Processed meats – cancer risk or hype

Bacon is perhaps the archetypical of processed meats – whether typical US or Canadian – it is one of the most identified foods by sight or smell.  Recently, the World Health Organization (WHO) classified  processed meats as a cancer risk, equating it to smoking.  How did they come to this decision, and can we infer the same risk about all meat – processed or not?

What did the WHO say?

The WHO evaluated data from about 800 studies of meat intake and cancer.  About 14 of them were designed well enough to analyze the information.  There were another 15 studies that had strong design to help with the decision-making.  Based on these 29 studies, they found evidence that processed meat increased cancer risk – specifically colon cancer by about 17%.  The data for red meat in general was not strong enough to make an association.

How should we interpret the WHO statement?

The association of processed meats and GI tract cancer has been known for quite some time.  In cultures where these foods are consumed regularly, stomach cancer has had an increased rate, leading to screening programs.  The statement from the WHO adds strength to the association, and should encourage people who have multiple risks for colon cancer to consider their diet as a controllable  risk factor.

What does this mean for most people?

The risks for colon cancer are age, smoking, a low fiber diet, family history and now processed meats.  Just like most health decisions we make, our diets should be modified based on our risks.  Moderation, or occasional consumption of processed meats is a better choice than daily consumption.  Of course, getting a colonoscopy based on your doctor’s recommendation further minimizes the risk of developing colon cancer!

Life is full of choices – moderation and a varied diet seems to be one of the better ones.  In the words of Joe Jackson, “Everything gives you cancer”

The path to wellness begins with a proper diagnosis.

 

Start Spreading the News…

Start Spreading the News…

I am thrilled to announce the next phase in my journey as a Physician.  After 3 years in Arizona, I am returning to NYC and will be practicing at NYU Langone Medical Center’s Internal Medicine Associates.

I have thoroughly enjoyed living in Arizona – it was a wonderful experience for my family, and I have grown as a physician.  I learned new skills, encountered diagnoses that I don’t often see on the East Coast and saw a two health care system merge and deploy a new Electronic Health Record system.  All changes that helped me see the challenges that both physicians and patients face in the coming years.

As I shared the news with my colleagues and patients in Arizona, the response was usually “sad for me, happy for you” and jokes about getting out of 119 degree summer days.  I am grateful for the support I have received!

Since I trained and had been affiliated with NYU since graduating from medical school, the news of my return has been like coming home – incredible enthusiasm from colleagues and former patients alike.  A response that again makes me feel grateful for the relationships I have built over the years – and reminds me of why I chose Internal Medicine as a career.

So I will say goodbye to excellent Southwest fare (best guacamole ever), and hello to Atlantic Ocean sushi, real bagels and pizza!  And look forward to NYC saying “AAHH”

Wishing health and happiness to all, and to more blogging now that my summer of transition is coming to a close.

The path to wellness begins with a proper diagnosis

Personalized Medicine isn’t necessarily Personal

3 months ago our family dog got sick.  Her liver was very inflamed.  The evaluation revealed copper deposits in her liver.  This was likely due to a genetic defect – very common in several breeds in dogs, but not common in hers.  Despite efforts to remove the copper with medication, the damage was too severe, and we lost her about a month ago.
This prompted some research into her family history – one “cousin” died from liver issues, but it was not known if it was copper related. There is a blood test that can see if a dog had the “copper” gene and my wife and I started discussing what we would have done differently if we had known.   
Since cloning the human genome, we have identified genes and mutations associated with cancer, drug sensitivities and the risk of other chronic conditions.  We have also identified mutations that may not have any impact on health, and others that the impact is unclear or unknown.
Using that genetic knowledge to direct diagnosis and treatment is called personalized or precision medicine. It was mentioned in the Federal Budget for 2016 and the National Institutes of Health is dedicating significant research money to it.  There have been several direct to consumer companies offering to read your DNA and tell you what diseases you are at risk for.

How is this done and what can you really learn?  

