Episode 4 Shownotes - Survivorship and the Most Important Changes You Can Make

Hi, and welcome back! This is episode 4. Almost a month in already! Time flies when you’re busy. Although, sometimes even busy doesn’t make it fly, and that is a bit of how I am experiencing social distancing. Today, I am going to spend a few minutes reviewing first. We have previously gone through allowing negative emotions. We discussed the differences between thoughts and circumstances. Last week we talked about our primitive brains vs. our upper brain, and how the primitive brain is working to keep us safe. I’m wondering - were you aware at all this week of your primitive brain in the background? It is interesting, whatever I write about, I find I think about a lot more that week. This past week, I was really noticing all the times my brain was trying to keep me safe, and how infrequently what it told me was useful. But, I am grateful for that old brain of mine, when I do things like step in front of a moving car in a parking lot, and my primitive brain acts quickly to have to me jump out of the way. It does still serve its purpose, and I am grateful to it! I have thought a lot this week about how I want to structure this podcast. I know I want to release it weekly. I think I am going to designate one week a month as a science/medicine episode, where I share my medical experience instead of my life coaching work. These might look at questions I get on the facebook page or from patients, my thoughts on what you really need to focus on, and so on.

Today, I am going to spend some time in talking about survivorship, what it means, and a few things that I prioritize as most important during my survivorship visits with patients. I have to make one thing clear, though. I am a doctor, but I am not your doctor. All decision making should be with you and your doctor. Nothing I say should override any medical advice your doctor has given you.

Let’s start with how many survivors there are in the US. Survival statistics, taken from Cancer.Net are so enlightening to review. The number of people who have had cancer has gone up greatly over the last 45 years in the United States. In 1971, there were 3 million people with cancer. Today there are more than 15.5 million. Before we jump to thoughts about why there are so many more, let me explain. The answer is 2 fold. The population is living longer as we treat cardiac disease and other medical problems better. Longer life leads to more cancers. Second, more people are surviving cancer as our treatments improve – leading to a significant increase in the number of patients living with cancer in the US. About 67% of today’s cancer survivors were diagnosed 5 or more years ago. About 17% of all cancer survivors were diagnosed 20 or more years ago. Nearly half of survivors are age 70 or older. Most cancer survivors have had common cancers. The top 5 by percents of survivors: 23% - breast cancer, 21% - prostate cancer, 9% - colorectal cancer, 8% - cervical, uterine, or ovarian cancers and 8% - melanoma. Higher survival rates now compared to the 1970’s are multifactorial. They are in part due to major improvements in cancer prevention and treatment. Screening tests may find cancers earlier, including mammograms for breast cancer, PSA check (a blood test) for prostate cancer, Colonoscopy for colorectal cancer, Pap test for cervical cancer. In terms of treatment, many cancers now have targeted drugs that have significantly improved the survival rates. Advances in radiation have lead to reductions in toxicity and improvements in survival there as well. As the numbers of survivors have increased, we have had more and more patients that need us to manage their post cancer side effects. This has lead to formal survivorship programs.

Survivorship is a relatively new concept in cancer care. When we google cancer survivorship, there are at least 2 common meanings. The first is having no signs of cancer after finishing treatment. The second, which I think is more applicable to this discussion is living with, through, and beyond cancer. This means that cancer survivorship starts at diagnosis. It also includes people who receive treatment over a longer time, and includes people with metastatic disease. “Co-survivor” is sometimes used to describe a person who has cared for a loved one with cancer. I love this term, because it is really true that those closest to cancer patients often struggle as well, and I think they need to be taken into account in recovery from cancer. Some cancer support sites describe 3 phases of survivorship. Acute survivorship starts at diagnosis and goes through to the end of initial treatment. During acute survivorship, cancer treatment is the focus. Extended survivorship starts at the end of initial treatment and goes through the months after. The effects of cancer and treatment are the focus. Permanent survivorship is when years have passed since cancer treatment ended. There is less of a chance that the cancer may come back. Long-term effects of cancer and treatment are the focus. For most cancers, 5 years is when the risk of recurrence significantly decreases, and this is when you may be told you are “cured”. This varies from cancer to cancer, though, so your doctor can give you a better idea of when you are really out of the woods.

Not everyone who has had cancer likes the word “survivor.” For instance, they may simply identify more with being “a person who has had cancer.” Or if they are dealing with cancer every day they may describe themselves as “living with cancer.” Therefore, they may not think of themselves as a survivor. Living with a history of cancer looks different for each and every person. But I think it is fair to say that most people feel that life is different after cancer. As I discussed in a previous podcast, for some, cancer has the silver lining of living more in the present, and worrying about the small stuff less, but for many people, this also comes with worrying more about one’s health. At the end of treatment, patients commonly have less frequent contact with their health care team. That fact has different patients thinking different thoughts, and feeling different feelings. Many people feel relief that treatment is over, but some worry MORE once treatment is complete. They have a feeling that as long as they are on active treatment, and they are seeing their doctors weekly, nothing bad can happen. Completing treatment leads to uncertainty about the future, increased anxiety and fear of recurrence. This is common and if you are feeling that, you are definitely not alone. Some people have guilt about surviving, especially if they have lost other family members to cancer. Physical, psychological, sexual or fertility problems, relationship struggles, discrimination at work can all surface in survivorship and need to be attended to. Most cancer centers have teams that can help with the physical sequelae of treatment, and many have resources to help with other issues like finances, fertility, work problems, so reach out to your team if you have specific issues following treatment.

