About the risks of cancer development and prevention

Can self-examination reduce the risk of breast cancer, when to quit smoking and which moles should be shown to the doctor? Afisha Daily spoke with Ilya Fomintsev, Executive Director of the Cancer Prevention Foundation.

– When a person on his own initiative does a magnetic resonance imaging of the whole body or a blood test for cancer markers - is it good or bad?

– There is a concept of a balance of harm and benefit. The real benefit of screening is when the probability of detecting and preventing cancer is high. If it is higher than the probability of death from the screening itself, then it makes sense. For example, fibrogastroscopy (FGS), which is needed to detect some stomach diseases, in very rare cases can cause perforation – in the process, the esophagus or stomach may be pierced. Very rarely, during FGS, a person may have a sudden arrhythmia, and he will die because of this. When a study is conducted on a large number of people, the probability of complications is no longer theoretical, these are specific people who will die or suffer. Therefore, it is one thing when you give a recommendation to your patient or decide on your own that you need this study. But it is quite another thing to give a recommendation to hundreds of thousands and millions when it is obviously clear that someone will definitely suffer. However, if a recommendation can save more people than it will kill, then it should be given.

And we have an ultrasound of the abdominal cavity in the state medical examination program – that's what they are looking for there? A needle in a haystack? When you do research, you need to know what you're doing it for, what you want to find there and what it threatens you with. People who decide to give such recommendations to tens of millions of patients, apparently, are not guided by either research or the concept of a balance of harm and benefit. If you tell them that screening can be harmful, I think they will be very surprised. It's still good that no one actually passes this medical examination. If they had, we would have received a lot of corpses from her alone.

– How then to treat the check-ups that are offered in private clinics?

– A check-up is a set of very different – including optional – studies that the clinic provides to a specific patient. This is not a mass recommendation, it is your personal choice. To give such recommendations to huge masses of people is to know that you will kill a certain number of people, and we are talking about thousands.

– Are there any types of screening that were massively used in civilized countries, and then they were abandoned?

– A lot of things have changed. Previously, fluorography and X-rays were used. Not now. This is inefficient. Instead, low-dose computed tomography is used for lung cancer screening, which has much greater sensitivity and specificity. If you do a chest X-ray, you only see the cardiac complex, which blocks the trachea and carina (bifurcation of the trachea. – Ed.). You will miss the central lung cancer in this way. Fluorography simply has a low resolution – it is very bad for cancer diagnosis. It does not reduce mortality from it. Therefore, low-dose CT is used.

Previously, research on prostate-specific antigen (PSA) was popular all over the world, but now it has ceased to be massively used. This cancer marker can be used, but, apparently, only in very narrow groups: research is currently underway on this subject. By the way, cancer markers are interesting only in dynamics. They are not interesting at one point of measurement. Moreover, they are observed in the dynamics of cancer patients – in a person who has not detected cancer, these indicators are increased, for example, due to inflammation.

Gastroscopy has also been tried for mass screening. But now they have stopped. Unless they do FGS in Japan, there is a huge incidence of stomach cancer.

– I have not seen such a recommendation anywhere except in Russia, but we advise women under 40-50 to do breast ultrasound instead of mammography. Is that right?

– Why?

– To find something.

– They will definitely find something. There really is no such recommendation anywhere in the world. Any woman can do anything at will, even an ultrasound of the little finger. Giving such a recommendation to everyone is a crime by and large. On ultrasound, of course, they will find something. The probability that it will be cancer tends to zero if the patient is not at risk. But even if this is a risk group, if cancer is detected on ultrasound, it is of a sufficiently large size. Such a finding will not have any serious impact on the probability of death. Ultrasound is a low–sensitivity method for breast cancer. But all sorts of cysts will find and scare. They will puncture these cysts, maybe they will find a fibroadenoma, they will strip a woman like Preobrazhensky Sharikov. All this could not interfere with the woman, but the operation will nevertheless be carried out. It's just that our doctors don't know how to behave correctly after they find something. If you are not at risk, it is now generally recommended to start mammography from the age of 50 and do it annually.

– Do women need to conduct self-examination?

– It has been shown that regular self-examination does not reduce mortality from breast cancer. In addition, this recommendation of women is by and large unnerving. They often turn to a mammologist, find something they don't need to find. And usually they conduct self-examination incorrectly, no matter how you train them. Personally, you can do whatever you want, but at the state level, implementing this recommendation, spending money, publishing booklets is pointless. If a woman accidentally feels something in her chest, of course, she needs to go to the doctor.

