The Inextricable Link Between Environment and Cancer

              In the spring of 2010, the US President's Cancer Panel released a 200-page report detailing the relationship between environment and cancer. Their findings? Shocking. Nearly 80,000 chemicals are approved for daily use by the American public. And yet only a few hundred of those chemicals have been tested for safety, meaning the vast majority of them are largely unstudied and their health consequences poorly understood. 1.5 million Americans would be diagnosed with some form of cancer in 2010, and over 550,000 would lose their lives.

              That's greater than the total number of American casualties suffered during World War I. And World War II. Combined. 

              Now here's the riddle: what fraction of those diagnoses and deaths are linked to environmental exposures? And here's the unsettling answer: we simply don't know.

              How can this be? Has our government become complacent in their duty to protect their citizens? Or have we the citizens fallen asleep at the wheel, no longer concerned about how our food or products are manufactured? Or is there a deeper, more insidious reason underlying our refusal to address this hugely significant problem? 

              Let me tell you the story of environment and cancer.

Regulations and Research on Today's Chemicals

            Taken directly from the Cancer Panel's report: "The prevailing regulatory approach in the United States is reactionary rather than precautionary."

            That is, our system to demonstrate the safety of new chemicals and products is, for lack of a better phrase, completely backwards. When a new chemical enters the US market, several agencies can be responsible for approving its safety. I'm sure you're familiar with some of these agencies like the FDA, EPA, OSHA, etc. But rather than require an incontrovertible demonstration of a new chemical's safety, these agencies will allow chemicals to enter the market as long as they meet a minimum baseline and follow them up only if obvious public health problems arise.

            Is it me or does that approach sound backwards to you too?

            I can hear the anti-regulation sentiment grumbling already. "This is the nature of the free market," one might argue, "we introduce new products with minimal government intervention, and if the product is unworthy or unsafe, the market will correct for itself without the need of strict regulation."

            And most of the time, I might agree with this line of thinking. But not when the consequences of lax regulation come at the expense of human health. To me, the argument for prioritizing free market over the status of our health holds no legitimate ground. 

            The heart of this issue lies in determining who bears the burden of proof. Should the industries that introduce new chemicals prove to us that their product is safe? Or should we shoulder that responsibility by consuming those products and waiting to see what happens? It seems only logical that the producers of these chemicals should be held responsible for proving their product's safety.   

            So with these points in mind, what do our environmental cancer researchers have to say about this? You may have to strain your ears, because there aren't too many of them around. Of the $4.83 billion NCI budget, only 14% of it was allocated for environmental and epidemiological research in 2008, and that fraction hasn't increased by much in the present day. But even that is enough to paint a compelling picture of how environmental factors may increase cancer risk. Many substances that we release into the world can alter hormone production and function, induce DNA damage and inflammation, and modulate gene suppression and overexpression. All of which is to say that we understand, at least to some degree, the mechanisms behind environmental exposure and the development of cancer. 

            So why aren't we doing something about it?

            We'll dive deeper into that question later in this piece, but one of the basic answers points us back to our reactionary tendencies when it comes to industrial regulation and medical research. Hold onto this thought for a minute.  

What's up with Nuclear?

            Let's briefly address the dramatic question of how nuclear meltdowns may affect cancer risk. Unsurprisingly, there are mixed findings associated with the three major meltdowns at Three Mile Island, Chernobyl, and Fukushima.

            Let's take a look into one of these events: Fukushima.

            On March 11, 2011, the most powerful earthquake to shake Japan clocks in at a magnitude of 9.0 and lasts 6 minutes just off the coast of Sendai. 50 minutes later, a 50 foot tsunami floods the city of Fukushima which is about 35 miles inland. At the Fukushima Daiichi Nuclear Power Plant, the three reactors in operation shut down automatically in response to the quake. However, when the tsunami reaches the city, the waves easily surpass the 20 foot seawalls and incapacitate the site's emergency generators. Without power, the pumps responsible for cooling the reactors begin to fail which eventually leads to the meltdown of all three dormant cores. Over the next few days, hydrogen leaks result in multiple air-chemical explosions which contribute to the release of radioactive material into the area. The response and evacuations were quick, but were they enough?

            Using the "linear no-threshold" model for radiation exposure, the World Health Organization estimated 130-640 cancer deaths that would come as a direct result of the accident. How has that estimate held up so far? 

            For starters, it's still too early to tell since a relatively short time has passed, at least in the context of cancer development. But the region of Fukushima was going to be proactive, so they launched an extraordinary thyroid screening program for children and teens. The thyroid, located just under your Adam's apple, regulates a number of metabolic hormones and is especially vulnerable to radiation induced cancer. The initial reports revealed a surprising number of abnormalities - almost 50% of the children had solid nodules or fluid filled cysts on their thyroids. An environmental epidemiologist grabbed headlines when he reported a 30-fold increase in the number of childhood cancer rates in Fukushima. 

            But many scientists were quick to criticize this finding. The level of thyroid screening in Fukushima was unparalleled, and a spike in abnormal findings is expected given the heightened attention to detail. This highlights yet another challenge in separating signal from noise when it comes to drawing conclusions between environment and cancer. The number of variables to account for is staggering. But this didn't stop the screenings and the research on their effectiveness from happening, nor should it. Even if there are an unexpected number of thyroid abnormalities, we can still learn from the data if it is interpreted correctly. And that seems to be the direction that scientists and doctors are heading. They are redefining what normal thyroids in children look and feel like in medical examinations, and are thus developing a better understanding of health and disease.

