Cancer prevention aspec

1. Cancer Prevention and Screening ASPEC 2019

2. Cancer Prevention and Screening www.aboutcancer.com

3. Discovering New Information We recently learned the important role the air force played in Washington’s success in the Revolutionary War

4. Can you reverse engineer mother nature and avoid cancer? Much of the ‘science’ about cancer is based on case-control studies which proves association. Correlation is not Causation! Hypothesis generating. Why are so many of the ‘intervention trials’ failures? Caveat emptor!

5. Key Web Sites for Cancer Prevention and Screening www.aboutcancer.com Dr. Miller Site cancer.gov/about-cancer/causes-prevention NCI prevention Site www.cancer.gov/types NCI specific cancers seer.cancer.gov/ Cancer Statistics epss.ahrq.gov/PDA/index.jsp Screening Guidelines www.nccn.org National Comprehensive Cancer Network (NCCN) Uptodate.com Current review article about all medicine gis.cdc.gov/Cancer/USCS/DataViz.html CDC Cancer Risk Graphs https://health.gov/dietaryguidelines/2015 Diet Guidelines

6. 1.Overall prevention strategies (can you lower the overall risk of getting any type of cancer?) 2.Specific cancers may have specific strategies (breast, prostate, lung and colorectal) 3.Screening…where to find the best advice

7. In 2019 in the US there would be over 1.7 million new cancer cases and over 600,000 deaths from cancer. The probability of getting cancer during your life time based on data from 2013 to 2015 is 39.3% for men and 37.1% for women (not counting skin cancers).

8. Site Men Woman All 39.3% 37.7% Breast 12.4% Prostate 11.2% Lung 6.7% 5.9% Colorectal 4.4% 4.1% Uterus 2.9% Melanoma 3.7% 2.5% Lymphoma 2.4% 1.9% Kidney 2.1% 1.2% Leukemia 1.8% 1.3% Thyroid 0.6% 1.8% Probability of Developing Invasive Cancer (US 2013-2015)

9. The best approach would be to prevent cancer in the first place. Some approaches are obvious and effective (e.g. avoiding known carcinogens like smoking and asbestos or excessive sun exposure to prevent skin cancer.) Next best approach would be screening (only if it’s been shown to be beneficial and ? cost effective)

10. Prevention is defined as the reduction of cancer mortality via reduction in the incidence of cancer. This can be accomplished by • avoiding a carcinogen or altering its metabolism • pursuing lifestyle or dietary practices that modify cancer-causing factors or genetic predispositions • medical interventions (e.g., chemoprevention) or risk-reducing surgical procedures • early detection strategies that can result in removal of precancerous lesions, such as colonoscopy for colorectal polyps cancer.gov/about-cancer/causes-prevention

11. Lifestyle factors have been linked to a variety of malignancies, including the most common in the developed world: lung, colorectal, prostate, and breast cancer. In a longitudinal study, participants who had all four lifestyle factors: 1. never smoking, 2. body mass index [BMI] <30, 3. physical activity >3.5 hours weekly, 4. prudent diet (high intake of fruits, vegetables, and whole-grain bread and low meat consumption) had approximately one-third lower risk of cancer compared with those who had none of these factors Ford ES. Arch Intern Med. 2009;169(15):1355.

12. Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study. Ford ES. Arch Intern Med. 2009;169(15):1355. 23,153 German participants aged 35 to 65 years end points included confirmed incident type 2 diabetes mellitus, myocardial infarction, stroke, and cancer. Risk of developing a chronic disease decreased progressively as the number of healthy factors increased. Participants with all 4 factors at baseline had a 78% lower risk of developing a chronic disease: - diabetes: 93% - myocardial infarction: 81% - stroke: 50% - cancer: 36% than participants without a healthy factor.