– How to understand that you are at risk?

– For example, if there is a special heredity that hints that there is some kind of mutation. There are many criteria that allow us to identify such a group of suspected hereditary cancer. It's not just the sick mother and sister. Another risk group for breast cancer are those who had a history of supradiaphragmatic radiation therapy, that is, the area above the diaphragm. For example, due to lymphogranulomatosis or thyroid tumor. A special situation also exists for those who have constantly taken medications that have been proven to increase risks. For example, if there was estrogen therapy in serious doses. We are not talking about oral contraceptives, they do not increase the level of estrogen. People of some nationalities suffer from breast cancer more often than others: for example, Ashkenazi Jews.

– And what can a woman do if she is at risk?

– It depends on the nature of the risk group. If a woman has received radiation therapy in the area above the diaphragm, then she needs to have an annual magnetic resonance imaging of the breast from any age.

If there are mutations that increase the risk of breast cancer, then perhaps we will talk about reducing the risk with mastectomy (removal of mammary glands. – Ed.) or taking tamoxifen (an antiestrogenic drug. – Ed.), but it is less effective in this sense. Our mastectomy is not paid for under the compulsory health insurance system, that is, it will be paid for a woman. To find the grounds for preventive mastectomy, there must be an oncogenetic conclusion. That is, it is necessary to do an oncogenetic test. It may be that everything points to hereditary risks, but in fact there are no mutations. But if there really is an increased risk, then work with the patient begins next. Many are not satisfied with Angelina Jolie's approach, they refuse such a path and choose a more dense observation. This may be due to our tradition or distrust of Russian medicine (suddenly you made a mistake with this test, and I'm so young, I have to remove my breasts and insert implants).

– Do I need to go to an oncologist or a family doctor once in my life and ask him about my risks?

– Why once in a lifetime? So you lived and lived, you didn't know anything about your risks, and then your blood relative got sick. This can happen more than once or twice. Therefore, it is necessary to make such an annual review of your life and see what has happened in general during this time. It may very well turn out that someone is ill, in addition, age inevitably changes, some other risk factors appear or disappear.

That's why we recommend taking a free test in our SCREEN system every year. It shows what is your personal probability of getting some type of cancer: cervical cancer, breast cancer, lung, prostate, stomach, skin and colorectal cancer.

If the probability is low, it means that the risk of complications from screening is higher than the probability of cancer, and you don't need anything – you don't need unnecessary medical intervention, doctors can really ruin your life, we are like that. But low risk is not a guarantee that cancer will not occur. If there are alarming symptoms, you need to go to oncologists, regardless of the risks.

If, according to the test results, the risk turns out to be average or even higher, this means that the probability of developing cancer exceeds the possible harm from medical intervention, and then action must be taken. In Western countries, a family doctor should consult you on all these issues, but we have few such specialists.

If your results give a suspicion of a hereditary syndrome, you should be recommended to consult an oncogeneticist who will tell you what to do next. This is a separate area of knowledge that requires constant digging in the literature and participation in conferences. There are more or less clear indications for referral to oncogenetics. For the mammary gland and ovaries, we reflected them in the test most fully. But we will improve the test and introduce other hereditary syndromes into it (an increase in the risk of developing certain types of cancer due to genetic characteristics. – Ed.). Now there is only HBOC syndrome (hereditary breast and ovarian cancer syndrome, hereditary breast and ovarian cancer syndrome. – Ed.).

– Is there a hereditary predisposition to oncological diseases in general?

– There are known hereditary syndromes, and they are quite diagnosable with the help of genetic testing and gene sequencing. In addition, I must say that we still do not know about the genes that encode a predisposition to cancer, and therefore sometimes there is such a situation: there are many relatives with oncological diseases, but there is not a single detectable genetic syndrome. In this case, we can talk about the increased probability of cancer only speculatively, based on statistical data and not relying on laboratory data.

In general, there is always a certain basic risk of getting cancer in any person. Relative risks are calculated from this level in the presence of various factors. In fact, the basic risk means that the area of knowledge about cancer that we do not yet know, plus some random events that can happen to everyone.

– For the risk of colorectal cancer (colon and rectal cancer), heredity is definitely important. How does this affect screening?

