Cancer prevention - 5 easy steps. - DoctorPodcasts || Cykiert Files

Cancer is the second leading cause of death in the USA after heart disease, with over 600,000 deaths annually according to the latest data from the CDC. So cancer prevention is obviously very critical and important. Hi, I'm Doctor Robert Sicard hosting episode 110 of the Doctor podcast, Sicard File Show. And we're going to discuss today what steps you can take to prevent cancer, which is very important. And today we're thrilled to welcome Doctor Teresa Beavers to the show. She's a leading expert in cancer prevention and early detection.

She is a professor in the Department of Clinical Cancer Prevention and the medical director of the Cancer Prevention Center at the University of Texas MD Anderson Cancer Center in Houston. It's the top cancer hospital in the USA and worldwide. She's board certified in family medicine. Doctor Beavers has dedicated over 25 years to advancing cancer prevention, notably collaborating on the groundbreaking Breast Cancer Prevention Trial, which we'll talk about some more later. As a passionate advocate for personalized screening and risk reduction, she works with multidisciplinary teams to develop evidence based cancer screening guidelines and empower communities with practical prevention strategies.

Her expertise spans lifestyle interventions, which are very important and which we'll talk about in detail, innovative screening methods and addressing overlooked risk factors like alcohol, which is very important, making her the perfect guest to guide us through today's discussion on reducing cancer risk. So Doctor Beavers, thanks for taking the time to share your expertise and knowledge and experience with us today. We really appreciate it. Well, Doctor Sacred, thank you for having me. I'm very excited to be here.

As you said, I'm passionate about this topic. I always like to get information out. Information empowers. Right, very important. So I want to start with the alcohol cancer connection discussion. About six months ago, the USA Surgeon General advisory highlighted that alcohol is a significant cancer risk factor and linked it to about 75,000 new cancer cases annually in the USA, which is a huge number. Can you explain why alcohol is often overlooked or not discussed as a cancer risk factors and what the public now needs to know about this cancer alcohol connection?

Sure. Well, alcohol is part of our society. It's a part of socialization. We often will meet together for a happy hour or something like that and don't think much about it. But a lot of that has to do with the fact that we have not educated well the public. We also haven't educated well physicians. And part of that comes about that the studies that have come out on alcohol, which have actually come out over several decades linking alcohol and cancer, they're relatively small and they don't garner a lot of public attention nor clinician attention.

It's only when the data is all looked at together that you start to see the power of alcohol. And in fact, when it's all put together, we see that alcohol is the cause, is the third most preventable cause of cancer behind tobacco and obesity. So it it took this surgeon general's report, kind of putting it all together and showing the magnitude of all these smaller studies to now capture attention. Right. And that's, that's important. But many patients that I have, I'm an ophthalmologist, but we talk about other risk factors and in medicine as well are not aware of that connection.

So the Surgeon General's report is very important, but it was only in the news for a few weeks and then it kind of fizzled out. So I think you're right, education of people as well as physicians and is important. Can you tell us which cancers are most strongly associated with alcohol consumption and how does the risk increase with the amount consumed? Sure. So I kind of like to go down the body and it starts with the oral cancers, mouth cancers, cancers of the throat or pharynx, cancers of the larynx or voice box, cancers of the esophagus.

We also see cancers of the liver. Most of those are not real surprising cancers to be linked to alcohol, but a couple of cancers that are rather surprising are that it increases the risk of colorectal cancer, which we have been seeing on the increase and on the increase in younger people possibly due to lifestyle such as alcohol intake. It also increases the risk of breast cancer and in fact that has that's an area that has a very significant impact is on the risk of breast cancer developing. That's interesting.

So basically when you drink the alcohol, everywhere the alcohol touches from your mouth down to your colon, but just the contact seems to increase the risk of cancer. It's somehow damaging those cells and and causing the cancer to rise. But how do you explain the connection to breast cancer? Because the alcohol doesn't pass by there, obviously. Yeah. Do we know? We don't know specifically, but we think it has effect on the hormones in the body, the hormone levels which certainly can affect the risk of breast cancer.

So that would be in addition to other ways that alcohol can cause cancer. It's a known carcinogen. It's by product as acetaldehyde is a known carcinogen, so there are several mechanisms by which it could increase the risk of breast cancer, even though it doesn't quote come in contact with the breast. Interesting, and that might account for liver cancer as well. Well, liver is how the alcohol is processed out of the body. So, you know, some substances are cleared through the kidneys, some through the liver.