13. Healthy Life Style Can Overcome Bad Genetics for Dementia Lourida. JAMA July 14, 2019 • Study of 196,383 • 4 Healthy Life Styles (healthy diet, proper exercise, no smoking, moderate alcohol • Included were polygenic factors associated with Alzheimer disease Lifestyle: Favorable (3, or 4) Intermediate (2) Unfavorable (0, 1) Risk of Getting Dementia

16. Risk Factors for Cancer Age Alcohol Cancer-Causing Substances Chronic Inflammation Diet Hormones Immunosuppression Infectious Agents Obesity Radiation Sunlight Tobacco

17. Probability of Developing Cancer During this Age Interval (2013-2015) Birth to 49 50 – 59 60 – 69 70 or older Lifetime Male 3.4% 6.1% 13.2% 31.9% 39.3% Female 5.6% 6.2% 10.0% 26.0% 37.7% So 82% in men (31.9/39.3) and 69% in women (26/37.7) occur at 70+ (when screening may be stopped!)

18. Probability of Developing Cancer During this Age Interval (2013-2015) Birth to 49 50 – 59 60 – 69 70 or older Lifetime Male 3.4% 6.1% 13.2% 31.9% 39.3% Female 5.6% 6.2% 10.0% 26.0% 37.7% So 82% in men (31.9/39.3) and 69% in women (26/37.7) occur at 70+ (when screening may be stopped!)

19. Avoiding Old Age and Cancer…only solution die young! Anne Frank 15 Ritchie Valens 17 Joan of Arc 19 Buddy Holly 22 River Phoenix 23 James Dean 24 Tupac Shakur 25 Kurt Cobain 27 Jim Morrison 27 Amy Winehouse 27 Janis Joplin 27 Jimi Hendrix 27 John Belushi 33 Mozart 35 Marilyn Monroe 36 George Gershwin 38 Chopin 39

20. There is a strong scientific consensus that alcohol drinking can cause several types of cancer, an estimated 3.5% of cancer deaths in the US are related to alcohol Type of Cancer Increased Risk Oral Cavity, Pharynx 1.8 X – 5 X Larynx 2.6 X Esophagus (squamous) 1.3 – 5X Liver 2 X Breast 1.04 (light) 1.23 (moderate) 1.6 X (heavy) Colon, Rectal 1.2 – 1.5 X

21. There is a strong scientific consensus that alcohol drinking can cause several types of cancer, an estimated 3.5% of cancer deaths in the US are related to alcohol Type of Cancer Increased Risk Oral Cavity, Pharynx 1.8 X – 5 X Larynx 2.6 X Esophagus (squamous) 1.3 – 5X Liver 2 X Breast 1.04 (light) 1.23 (moderate) 1.6 X (heavy) Colon, Rectal 1.2 – 1.5 X

22. There is a strong scientific consensus that alcohol drinking can cause several types of cancer, an estimated 3.5% of cancer deaths in the US are related to alcohol According to the federal government’s Dietary Guidelines for Americans 2015-2020, individuals who do not drink alcohol should not start drinking for any reason. It recommends that if alcohol is consumed, it should be done in moderation and defines moderate alcohol drinking as up to one drink per day for women and up to two drinks per day for men. Heavy alcohol drinking is defined as having 4 or more drinks on any day or 8 or more drinks per week for women and 5 or more drinks on any day or 15 or more drinks per week for men

23. Drinking alcohol raises your risk of getting six kinds of cancer—mouth and throat, voice box (larynx), esophagus, colon and rectum, liver, and breast (in women).

24. Drinking alcohol raises your risk of getting six kinds of cancer—mouth and throat, voice box (larynx), esophagus, colon and rectum, liver, and breast (in women).