– If one of your relatives had colorectal cancer, then, according to the recommendations of the American Cancer Society, you need to start screening from the age of 40 or 10 years before the age at which the relative was diagnosed with this disease. Colonoscopy should be done every 5 years. If the risk is average, then the European norms are such that you do not need to do a colonoscopy just like that from some age. In this case, European recommendations are relevant for us, not American ones, because we do not have the right number of qualified colonoscopists. And it is necessary to do this research only in those places where they really know how, and only to those people who are shown. Therefore, I am in favor of two-stage screening of colorectal cancer in medium-risk groups. This is selection through quantitative analysis of feces for hidden blood. There are quality tests: they only answer the question "Is there blood in the feces or not?" and do not say how much. And for colorectal cancer screening, a quantitative test is needed that shows how much blood is in the stool. And according to these indicators, it is already possible to select people for screening.

– And prostate cancer screening also needs selection, right?

- Yes. First of all, these are men over 55 years old, since those who are younger have a very low risk. In our test, we rely on the recommendations of SWOP (the Netherlands Prostate Cancer Research Foundation, Stichting wetenschappelijk onderzoek prostaatkanker. – Ed.). For men over 55 years old, we ask questions about dysuria (violation of urination) in the test. If there are appropriate signs, we send a person for a consultation with a urologist to resolve the issue of prostate cancer diagnosis. The doctor will prescribe a PSA test, conduct a finger examination, and do a TRU (transrectal ultrasound. – Ed.). If there is cancer, they will do a biopsy. And the doctor will decide what is more likely: a person will die from cancer or from something else, whether it is necessary to treat.

– By the way, in some recommendations you can find: screening is carried out until the life expectancy is less than how many years. Why is this necessary and how is it calculated?

– This indicator is taken into account when screening for lung cancer and prostate cancer. But mammography in many recommendations is now advised to do it all the way while you walk. The fact is that breast cancer surgery has become very minimally invasive (with minimal intervention. – Editor's note) and removing the tumor is not a big problem even for a 90-year-old person. If surgery is complicated, as with prostate cancer or lung cancer, it does not make sense to be checked there until the end of your days, from a certain point on, even if you detect cancer, doing something with it is more dangerous than not doing it. Then life expectancy is calculated. It can be calculated by risk groups. Or just take statistics: with such a set of diseases, according to statistics, a person can live another five years at most. Then should he be treated for cancer, which will seriously interfere with him in 5-6 years? There are no such statistics in Russia, but there are global ones.

– At what age should I be tested for lung cancer?

– It's not just age that matters. About 90 percent of all lung cancer patients belong to the highest risk group for this disease. It is very easy to understand whether you belong to this group or not. There should be a combination of three signs: you are 50 years old or older, you smoke now or quit smoking less than 15 years ago, your smoking experience is 30 or more pack-years (this is considered as follows: multiply the number of years of smoking by the number of packs of cigarettes that you smoke per day). If you really have all three signs of the highest risk group, it means that you either already have lung cancer (but it does not manifest itself in any way), or it is highly likely to develop in the near future. What should I do then? First, quit smoking. After 15 years, if cancer does not occur during this time, your risk will be almost the same as in the non-smoking population. Secondly, to do a low-dose CT scan of the lungs annually. This will reduce the likelihood of death from lung cancer by about 30 percent, and if you give up smoking at the same time, then by more than 30 percent.

– And what should young people pay attention to? What kind of cancer should I be tested for?

– For example, for skin cancer. Here self-examination is quite effective. Some changes are visible when they have not yet reached cancer, when it is still a dysplastic nevus. There are very simple signs of a suspicious mole, which may turn out to be a precancerous or skin cancer: it is asymmetrical, with uneven edges, multicolored, its diameter is more than 6 mm, it grows and changes. That is, there is not even a need to go to a dermatologist every year: just look at yourself from all sides with mirrors. It's good if you live with a person who periodically sees your back, buttocks and the back surfaces of your legs: he may notice moles that require medical attention.

A map of moles (information about the location and characteristics of moles recorded on paper or in a special program. – Editor's note) is needed by those who are at risk. These are, for example, sunburn in the past, fair skin, melanoma in relatives, a weakened immune system, living in southern latitudes, visiting a solarium. A doctor can accurately determine whether you belong to a risk group, although we have also provided for this in the SCREEN system.

