Cancer – Just Bad Luck?

Elizabeth A. Grosen, M.D.
Gynecologic Oncologist
Cancer Care Northwest

Cindy was an energetic, 23-year-old woman who arrived with her mother for consultation regarding treatment of her cervical cancer. How could such a young woman have cervical cancer? Cervical cancer primarily affects women in their late 30’s and 40’s. There must be a mistake in the diagnosis. There was not. Cindy had an advanced cancer of the cervix. Well, then, it must be bad luck. The reality is however, that cervical cancer does not result from “bad luck”. Cindy’s cancer journey began in her early teenage years, when she became sexually active, and progressed when she failed to have follow-up for an abnormal pap smear at the age of sixteen. Aggressive treatment with chemotherapy and radiation was initiated to treat a cancer that had seven years to develop in Cindy. At the end of treatment, it appeared that the cancer was successfully eliminated. But the cancer refused to be destroyed, and despite surgery, more chemotherapy, and endless prayers, Cindy died of her cancer at the age of 25. Like most deaths from cervical cancer, it was a long, painful, and devastating ending to what could have been a beautiful life.

Gynecologic oncologists treat gynecologic cancers, or cancers of the female reproductive organs. Although it is common knowledge that smoking may cause lung cancer, very few women seem to understand that other lifestyle choices affect their risk of gynecologic cancers. This means that much of cancer risk can be reduced, or as in the case of cervical cancer, can be almost eliminated. It is time that women stop viewing cancer as something that “just happens” and start taking action to reduce cancer risk. The first step in this process requires recognition that our bodies do suffer injury from exposure to harmful behavior, substances, and infection.

Cervical cancer is a classic example of a cancer that should not exist. Not only is the cancer preventable, but Pap smears are an excellent screening test for this disease. The two major risk factors for cervical cancer are human papilloma virus(HPV) infection and smoking. Other risk factors include early age at sexual intercourse, large number of sexual partners, and failure to have routine Pap smears. Some strains of HPV are sexually transmitted, and have been strongly linked to the development of cervical, vaginal, and vulvar cancers. Therefore, sexual activity, especially exposure to multiple sexual partners, increases the risk of infection with HPV. Also, the younger the woman (or girl) is exposed to HPV, the greater her risk of developing the precancerous conditions of the cervix. This occurs because the younger woman’s cervix, which is less mature, has a larger area on the cervix that is especially susceptible to HPV infection. As a woman matures, the area of the cervix that is susceptible to this infection becomes smaller. What about the woman who did not start having intercourse at a young age, or who has had only one partner? Of course, not all of the responsibility with HPV infection rests with the woman. The woman may have only had one partner, but if her male partner has had several partners, and especially if any of these women have had precancerous or cancerous conditions of the cervix, her risk for HPV and cervical cancer increases. Therefore it becomes apparent that delaying the age at first intercourse, abstinence, monogamy, or use of barrier contraceptive methods (reduce the risk of infection) will decrease the risk of cervical cancer. The other major risk factor, smoking, is also under the control of the woman – just don’t smoke! Unfortunately, second hand smoke may create just as much risk for these cancers as firsthand smoking. Despite smokers claims that they are only affecting themselves, this is not true. They are increasing the risk of diseases, including cervical cancer, in other individuals who don’t smoke. So it is apparent that women can take steps to significantly reduce risk for cervical cancer. As I mentioned, there is also an excellent screening test for this disease. The sad truth of cervical cancer, is that most women who present with this disease have not had regular Pap smears. Many of them have not seen a physician for years. Cervical cancer generally has a very slow course of development, so a woman who has regular screening should have this disease detected in its precancerous stages, when it is highly treatable.