25. Cancer-Causing Substances in the Environment Aflatoxins Aristolochic Acids Arsenic Asbestos Benzene Benzidine Beryllium 1,3-Butadiene Cadmium Coal Tar and Coal-Tar Pitch Coke-Oven Emissions Crystalline Silica (respirable size) Erionite Ethylene Oxide Formaldehyde Hexavalent Chromium Compounds Indoor Emissions from the Household Combustion of Coal Mineral Oils: Untreated and Mildly Treated Nickel Compounds Radon Secondhand Tobacco Smoke (Environmental Tobacco Smoke) Soot Strong Inorganic Acid Mists Containing Sulfuric Acid Thorium Trichloroethylene Vinyl Chloride Wood Dust

26. EPA: Glyphosate, the Herbicide in Roundup, Does Not Cause Cancer EPA reaffirmed that glyphosate does not cause cancer in its review process of the U.S.’s most widely used herbicide. US News April 30, 2019 President Trump's first EPA Administrator, Scott Pruitt, resigned effective July 6, 2018, amid a series of scandals. Deputy Administrator Andrew Wheeler, a former coal industry lobbyist was confirmed as EPA Administrator on February 28, 2019.

27. Chronic Inflammation Chronic inflammation may be caused by infections that don’t go away, abnormal immune reactions to normal tissues, or conditions such as obesity. Over time, chronic inflammation can cause DNA damage and lead to cancer. For example, people with chronic inflammatory bowel diseases, such as ulcerative colitis and Crohn disease, have an increased risk of colon cancer. Many studies have investigated whether anti-inflammatory medications, such as aspirin or non-steroidal anti-inflammatory drugs, reduce the risk of cancer. However, a clear answer is not yet available

29. Diet With few exceptions, studies of human populations have not yet shown definitively that any dietary component causes or protects against cancer.

30. Balanced, Low-Fat Diet Reduces Risk of Death From Breast Cancer in Postmenopausal Women May 15, 2019 The federally funded Women’s Health Initiative (WHI) clinical trial of dietary modification This is the first large, randomized clinical trial to show that diet can reduce the risk of dying from breast cancer.

34. The Importance of Dietary Fiber Denis Parsons Burkitt , British surgeon noted how rare colon cancer was in Africa which he related to dietary fiber

35. Fiber — A number of laboratory, nutritional, and epidemiologic studies have identified a role for dietary fiber in the pathogenesis of colorectal cancer.

36. ●A decreased risk of colonic adenomas and CRC with higher intake of fiber was reported in five large epidemiologic studies. ●On the other hand, in the Nurses' Health study, no relationship was noted between fiber intake and the risk of CRC or adenomas. Similarly, the Women's Health Initiative Trial found no protective effect of a modest low-fat, increased fiber, and increased fruit and vegetable dietary intervention on CRC incidence.

37. ●A pooled analysis of 13 prospective cohort studies (involving 725,628 men and women followed for 6 to 20 years) found that dietary fiber intake was inversely associated with the risk of CRC, but the association was no longer apparent after accounting for other dietary risk factors. ●A meta-analysis funded by the World Cancer Research Fund found that for every 10 g/day increase in dietary fiber consumption, there was a significant reduction in the risk of CRC by 10 percent.

38. ●In two randomized controlled studies from the United States as well as one from Australia, fiber supplementation had no significant protective effect for the development of total colorectal adenomas. ●A systematic review of five studies involving a total of 4349 patients concluded that there was no definitive evidence that increased dietary fiber reduces the incidence or recurrence of adenomatous polyps within a two- to four-year period.

39. A systematic review of 38 studies found that neither vitamin C nor vitamin E supplementation was beneficial for prevention of the cancers evaluated . A 2006 National Institutes of Health (NIH) consensus conference panel concluded that "present evidence is insufficient to recommend either for or against the use of multivitamin supplements by the American public to prevent chronic disease“ VITAMINS AND MICRONUTRIENTs

40. A subsequent long-term randomized trial (mean 9.4 years treatment) in 8000 women found no evidence that supplementation with vitamin C, E, or beta- carotene (singly or in combination) decreased cancer incidence or cancer mortality. VITAMINS AND MICRONUTRIENTs

41. Additionally, two long-term observational studies, one including over 160,000 women with follow-up of approximately eight years and another including over 180,000 multiethnic participants with 11-year follow-up, found no association between multivitamin use and risk of cancer. It has not been established that multivitamin and mineral supplements provide added benefit to a balanced, healthful diet for most individuals VITAMINS AND MICRONUTRIENTs

42. The Selenium and Vitamin E Cancer Prevention Trial (SELECT) SELECT is a phase III randomized, placebo-controlled trial of selenium and/or vitamin E supplementation for prostate cancer prevention. A total of 35,533 men were randomized from 427 sites in the U.S., Canada, and Puerto Rico achieving minority representation of 21% (15% African Americans).

