Cancer Prevention With Lisa Richardson, MD

[MUSIC PLAYING] Hi everyone. I'm Dr. John Whyte, Chief Medical Officer at WebMD. We talk a lot about cancer treatments, and we have had amazing developments in cancer therapies. But we also need to talk about prevention and why we need to spend more time on those preventive strategies. So joining me to discuss the latest data and the latest research is Dr. Lisa Richardson. She's the director of the Division of Cancer Prevention at the CDC. Dr. Richardson, thanks for joining me.

Well thanks for having me Dr. Whyte. I'm glad to be here.

Let's start off with the data. Some say that cancer rates are decreasing, but we have to unpack that data a little more, don't we? Because it's not for all cancers, and it's not for all demographics. So fill us in. What's the latest?

So absolutely. So over the last five years or so, cancer deaths have dropped about 20%. But you're right, it's not equal. It's slower for African Americans, it's slower for some other minority groups. But it really is going down for all, but we have a lot more that we need to do to equalize the improvements in cancer outcomes.

What's happening with colon cancer? There's been some data to show that it's appearing in younger populations where traditionally, we thought of it as a disease of old age. We don't start screening for most people of average risk until their 50s. And then we see these stories of celebrities and others who have it diagnosed and die much earlier. What's the latest there?

So even under the age of 50, colorectal cancer is fairly rare. One of the messages we're trying to get out here at CDC is about on-time screening. So for instance, about less than 30% of 50-year-olds are screened for colorectal cancer. Within 50 to 54, it's about 50%. So really on time.

In the younger age groups, different medical conditions like colitis, Crohn's disease can raise your risk, and family history. One thing that people really need to know is their family history for cancer, especially colorectal cancer because we will definitely start early.

Something you and I have talked about is why don't people have the same perspective on cancer prevention as they do for heart disease or diabetes, right? We all say, we're going to go do cardio to protect our heart. Or if you have a heart attack, then you enroll in cardiac rehab, and you change everything in your kitchen. The same thing for diabetes. You associate lifestyle with diseases.

Yet in cancer, we don't really think about, oh hey, I have to do certain things to prevent cancer. Is it because many people feel it's family history, genetics, or they just don't know? What's the challenge, and how do we change that mindset?

Great question, John. That's one of my communication objectives for the division. Why is it that people don't know that being physically active, eating a balanced diet, not smoking-- and there's a lot of smokers still in this country, about 30 million. But what are those messages, and why aren't we getting the message out about that?

What I find is all the risk factors that you've listed, all the healthy behaviors, work for cancer as well. But I've noticed that when we get with the other conditions where people are talking about chronic disease, it's always at the end of the sentence, and cancer. So I think it's one of those things where we have to raise the level of awareness for cancer in the population and that there are things that you can do.

As a medical oncologist, one of the things I've noticed is that people think cancer is inevitable. So there's really nothing I can do about that and without understanding there's tons that you can do about that. Everything that works for heart disease works for cancer.

We're going to talk about them. But I also want to go back to this idea of genetics and inherited mutations. We think roughly 15% to 20% is due to genetics or inherited mutations. Is that right? And the rest is lifestyle.

I would say a lot of it is-- you're right, most of it is lifestyle, but the genetics are very important. Like I was talking about earlier about colon cancer, if it runs in your family, you have to be screened earlier, right? You need to be aware of the risk factors. A lot of us don't even know our family history so we can start earlier, right?

And so one of the things I encourage people to do is talk with their families. And in November around Thanksgiving, the Health and Human Services Department has a huge push on knowing your family history, which as we talked about earlier, really is the number one genetic test for whether you have a hereditary cancer.

You and I did talk about that when we were wondering whether people should be getting some of these direct to consumer, these over-the-counter tests that people spit in a tube and send in. They don't check for all the mutations. I want to talk about those. But it's to your point where you've mentioned, you know what John? Do a detailed, good family history because that's going to trump anything that an over-the-counter test says. So can you help guide listeners when they're thinking about some of those over-the-counter tests and how they ask a good family history? You have information on your site?

So yes we do. And the main information we have is in our Bring Your Brave campaign, which is for women under 45 to train them and teach them questions to ask, to know your family history, but really when we talk about family history, we're talking about your mother and father, your brothers and sisters, your aunts and uncles, not more broad than that.

Cancer is fairly common as we get older. So a 70-year-old, you'd have to take the whole history to see if that relative is a significant person in your family history. But we just don't take the time to ask our family members. And for whatever reason, cancer is still one of those taboo topics in families. People still keep it to themselves when they get cancer like Chadwick Boseman did. He didn't tell anyone that he had colon cancer. And we found out when he passed away.

What's the role of the over-the-counter tests?

LISA RICHARDSON: The over-the-counter tests are difficult to really get your head around as an oncologist or as any other medical provider. They tell you a lot about the known genetic abnormalities, but most of the things that cause cancer, we have not found those genes yet.

Let's talk about some of those lifestyle changes that people can make. And I want to start with ones they may not be aware of, the role of sleep. And there's been data that shows that shift workers have increased risk of certain cancers. That's not something I knew until recently. We really have learned about the power of restorative sleep. So what's your guidance about how much sleep we need, and how much we need to focus in terms of lifestyle change on the role of sleep as we think about our personal cancer prevention programs?