Endometrial, or uterine, cancer is the fourth most common cancer in women, and also highly associated with behaviors and choices that can be modified. The major risk factor in recent years has been obesity. Even for women who are 20 – 30 pounds overweight, the risk of uterine cancer is tripled. Women who are 50 pounds overweight increase their risk by 10 times. This occurs because fat tissue converts a circulating hormone into a weak form of estrogen, that over time can stimulate the lining of the uterus to thicken and become malignant. Women also affect their uterine cancer risk by choices regarding estrogen use and use of such drugs as Tamoxifen. Estrogen alone can increase the risk of uterine cancer by 4 to 15 times, but the addition of a progesterone can bring that risk to baseline. Tamoxifen, which is used for breast cancer treatment and prevention, can also increase the risk of uterine cancer. This risk is increased especially for women who continue its use beyond 5 years. Although there is not a standard screening test for endometrial cancer, the most common symptom of endometrial cancer is abnormal bleeding. This may include irregular menstrual cycles, especially heavy bleeding around the time of menopause, or any bleeding after menopause. Abnormal bleeding should be reported to a physician, who can then evaluate and do biopsies to determine the cause of bleeding. Women who are at high risk of endometrial cancer should be especially alert to changes in menstrual patterns. The risk for endometrial cancer can be reduced by hormonal manipulation, including use of progestins or oral contraceptives. Although most endometrial cancers are related in some way to excess exposure to estrogen, some endometrial cancers are not. There is perhaps nothing that can be done to reduce the risk of these cancers, except recognize that some of them are linked to hereditary cancer syndromes. Individuals who have a high incidence of cancer in their family (paternal or maternal), especially cancers of the colon, uterus, ovary, stomach, small bowel, pancreas, biliary tract (Lynch syndrome). Female members of these families are at high risk for uterine cancer at a young age. Identifying families who have these genetic syndromes can lead to earlier screening for the disease, or surgical treatment to reduce the risk of developing the disease.

The most devastating of the gynecologic cancers is ovarian cancer, which is the leading cause of death from gynecologic cancers in the United States. This cancer is the fourth most frequent cause of cancer death in women, and surpasses the death rate of uterine and cervical cancer combined. Unfortunately, a good screening test does not exist for ovarian cancer. The exact cause of ovarian cancer remains unknown, but several risk factors are known. It is known that the risk of ovarian cancer is reduced by interrupting ovulation. The theory is that the repair mechanism in the ovary after ovulation is somehow damaged, so that the ovarian cells start to undergo malignant change. This malignant transformation of ovarian cells is probably influenced by other factors as well. Any change that reduces the number of ovulatory (egg-releasing) cycles in a woman’s lifetime, will decrease her ovarian cancer risk. The most important of these factors that decrease ovulation are pregnancy, breast-feeding, and use of oral contraceptives. Another identifiable risk factor is heredity, even though it is estimated that only 10% of ovarian cancers result from a hereditary disposition. However, if a woman has had a mother, sister, or daughter (first degree relative) with ovarian cancer, her risk is increased. Ovarian cancer is also linked to breast and ovarian cancer syndromes, and to Lynch syndromes. Genetic counselling and testing are available to help identify these high risk individuals. Such individuals can choose to have close screening or prophylactic surgical removal of their ovaries to reduce the risk of developing ovarian cancer.

The most important steps in cancer prevention and risk reduction must start very early in life. Children must be raised to lead healthy lives and avoid high risk behaviors. Women must understand that decisions they make about their bodies may have important long term implications for cancer risk. This includes the benefits about delaying sexual activity, limiting exposure to sexual partners, the benefits of oral contraceptives in reducing ovarian and uterine cancer risk, the benefits of breast feeding, and the importance of maintaining a healthy weight. Women must also take advantage of cancer screening programs, and testing that is available for families that are at high risk for cancer.

Women must become more like Amy, another patient who was at high risk for breast and ovarian cancer. Amy carefully obtained her family’s cancer history and realized that she was at high risk for breast and ovarian cancers. She underwent genetic testing, and discovered that she carried the gene for breast and ovarian cancer. Armed with this knowledge, she could make decisions that would significantly reduce her cancer risk, and allow her to lead a long life with her children. Like Amy, all women can change their “luck” and reduce cancer risk by making choices that promote healthy bodies and long lives.