43. The Selenium and Vitamin E Cancer Prevention Trial (SELECT) Primary results were reported early (planned futility analysis) indicating neither vitamin E nor selenium supplements were associated with prevention of prostate cancer. An updated analysis in 2011 showed a statistically significant increased risk of prostate cancer in the vitamin E compared to placebo arms (hazard ratio 1.17)

44. Beta-carotene and lung cancer: a case study. Am J Clin Nutr. 1999 Jun;69(6):1345S-1350S. More than 30 case-control and cohort studies were conducted over many years in various populations and indicated that people who eat more vegetables and fruit, foods rich in carotenoids, and carotenoids (beta-carotene in particular), as well as those with higher blood beta-carotene concentrations, have a lower risk of lung cancer

45. Beta-carotene and lung cancer: a case study. Am J Clin Nutr. 1999 Jun;69(6):1345S-1350S. In contrast, the intervention results from large, controlled trials of beta-carotene supplementation do not support the observed beneficial associations or a role for supplemental beta-carotene in lung cancer prevention; instead, they provide striking evidence for adverse effects (ie, excess lung cancer incidence and overall mortality) in smokers

46. Beta-carotene and lung cancer: a case study. Am J Clin Nutr. 1999 Jun;69(6):1345S-1350S. One study of 29,000 male smokers (ATBC Trial) found an 18% increase in lung cancer in the group receiving 20 mg of beta-carotene a day for 5 to 8 years. Another study of 18,000 (CARET Trial) people found 28% more lung cancers in people with a history of smoking and/or asbestos exposure. These people took 30 mg of beta-carotene

47. Beta Carotene No Beta Carotene 18% More Lung Cancer ATBC Trial New Lung Cancer

48. CARET Trial…Beta Carotene and Vitamin A Prevention Trial New Lung Cancer 28% Higher in those taking Beta Carotene and Vitamin A N Engl J Med 1996; 334:1150-1155

49. Hormones Taking estrogen alone will increase the risk of breast and uterus cancer Taking estrogen plus progesterone will lower the risk of uterus cancer but further increase the risk of breast cancer Premarin is a mixture of the sodium salts of estrogen conjugates found in the urine of pregnant mares used since 1942

50. Immunosuppression Many people who receive organ transplants take medications to suppress the immune system so the body won’t reject the organ. These "immunosuppressive" drugs make the immune system less able to detect and destroy cancer cells or fight off infections that cause cancer. Infection with HIV also weakens the immune system and increases the risk of certain cancers. transplant recipients are at increased risk of a large number of different cancers. Some of these cancers can be caused by infectious agents, whereas others are not. The four most common cancers among transplant recipients and that occur more commonly in these individuals than in the general population are non-Hodgkin lymphoma (NHL) and cancers of the lung, kidney, and liver.

51. Infectious Agents Certain infectious agents, including viruses, bacteria, and parasites, can cause cancer or increase the risk that cancer will form. Most of the viruses that are linked to an increased risk of cancer can be passed from one person to another through blood and/or other body fluids. As described below, you can lower your risk of infection by getting vaccinated, not having unprotected sex, and not sharing needles. Epstein-Barr Virus (EBV) Hepatitis B Virus and Hepatitis C Virus (HBV and HCV) Human Immunodeficiency Virus (HIV) Human Papillomaviruses (HPVs) Human T-Cell Leukemia/Lymphoma Virus Type 1 (HTLV-1) Kaposi Sarcoma-Associated Herpesvirus (KSHV) Merkel Cell Polyomavirus (MCPyV) Helicobacter pylori (H. pylori) Opisthorchis viverrini Schistosoma hematobium

