Second Opinion
How can we better catch and combat cancers that are increasing in people who don’t have known or established risk factors?
Dr. Ravi SharafAssociate Professor of Medicine
Associate Professor of Population Health Sciences
While cancer care has traditionally focused on diagnosis and treatment, there’s a growing movement to advance its early detection and prevention. Elucidating cancer risk through genetic testing fosters this goal.
Up to 5% of the general population has an increased predisposition to cancer caused by an inherited single gene mutation. Knowledge of this susceptibility allows us to tailor medicine and preventive steps to your specific risk.
We suggest that individuals speak to their providers to see if their personal and family history meet criteria for genetic testing. Genetic testing can identify those who have a gene mutation that increases the risk not only for one but multiple malignancies, including but not limited to breast, ovarian, pancreatic and prostate cancers.
Some cancers, such as breast and thyroid cancers, are increasing in incidence in adults under the age of 50. We want to make sure these increases represent a true rise in disease occurrence. Changes in cancer screening behavior, clinical diagnoses or electronic health record documentation can give the perception of an increased incidence when that may not be the case.
But the increased incidence in colorectal cancers in people under age 50 reflects a genuine rise. Such a change within a generation suggests an environmental reason rather than a genetic link because population-based genetic predisposition doesn’t change that quickly. We need to think about what lifestyle factors could be correlated, such as obesity, sedentary behavior and diet. Exposures can contribute as well: air pollution and perhaps microplastics may be linked to the rise. Overall, we know that about 50% of cancer deaths globally and 40% of cancer cases in the United States are linked to preventable lifestyle choices.
Developing technologies like multi-cancer early detection testing and whole-body MRI may prove useful for cancer screening in the future. Both have the potential to screen for multiple cancers concurrently. We need more data to determine if they actually work in practice. Initial enthusiasm fueled by observational study results may temper after a lack of efficacy in randomized control trials.
The ultimate goal is to facilitate prevention and early detection, which ultimately are the most important factors for prognosis.
Dr. Bradley PuaAssociate Professor of Radiology
Associate Professor of Radiology in Cardiothoracic Surgery
For many types of cancer, it’s time to rethink screening guidelines. Consider lung cancer, the leading cause of cancer deaths in the United States.
Increasingly, we’re seeing more individuals who have never smoked present with lung cancer, a trend that challenges long-standing assumptions about who is truly at risk. Yet our national screening guidelines remain built on a structure that ties eligibility to a history of smoking. Lung cancer screening is the only major cancer screening program that relies not only on age, but on proof of a behavior that has long carried powerful stigma. This linkage creates unintended barriers to care.
Currently, in order to qualify for screening, people must be between 50–80 years old and be either current smokers or relatively recent smokers (having quit within the last 15 years). Through these requirements, we have built an implicit narrative that lung cancer is primarily self-inflicted. This leads many people to incorrectly believe that the disease doesn’t apply to them unless they smoked, even though data now show that about 20,000–40,000 lung cancers each year occur in those who never or rarely smoked. It also discourages eligible patients from seeking care due to fear of being labeled or judged. When individuals associate eligibility with fault, they are less likely to walk through the door, even when doing so may save their life.
As a medical community, we need to reflect upon whether our approach inadvertently reinforces these biases and to consider whether age alone should guide lung cancer screening eligibility, similar to how age is the primary factor for breast, colorectal and cervical cancer screening guidelines. Recent modeling showed that lung cancer screens based solely on age would not only capture more cases than those using other criteria, but also ensure that more malignancies would be found in women and never-smokers. Additionally, multiple studies have shown that even modestly expanding eligibility criteria beyond the traditional definition of heavy smokers increases the proportion of Black and Latino individuals who qualify for lung cancer screening.
Removing the requirement for smoking history isn’t simply a policy change. It’s a cultural shift that acknowledges the evolving epidemiology of lung cancer, reduces stigma and improves access to care. If we believe in early detection and if we believe in equity, then we should be prepared to question long-held assumptions and build the evidence needed to support more inclusive screening criteria.
Dr. Erica Phillips, M.S. ’03Professor of Clinical Medicine
Jack Fishman Professor of Cancer Prevention
We don’t often develop cancer prevention programs focused on youth. Although people under 50 are experiencing rising cancer rates, their awareness of cancer risk factors remains low, and few evidence-based programs are integrated into school curricula.
What if prevention efforts were to come before behaviors like tobacco use, diet and environmental exposures are ingrained? What if they start in a middle school science classroom instead of a clinic?
Our study “Cancer Risk Education in Schools for Youth and Families” (CARES4You), published last year in the Journal of Cancer Education, integrates cancer risk awareness into school science curricula and community settings to support healthier behaviors early in life. It is part of the Center for Social Capital, a collaboration between Weill Cornell Medicine, Columbia University Irving Medical Center and SUNY Downstate Health Sciences University.
With support from the National Cancer Institute’s Persistent Poverty Initiative, we worked directly with 39 teachers and administrators from five New York City public schools to co-design a cancer prevention curriculum, embed it directly into science education and ground it in students’ lived experiences. Our other partners were Math for America (MƒA) STEM teaching fellows and an interdisciplinary research team spanning medicine, cancer epidemiology, nutrition and education.
Feedback from the teachers has been critical. With our lessons on dietary-related cancer risk, we found that nutrition was a hard topic to teach because of the sensitivities around it: There were teachers who internalized what they were hearing because of their own potential health issues around diet and obesity.
We learned a lot in terms of developing and shaping the curriculum and what words to use and not to use. We focused on the science behind a fat cell, never bringing up the word “obesity.” We didn’t talk about weight because you know that if adults are experiencing sensitivities, then adolescents are going to as well.
For the tobacco use unit, which is one of the most popular, we supplied science kits for lab work inside the classroom. The students used simulated lung cells and tested vaping juices to learn about the harm they can cause.
A teacher at one of our schools in the Bronx told me that a student revealed that they and some other students used to vape significantly. But ever since that lesson, they had stopped. To me, that makes all our work worth it.