Alcohol happens to be cleared through the liver, so it touches the liver if you want to say it that way. Now you mentioned the acetaldehyde, that's the metabolic breakdown product of of alcohol, right? I wasn't aware that's actually a carcinogen. So that's been proven to cause cancer. That is a known carcinogen and many people don't realize the link between acetaldehyde and alcohol. So when you drink alcohol, the more you consume, the more acetaldehyde your body is producing and bathing all your tissues and organs with that carcinogen, which increases the risk of cancer.

Correct, correct. And and that's an interesting way to say it is bathing your tissues. Another way that alcohol increases the risk is in addition to being a carcinogen itself, it is a solvent for carcinogens, which is why it maybe is synergistic with tobacco. So people will drink and smoke at the same time. Tobacco's a carcinogen. Alcohol is a carcinogen but also a solvent. So now you've got the solvent helping the tobacco to be better absorbed and hazardous to the tissues. Wow, so happy hour is really sad hour.

It is. It is, yeah. Now you've noted that stopping alcohol can reduce cancer risk, which makes sense based on what we've just discussed. Over time that occurs, but it it may take years. So what practical steps can people take to cut back or quit? And how impactful is, is moderate drinking versus complete abstinence? And the question is, is there a safe amount of alcohol that you can drink? You know, 5-10 years ago they were saying, oh, you know, if you just have a glass or two of wine a day, that's OK.

But recently that's been changed and it's, it's closer to 0 now. I think 0 alcohol seems to be optimal. Yeah, it is certainly the old adage of two drinks for men and one drink for women per day. And it has been challenged. Yeah. I think we need to make the public more aware of the risk so that before they take a drink, they pause and think about it. Do I really need to have this drink? They need to realize that, you know, less is better and none is best for cancer risk. There is no safe level of alcohol for cancer.

Safe level is 0 Now. The surgeon general in his report a few months ago called for warning labels on alcohol beverages similar to the warning labels on on cigarettes that they cause cancer. Do you think that will change public behavior and what other strategies could complement that effort to to raise awareness? Sure. I'm not sure. I'm not sure, especially since the surgeon General, although he has pointed out the link between alcohol and cancer, he said if you choose to drink, it's 2 drinks for men and one drink for women per day.

So it's very different than the old tobacco, no safe level of tobacco. You've got to quit. Or we knew that tobacco was an addictive substance. And for most people, alcohol is a social substance. It's not addictive. And so, you know, one drink, they don't have to have 10, you know, But we know that the more they drink, the greater the risk is. In fact, that risk is linear. Each drink they drink further increases that risk. So we want the public to be made aware. We need to be asking patients about their cancer or their alcohol intake and warning them that the link between cancer need to be doing more podcasts like this and getting more information out in the public.

Do I actually think that we will get to the point of warning labels? I'm not sure. It would take an act of Congress literally to implement a warning label. They would have to go up against the very well funded, very powerful beverage industry. And we saw the fights that went on with the tobacco industry and I, I'm not sure if they're willing to take that on at this point in time. Seems like RFK Junior who's talking about chronic disease and and things like that, would want the FDA to require that somehow.

But like you said, it might require an act of Congress to. But I think he should be a proponent for that label or at least bring it up frequently in his news conferences. He doesn't discuss alcohol too much. No, no. And you know, a lot of people don't want that to be discussed because they still want to have their happy hour or their glass of wine with dinner. They they they feel that they're it take in consuming alcohol in moderation or low amounts. And why should I be concerned? I'm not addicted to it and so but any alcohol is a risk.

So 0 is best. That's good. Let's talk about tobacco. We've known tobacco is a carcinogen. It causes cancer. It's a well known risk factor and its impact remains staggering. It accounts for billions of dollars in healthcare spending. Can you take us through the major cancers linked to tobacco use and why it's so dangerous? Yeah. So interestingly, the first few are very similar to the ones on alcohol. It's your oral cancers, your pharyngeal or or throat, your voice box or larynx and the esophageal.

Then it kind of departs from there. The other risks are for lung cancer, for pancreatic cancer and for cervical cancer. So you know, tobacco is the number one cause of cancer. It's also the number one cause of cancer deaths. So a preventable cancer deaths. So we've we've talked about two big causes of preventable cancer deaths and so we need to be paying attention to these. Right when I was a medical intern prior to doing ophthalmology residency and training, the vast majority of my patients in the hospital as a medical intern were there due to alcohol and tobacco related medical complications.