52. Infectious Agents Certain infectious agents, including viruses, bacteria, and parasites, can cause cancer or increase the risk that cancer will form. Most of the viruses that are linked to an increased risk of cancer can be passed from one person to another through blood and/or other body fluids. As described below, you can lower your risk of infection by getting vaccinated, not having unprotected sex, and not sharing needles. Epstein-Barr Virus (EBV) Hepatitis B Virus and Hepatitis C Virus (HBV and HCV) Human Immunodeficiency Virus (HIV) Human Papillomaviruses (HPVs) Human T-Cell Leukemia/Lymphoma Virus Type 1 (HTLV-1) Kaposi Sarcoma-Associated Herpesvirus (KSHV) Merkel Cell Polyomavirus (MCPyV) Helicobacter pylori (H. pylori) Opisthorchis viverrini Schistosoma hematobium

53. Human papillomavirus (HPV) causes most cervical cancers, as well as some cancers of the vagina, vulva, penis, anus, and oropharynx (cancers of the back of the throat, including the base of the tongue and tonsils).

54. Human papillomavirus (HPV) causes most cervical cancers, as well as some cancers of the vagina, vulva, penis, anus, and oropharynx (cancers of the back of the throat, including the base of the tongue and tonsils).

55. Non-HPV = Yellow, HPV = blue HPV Infections and Oropharynx Cancer

56. HPV Most Common Smoking Less Common Dramatic Rise in HPV + Tonsil Cancer

57. Obesity

58. There is sufficient evidence for an association between excess body fatness, including overweight, obesity, and weight gain, and at least 13 cancers—adenocarcinoma of the esophagus; cancers of the adenocarcinoma of the esophagus; cancers of the breast (in postmenopausal women); colon and rectum; endometrium (corpus uterus); gallbladder; gastric cardia; kidney (renal cell); liver; ovary; pancreas; thyroid; meningioma; and multiple myeloma.

59. There is sufficient evidence for an association between excess body fatness, including overweight, obesity, and weight gain, and at least 13 cancers—adenocarcinoma of the esophagus; cancers of the adenocarcinoma of the esophagus; cancers of the breast (in postmenopausal women); colon and rectum; endometrium (corpus uterus); gallbladder; gastric cardia; kidney (renal cell); liver; ovary; pancreas; thyroid; meningioma; and multiple myeloma.

60. Radiation Radiation of certain wavelengths, called ionizing radiation, has enough energy to damage DNA and cause cancer. Ionizing radiation includes radon, x-rays, gamma rays, and other forms of high-energy radiation. Lower-energy, non-ionizing forms of radiation, such as visible light and the energy from cell phones and electromagnetic fields, do not damage DNA and have not been found to cause cancer.

61. www.xrayrisk.com

62. Older man and one hip X-ray will increase cancer risk by 1 in 37,189

63. Multiple PET scans in a child increase the cancer risk by at least 1 in 42

64. Sunlight The sun, sunlamps, and tanning booths all give off ultraviolet (UV) radiation. Exposure to UV radiation causes early aging of the skin and skin damage that can lead to skin cancer. People of all ages and skin tones should limit the amount of time they spend in the sun, especially between mid-morning and late afternoon, and avoid other sources of UV radiation, such as tanning beds. It is important to keep in mind that UV radiation is reflected by sand, water, snow, and ice and can go through windshields and windows. Even though skin cancer is more common among people with a light skin tone, people of all skin tones can develop skin cancer, including those with dark skin

