creatinghope PREV ENTION • RESE A RCH • INNOVATION
SEPTEMBER 2013
Managing cancer risk through testing, genetic counseling B Y M A RY VA N D E V E I R E
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harlene Cunningham isn’t giving breast cancer a chance. Two of Charlene’s great-aunts died of breast cancer, her grandmother died of ovarian cancer, two aunts are breast and ovarian cancer survivors, and a second-cousin has been diagnosed and treated for breast cancer more than once. As Charlene says,
“Cancer has been lurking over my shoulder my entire life.” Charlene, 40, and her sisters and cousins were tested for breast cancer risk, and 16 of the 20, including Charlene and three sisters, tested positive for the breast cancer susceptibility gene, BRCA. About 5 to 10 percent of breast cancer is hereditary, often caused by a mutation in the BRCA1 or BRCA2 gene. Risk increases in families with cases of breast cancer and cases of both breast and ovarian cancer. GENE TESTING 2
INSIDE
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Scare off cancer with nutrition and exercise
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Genetics and family history: Predisposed to cancer?
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What makes cruciferous vegetables ‘super veggies?’
COVER FEATURE
A mother of three, Charlene Cunningham says, “I have to be there for those babies of mine.”
FROM THE COVER
GENE T E S T I N G The Banner MD Anderson Clinical Cancer Genetic Program in Gilbert coordinates genetic testing and health surveillance for patients with hereditary cancer syndromes. The Breast Cancer Program offers services in screening, treatment, support and recovery. Counseling before and after genetic testing is vital, says Mary Cianfrocca, DO, FACP. Cianfrocca is Director of Banner MD Anderson’s Breast Cancer Program and is Medical Director of the Clinical Cancer Genetics Program. Genetic counseling reviews a woman’s personal and family history to determine the appropriate type of testing and, secondly, discusses the implications of potential test results, so the woman can decide whether to be tested, Cianfrocca says. “That is the first decision that women need to make when they have a family history,” Cianfrocca says. MA NAG I N G RI S K Even if a patient’s test results are negative, counseling afterward is important to determine whether additional testing is needed. Patients who test positive for a mutation will sit down with a medical oncologist for counseling about available treatments. “If you have the information, you can decide how you want to manage your risk,” Cianfrocca says. “The right decision for your neighbor might not be the right decision for you.” In addition to surveillance and medications, treatment options for patients with a genetic mutation includes prophylactic, or preventive, surgery. A prophylactic mastectomy lowers breast cancer risk by as much as 90 percent. The prophylactic salpingo-oophorectomy, which removes fallopian tubes and ovaries, lowers breast cancer risk by 50 percent. Breast reconstructive surgery options include “direct to implant,” with full reconstructive surgery immediately following the mastectomy. Also, “expanders” can be inserted in a surgery following the mastectomy. The expanders slowly fill over time, and implants are inserted in a final surgery. 2 S EPT E MB E R 2013 CRE ATING HOPE
GENETIC TESTING For more information about genetic testing or to schedule an appointment with a genetic counselor, call 480-256-6444.
C H O O SIN G OP TI ON S Charlene and her sisters chose to have surgeries to reduce their risk. One sister will travel from out of state for a mastectomy at Banner MD Anderson in September. Charlene had a salpingo-oophorectomy in 2012. She went to Banner MD Anderson in April for a double mastectomy and initial reconstructive surgery. “I have two more follow-up appointments, final reconstructive surgery at the end of August and, then, done,” Charlene says.
Charlene is a high school teacher and part-time community college instructor raising 10-year-old twin sons and a daughter, 14, on her own. “I have to be there for those babies of mine,” she says. She adds, for a cancer patient, Banner MD Anderson is the place to be. “I have loved everything about it,” she says. “I have a team of doctors. They meet to discuss this comprehensive care. You can do all the blood work here, the surgery prep, everything. I’m so lucky I have this place.” • ch
PREVENTION
Scaring off cancer with nutrition, exercise GRADUALLY INTRODUCE MORE FRUITS, VEGETABLES AND EXERCISE TO YOUR ROUTINE BY BRIAN SODOMA
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ords like polyphenols, flavonoids and isoflavones don’t roll off the tongue too easily; but they quickly become part of your vocabulary when dealing with Christi Kirk. The registered dietitian at Banner MD Anderson Cancer Center in Gilbert helps cancer patients, survivors and those predisposed to the disease understand how food choices that include these powerful phytochemicals are perhaps the best medicine in the fight against cancer. Kirk says a plant-based diet rich with fruits, vegetables and plant proteins like beans, quinoa, lentils and tempeh, is a great anti-cancer foundation. But Kirk also understands that building this type of diet takes baby steps for some. So the “five-a-day” approach to fruits and vegetables is where she starts. As Kirk notes:
“The problem isn’t so much that patients don’t know what to eat; it’s figuring out how they can implement this type of nutritional program into their lives.” For many, time crunches can be a barrier to menu planning. So Kirk is always on the lookout for quick and easy tasty meals. The nutrition pro also says with better diet choices, people are more likely to make exercise a priority.