Absolutely. And I think that. Yeah, I, I just mentioned cancer risk. It increases the risk for cardiovascular risk, you know, heart disease and stroke, lung disease. So yeah, the risks are staggering. Right. And I didn't realize you just mentioned that the alcohol actually allows the carcinogens and tobacco to get into the target tissues even better. Yeah, yeah, that's that's a kind of surprising and it definitely makes you want to separate out. If you're going to smoke and drink, don't do them together.

Right now for former smokers the the risk of lung cancer decreases over time. How long does it take for the risk to approach that of a non-smoker? And what can ex smokers do to further protect themselves? Yeah. So for many cancers, the risk can be cut in half by about five years of non-smoking. Lung cancer, it's a little bit longer, it's about 10 years to reduce the risk by 1/2. But what can former smokers do? They can talk to the doctor to see if they are eligible for lung cancer screening. So if they have a 20 pack year smoking history and pack years are the number of packs smoked per day times the number of years smoked.

So one pack per day for 20 years is a 20 pack year smoking history, but 2 packs a day for 10 years is a 20 pack year smoking history. If they have quit within the past 15 years and they're between the ages of 50 and 8078 to 80, depending on what their coverage for insurance is, Medicare or private payer, they may be eligible for lung cancer screening. Lung cancer screening can detect lung cancers at an earlier stage and when it's more treatable, and it can reduce the risk of dying from lung cancer by 20%.

Wow, it's a lot. It's a lot. Can you tell us what the lung cancer screening process is? What specific test is that? It is a low dose CT scan and the low dose refers to the amount of radiation that is used. We know that radiation exposure is cumulative in the body and we certainly don't want to be significantly adding to that risk by screening with a traditional three phase scan, et cetera. So they do a low dose non contrasted CT scan. Probably takes about 10 minutes to do the CT scan. They then read it and will interpret it as to whether normal or benign.

Repeat in a year or needs short term follow up, say three or six months or needs other intervention. It also may have serendipitous findings such as something going on elsewhere because it'll pick up maybe the top of the abdomen. So they may see a mass in the abdomen that they say, you know, that ought to be checked out. Make sure it's benign, right? And the dose again in this is, is very low. Because. Some of the patients I've spoken to about this, who I know smoke, I mentioned this to them, they're concerned about the the radiation that they're exposed to, not.

More concerned about their smoking. Right, right. So, you know, I explained that to them that this is low dose and it's, it's very important to do. Yeah. Now what about smokeless tobacco? There are people who are putting tobacco in inside their mouth, next to their gums, between their teeth. And now there's a lot of people vaping. I see them in the street all the time. What are the cancer risks from vaping and smokeless tobacco? Well, the risk from smokeless tobacco have long been known. We know it increases the risk of cancer at the oral cavity and can be quite deforming in the management of it.

As far as vaping, we are still trying to better understand the risk, but at this time we do not consider it a safe alternative to smoking. Quitting smoking is the best. Right. So both of those should be avoided. There's a lot of younger people doing vaping. Yes, yes. And they and I feel like they're, they're being safe. I actually had a patient who I saw every year who was a heavy smoker and every year I would talk to her about her smoking and to quit smoking. And one year I walk into the exam room and she's so excited.

Doctor Beavers, you're going to be so excited. I've quit smoking and I'm like, oh, that's wonderful news and and just really praise her. And then all of a sudden she starts talking about her vaping and I'm like, no, doesn't count. It's not a good alternative. It's like switching from vodka to gin. Yeah, yeah. And, and we don't know that it's a good step down as a way to quit smoking. So yeah. Now, what about lifestyle that seems to be becoming more and more important and emphasized, and you emphasize lifestyle changes as a cornerstone of cancer prevention.

What are the most impactful dietary choices that people can make to lower their cancer risk? We'll we'll start with diet and then go on to the other things. OK, so diet, you want a diet that is largely plant based? I don't. I'm not telling patients that they need to be vegetarian or vegan. I'm saying that 2/3 of your plate should be vegetables, fruits, whole grains, and beans. It should also be very colorful in those vegetables and fruits because that's going to give you a wide variety of nutrients.

Only 1/3 of the plate should be animal based and it should be lean animal protein such as chicken or fish, or it could be plant protein. You also want a diet that limits the sugar especially to help maintain a healthy body weight. Obesity being the number 2 cause preventable cause of cancer. So wait, we've got number one is smoking #2 is obesity #3 is alcohol something all of us can do something about? We've set our minds to it. Yeah, yeah, of course, avoid alcohol like we've talked about. Those are some of the big recommendations I make.