65. Cigarette Smoking Smoking is the leading cause of premature, preventable death in this country. Cigarette smoking and exposure to tobacco smoke cause about 480,000 premature deaths each year in the United States. Of those premature deaths, about 36% are from cancer, 39% are from heart disease and stroke, and 24% are from lung disease. Mortality rates among smokers are about three times higher than among people who have never smoked. Smoking harms nearly every bodily organ and organ system in the body and diminishes a person’s overall health. Smoking causes cancers of the lung, esophagus, larynx, mouth, throat, kidney, bladder, liver, pancreas, stomach, cervix, colon, and rectum, as well as acute myeloid leukemia Lauren Bacall

66. Cigarette Smoking Cigarette smoking and exposure to tobacco smoke cause about 480,000 premature deaths each year in the United States. Of those premature deaths, about 36% are from cancer, 39% are from heart disease and stroke, and 24% are from lung disease. Mortality rates among smokers are about three times higher than among people who have never smoked. Lauren Bacall

67. Cigarette Smoking Smoking harms nearly every bodily organ and organ system in the body and diminishes a person’s overall health. Smoking causes cancers of the lung, esophagus, larynx, mouth, throat, kidney, bladder, liver, pancreas, stomach, cervix, colon, and rectum, as well as acute myeloid leukemia Lauren Bacall

68. Tobacco smoke has at least 70 chemicals that cause cancer, also known as carcinogens.

69. Smoking cigarettes can cause cancer almost anywhere in your body, including in the bladder; blood (acute myeloid leukemia); cervix; colon and rectum; esophagus; kidney and renal pelvis; liver; lungs, bronchi and trachea; mouth and throat; pancreas; stomach; voice box (larynx)

70. Additionally, the use of smokeless tobacco (snuff and chewing tobacco) causes cancers of the oral cavity, pancreas and esophagus; cigar use causes cancers of the oral cavity, pharynx, esophagus, larynx, and lung; and secondhand smoke exposure causes lung cancer.

72. Cigarette Consumption in the US and Health Events

78. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 Men Women Smoking in the US Humphrey Bogart Dead at 57 from esophagus cancer in 1957

79. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 Men Women Smoking in the US Humphrey Bogart Dead at 57 from esophagus cancer in 1957 Men

80. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 Men Women Smoking in the US Humphrey Bogart Dead at 57 from esophagus cancer in 1957 Women

81. Smoking Steep decline since 1950 - 60’s Less dramatic decline in women Time 1975-82 1982-91 91-2008 2008-15 Men + 1.5% -.5% -1.7% -2.9% Women +5.6% +3.4% +.5% -1.5% Lung Cancer Incidence

84. Lung cancer mortality in men starts declining in the 1980-90’s Doesn’t start down in women until the 2000’s

85. Lung cancer mortality in men starts declining in the 1980-90’s Doesn’t start down in women until the 2000’s

86. Lung cancer mortality in men starts declining in the 1980’s Doesn’t start down in women until the 2000’s

87. Percentage of adults aged ≥18 years who reported cigarette use “every day” or “some days,” by selected characteristics — National Health Interview Survey, United States, 2017

88. Percentage of adults aged ≥18 years who reported cigarette use “every day” or “some days,” by selected characteristics — National Health Interview Survey, United States, 2017

89. Smoking by Level of Education in 2017

90. Smoking by Level of Education in 2017

91. Smoking by Income or Health Insurance in 2017

92. Smoking by Income or Health Insurance in 2017

93. Lung Cancer Mortality by County in the US in 2014

94. Smoking By State in 2018 Utah 8.9% California 11.3% New York 14.1% Texas 15.7% Florida 16.1% US 17.1% Alabama 20.9% Mississippi 22.2% Kentucky 24.6% West Virginia 26.0%

95. Smoking By State in 2018 Utah 8.9% California 11.3% New York 14.1% Texas 15.7% Florida 16.1% US 17.1% Alabama 20.9% Mississippi 22.2% Kentucky 24.6% West Virginia 26.0%

96. Genetics of Cancer Genetic changes that promote cancer can be inherited from our parents if the changes are present in germ cells Cancer-causing genetic changes can also be acquired during one’s lifetime, as the result of errors that occur as cells divide or from exposure to carcinogenic substances that damage DNA such as certain chemicals in tobacco smoke, and radiation, such as ultraviolet rays from the sun. Genetic changes that occur after conception are called somatic (or acquired) changes.