Precision Medicine assumes that by running a person’s DNA code you will get results that shows what diseases you are likely to get – heart disease, diabetes, cancer, etc.  For those diseases you already have, it can tell you which medications are most likely to be effective.  Plans can then be developed to treat illness and recommend screening programs based on one’s DNA code – offering medications with the best chance of success to those with the proper codes and not giving them to people who are not likely to respond or be at increased risk of toxicity.
There are already examples of this in use today.  We avoid medications in people with certain genetic markers because they are more susceptible to side effects (people may be more or less sensitive to certain blood thinners based on their DNA). Many cancers, from lung to breast to lymphoma and leukemia have genetic markers run to see what treatments are likely to work. Perhaps the most famous use of genetic testing determining treatment is Angelina Jolie.  She tested positive for the BRCA1 gene greatly increasing her risk of breast and ovarian cancer.  She then elected to have mastectomies and her ovaries and uterus removed before any cancer developed.
Genetic based diagnosis and treatment has the potential to change the way we evaluate risk and treatment.  However, checklist testing and treatment is not personal.  Blind application of data to a person without context (history) reduces medical care to algorithms and formula without the personalization it is supposed to offer. There is a social and ethical side to the use of genetic information that we are just beginning to understand, from privacy laws to insurance regulation to job security.  Would you hire someone you knew had an increased risk of and potentially expensive illness if you were responsible for paying for their care?  Would you marry someone knowing their illness potential?  Have children?  These are all issues that need to be sorted out as we move into this new paradigm for healthcare.
Most importantly, people need good information on what their tests mean.  Many of the kits available now report mutations that aren’t clearly associated with disease.  The FDA ordered one company to stop selling its test and services due to non-compliance with testing regulations.  They have since started selling a very specific test for a single condition, but not a general DNA analysis.  The next age of primary care will involve helping people curate and collate their genetic information.

Do I worry that the genetic classification of diagnosis and treatment will make me obsolete?  

To the contrary, I think it can make me better at what I do.  I already strive to get to know my patients, understand how health or lack thereof fits in the rest of their life.  We discuss risk for future disease, concerns about hereditary and what medicines are best for them.  That is personalized medicine.  Getting to know my patients at the genetic level can only strengthen that bond.  Using the information we get from genetic testing and putting it in the context of the person sitting across from me is how we put the Personal in Personalized Medicine.

The path to wellness begins with a proper diagnosis

Reality Check – why an Internist is important

It was a typical Monday for an Internist – lots of phone calls, catching up on results that came in over the weekend, a full office schedule.  I was about to go see my next patient when my assistant said that Dr. X was on the phone about a patient, could I take the call.  I popped into my next patient’s room and told them I’d be 2 minutes – they said no problem and I went to my office to take the call.

The call was from a sports medicine fellow working with a specialist that I’d sent Mr. Smith to (name changed).  I met Mr. Smith about 2 months ago, he had new onset high blood pressure and complained of back pain.  We’d started some blood pressure medication and he was seeing the sports medicine specialist to design an exercise program for his back.  He’d gotten an MRI as part of his evaluation, and instead of showing the expected herniated disc, it showed metastatic cancer – from where, we did not know.  We called Mr. Smith and had him come in the next day to review his scan.

I met with Mr. Smith and his wife the next day.  I took them through the scan findings, explaining what we could and couldn’t tell.  He told me his back wasn’t too painful, and the specialist was helping manage it.  We talked about a plan – blood tests and CT scans to find the source of the cancer.  I told them I’d speak to an oncologist – and arranged his appointment with him.

Two days later, I had the blood work and his CT results, and we met again.  The news was not good – there were extensive metastases in his spine and it looked like lung cancer – though we still couldn’t be sure.  I sat with the Smiths, and we discussed a plan.  They’d be seeing the oncologist in a couple of days, I’d already sent there results over.  We discussed the next steps, what the oncologist would likely do next.  We talked about how he hadn’t been sleeping well, and that I could help with that.