I notice you didn't include beef anywhere in there, so should you avoid cows and sheep and other? Tell people to limit their red meat and processed meats. So that's, that's a real good point. Yeah. Processed meats also increase the risk. Have been shown to increase the risk of cancer. Right. They contain various chemicals that process meats that may increase the risk of cancer. Yeah. Well, that's that's good to know. Now you spoke about obesity. Why is obesity a risk factor for multiple different cancers?

Do we know why that is? Sure. You know, we believe that it sets up an inflammatory environment and much of cancer, the basis of it is inflammation. So being overweight or obese just creates this inflammatory environment baseline in your body, let alone where you may contribute other risks such as alcohol or tobacco.

It also increases the peripheral conversion of estrogen, so there's higher estrogens. We know women who are overweight or obese have a higher incidence of breast cancer, especially in the post menopausal period. So that's another potential mechanism. Insulin growth factor may be a variable as we better understand some of the pathways of cancer development that may be a part of it. So multiple factors there. So now on that same topic or similar topic, how and why does exercise reduce the risk of many different cancers?

Is it just because it's reducing the risk of obesity or the incidence of obesity? Or are there other factors that exercise contributes to prevention of cancer? Well, that is a big factor is that it does help with maintaining a healthy body weight, but it also appears to help regulate hormones, which as I just discussed are a variable in cancer development. For certain cancers, including breast, it also helps to promote digestion and so may decrease the build up of toxins in the body that would put a person at risk for cancer.

So we still need to better understand it, but the data is increasingly coming out about the the benefits of exercise outside of cardiovascular benefits and overall feelings of Wellness. It it's helped, it reduces the risk of cancer. Yeah, seems to reduce the the incidence of everything bad. Exactly, heart. Disease. Dementia, just about anything you can think of it, reduce it and. Diabetes. Cancer. Yeah. Right, I've spoken to many doctors on this interview and various specialties and exercise seems to help with everything, including the psychiatrist tell me it's it's the best drug for treating.

It it is, Yeah. I saw a patient today who was in her 70s, not on any prescription medications, quite spry. I asked her about her exercise regimen and she tells me she does elliptical 45 minutes three times a week with treadmill 15 minutes as a slow down after that. And she said I have found that the best medicine is exercise. And I went, you were so right. That's what's going to keep you healthy. Right, somebody should figure out how to put exercise in a pill that. Yeah, it, you know, I just it it when things stop exercising, you know, you injure yourself or you're used to going outside and running and you encounter big snowstorms or ice storms or something and you stop exercising.

It's so easy to stop. I wish we could figure out something that would had to pull toast back into getting started. Sometimes once people stop they they become couch potatoes again and don't restart. Maybe they should figure out a a tax benefit for your BMI if you pay. If you have a high BMI, you pay higher taxes. You know, there's a lot of employers that are giving benefits to their employees if they do certain things like do exercise, they, they walk 10,000 steps a day for at least X period of time, you know, and then they checked off that box or that they can do a number of things.

Employers are great motivators. That's what can redo. Allow the employer to reduce the employee's insurance rate as compared to somebody who is continuing to smoke or drink or remain overweight. That's a great idea. So you we see you lost 5 lbs this month, we're going to give you a 5% raise. Wouldn't that be great? That that would get people to exercise. Oh, absolutely. Now, what about cancers that are detected late, like colon, lung and pancreatic cancers? I have patients who tell me they were diagnosed and you know, it's too late.

There is not much that can be done. The cancers have spread or metastasized. What's the best way to get early detection for those three or or any other cancers? We talked about lung. What about colon and pancreatic cancer, which seemed to have a problem with late detection? Yeah, so I think that part of the problem with colon and late detection is twofold. 1 is that people aren't getting the recommended screenings, which now is to start at age 45 instead of 50. Also, we're seeing or you. Mean for colonoscopy.

Preferably A colonoscopy. Colonoscopy is not only early detection as like the non invasive test the Cologuard or other stool test can be, but it's also prevention. If we remove a polyp that was precancerous and destined to become a colon cancer, that doctor just prevented you from getting colon cancer. So but we're also seeing even earlier onset colon cancer earlier than age 45. And and that may well have to do with lifestyle. A lot of what we've talked about being overweight, sedentary lifestyle, binge drinking when people were younger set them up to get colon cancer earlier.

They should for colon cancer and pancreatic cancer. Pay attention to any type of symptoms. Abdominal pain for pancreatic cancer, unexplained weight loss, loss of appetite. Feeling full early blood in the stool would be a symptom of colon cancer, as would a change in the stool caliber. In other words, it's becoming thinner. Something like that, but for colon cancer. Get your colon cancer screening, preferably a colonoscopy. Now, having said that, there is some exciting news on the horizon. I think it still needs more investigation to make it something that becomes part of standard guideline recommendations.