Kirk’s colleague, Josh Wludyga, an exercise physiologist at Banner MD Anderson, helps patients learn the role of exercise in cancer prevention. About 20 percent of cancer cases are obesityrelated, he said. Hormones like estrogen and insulin become elevated in overweight and obese people, which can increase cancer risk, Wludyga added. A little exercise can go a long way in reversing these problems. “We’re not trying for a beach body. We want to help people get to a weight where the body can comfortably regulate itself,” he says. “And that’s good for cancer prevention.” • ch
TIPS TO LOSE WEIGHT, FIGHT CANCER Mix it up Eat a wide variety of colors of fruits and vegetables to get a broad range of cancerfighting phytochemicals. The discomfort zone Try new recipes to get those red, orange, yellow and green plant colors into your diet. A little variety can make a diet shift a lot easier, says Kirk. Avoid “sitting” disease With technology and other modern conveniences, too much work is done sitting down. Find reasons to get up; walk instead of ride every chance you get, adds Wludyga. Embrace resistance Cardiovascular exercises burn calories while you do them. But to continue elevating your calorieburn throughout the day, work in some resistance training as well.
RECIPES See page 6 for some delicious and nutritional recipes. And for more healthy recipies, visit banner health.com/recipes.
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GENETICS
THE TIES THAT BIND
Genetics, family history and the predisposition of cancer
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BY KRISTINE BURNETT
ancer is a tricky and unexpected disease. When and who it will strike can never truly be confirmed ahead of time, even when family history makes a cancer diagnosis seem imminent. Despite inherited genetic defects that may cause cancer to run strong in certain families, the role of lifestyle and environmental factors cannot be underestimated. The media has been abuzz with stories about family ties to cancer, but Mary Cianfrocca, DO, director of the Breast Cancer Program and medical director of the Clinical Cancer Genetics Program at Banner MD Anderson Cancer Center in Gilbert, says hereditary cancers are much less common than people may think:
“Only about five to 10 percent of all cancer is known to be hereditary based on genetic testing that can identify a specific cancer-causing gene.�
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FUNDRAISING CAMPAIGN
NO GUARAN T E E Hereditary cancer can be more aggressive and difficult to treat; however, carrying an inherited genetic defect is not a guarantee that cancer will develop. It simply means the odds are higher and that considering preventive measures is important. While one’s hereditary risk of cancer isn’t something to be ignored, 80 percent of cancers occur sporadically, generally as a result of an environmental trigger or toxin. “In such cases, an external factor like sun exposure or smoking causes a gene to go awry, ultimately triggering the abnormal cell growth that leads to cancer,” Cianfrocca said. The remaining 20 percent of cancers are either hereditary or familial with a genetic predisposition that cannot be linked to a specific identifiable cancer-causing gene. DETER MI N I N G RI SK Determining one’s risk of hereditary cancer requires genetic counseling to evaluate the health history of first-degree family members (parents, siblings and children) as they have the closest genetic makeup. A presence of cancer younger than age 50, two or more relatives on the same side of the family with the same cancer or cancer syndrome such as breast and ovarian cancer, or a rare cancer show an increased risk. Certain ethnicities also have a greater risk of hereditary cancer. Genetic counseling is the first step in genetic testing, which requires a simple blood draw and DNA analysis to identify the presence of a particular gene. “Knowledge is power and the information derived from genetic counseling and testing helps ease uncertainty,” Cianfrocca said. “The hardest part truly is showing up and having the talk.” • ch CLINICAL CANCER GENETICS PROGRAM For more information about the program at Banner MD Anderson or to schedule an appointment with a genetic counselor, call 480-256-6444.