            The only issue is the degree to which these screenings may actually have a negative impact on the children and their families. Detecting a thyroid abnormality in the wake of the Fukushima disaster incites great anxiety. Further tests to confirm or deny the presence of cancer can be rather invasive. And treatment, which includes the surgical removal of the thyroid, has been called into question as to whether or not it's the safest medical practice.

            So do we villainize the nuclear industry for repeatedly failing to prevent meltdowns throughout the years? Well, maybe we hold them more accountable through better policy making and regulation, but let's also be careful not to paint the entire industry with a single broad brush. Safer practices and technological developments in this arena may in fact play a huge role in mitigating climate change and cancer risk in the very near future.

Upstream Versus Downstream Medicine

            Okay, let's get back to that idea of reactionary versus precautionary regulation. Except now, let's apply that attitude to the world of medicine and how we treat illness. What do you see? Well, the American healthcare system of course!

            Medical sociologists have long criticized our collective approach to healthcare which they have labelled as "downstream medicine." Let's use a metaphor.

            Imagine standing on the banks of a river when you suddenly notice a person struggling to stay afloat as they drift down the current. Being the courageous and altruistic individual that you are, you jump in to save that person's life. After an exhausting and heroic effort, you pull the person onto land and out of harm's way. But when you look up, you see two more people drifting down and struggling for their lives. Once again, you gather yourself and jump in. Surely, this must be it, you think. But after pulling them out and expending nearly all of your energy, you look up to see a horrifying picture. Hundreds, if not thousands of people are now drifting down the river, and there's no possible way you can save them all. In this metaphor you, my friend, represent the great majority of medical doctors in the US. In your heart, all you want is to help those in need, but you are stretched way too thin as the safety net at the bottom of this river. 

            So, you take a step back and ask yourself, "why are all of these people falling in?" To find the root cause, you abandon your downstream post and track up the river  to find a collapsed bridge no longer providing safe passage over the river. Discovering this upstream cause and working to fix it is the critical step that our nation is struggling to take. This is the focal shift, from downstream to upstream, that is so desperately needed in our healthcare system. It would make prevention the focus of our medical efforts and arguably be as effective, if not more, than the standard chemotherapy or radiation that we use to treat cancer today.

            Furthermore, a refocusing from the downstream to the upstream shifts the burden of responsibility off the individual and onto the industries and agencies that are in place to protect us. Rather than the default question of "what did I do to get cancer?" the more appropriate question of "how can these groups better prevent cancer for all of us?" takes center stage.

The Bad Actors

            In the river metaphor, there are more nefarious reasons for why people might be falling into the river. The cause may not be as innocent as a collapsed bridge, but may include bad actors who are actively pushing people in. I present to you one such actor: Koch Industries.

            In her book Dark Money, Jane Mayer describes the shameless violation of environmental and health regulations by this corporate giant. In 1995, a new federal regulation was introduced requiring oil refineries to reduce their emissions of benzene into the atmosphere - a known environmental pollutant and human carcinogen closely linked to leukemia. 

            Charles Koch, CEO of Koch industries, maintains a strong philosophical opposition to such regulations claiming that his goal is to "unceasingly advance the cause of liberty" in the face of "arrogant, intrusive, and totalitarian laws." So when one of his own employees, an environmental technician, reported that their benzene emissions were 15 times greater than the legal limit, not only was that employee ostracized from the company, but the reports to the government were falsified to show that emissions were just 1/149th of what the technician had calculated. 

            No, Koch Industries didn't get away with it entirely. They pleaded guilty to just one felony charge - "concealment of information" - and paid $20 million in fines. But that number pales in comparison to the profit that that single refinery earned in 1995 alone: $176 million. After the fact, the lead prosecutor remarked, "Environmental crimes are almost always motivated by economics and arrogance, and in the Koch case there was a healthy dose of both." This type of reckless and startling behavior is yet another challenge to be recognized in our pursuit for a cure. 

What Can You Do?

            Invariably, this discussion comes back to what one individual can do in the face of our current environmental and cancer landscape. While there is still much to be learned, there is plenty that we already know. And the first step in any effort to mitigate cancer risk is to educate yourself. Understand which exposures pose the greatest threat and work to minimize them in your daily routine and for those around you. Know that children are far more susceptible to environmental carcinogens, and as such, additional effort should be made to ensure their safety. 

            For a comprehensive list of possible exposures and best practices for prevention, check out what the NCI recommends here.

            Finally, be an advocate for yourself, your loved ones, and your community. If you observe occupational or public hazards that pose cancer risk, don't let it go unnoticed and report it to the appropriate authorities. Call or email your local and state representatives. Encourage them to support public safety measures and funding for epidemiological research. If you live in Washington State, here is the easiest way for you to reach your senators and house representatives

            The effort to solve the problem of cancer must be a collective one. It's vitally important that the public is as engaged in that effort as the leading researchers and doctors. And if humanity's track record for overcoming daunting challenges is any indication, then I am confident that a world without cancer and environmental catastrophe is not only possible - it is indeed quite probable.

Links and References - The Emperor of All Maladies, Siddhartha Mukherjee - Dark Money, Jane Mayer - President's Cancer Panel 2010 report - NCI cancer facts and figures 2010 - Article on developed world and cancer - Fukushima screening aftermath - Fukushima alternative reaction - NCI benzene facts - World War II facts - World War I facts