The Smiths left – and I was drained.  It was very emotional telling someone who felt fine they have metastatic cancer.  Yet we both left the encounter optimistic.  The Smiths understood they have an uphill battle, but together they felt informed, guided and supported.

How Mr. Smith does is mostly out of my hands – yet I know I played a huge roll in getting them ready.  I did all the things I love about medicine – bonded with a patient, made a diagnosis, educated them and got them ready for the next steps.  This is Internal Medicine, and why I do what I do.

E-cigarettes – deterrent or path to addiction

Recently, the CDC published its 2014 National Youth Tobacco Survey – which looks at smoking in middle and high school students in the US.  As a physician, but more as a parent of a newly minted teenager, the results were of great interest – and concern.  While cigarette use declined in high school students, e-cigarettes and hookah use tripled – and surpassed cigarette use for the first time.  E-cigarettes are not regulated by the FDA or subject to current tobacco marketing laws – allowing companies to market directly to teens with flavors more like candy than tobacco – something traditional tobacco companies have not been able to do since the 1970s.
The increase is not surprising – e-cigarettes are marketed as safer, they are easier to access and less expensive than cigarettes.  The real question, and one that comes up frequently in the office, is if they can help people quit smoking regular cigarettes, and are they safer?

Are e-cigarettes safer? 

There is not great data available yet.  What we do know is that the vapor produced contains particles that can irritate the lungs, and that it contains chemical byproducts such as formaldehyde – but in much lower concentrations than traditional cigarettes.  They also contain nicotine, the same addictive drug in cigarettes.  Nicotine affects brain development, may promote tumor growth and interfere with chemotherapy.  Nicotine also constricts blood vessels and increases blood pressure.  That increases stresses on any plaque buildup in a blood vessel – a precursor to heart attack and stroke.

Do e-cigarettes help you quit?

Again, the studies are still in progress.  There is some data that smokers who switch to e-cigarettes refrain from tobacco longer than those who try to quit while still using tobacco.  Neither the World Health Organization or the American Heart Association recommend e-cigarettes as a smoking cessation method.  There is no information yet as to whether those who switch to e-cigarettes quit nicotine completely, or have simply switched from one addiction to another.

How does this affect us?

So, while we await studies to more definitively address the safety question, what am I telling patients about safety?  Obviously, the best choice is not using any nicotine product.  If you are deciding between tobacco and e-cigarettes, it is reasonable (but not proven) to assume there is a lower lung cancer risk with e-cigarettes, but no data on oral or head and neck cancer.  However, since there is nicotine in both products, I advise people that there is still similar heart disease risk.  There is also no path to stopping e-cigarettes, unlike other nicotine replacement methods like the nicotine patch – which gradually reduces the dose delivered.  Studies are ongoing, so hopefully we get good information to make healthy decisions.  In the meanwhile, the FDA is seeking ability to regulate these products, and limit their marketing to children.
The path to wellness begins with a proper diagnosis

Annual Physical Exam vs Personal Health Assessment

I read a piece in the New York Times this week questioning the usefulness of a yearly checkup with your doctor.  It cited a study from 2012 that said that people who went for an annual exam did not live longer, avoid the hospital more or visit the doctor less.  A similarly themed Op-Ed piece was written by Ezekiel Emanuel earlier this year.  With all due respect to Dr. Emanuel and the New York Times, I will disagree, although with a caveat.
The usefulness of anything depends on how you define it and the what you seek to accomplish.  A checkup that ticks off boxes on a form for an insurance discount – maybe checking blood pressure, weight, blood sugar and cholesterol may identify some people with a health issue.  A fuller exam that looks at when recommended screening exams and vaccines were last done may increase health care usage, but no one argues that a colonoscopy at the right time in one’s life can be life saving and cost-effective.  Medicare covers an annual wellness exam, designed to identify those things that cost medicare money and increase health expenses – dementia, falls and depression.  It also requires a discussion about advanced directives – what a person does or doesn’t want done if they get too sick to make decisions for themselves.  It does not cover lab work, blood pressure checks or other “problems”.  In fact, there is no “laying of hands” at all.
The argument often cited for the yearly exam is relationship building.  If you see your physician when you are well, it is a chance to know what your baseline is, and later you are not trying to establish a relationship in a crisis.  There are pros and cons to this argument – in a mobile society, when you are young, will you have the same doctor when you get ill?  Or do you view your relationship as an insurance policy?  You have the relationship, and hope not to use it.  If there wasn’t precedence for this, wouldn’t we only buy auto insurance after the accident?  Or do you view your physician as a trusted advisor, investing in your health like you might your financial portfolio, with regular review to try to optimize things?