But that's these multi cancer early detection tests which are simply a blood test and may test up to 40 different cancers. And so you may get a test result back that says oh you're high for pancreatic cancer. In which case we would then pursue a work up to see if there is something going on in the pancreas, not always as early a detection with those in said tests as we would like to see and a number of false positives. So that's why I said it. It still needs a little bit more refinement before I think it becomes a part of national recommendations.

But but there's exciting news on the horizon. Think exciting things are happening. Yeah, I, I think there are one or two companies that have that test already the blood. Yeah, yeah. FDA approved, commercially available, not covered by insurance as a rule. So it's self pay. Often the work up of the abnormality will be covered by insurance typically. Right now, what about pancreatic cancer? That seems to be the one where the symptoms arise when it's too late too. Late. Should people get MRI scans routinely?

Maybe once every year or two when they're 50? Because an MRI could potentially pick that up, and MRI has no radiation, and if you don't use contrast there's essentially near 0 risk. Well, there actually isn't near 0 risk in that Mris produce a significant amount of false positives with a very small cancer yield. And so you start getting all these little findings that turn out to be nothing, but you have to do other scans, maybe even ACT scan, which does have radiation and I need to do a follow up of it.

And a lot of anxiety is generated. So there are risks associated with it. So we don't recommend pancreatic cancer screening for everyone. MD Anderson does recommend pancreatic cancer screening for certain individuals, largely individuals who have a genetic predisposition or a strong family history of pancreatic cancer, then we, yes, may recommend AMRI. But for individuals otherwise with a distant family member, yeah. You heard about Uncle Bob. He got pancreatic cancer and he was gone in three months.

That that's devastating news. But the impact on that individual's cancer risk, risk of pancreatic cancer is actually fairly small and the risk of false positives is so much greater. Right. That's, that's important to know. There are a lot of these health centers popping up which do annual Mris and all those sorts of screening. You think that's overdone? I do, I do, we do whole body Mris for very selected individuals, very high risk individuals. These individuals tend to carry a 70 to 90% lifetime risk of developing at least one cancer.

And I have one who's actually had six cancers. So, so their yield of cancer being identified is much, much higher and it counterbalances those false positives. But we do still find a lot of false positives and it creates a lot of angst. I want to discuss prostate cancer. There's a lot of controversy about whether to do the PSA blood test or not and at what age it it should be done. I know they were used to do a lot of them. Then the recommendation was, well, don't do it. And apparently from what I've read recently, the incidence of prostate cancer has gone up because of that.

And there's also a lot of probably unnecessary biopsies. So what? What's the current recommendation for who should have the PSA blood test and at what age? So the National Comprehensive Cancer Network, which is an alliance of the comprehensive Cancer Centers in the United States, the they recommend that individuals at the age of 40, no later than 45, talk to their doctor about prostate cancer screening and discuss what are the benefits and what are the risk? What might I be facing? You know, if it was positive and, and do I want to do that?

If they desire to pursue screening, they get a baseline PSA and that level will dictate if they need APSA in three years or in a year or maybe they need to move forward with additional evaluation. So it's it's really more shared decision making and then risk stratification based on family history and the PSA level. There's no set answer that's good for everyone. It has to be customized. Yeah, yeah, it, it, it really needs and, and many men, which I will say men are not, don't tend to be health seekers as much as women.

It's often the woman dragging the man in and saying he needs prostate screening. So we'll have a discussion and he squirms the whole time and she goes, he's going to get it. I go, do you want it? He goes. I see you've been through this a few times. Yeah, yeah. So but it it is shared decision making and risk stratification. What is the family history? What is their PSA level and we we don't necessarily need to do annual Psas on all men and. But the discussion should start somewhere between age 40 to 45.

Yeah, yeah, OK. Good to know. Now I want to talk about breast cancer, which you're a super specialist in. Tell us about breast cancer screening guidelines. I I see they change every few years, with some people recommending mammograms at age 45. Others believe it should start at age 40. What is the correct age to start the screening and does it depend on other factors? Sure, sure. So there there has been a lot of movement across the age range over the past decade and we saw it go up to age 50 and then ACE American Cancer Society said age 45, but Oh yeah, they can start at age 40.