Yeah, so CDC just-- I think it was last year. We'd have to go back and look it up-- put out recommendations for how long people need to sleep because it has become one of those public health issues. It's sort of a heroic act to stay up all night, right? Remember in med school, we would stay up for days at a time, trying to get through all the material?

But it turns out that it really is sleep, as you said, restores the body. I think it has a link with inflammation. It gets everything back in balance again after you've been up all day. But six to seven, maybe eight. I generally sleep about eight to nine hours a night myself.

You mentioned about exercise, and much of the data has focused on the need for moderate to vigorous exercise. Is that right, in terms of elevating our heart rate? It's not simply walking around the house or walking around the office or-- a lot of folks will say, well they're active as part of their daily life. But the data really points to not just aerobic, but also strength training as well. Is that correct?

Yeah, so to start out with the less than vigorous physical activity is what is the term that we use here at the CDC. Almost any physical activity versus none is good for you. But you're right, walking around my house right now, working at home, I may get, I don't know what, 600 steps in a day? So you really do have to make an effort to get--

600? That's on the low end.

That's almost zero, right? But anyway, my son is the perfect poster child for less than vigorous activity. He went to college. He was overweight. And with just being physically active, walking around campus, actually being intentional about that, he's lost about 50 pounds in the last year and a half. And so he looks like a completely different person. But to your point, there is a dose response curve with physical activity. So the more physically active you are, the more benefit you get in cancer prevention, yes.

Let's talk about the concept of food is medicine. And some people like to use the term super foods. We know there is some association with certain cancers and certain foods. That's probably the biggest struggle for people. What does your office recommend in terms of how we look at diet, in terms of what we consume on a daily basis?

LISA RICHARDSON: Well the usual recommendations, I think-- what does people say? It's what your grandmother told you. Lots of fruits and vegetables, things that are what, orange and red with the more vitamins. Not a lot of red meat because there's carcinogens in that. Mainly, less fat in your diet.

And also fiber to keep your colon moving, right? So that you're not-- and physical activity, obviously, to get off of our tushes and get out there and do something other than sit in front of our computer. But yeah, the recommendation is just to eat a balanced diet. And vitamins are not necessary if you do that.

And coffee's OK. That's what I read.

It is, yes. Coffee is definitely OK. I've had my coffee already. Now I'm on the green tea.

What about the role of stress? People say it's the role of cortisol. It's the impact of hormones, particularly as it relates to cancers that are hormone related, such as breast cancer and prostate cancer. Do we have good data about the role of stress? And therefore, do we need to practice mindfulness and meditation? What are your thoughts on that?

So stress impacts almost every one of our-- all the healthy things that we do. Stress is not good for any of us. So you're right, mindfulness is really one of the things that is in vogue right now. Should have probably always been in vogue. But it really just to get your heart rate down, to get yourself in another place mentally and physically because stress can impact almost every single thing in your life and your health.

And what about screening? There seems to be a lot of confusion about screening at times, especially as it relates to mammography, as it relates to colorectal screening. We use terms that patients don't understand. So where can they go for good guidance? It's always good to talk to their physician obviously. But many people are going to urgent cares and others to get care. And they need to be informed as well about the appropriate screening recommendations. So what's your counsel on that?

LISA RICHARDSON: So if you're looking for information that's written well and simply, CDC's website cdc.gov/cancer is a very good place to go. But to answer your question about confusion, when I'm talking to patients about screening, I usually go to the place where we can agree on who needs to be screened.

For women, it's 50 to start. For colon cancer, it's 50 to start. And the other tests also have other ages. Then when you're speaking with someone, you break down what their personal risk is and what their personal risk is as far as their mental-- I can't think-- people have very stressed out about screening. We're going to get cancer. So then to see is-- what do we call it-- the well patient situation where we really know that you're OK, but sometimes people's decisions have to be based on their comfort level for not getting something versus getting something. So it requires a conversation with the patient about what their personal risk is and what their values are in their health care.

Something our listeners may not be aware of is the role of vaccination. Here, we're talking about cancer. And there is a role for vaccines, specifically HPV and hep-B, correct? And CDC has put out guidance in terms of recommendations for vaccination in both of those categories. Is that correct?

Absolutely. It's the ACIP recommendations. They meet twice a year. And you're absolutely correct. The initial message on HPV was that it is a sexually transmitted disease where we maybe got into some difficulty with those messages. But now, we've switched it to it's a cancer vaccine. And it really is a cancer vaccine. It's almost 100% effective against cervical cancer. And the data coming out now around the other HPV-related cancers that it is helpful in those as well.

What does the future of cancer prevention look like?

I tell you, I think for me, the future of cancer prevention looks like how can we more deliberately and clearly message what is going to prevent cancer? I think within the realm of medications, there's more and more research on that side. And genomics. Genomics are quite powerful with the family history to try to figure out how to help people live healthier.

And in the long run, I see the main thing in cancer control is the number of cancer survivors that we have. We really have to double down on healthy behavior messages for that population because the thing that got you the cancer in the first place is the thing that's going to get the cancer back or a new cancer if we can't help people change their behaviors.

And to your point of making it more personalized, so looking at your personal risk based on family history, based on lifestyle, based on weight, and other factors as well. Well Dr. Richardson, I want to thank you for taking time today to help dispel some of those myths that people have about cancer, specifically as it relates to prevention. And the reality is, as you point out, most cancers are lifestyle related. And we can make those changes. Not that they're easy, but they're important to do and to make changes over time to take control of one's risk. So thank you.

Thank you.