97. Interventions That are Known to Lower Cancer Risk • Selective estrogen receptor modulators (SERMS) such as tamoxifen or raloxifene have been shown to reduce the risk of breast cancer in women at high risk. • Finasteride has been shown to lower the risk of prostate cancer. • COX-2 inhibitors may prevent colon and breast cancer. COX-2 inhibitors may cause heart problems. Because COX-2 inhibitors may cause heart problems there have not been many studies on their use to prevent cancer. • Aspirin may prevent colorectal cancer. Bleeding in the gastrointestinal tract or brain is a side effect of aspirin. Because aspirin may cause bleeding problems there have not been many studies on their use to prevent cancer.

98. The Influence of Finasteride on the Development of Prostate Cancer. N Engl J Med 2003; 349:215-224 Prostate Cancer Prevention Trial, randomly assigned 18,882 men 55 years of age or older to treatment with finasteride (5 mg per day) or placebo for seven years. Outcome Placebo Finasteride Cancer 1147 803 Gleason 7+ 237 280 Incidence of New Prostate Cancer Placebo Finasteride

99. Interventions That Are Not Known to Lower Cancer Risk There is not enough proof that taking multivitamin and mineral supplements or single vitamins or minerals can prevent cancer The following vitamins and mineral supplements have been studied, but have not been shown to lower the risk of cancer: Vitamin B6 Vitamin B12 Vitamin E Vitamin C Beta carotene Folic acid Selenium Vitamin D

100. Physical Activity and Cancer There is substantial evidence that higher levels of physical activity are linked to lower risks of several cancers: Colon cancer: most physically active individuals had a 24% lower risk of colon cancer other studies reported a risk reduction of 16%, also associated with a decreased risk of colon adenomas (polyps Breast cancer: average breast cancer risk reduction associated with physical activity was 12%. Endometrial cancer: the average endometrial cancer risk reduction associated with high versus low physical activity was 20%

101. Physical Activity and Cancer Nearly all of the evidence linking physical activity to cancer risk comes from observational studies, but such studies cannot definitively establish that being physically inactive causes cancer (or that being physically active protects against cancer). That is because people who are not physically active may differ from active people in ways other than their level of physical activity.

102. Strong evidence suggests that physical activity reduces the risk of several cancers, including breast cancer in post-menopausal women, endometrium (corpus uterus) cancer, and colon cancer.

103. Strong evidence suggests that physical activity reduces the risk of several cancers, including breast cancer in post-menopausal women, endometrium (corpus uterus) cancer, and colon cancer.

104. Are you eating healthy? “I don’t think all that natural food is doing you any good!” “I don’t know what you’re eating, but you gave the dog a can of spaghetti sauce!”

105. Every 5 years, HHS and USDA publish the Dietary Guidelines for Americans, the Nation’s go-to source for nutrition advice. https://health.gov/dietaryguidelines/2015/

107. Consume a healthy eating pattern that accounts for all foods and beverages within an appropriate calorie level. A healthy eating pattern includes: • A variety of vegetables from all of the subgroups—dark green, red and orange, legumes (beans and peas), starchy, and other • Fruits, especially whole fruits • Grains, at least half of which are whole grains • Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages • A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts, seeds, and soy products • Oils

108. A healthy eating pattern limits: • Saturated fats and trans fats, added sugars, and sodium Quantitative limits are provided for several components of the diet • Consume less than 10 percent of calories per day from added sugars • Consume less than 10 percent of calories per day from saturated fats • Consume less than 2,300 milligrams (mg) per day of sodium • If alcohol is consumed, it should be consumed in moderation—up to one drink per day for women and up to two drinks per day for men—and only by adults of legal drinking age