NCCN and MD Anderson have remained at annual beginning at 40, which the US Preventive Services Task Force has now dropped back down to saying women should start at age 40. We do see breast cancers in the 40s it they tend to be more aggressive breast cancers. It, it is something again, that I think a shared decision making, any cancer screening should be shared decision making. Understand what door you're opening. And yeah, it's all nice and cozy if it comes back negative, but what if it comes back positive?

I didn't realize I was biting this off and I was going to end up having to do this and this. And, you know, so be sure to understand the benefits of screening, the risk of screening, especially false positives, and make an informed decision of what's best for you. We the data is certainly there that fewer women die of breast cancer by beginning screening at age 40. And MD Anderson, as is the NCCN is about fewer women dying from the disease. That's why we recommend annual at 40. We're glad the task force has moved back down to 40, although they remain at biennial.

American Cancer Society says start at 45, but they always have had the provision that a woman may elect to start annual at age 40. So there's some variation there. Yeah, and that makes it very confusing. It it was nice in the old days when it was a succinct statement. Everybody said the same thing. Right. So how much radiation is there in a mammogram? And that's what people's concern is, is that they're getting radiation for no reason possibly, especially if it's negative. How would you compare the amount of radiation in a mammogram to let's say the lung cancer low dose radiation CT scan?

It is something they are worried about, but it is a risk they should not worry about. It is the least ionizing radiation procedure of all ionizing radiation procedures that are done. It's even lower than the low dose CT scan for lung cancer screening. OK, to help my patients get kind of a handle on what the scale I'm talking about, I tell them it's about equivalent to a round trip flight from Houston to Paris and back. And I, you know, if as you go up closer to the sun, you get ionizing radiation, I tell them if you are willing to go to Paris this year, you should be willing to get a mammogram this year.

Wow, that's a great analogy and I'm sure they sign up right away after hearing that. Yeah, it's kind of hard to argue with. It's very low dose. So that's, that's good to know. Now I know that sometimes after a mammogram, if there's a question about it, they'll do an MRI scan or ultrasound. Are those helpful in differentiating cancers from non cancers? And if they are, why not just do MRI scans again which don't have any radiation at all? Sure, sure. So when we get an abnormal screening mammogram, traditionally the radiologist will ask for additional mammogram views to further analyze it at a closer level, bring that area into focus better by magnifying it and may recommend an ultrasound depending on whether it's a mass or calcifications, etcetera.

We don't use Mris a whole lot in the diagnostic evaluation of abnormal mammograms. If the mammograms are abnormal and we don't see anything on ultrasound and the radiologist remains concerned, we can just biopsy the lesion by mammogram guidance. MRI really wouldn't change our opinion. The value of MRI is more in breast cancer screening in early detection, so not so much the diagnosis. We do use MRI for diagnosis but it's it most women will go through the diagnostic evaluation process and not get an MRI.

Most. What about tell us about the role of tamoxifen? Explain that drug and and how it's used and what its purposes are. Tamoxifen is a hormonal agent. It's technically a selective estrogen receptor modulator or SERM, and that means it modulates the estrogen receptor selectively. In some tissues it is acting on the estrogen receptors like an estrogen and in other tissues it's acting like an anti estrogen. So it has varying effects in different tissues. On the breast, we actually see that it can reduce a woman's risk of developing breast cancer if she's at increased risk by 1/2 and for certain women with high risk breast lesions by as much as 75%.

So very significant risk reduction. There are risk associated with tamoxifen that are greater for women over 50. Under 50, we really don't see significant risk, but we see the benefits. But over 50, we do see some other risk. There is a risk of uterine cancer and common question of the patient will say is, well, why would I take a pill to prevent breast cancer only to get uterine cancer. And I like to tell them it's a numbers game. Breast cancer occurs much more frequently and we can decrease that risk by 1/2, which is cutting out a whole lot of breast cancers.

However, uterine cancer is infrequently occurring, and the increase in uterine cancer is very incremental. It's only about 3 more cases per 1000 women, so it's very tiny, whereas we may be preventing 100 or so more breast cancers in a population of women taking tamoxifen. So the benefits greatly outweigh the risks. It it for many women, if they are at increased risk, there are risks associated with other hormonal drugs such as risk of blood clots. If a woman was told she shouldn't take birth control pills, she's had a previous blood clot, she shouldn't take tamoxifen and there's an increased risk of cataracts, which we also see with estrogen.

So it it's has risk, probably those are all really rare. More notable is some of the side effects and women will get on the Internet. I hate doctor Google, but they'll get on the Internet and start reading about the side effects and they will hear horror stories is what they tell me. And yet I tell women, you know, 80% of the women in the clinical trial didn't experience side effects. Many women when I put them on tamoxifen and see them back for follow up, I'll go, how are you doing? And they'll go can't even tell I'm taking it.