For most of my patients, I do a formal survivorship appointment at 3 months. I find this is a great time to review where I really want patients focusing their energies. Today I will spend some time discussing the things I focus on. What I recommend the most strongly to all of my patients: I recommend that you limit bringing toxins into your body. From my standpoint, the two places that people most commonly bring toxins into their bodies is with cigarettes and alcohol. If you smoke currently, and have had a cancer, I highly recommend you stop smoking. If no one has told you this, your body allowed one cancer to grow, and your immune system let it happen. Smoking is a carcinogen, and increases your risk of another cancer. If your immune system let one cancer start, I think you are really rolling the dice continuing to smoke. Just so we are clear, smoking is the number one cause of preventable death in the US. It causes 1 in 5 deaths – 20% of all deaths in the US per year! It increases your risk of cancer, heart disease, COPD and emphysema, Diabetes, stroke. The CDC tells us the following about smoking. Cigarette smoking is the number one risk factor for lung cancer. In the United States, cigarette smoking is linked to about 80% to 90% of lung cancer deaths. Tobacco smoke is a toxic mix of more than 7,000 chemicals. Many are poisons. At least 70 are known to cause cancer in people or animals. People who smoke cigarettes are 15 to 30 times more likely to get lung cancer or die from lung cancer than people who do not smoke. Even smoking a few cigarettes a day or smoking occasionally increases the risk of lung cancer. The more years a person smokes and the more cigarettes smoked each day, the more risk goes up. Quitting smoking at any age can lower the risk of lung cancer.

Furthermore, cigarette smoking can cause other cancers elsewhere in the body. It causes cancer of the mouth and throat, esophagus, stomach, colon, rectum, liver, pancreas, voicebox (larynx), trachea, bronchus, kidney, bladder, and cervix, and causes acute myeloid leukemia in addition to lung cancer. I am sorry if I sound like I am on a soap box (I can’t help myself, cancer patients smoking makes me want to freak out a little). There are many ways to work on quitting, and medications that can make it easier, so think about it. If you quit, you might even have enough money left over to plan an awesome vacation.

The next place we bring toxins into our bodies is with alcohol. I will admit, I struggle more with this. Before the data that I am about to share came out, I had a glass of wine every night with dinner. The Mayo Clinic and the CDC give the following guidelines regarding alcohol use. They define heavy or high-risk drinking as more than three drinks on any day or more than seven drinks a week for women and for men older than age 65, and more than four drinks on any day or more than 14 drinks a week for men age 65 and younger. I was fine following this recommendation and keeping it to 7 or less, but then data began to come out about the risk of breast cancer with alcohol use. Therese Bevers, medical director of MD Anderson’s Cancer Prevention Center, shares the following on the MD Anderson website: More than 100 studies have looked at the association between alcohol consumption and breast cancer risk in women. These studies, although observational, have consistently found an increased risk of breast cancer associated with alcohol intake. What that means is that the studies weren’t randomized to half of the people drank and half didn’t. They look at breast cancer rates among those who drink, and those who don’t, and draw conclusions. Data suggests that compared to women who don't drink at all, women who have three alcoholic drinks per week have a 15% higher risk of breast cancer. Experts estimate that the risk of breast cancer goes up another 10% for each additional drink women regularly have each day. Those numbers are somewhat confusing – but to give you an idea, the risk of breast cancer across the whole population is about 1 in 8 women. So, a 15% increase approximately takes it from about 1 in 8 to 1 in 7.

