Have you noticed those small pink ribbon brooches on sale this month? They are only available in October and you can see them being sold all over the world. What are they for? Well, October is the Breast Cancer Awareness Month and the pink ribbon is synonymous with the breast cancer awareness movement.

The breast cancer awareness movement has achieved a great deal in raising awareness of breast cancer. It has encouraged women to go for screening and has empowered women with information on the various treatment options available. Perhaps the movement has been too successful. For example, we may have oversold mammography in that some people believe mammogram will detect all breast cancers. They forget the role of monthly self breast examination as an integral part of any scheme to detect breast cancer early. Some breast cancers may not show up on mammography but are felt. Hence mammography is not the be-all and end-all for early or earlier detection of breast cancer. The breast cancer awareness campaigns tend to focus on detection and treatment but are light on prevention issues and information for women with advanced breast cancers. One could argue that the breast cancer campaign would be even more successful if it included more information and help for those with advanced disease and also gave equal weight to the influence of lifestyle factors on the occurrence of breast cancers.

The breast cancer awareness campaign has taught us much and has helped tremendously in our fight against breast cancer. However, I would argue that cancer awareness in general should not be a once a year event. Cancer awareness should be in our psyche constantly. The fight against cancer should not be construed as purely a technological pursuit. No imaging techniques and no blood tests can detect all cancers. Each of us has to play an active part. We have an obligation to find out what lifestyle factors can lead to the occurrence of cancer. We have a duty to learn about the early symptoms and signs of the various types of common cancers. We cannot place all our hopes in ‘tests’ only.

To make an impact on our fight against cancer, we have to take ownership of our health and our well-being. To do the job well it is not a once a year thing, it is a 24/7 job.

The relationship between caffeine consumption and breast cancer has been a point of contention for a while. While most studies have not shown an association, several have shown an inverse relation or a weak positive association. Two recent studies from the United States have further examined this relationship.

The first study from the Brigham and Women’s Hospital took detailed dietary information from 38,432 women who were 45 years or older and were free from cancer during the period 1992 – 1995 (Arch Intern Med 2008; 168: 2022 – 2031). These women were followed up for a mean period of 10 years. Women who almost never drank coffee and those who drank 4 or more cups of coffee daily did not show an increased risk of developing breast cancer. The same findings were seen in women who drank tea (≥ 2 cups daily vs almost never). However, the study did find a borderline significant positive association with breast cancer risk in women with existing benign breast disease who consumed the most amount of caffeine and coffee. The study also found a significant association between caffeine consumption and the risk of developing estrogen and progesterone receptor-negative breast cancer (68% more likely) and breast tumours larger than 2 cm (79% more likely).

In another report from the Harvard School of Public Health, 85,987 female participants in the Nurses’ Health Study were followed up for 22 years (Int J Cancer 2008; 122: 2071 – 2076). Their consumption of coffee, tea and caffeine consumption was assessed in 1980, 1984, 1986, 1990, 1994, 1998 and 2002. Women who consumed ≥ 4 cups of coffee / day did not have an increased risk of developing breast cancer. Similarly, intake of tea and decaffeinated coffee was not associated with breast cancer risk. However, in postmenopausal women, an inverse association was found. There was a 12% difference in the risk of breast cancer for the highest intake group compared to the lowest intake group.

While these two big studies have shown that caffeine in general is not associated with risk of breast cancers, too much caffeine can be bad for a sub-set of women. If you were to develop breast cancer, caffeine consumption may give rise to poorer tumour characteristics. While this is not confirmed beyond reasonable doubt, it might be prudent for you to remember the saying ‘Everything in moderation please’ while the jury is still out.

Colorectal cancer (CRC) is a common cancer worldwide. In the United States, CRC is the third most common cancer and is the second leading cause of cancer death. In 2008 it is estimated that a total of 148,810 cases will be diagnosed and 49,960 people will die of CRC in USA. Screening for CRC is one effective way of detecting the cancer earlier and thus leading to better outcome and lives saved. It is estimated that effective CRC screening in USA could lead to 18,800 lives saved per year.

The US Preventive Services Task Force (USPSTF) recently updated its recommendations on CRC screening. The USPSTF has now stated that screening should start at 50 years of age and stop at 75 for individuals who have a consistent history of negative screening results. (More than 80% of CRC cases occur in patients older than 55.) In addition, screening should stop in all adults older than 85 years. It also recommends that the screening methods should be performed with high-sensitivity faecal occult blood testing (HS-FOBT), sigmoidoscopy with FOBT and colonoscopy. The USPSTF recommends that screening should be done with HS-FOBT annually or sigmoidoscopy every 5 years with HS-FOBT every 3 years or screening colonoscopy every 10 years. (HS-FOBT refers to the high-sensitivity guaiac testing or the faecal immunochemical test. All patients with positive HS-FOBT require a subsequent colonoscopy.) The lead author of the USPSTF recommendations stated that “Life years saved is just about the same for the 3 different approaches to screening. You can choose from these 3”. The USPSTF is also not recommending CT colonography (CTC) and faecal DNA testing as screening tools. The arguments against CTC include the following. (1) Uncertainties about radiation risk and CTC, especially with repeated screenings over time. The risk of radiation exposure leading to the development of cancer has been estimated as 1 per 1000. (2) Somewhere between 1 in 3 to 1 in 8 patients who undergo CTC will need subsequent colonoscopy to confirm, refute or treat the underlying problem.  (3) Up to 16% of patients will need additional testing for follow-up of incidental findings outside the colon; the implications of these findings are still not clear. (Performing CTC can also lead to colonic perforation. The incidence of perforation is estimated to be 0.9 to 6 per 10, 000 studies. This compares with 3.8 perforations per 10,000 colonoscopies.)

In USA, there is another learned body called the American Cancer Society-US Multi-Society Task Force (ACS-MSTF) which issues recommendations on CRC screening as well. (The ACS-MSTF is commissioned by the American Cancer Society and issued jointly by professional societies representing gastroenterology and radiology.) The ACS-MSTF recommends both CTC and faecal DNA testing as screening tools. However, it did not recommend a specific age for cessation of CRC screening.

For the public, the differences in the recommendations from both task forces can lead to confusion and angst. To help with the situation, I think it is important for Joe Public to bear in mind the following points.  (1) CRC screening has been proven to save lives. (2) The gold standard for CRC screening is still colonoscopy and FOBT. (3) Colonoscopy is both diagnostic and therapeutic.  (4) Screening colonoscopy should start at 50 and, for those with negative screening, subsequent screening colonoscopy is to be performed at 10 year intervals.