$20 million raised in cancer fight, treatment CANCER HAS MET ITS MATCH CAMPAIGN COMES TO A CLOSE: COUNTLESS PROGRAMS AND SERVICES BENEFIT FROM GENEROSITY OF COMMUNITY
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hen Banner Health announced plans to build a world-class cancer center, they knew support from the community would be essential to their success. As the project moved forward with The University of Texas MD Anderson Cancer Center, planning also began for a $20 million campaign called Cancer Has Met Its Match. Numerous business and community leaders were identified to lead the campaign, including Richard Adkerson, president and chief executive officer of FreeportMcMoRan Copper & Gold as chair. Steve Rizley, senior vice president of Cox Communication and Kari Yatkowski, founder of Corporate Citizen signed on as co-chairs. In May 2010, Arizona Cardinal’s star wide receiver Larry Fitzgerald agreed to serve as honorary chair of the campaign. Larry’s passion for cancer prevention, treatment and research was evident as he participated in numerous events to advocate on behalf of cancer center. Fundraising efforts moved swiftly. Early gifts of $1 million and $5 million were received before the campaign officially launched in January 2011. By the time Banner MD Anderson opened its doors on Sept. 26, 2011, countless community members had already made
generous donations to fund education and outreach activities, patient support programs, the latest technology and more. As a result,
Banner MD Anderson Cancer Center will have a profound impact on the 26,000 Arizonans diagnosed with cancer each year — assuring a new level of comprehensive cancer care and prevention education will be available right here in Arizona. Recognizing this potential, more than 1,500 individuals, corporations and foundations supported the Cancer Has Met Its Match campaign. Particularly notable gifts allowed for the establishment of the Pearce Family Trust Diagnostic Imaging Center, the James M. Cox Foundation Center for Cancer Prevention and Integrative Oncology and the recently renamed Virginia G. Piper Charitable Trust Lantern of Hope. Thank you to everyone who supported Banner MD Anderson. • ch
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ASK THE EXPERT
C H R I ST I K I R K
Registered dietitian Banner MD Anderson Cancer Center
Q: What are
‘super veggies?’
A:
Cruciferous vegetables — which include Brussels sprouts, broccoli, kale, cabbage, red cabbage, collard greens, bok choy, radishes, turnips, rutabaga and horseradish root — could all be considered “super veggies” because of their potential cancer-fighting properties. Their name is derived from the fact that their four-petal flowers are cross-shaped. What makes these vegetables special is that when they are chopped, chewed or cooked, they release chemicals known as glucosinolates, which break down into biologically active compounds that some researchers think may fight cancer. It’s been shown that glucosinolates may induce cell death, inactivate carcinogens and protect cells from DNA damage. These super veggies also are packed with fiber, vitamins, minerals and antioxidants and that means they play an important dietary role. Although no hard and fast recommendations have been established, most people should aim to eat at least five of these super veggies per week. But since cruciferous vegetables contain sulfur, they often have a strong or bitter flavor and pungent odor, so many people omit them from their diet, which can lead to a gap in nutrition. One way to counteract sulfur’s unpleasant effects is to drizzle in some balsamic vinegar near the end of sautéing the veggies. All the super veggies are quite versatile and you might be surprised at how easy it is to use them. When sautéing them, be sure to look for a bright green color and keep the veggies crisp. Also, be careful not to overcook them in water because that only amplifies the sulfur taste. I like to put kale or collard greens in soups, and kale makes a great standin for lettuce in most any salad. It’s healthier than iceberg lettuce and a one-cup serving size of this leafy green vegetable is only 36 calories. That’s another great thing about all of these cruciferous wonders — they’re low in calories and fill you up. Enjoy! • ch 6 S EPT E MB E R 2013 CRE ATING HOPE
RECIPES
CAULIFLOWER, CABBAGE AND CARROT SALAD
NOT-SO-BORING BROCCOLI
1 small cauliflower, cut into florets 1 cup finely shredded red cabbage 2 medium carrots, grated 1 small red onion, finely chopped ¼ cup chopped walnuts 2 Tbsp. chopped fresh parsley 1 Tbsp. white vinegar 1 tsp. Dijon mustard 1 Tbsp. extra virgin olive oil 1 Tbsp. low-fat plain yogurt
1-2 heads of broccoli crowns (about 1 lb.) 1 Tbsp. extra-virgin olive oil 2 cloves garlic, finely minced 1 tsp. red pepper flakes Salt and freshly ground black pepper, to taste
Toss cauliflower with cabbage, carrots, onion, walnuts and parsley. Whisk together vinegar and mustard. Add oil and yogurt and whisk. Drizzle over salad and mix. Makes 6 servings. Per Serving: 90 calories, 6 g total fat (1 g saturated fat), 7 g carbohydrates, 2 g protein, 2 g dietary fiber, 70 mg sodium.
BRUSSELS SPROUTS WITH PECANS AND DRIED CRANBERRIES 1 bag (16 oz.) frozen, petit baby Brussels sprouts 1 Tbsp. extra virgin olive oil 2 tsp. balsamic vinegar 2 Tbsp. finely chopped, lightly toasted pecans ¼ cup dried cranberries Salt and freshly ground black pepper, to taste Cook Brussels sprouts according to package directions. Meanwhile, in small bowl, stir together oil, vinegar, pecans and cranberries. Transfer cooked sprouts to serving dish. Gently toss with dressing. Season with salt and pepper; serve immediately. Makes 4 servings. Per serving: 102 calories, 6 g total fat (>1 g saturated fat), 11 g carbohydrates, 2 g protein, 2 g dietary fiber, 13 mg sodium.