While only a few studies have been done on drinking alcohol and the risk of recurrence, a 2009 study found that drinking even a few alcoholic beverages per week (three to four drinks) increased the risk of breast cancer coming back in women who’d been diagnosed with early-stage disease. This data was enough for me to tell my patients that they should limit their alcohol to 5 drinks per week or less, and follow that recommendation myself. I admit, on vacation, I have more, but most of the year, I really try to stay at that level. Just an aside – if this is a struggle, try sparkling water in a wine glass with a twist of lime. I have switched to that most nights, and making it still be fancy – in a nice glass, and so on, has given me part of the experience. I think has tricked my primitive brain into thinking it is still getting a treat and doesn’t need to be squawking away. It isn’t the same, but better than nothing.
The other place I think we have to think about toxins is in what we eat. I think our bodies are not made for lots of processed food. Genetically speaking, our bodies are designed to eat veggies, fruit and protein. That is what we ate for almost 150,000 years. It is only in the much more recent past that we began having highly processed grains as a daily staple in the form of breads, cereal, pasta and so on. It is only the last 50 years that foods came in boxes, with shelf lives of months or years. We all know just from reading the side of a box of food that much of what is in there is chemically processed, significantly altered, preserved, colored, with chemicals added for texture and taste as well. Some of the more scary ones: Sodium nitrate Added to processed meats to stop bacterial growth. In 2015, the World Health Organization (WHO) classified processed meats as Group 1 carcinogens, citing sufficient evidence that they cause cancer in humans, and this appears linked to their nitrate concentration. Potassium bromate in breads, Propyl gallate which is added to fat-containing products, BHA/BHT, a fat preservative, used in foods to extend shelf life, Butane in chicken nuggets to keep them tasting fresh, all have been questionably linked to cancer. Refined vegetable oil: Includes soybean oil, corn oil, safflower oil, canola oil, and peanut oil. High in omega-6 fats, which are thought to cause heart disease and cancer. Sodium benzoate is used as a preservative in salad dressing and carbonated beverages is a known carcinogen. Propyl gallate: Found in meats, popcorn, soup mixes and frozen dinners. Shown to cause cancer in rats and is banned in some countries. Polysorbate 60: A thickener that is used in baked goods. Can cause cancer in laboratory animals. Magnesium sulphate: Used in tofu, and can cause cancer in laboratory animals.

There is a simple solution to all of this. It is beautifully stated by Michael Pollan in his Three Simple Rules for Eating. Eat food. Not too much. Mostly plants. If you eat in moderation, with plants as the bulk of your meal, with or without some meat on the side, you will avoid most of these chemicals. Choosing some organic is helpful if financially available to your household. Our household went to organic meats and milk when we had kids. We also get our veggies in the summer from a local organic farm that we subscribe to for the summer. I have to say, this is a great option on so many fronts – it supports local suppliers, limits your carbon footprint by getting your veggies close to home, encourages you to try things you might not normally eat, and encourages eating more veggies, if for no other reason than just to get them out of the fridge before the next box comes the following week! Many patients ask what I buy, and what I eat. Even before I started life coaching and lost weight, my household cooked most of what we ate, but we did eat bread, pasta and other carbs. We eat organic meat and milk, because I believe the hormones in meats and milk are bad for children especially, but also not good for women in terms of breast cancer. Since losing weight, I follow an intermittent fasting program, as outlined in the book “The Obesity Code” by Dr. Jason Fung – my patients will tell you, I tell them all to read this book if they are struggling with weight, and I will talk more about it in another one of the science based podcasts. I predominately eat veggies, including white and sweet potatoes, squash and other starchy vegetables, brown or haiga rice, protein, some fruit, and some fats to help with satiety. I am a huge fan of putting avocado on just about everything. I have continued to slowly lose weight over 18 months on this program, and feel good about what I am putting in my body. My husband and kids eat the same, but with the addition of pasta and bread if we aren’t having rice or potatoes. One of the things that is key is learning to shop the periphery of the grocery store first, and get 98% of your food from there. I only venture down the other aisles if there is something on the list that we need and I really try not to impulse purchase. Patients ask all the time about canned or jarred stuff. Most of the time, you can get stuff in a can or a jar with less in terms of preservatives and chemicals, and I do use canned beans, jarred tomato sauce, ketchup and so on (I mean, really, can you imagine a house with 4 boys between the ages of 11 and 16 with no ketchup?). I just check the labels and go from there.

So that is about it for today. I will tell you – if I had my choice – I would pick that you spend 100% of your effort on stopping smoking if you are a smoker. If you aren’t a smoker, then I would tell you to do 95% effort on reducing your drinking, especially if you drink more than 1 drink per day as a woman, and 5% of your effort on food, predominately with cutting out most of the processed meats first, since we have a pretty clear idea that nitrates are related to malignancy. If you don’t drink, don’t smoke and have the time and energy to cook your food, then awesome, try to reduce your processed foods. If this causes a huge amount of stress and misery for you, then it is probably NOT worth it, and I would suggest that you just consider limiting processed meats and nonorganic milk. As I am typing, I am feeling guilty, and like I have to tell you something so you are saying to yourself what? This woman is a doctor, has 4 kids, does this podcast AND cooks all of her household’s food from scratch? We have a nanny that does much of our shopping and cooking, now that the kids are bigger and don’t need as much help. SO – I get it if your life just won’t support cooking daily. We are blessed that we have the option to have someone help us. Just want to be real with you, and let you know I understand the struggles of the working moms! When the kids were little, and the nanny was just trying to keep them all alive, it was a lot harder getting a good healthy meal on the table when I got home from the hospital.

So that is all for now – hope you have a great week, and hope this motivates you to make some positive changes in your life that will help to reduce your overall risk!