So there are other medications that since have been studied and shown to reduce breast cancer risk. A similar drug, also a SERM, is Raloxifene, which interestingly was first FDA approved as an osteoporosis prevention and treatment medication and later found to have the breast cancer benefits. And then there's some aromatase inhibitors, which work on the enzyme aromasin to decrease the conversion of androgens to estrogens and thus reduce breast cancer risk. Those have also been studied in smaller trials.

So we have a number of agents for women who are at increased risk of developing breast cancer that we can talk to them about, in addition to lifestyle changes that we know will reduce the risk of breast cancer. And so those women are high risk or if they're broncogene positive or if they have a strong family history of breast cancer. Typically it's women with a strong family history of breast cancer or women with high risk breast lesions, or possibly one whose risk has been determined to be increased by a constellation of variables that when put into a computerized model, it spits out a number that says she's at increased risk.

We don't have as much data on the use of medications like tamoxifen in women with genetic predispositions, very tiny studies. I mean, we're, we're talking a handful of patients. So we, we, we will talk to them about it. But we still more for women with BRCA one or two, we're going to talk to them about prophylactic mastectomies once they're through with breastfeeding. Now you've been involved in some trials, clinical trials with tamoxifen gel for for breast cancer prevention. Can you tell us about that?

Yeah. So I talked to you about tamoxifen has a significant benefit reducing the risk of developing breast cancer, but it does have side effects and a small risk in other organs. So the idea came about, well, what about if we put tamoxifen on the target organ, IE the breast so that they get the benefit, but we don't have the systemic level absorption and may not see the same side effects. So that trial, it has been ongoing and is in final analysis and manuscript preparation. So it hasn't been published.

I, I haven't seen the final data. It'll be interesting to see. We were looking to see changes in mammographic density with the idea being that if the density of the breast tissue decreased from one year to the next while using the tamoxifen gel that it was taking an effect in the breast tissue. And then we would do a symptom assessment scores so we could determine what their quality of life was on the topical gel, right? So it's absorbed through the skin into the breast tissue. It is, it is so increasingly, you know, it's, it's like can we give a more targeted agent to that organ, it get the benefits, but we don't have systemic effect.

The cataract issue. I've seen hundreds of women over the years were on tamoxifen. I haven't really seen the the cataract side effect. I know it's reported in the literature and in the package insert, but I think it may be overstated. Although I do tell women to have an annual check. If absolutely. Absolutely. Just to be on the safe side now, what about women who feel anxious about screenings or are confused by the conflicting guidelines? What advice do you offer to them to help them navigate the cancer risk and screening decisions?

A lot of women get anxious because they get different opinions and they don't know what to do. Yeah. So I think you needed need to go to your trusted provider and you need to have a good and frank discussion. It should start off with doctor, what is my cancer risk? And there's a number of ways the doctor can determine if you are at increased risk. And I like to drop the patient into one of three buckets of risk. Are they at average risk? In which case I'm going to recommend healthy lifestyle and screening mammogram beginning at age 40.

And that healthy lifestyle is maintain a healthy body weight, exercise, avoid alcohol, things we've talked about already. The next bucket is women who are at increased risk. Those women, I will talk to them about tamoxifen or Raloxifene or one of the aromatase inhibitors depending on our pre or postmenopausal. I will also talk to them about high risk screening with breast MRI, which we do on an alternating 6 month schedule with the mammo. We don't eliminate mammos ever. It's the gold standard. It's the only one that is only test that has been studied for breast cancer screening in a randomized controlled trial and shown to reduce breast cancer mortality.

All the others don't have that level of data, only say yes we find breast cancers but does their detection really make a difference? We still need to understand. So that's what I do to the increased risk healthy lifestyle. Talk to them about preventive medications and I'll talk to them about high risk screening with breast MRI. Then I have that bucket of high risk and these are typically my gene mutation carriers. Another group is women who received thoracic therapeutic radiation treatment radiation between the ages of 10 and 30.

So they had say Hodgkin's lymphoma and got radiation to the chest area and the breast were encompassed in that radiation. They are at high risk, so we will talk to them as well. And then certain high risk breast lesions may also drop into that bucket. So we talked to them about healthy lifestyle in certain cases. We talked to them about preventive medications. This is when we may bring out the prophylactic mastectomies especially for the gene carriers and again for those women who retain their breasts.