109. “You need more exercise. Run out and get me a cheeseburger with onions!” Getting Good Advice about Exercise

110. Strong evidence shows that regular physical activity helps people maintain a healthy weight, prevent excessive weight gain, and lose weight when combined with a healthy eating pattern lower in calories. Strong evidence also demonstrates that regular physical activity lowers the risk of early death, coronary heart disease, stroke, high blood pressure, adverse blood lipid profile, type 2 diabetes, breast and colon cancer, and metabolic syndrome; it also reduces depression and prevents falls

111. Less than 20% of seniors!

112. All adults should avoid inactivity. Some physical activity is better than none, and adults who participate in any amount of physical activity gain some health benefits.

113. For substantial health benefits, adults should do at least 150 minutes (2 hours and 30 minutes) a week of moderate- intensity,

114. Aerobic activity should be performed in episodes of at least 10 minutes, and preferably, it should be spread throughout the week. Adults should also include muscle- strengthening activities that involve all major muscle groups on 2 or more days a week.

116. https://www.cancer.gov/types

118. Endometrial Cancer Prevention KEY POINTS Avoiding risk factors and increasing protective factors may help prevent cancer. The following risk factors increase the risk of endometrial cancer: Endometrial hyperplasia Estrogen Tamoxifen Obesity, weight gain, metabolic syndrome, and diabetes Genetic factors The following protective factors decrease the risk of endometrial cancer: Pregnancy and breast-feeding Combination oral contraceptives Physical activity Cigarette smoking It is not known if the following factors affect the risk of endometrial cancer: Weight loss Fruits, vegetables, and vitamins Cancer prevention clinical trials are used to study ways to prevent cancer. New ways to prevent endometrial cancer are being studied in clinical trials.

119. Cigarette Smoking and the Risk of Endometrial Cancer: A Meta-Analysis American Journal of Medicine June 2008, 121:6:501 an increase in smoking of 20 cigarettes per day was statistically significantly associated with 16% and 27% reduced risks of endometrial cancer Conclusion Cigarette smoking was found to be significantly associated with a reduced risk of endometrial cancer, especially among postmenopausal women. The antiestrogenic effect of cigarette smoking in women American Journal of Obstetrics and Gynecology Volume 162, Issue 2, February 1990, Pages 502-514 Epidemiologic results indicate that women who smoke cigarettes are relatively estrogen-deficient. Smokers have an early natural menopause, a lowered risk of cancer of the endometrium, and an increased risk of some osteoporotic fractures. Moreover, women who smoke may have a reduced risk of uterine fibroids, endometriosis, hyperemesis gravidarum, and benign breast disease. Several possible mechanisms for these effects have been identified. Smoking does not appear to be clearly related to estradiol levels, at least in postmenopausal women, although levels of adrenal androgens are increased. Moreover, smoking appears to alter the metabolism of estradiol, leading to enhanced formation of the inactive catechol estrogens.

120. Endometrial Cancer Screening KEY POINTS Tests are used to screen for different types of cancer when a person does not have symptoms. Endometrial cancer is usually found early. There is no standard or routine screening test for endometrial cancer. Tests that may detect (find) endometrial cancer are being studied: Pap test Transvaginal ultrasound Endometrial sampling Screening tests for endometrial cancer are being studied in clinical trials.

123. http://epss.ahrq.gov/PDA/index.jsp

127. Data to Justify or Explain Their Recommendation

129. General lifestyle recommendations ●Avoid tobacco ●Be physically active ●Maintain a healthy weight ●Eat a diet rich in fruits, vegetables, and whole grains and low in saturated/trans fat, red meat, and processed meat ●Limit alcohol ●Protect against sexually transmitted infections. Vaccinate girls and boys against HPV. ●Avoid excess sun ●Get regular screening for breast, cervical, and colorectal cancer

130. Cancer Information Cancer Videos Radiation Cancer Calculators Other Topics www.aboutcancer.com Childe Hassam Clearing Sunset

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