Separate the broccoli florets from the stalk. In a shallow bowl filled with 2 Tbsp. of water, steam the broccoli, covered, for 1-minute. The broccoli should be bright green, but still crisp. Drain the broccoli and set aside. Meanwhile, heat the oil in a medium-size sauté pan over medium heat. Add the garlic and cook for 1 minute, stirring frequently. Add the red pepper flakes and cook for 30 seconds more. Add the steamed broccoli, stirring well to coat the florets. Cook for 2 minutes. Season to taste with salt and pepper. Makes 10 servings, ½ cup each. Per serving: 25 calories, 1.5 g total fat (0 g saturated fat), 3 g carbohydrate, 1 g protein, 1 g dietary fiber, 40 mg sodium. SOURCE: American Institute for Cancer Research (AICR)
TESTING
Speedy test results mean piece of mind BANNER MD ANDERSON CANCER CENTER’S UNDIAGNOSED BREAST CLINIC OFFERS REASSURANCE TO PATIENTS BY DEBRA GELBART
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hen someone discovers a lump in her breast, experiences breast pain or has a mammogram that shows something not normal, the Undiagnosed Breast Clinic at Banner MD Anderson Cancer Center in Gilbert is there to reduce a patient’s anxiety and get answers quickly. A patient can self-refer, or her doctor can refer her to the Clinic. At her appointment, she’ll likely meet with Shefali Birdi, MD, an internal medicine doctor who came to Banner MD Anderson last September from the Cleveland Clinic. “I’ve always had an interest in oncology,” she said. She has met with nearly 150 patients at the Clinic, who have come from all across the Valley and even as far away as northern California. While most patients are women, the Clinic has treated men, too. AS S ESS I N G N E E D Everything the patient needs to find out if there is the presence of disease is managed at the first appointment. Dr. Birdi examines the patient and determines what steps are needed next. If further imaging (such as a mammogram or ultrasound) is required, the patient can complete that within the facility right away. If a blood draw is needed, that, too, is done at the same location. Even a biopsy, if necessary, is performed there, usually on the same day of the appointment. And instead of waiting up to a week for the pathology results from a biopsy, the patient is informed within
24 to 48 hours. Then, further care can be delivered, if needed, at the same location. The Clinic is designed to diagnose breast cancer in its earliest stages. Dr. Birdi adds:
“Same-day testing offers a tremendous amount of peace of mind to our patients. And providing all of our services under one roof is very reassuring.” Patients can expect the doctor to spend much more time with them than in other settings. “In a doctor’s office, you might expect a 15-minute appoint-
ment,” she said. “Here, I take the time to explain everything about the situation to the patient, talking to her about genetic counseling if appropriate — which we offer — and about the diagnostic procedures I’m recommending.” DISC USSIN G OP TI ON S If more imaging is needed, Dr. Birdi typically will ask Vilert Loving, MD, a radiologist and director of breast
MAMMOGRAMS OFFERED AT BANNER MD ANDERSON CANCER CENTER The Women’s Imaging Center at Banner MD Anderson Cancer Center in Gilbert offers both screening mammograms (for women with no breast-related symptoms) and diagnostic mammograms (for women who do have at least one symptom of possible breast disease) using digital technology. A new technology called 3D tomosynthesis produces digital breast images that are viewed in stacks of very thin layers or slices — essentially a three-dimensional mammogram. This allows radiologists to see breast tissue with detail not possible before. Appointments can be made by calling 480-543-6900.
imaging at Banner MD Anderson, to examine the mammogram or ultrasound images. If the imaging shows something abnormal, Dr. Loving can perform a biopsy. “A breast biopsy can take as little as 15 minutes,” he said. “If the biopsy is done in the morning,” he said, “we usually get the results back that afternoon. Then, I’ll discuss with the patient what her options are.” Typically, patients visit the Clinic twice. The second visit is a follow-up and may include a referral to a specialist, or the patient may be referred back to her primary care doctor. Dr. Birdi will be completing a fellowship in integrative medicine through the Tucson-based Center for Integrative Medicine, headed by Andrew Weil, MD “I hope this fellowship allows me to use a more integrative approach to help my patients take care of themselves,” she says. • ch To schedule an appointment at the Undiagnosed Breast Clinic, call 480-256-6444. BannerMDAnderson.com 7
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Latest Research and Tools in Cancer Prevention
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