions of the colon), or have inflammatory bowel disease such as ulcerative colitis or Crohns disease, then you should have your first colonoscopy by age 40. Some people should begin even earlier for certain rare conditions, but your doctor can tell you about that.
Now, what are you to do if you can’t afford colonoscopy or don’t want to go through the hassles to have the test? The fecal occult blood test (FOBT), combined with sigmoidoscopy, is acceptable. But you are taking a calculated risk. Opt for the colonoscopy if at all possible.
What about CT scanning for colon cancer at those centers that are doing so much advertising lately? Actually they are very good and, with more experience, will probably rival the accuracy of the colonoscopy test. But remember – if they find a polyp on CT scanning you still have to go in and have a colonoscopy anyway, to get the polyp biopsied. Extra cost and hassle.
Colon Screening – The Future:
Newer tests for colon cancer are being developed that would be more patient friendly and easier than colonoscopy and more accurate than fecal occult blood testing. These include fecal immunochemical tests and DNA tests on the stool. Stay tuned.
Cervix:
The cervix is the opening in the lower end of the uterus. Pap smears, which consist of scraping a small amount of cells from the external cervical lining, have been a godsend to the diagnosis and treatment of cervical cancer. Unfortunately, many women still do not get their pap smears and exams as they should. Cervical cancer is 100% curable if caught early, and it is primarily detected through the Pap test.
Because cervical cancer is caused by human papilloma virus, which is transmitted during intercourse, it is considered a sexually transmitted disease. Therefore, only women who are sexually active need have a Pap smear. And because the disease is very slow growing, you can go three years between exams after the age of 30 (younger sexually active women need Pap smears every 1-2 years until age 30). If you have had a hysterectomy there is no need for a Pap smear at all – the cervix has been removed along with the uterus. And after age 65 you can quit having Pap smears all together.
So, to review: first Pap test within three years of becoming sexually active, then every one-to-two years until age thirty, then every three years thereafter until age 65.
Breast:
Women age 40 to 50 should have breast mammography every one to two years, and then every year after 50. It is not yet known at what age a woman can discontinue having mammograms. Self-breast exams (those done by the patient) have been shown to be virtually worthless in detecting cancer. The American Cancer Society no longer recommends a formal self breast exam (remember all those diagrams and instructions showing you how to do the perfect breast exam? No one ever seemed to master it or do it). The only recommendation is for a woman to be familiar with her own body and report any differences she notices to her physician.
Breast exams done by the physician are still recommended during one’s routine physical exam.
Just a personal side note: there is no excuse for postponing or forgoing a mammogram just because you do regular self breast exams and haven’t found a lump, or because you may think you do not have any breast cancer risk factors. Get your test!
Prostate:
A prostate specific antigen test (PSA) should be considered by every man age 50 and older. Younger men who are in a high-risk group (African-Americans and men with a first degree relative with prostate cancer) should begin PSA testing at age 40. Now, you should know that the PSA test is not infallible, so every man age 50 and above should still undergo a prostate exam by the physician annually. Some prostate cancers will be picked up just by the exam, even though the PSA is “normal.” And of course many prostate cancers will be detected solely through the use of the PSA (tumors too small to be felt during exam).
A PSA level greater than 4.0 is a strong indicator for the need for prostate biopsy. Also, a rapidly increasing PSA level, even though it might be less than 4.0, is an indication for biopsy.
Because most prostate cancers are slow growing and many older men will die from another cause even if they have prostate cancer, one can consider stopping PSA screening after the age of 75. Discuss this with your doctor before making that decision.
Other Cancers
You are probably wondering why I didn’t mention screening for the most common cancer of all: lung cancer. This is because there is no screening test for lung cancer, as well as stomach and esophagus cancer, pancreas cancer, liver cancer, bladder/kidney cancer, ovarian cancer, and the list goes on. And so it becomes very important for the patient to be vigilant of changes in one’s body, and aware of the cancer warning signs, and report any changes to the physician.
Cancer Warning Signs:
You don’t have to memorize any acronyms or formulas to remember the cancer warning signs. Just use good old fashioned common sense: if you notice a change in a mole, or see a new skin lesion that looks different than you think it should, tell your doctor. If you notice a lump under the skin that persists a few months, see your doctor.
If you begin to have blood in your stool or black stools, or see a change in the size of the stool, call your doctor.
If you see blood in your urine, call us. If you develop a chronic cough that doesn’t go away after a couple of months, or cough up blood, let us know.
If you experience unexplained weight loss (losing more than 10 lbs without trying), extreme fatigue that lasts longer than several weeks, a loss of appetite that again doesn’t improve after several weeks – call us.
Believe it or not, despite the excellent screening tests we have, most cancers are still detected by the patient!