In general, skin cancer screening can be done opportunistically. Anyone goes to the doctor periodically. If all doctors more or less knew the signs of malignancy of moles, it would be possible to greatly reduce the incidence and mortality from skin cancer. But we do not undress patients, and if they undress, they do not look. And if they do, they don't see it.

– Cervical cancer also concerns the young.

– Yes, in the USA, the recommendations are as follows: from the age of 21 to 30, a Pap test is done every three years (cytological examination of a smear from the cervix), and from 30 to 65 years, you can do a Pap test together with a test for oncogenic types of human papillomavirus (HPV). The fact is that HPV of some types has been proven to provoke the development of cervical cancer. In the UK, they offer to do a Pap test every three years from the age of 25 to 49, and then every five years until the age of 64. This approach is probably better: it is ineffective to do such screening before the age of 25, it does not affect mortality.

– Very often you can hear from our gynecologists that you need to be checked once a year. And even those who know that it is not necessary, say that our women have such a mentality – if you tell them: "Go to the gynecologist once a year," they will go once every five years. Therefore, it is necessary to intimidate like this.

– Was there any research where the mentality of Russian, Italian and Portuguese women was compared? It would be interesting to read. If you do cervical cytology every year, then you are harming. If it's so harmless, let's do cytology every day: in the morning before work. But you need to know at least an elementary theory of carcinogenesis. Cervical cancer develops for about 10 years. Frequent cytology is dangerous because sooner or later they will find some kind of dysplasia (a change in cells that is a precancer in severe form. – Ed.). At the same time, dysplasia in a huge percentage of cases degenerate themselves. Question: what will happen to our woman if she is found to have dysplasia? First of all, she will be scared. Secondly, a whole series of troubles will happen to her. She may undergo cervical conization (removal of part of the cervix. – Ed.). And this is quite likely to lead to infertility, as it will affect the patency of the cervix. When you talk about big numbers, the responsibility is greater. It may very well be that a particular person needs to be told: "Go every year," and then he will go at least every ten, but it is not necessary to generalize and give such recommendations at the population level without research.

– What about colposcopy, when the cervix is examined under a microscope? In what cases is it necessary?

– Colposcopy is post–screening management, so to speak. That is, if something is wrong with the Pap test, a colposcopy is needed to understand how to proceed. It doesn't have to be done by everyone.

– It seems that we have discussed all types of cancer that can be caught early in screening. If the rest are not caught like this, then at least how to reduce the risk of developing these oncological diseases?

There are hundreds of risk factors that can move the probability of developing cancer here or there. Yes, a healthy lifestyle will improve the situation, but there are factors that we do not know. For example, a person may have a mutation that we have not yet linked to cancer. That is, there is not a single risk factor that we know about, but cancer is developing. This is possible, although unlikely. Do not smoke, do not drink, exercise, maintain a normal weight; if you have more than one sexual partner, then try to get vaccinated before you get HPV.

As for such a carcinogen as meat, even a complete rejection of it will only slightly reduce your risk of developing colon cancer. X-ray examinations increase the risk of developing cancer, but they increase it so insignificantly that if there are indications, then radiography or CT should be done without questions. With magnetic resonance imaging, there is no ionizing radiation, it does not affect the risk.

There is also an ambiguous situation with the bacterium Helicobacter pylori, which can live in the stomach. Yes, it increases the risk of developing cancer. But this does not mean that screening for Helicobacter pylori will reduce the incidence of stomach cancer. In any case, I have not seen such studies. But if the bacterium is found for some other reason, then the gastroenterologist decides whether to use antibiotics to get rid of it.

– Are there any websites where you can learn more about all this?

Most often, sites in Russian are not based on evidence-based medicine, on proven statements. They may be correct, but there is no guarantee, because there are no links, it is unclear when these articles were last updated. And they must be updated constantly, otherwise they become obsolete. It remains only to read English-language sites. Personally, I really like the website of the National Universal Cancer Network. It contains competent recommendations, and most importantly – links to the studies on which they are based. This is a very convenient research navigator.

The Cancer Prevention Foundation, together with the N.N.Petrov Research Institute of Oncology, is preparing to launch the first web version of the SCREEN cancer risk detection and cohort screening system. The launch is scheduled for the third decade of March. Now you can pre-register on the website nenaprasno.ru to receive an invitation when the system is working.

Portal "Eternal youth" http://vechnayamolodost.ru 17.02.2015