San Antonio Express-News (Sunday)
No good screening tool for stomach cancer
Q: I read with interest your recent column regarding the benefit of a colonoscopy for detecting colon cancer. I am 58 and started experiencing frequent light nausea about two months ago, a few days after getting my first Moderna vaccine. My doctor had me get a blood test. It was generally normal except the liver’s enzyme activity level was very high. That led to a second, liver-focused blood test, an abdominal ultrasound, an abdominal CT scan, followed by a colonoscopy and endoscopy. The last test’s biopsy determined that I have stomach cancer, and a liver biopsy, torso PET scan, chemotherapy and immunotherapy are next.
If the cancer has spread to the liver, which appears likely, then I have stage 4 stomach cancer, which may be fatal. I am not aware of any family history of stomach cancer.
Why aren’t endoscopies a recommended test for all age 50-plus individuals, as colonoscopies are? I might have a much better survival prognosis if they were. Has any doctor found a way to beat stage 4 stomach cancer?
A: I am very sorry to hear about your diagnosis and wish you well with your treatment. The prognosis for stage 4 stomach cancer is not good, but recent advances with immunotherapy and chemotherapy should give you hope.
Successful screening for cancer requires two factors: a cancer that is detectable at a time when it can be successfully treated, and a screening test that is safe and accurate at detecting early cancer.
Some cancers are initially very slow-growing. The best examples are cervical and colon cancer, where screening clearly saves lives. They normally grow for five to seven years before they become invasive and spread locally and to distant organs. This allows screening tests (Pap smear and HPV testing for cervical cancer, colonoscopy or stool cards for colon cancer) to have a good chance of finding the cancer while it can be easily cured.
Unfortunately, cancers are highly variable from one person to another. Some breast cancers may be detectable and treatable for 10 years before they spread, but other breast cancers are so aggressive they have already spread by the time the most sensitive test can find them. Stomach cancer in a 50-year-old is detectable for an average of about three years before causing symptoms, which makes early detection possible but difficult.
The best-studied screening test for stomach cancer has been an endoscopy, which is relatively invasive and has some potential for harm. In some countries where there is much more stomach cancer, such as Korea and Japan, recommendations are for people older than 50 to have endoscopy every two years. Unfortunately, there are no good trials showing that screening for stomach cancer reduces the likelihood of death, probably because stomach cancer is relatively uncommon in North America and a successful trial requires many subjects. Screening is recommended for people at high risk, including some people with familial cancer syndromes such as FAP and Lynch syndrome.
Cancer screening may be about to change dramatically with the development of a blood-based cell-free DNA test, which has shown great promise
in early diagnosis of many kinds of cancers, including stomach cancer. Further evidence is necessary before these should be used for general screening.
Q: My question concerns the benefits and risks of taking oral estrogen following removal of ovaries and uterus due concerns about ovarian cancer. I have recovered well from having this laparoscopic-robotic surgery. I am a healthy 69-year-old with a family history of ovarian cancer (mother) and breast cancer (mother and sister). The genetic testing ordered by my primary care doctor was negative for BRCA1 and 2 mutations.
The specialist recommended removing the uterus at the same time since it would give me the option of taking oral estrogen, which could have many benefits. I have not decided on taking estrogen yet. I am concerned whether that would increase my risk of breast cancer and if there are other risks to consider.
A: There are some risks and some benefits to taking estrogen, but no authorities recommend taking estrogen to prevent future problems. Estrogen should be considered as treatment for several conditions, probably the most common of which is the hot flashes of menopause.
An increased risk of breast cancer is clear among women taking combined estrogen and progestins; however, there seems to be little or no risk among women who take estrogen without a progestin (called “unopposed estrogen”), which is normally only prescribed to women who have undergone hysterectomy. One large study showed even a reduced risk of breast cancer.
Other risks include an increase in blood clots. The association between estrogen and heart disease remains uncertain, but it appears that women older than 65 have a greater risk from heart disease than women within a few years of menopause (who may have a reduced risk of heart disease with unopposed estrogen). Estrogen reduces the risk of osteoporotic fractures and colon cancer, as well as diabetes.
Q: I have a question about routine bloodwork — including D and magnesium levels — that is usually part of a yearly physical. In the morning I take a multivitamin and calcium supplement with D3 and magnesium. Should I stop taking any or all of these a few days before fasting bloodwork to get an accurate reading?
A: Most people don’t need to take magnesium and calcium supplements, but if your doctor has recommended it, then you absolutely do want to take it when you get your blood levels checked. Your doctor wants to know whether the doses you are taking are getting you to the desired level. The same is true with blood pressure and diabetes medicines: The goal isn’t (usually) to see whether you still have the condition; it’s to be sure the doses are correct.
Unless your doctor tells you differently, you should come in for blood tests taking your medication the same way you always do.
Q: My sister gets flu shots without preservatives and has been unable to find out if any of the COVID shots available are preservative-free. What does your research say on this subject? She won’t get the shots until this is an option.
A: Neither the Pfizer nor the Moderna vaccine contain preservatives. I hope this reassures her. The new variants of the virus are much more easily transmissible. More than 99 percent of people admitted to the hospital with COVID-19 now are unvaccinated, as the vaccine offers very high protection.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med .cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.