So what do I think of an Annual Exam?

The issue with studies on physical exams are multiple – inconsistent definitions, goals and outcomes make it hard to compare results from various studies.  Besides the studies the NY Times quoted, there are several studies that show recommended screening occurs more in people who come for annual physicals, and that there are health benefits – such as identification of high blood pressure – which has no symptoms and won’t be found until it is too late.
I believe in a yearly checkup.  However, I think the definition needs to change, and it has a very specific goal.  Personal Health Risk Assessment.  All the studies are based on large populations, and when I am with a patient, the most important thing is that person across from me.  We can use population data for a discussion, but what really matters is your risk.  So I like to use the opportunity of an annual exam to go through a person’s history, family history, social history and medical concerns.  Using that information, we can use population studies and decide what studies are appropriate for you!  We can look for the things you are at highest risk for and are most concerned about.  We can decide on a risk reduction plan once we have testing data back.  Can I guarantee you will be healthier for it? No, life does not come with guarantees.  We will be able to say that we identified your risks and did our best to reduce them.  We come away with information and recommendations that are specific to you.  I know your health risks, fears and concerns, and can provide advice that addresses them.
Will you live longer for our time together?  I don’t know.  Can you live better for it – absolutely!
 The path to wellness begins with a proper diagnosis
 

Stop Counting Cholesterol? New Dietary Guidelines say so

At the end of 2014, The Dietary Guidelines for Americans Council issued its 2015 guidelines and analysis of what we should eat, what we do eat, and what the consequences of what we eat are.  Many of the recommendations and observations are what we expected – we eat too much sodium and sugar, not enough fruits, and are overweight.  What was surprising is that they do not recommend watching cholesterol intake any longer – saturated fat yes, but cholesterol, no.

What did the report say?

The main thrust of the report emphasizes a diet with lots of fruits and vegetables, whole grains, low in saturated fat.  Limiting processed meats, refined grains (white bread) and drinks with added sugar is also recommeded.  Good food such as seafoods, nuts and legumes, as well as low-fat dairy are emphasized.
Notably, the report for the first time removed the recommendation to limit cholesterol intake.  Prior recommendations were to limit cholesterol intake to under 300mg daily.  Instead, it is recommended to limit saturated fat and empty calories such as processed sugars.  It is these foods that are contributing to obesity and its consequences much more that dietary cholesterol.  Added sugars and saturated fat should be < 10% of total calories in a day.
Saturated fat has 9 calories per gram.  So in a 2000 calorie diet, saturated fat should be limitied to 22 grams daily.  Sugar has 4 calories per gram.  In the same diet, sugar should be limited to 50 grams daily.
For a real world example, a Snickers bar has 250 calories.  That is over 10% of a 2000 calories diet.  It has 4.5 grams of saturated fat, which is 20% of daily recommendation, and 27 grams of sugar, which is 54% of the daily recommendation!  By contrast, 2 scrambled eggs has about 200 calories and the same amount of saturated fat, but only 2.1 grams of sugar, or about 4% of the daily recommendation.

So what does this mean?

The report brings dietary guidelines more in line with current research.  We have seen several studies showing the benefits of a Mediterranean style diet – high in fish, nuts, vegetables and good fats such as olive oil.  The guidelines now support those findings.  It means a heart healthy diet can include some fats, and should limit the empty starches – those made with refined flour that add little nutrition but many calories.  It means that moderate intake of eggs and lean meats is healthier than meals based on breads, rice and pasta.
Perhaps the best news in the report (at least for me) is that up to 5 cups of coffee a day does not seem to be harmful!!!