Talk about high risk screening with MRI alternative with mammo. So in such a way we are giving those patients we're we're defining what their risk is and we're giving them a plan. We've got a plan that we can follow and and address your risk and catch it early if we don't prevent it. Sounds like the way to go if you can stratify the risks for different patients and you can help them out better. Now. You mentioned earlier about Doctor Google. There's a new one to replace that. It's Doctor AI. Do you find a lot of patients using AI like Grok or GPT to figure out what to do or what to do to prevent cancer or treat cancer?

I have only had one patient come in so far with that, I expect to see it increase, but I've only had one so far. Typically it's, it's the Internet that they've gone to, to just do kind of surfing searches and, and not being real focused on AI, right? I think we're going to see more of that 'cause I'm, I'm seeing it in my practice. I'm sure people looking up diagnosis and coming in telling me how they want to be treated based on AI and often it's actually accurate. I don't want to put it. It often can be, and if that sells the patient on the treatment, it makes your job easier.

Of course, now we talked a lot about lifestyle changes and and recommendations. I find that doesn't work that well, even when I tell patients certain things. What do you do with the patient who just won't stop drinking? Won't stop smoking? Is 10 lbs heavier every year? How do you deal with that? Well, you know, there are certain things that I am going to do, like if they're continuing to smoke and they meet the criteria for lung cancer screening, I'm not going to withhold lung cancer screening from them just because they haven't quit, OK?

So I still will look for opportunities to reduce the risk in other ways, but I think it is critically important for clinicians to be asking their patients about tobacco, alcohol, body weight and addressing those risks at every well exam annually, if not more frequently. And, you know, I go back to my patient who was so excited she had quit, although she did end up vaping. Clearly, after years and years of me saying it, she, she had heard what I'd said and she knew what she needed to do. She just didn't get it quite right.

So we, we're now we're working on the next part, but it, it's, I think the doctors are the best source of giving information to our patients and carry the greatest weight. So we should be using that to help patients at least implant that seed in their mind that I need to make a change. You know, I think it's important that doctors and other specialties also talk to patients about that. It's usually the primary care physician, internist, family physician, but I've for years I've been asking patients about tobacco because it increases the risk of macular degeneration and cataracts and things like that.

But I think it's important for me to talk about alcohol as well and also discuss weight and exercise to hear it from 5-10 different doctors. Eventually ago. I guess there's something to it. Right, especially when they're ophthalmologists tells them to go out and exercise. I think we can also see if they feel a resource would help them. Can I refer you to a tobacco cessation program? Would you be willing to go? And, you know, there wasn't a lot of good things about COVID, but if one of the good things about COVID was that we learned how to do some visits virtually.

And there are a lot of visits such as tobacco cessation visits that are ideal virtually. And whereas patients wouldn't always make it in for their weekly visit in person, doing it virtually, we see a higher attendance rate. So, you know, offer them resources if they're a drinker and there's problem drinking A, A and other resources for individuals who are overweight or obese. I actually do endorse anything that will help patients to safely lose weight with what we know today. Now patients may say, well, we don't know the risk of these diabetes, newer diabetes medications and we don't know all the long term risk.

We do have data. But I'll turn and look at them and I go, I know the risk of your being overweight. I know it's heart disease, diabetes, cancer. I don't know that there's any risk long term with that. But if we don't get weight off you, you're you've got a dismal future that you could be facing. Right. So I, I'll endorse surgery if they can get it covered or they have the resources to pay and they feel that's the best route, whatever will help them to lose weight. I do want it to be a lifestyle change.

And so, you know, if you use these diabetes medications, is it going to mean you take them long term? Maybe maybe you just learned to eat smaller portions and you're satisfied and, and, and in the process, you learn to eat healthier. I've seen people who started on those medications, they started losing weight, so they got interested in a healthier diet and then all of a sudden they started exercising. They started leading a healthier lifestyle. So part of their weight loss was just what they were doing.

It gave them a jump start and that was good. Yeah, I've seen that jump start. I I've had many patients who start with Ozempic or with Govi. They lose some weight and then they have a better exercise tolerance so they can exercise more. Yes, they feel like getting out and exercising. Yeah, Previously they were out of breath after 2 minutes. Now they can, you know, walk for 1015 minutes or an hour. So that's very important. Yeah, well. This has been extremely educational and informative for me. I'm sure the audience out there as well, and I'd like to thank you again for taking the time from your busy day to promote healthy lifestyles and stopping alcohol and stopping cigarettes and doing exercise.

Very important for people to get this message. And getting their trainings. I really appreciate you inviting me out this program. It's been a lot of fun. Thanks very much. Thank you.

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