The path to wellness begins with a proper diagnosis 

Challenge Completed

So many people start the New Year stating what they wish to accomplish, without reflecting on the past year. So for my first post of 2015 I’d like to reflect back on the first year of TheDiagnosisMD.com – and a challenge I undertook.

In the first year of my blog, I posted 34 times – with over 3400 views from 76 countries! Reflecting on what I posted, and the responses I got will help me shape 2015.

My goal for 2015 with TheDiagnosisMD is to make it educational, useful and fun!

In January of 2014, I ran the PF Chang’s Rock n Roll Half Marathon, with my running partner, Dr. Craig Primack. After the race, he suggested we try to run one half marathon a month for 2014. I accepted the fitness challenge. Two weeks later, on a cold morning in Sedona, we ran our 2nd half marathon of the year. It was a fun race, but we had not trained for the hills in Sedona!

After another organized race in March, schedules and races became difficult to match up, so we mapped out several 13.1 mile courses near our homes, and, on December 20, 2014 we completed our 12th Half Marathon in 2014.

Training for this, I ran over 545 miles and 83.5 hours. I went through 4 pairs of running shoes, several minor injuries and 4 toenails. The injuries have healed, and 3 out of 4 toenails are normal again.

So what did I learn?

Consistent long distance running is great for cardiovascular endurance. I have no doubt that at any time I could go run 13 or so miles without worry. However, from an overall fitness perspective I’m the same as I was in January of 2014. Same weight and non-running strength!

When I knew I was running long distances on the weekend – I found it mentally difficult to go for a 3 or 4 mile run during the week – it didn’t seem worth it if I couldn’t run 6 miles – so I ended up stacking the runs and concentrating things on the weekends. So there was less balance to my overall activities.

I’ve always told my patients that moderation was the key to success for health. So it’s time for this physician to heal himself. My goal for 2015 is to be more balanced in my fitness and in life. Challenge accepted.

I look forward to writing more about the topics you are interested in – so let me know what you’d like to learn about!

Wishing you health and happiness in 2015.

The path to wellness begins with a proper diagnosis.

Got Milk? Too much of a good thing?

The USDA recommends 3 cups of milk or dairy a day.  This is mostly to promote bone health.  However, it has also been linked to increased cancer risk in some studies, others have supported health benefits.  A recent study tried to sort out these conflicting results by separating milk from other dairy products and looking at death rates, heart disease, cancer rates and fractures.
What they found was surprising – adults who drank 3 or more glasses of milk a day died sooner, had more fractures as well as heart disease and cancer.  Those with similar dairy intake, but from fermented dairy like yogurt, cheese, sour milk, etc. had a lower incidence of death and disease.  The difference?  Lactose content.

What is lactose?

Lactose is a sugar found in milk.  When digested, it is broken down into glucose and galactose.  Galactose has been linked to oxidation and inflammation – triggers for disease.  The study authors hypothesized that the difference in lactose, therefore galactose intake with milk versus other dairy products is the cause of the difference if death and disease

What did they do?

The researches used 2 health registries of residents in Sweden where records are centralized, totaling over 61,000 women and 45,000 men and sent them questionnaires that looked at milk and dairy intake.  They then followed their records from the early 1990’s until now, looking at death and disease rates.  What they found was that women who drank 3 or more glasses of milk daily were:
  • 1.9x more likely to die
  • 1.4x more likely to get cancer
  • 1.6x more likely to fracture a hip
In men, the effects were less pronounced:
  • 1.1x more likely to die, mostly from cardiovascular disease
  • no increase in fractures
They also messed marks of inflammation and oxidation in the blood of participants and found higher levels of both in those with higher milk intake.

So what does this mean?

There are some interesting associations based on this study.
  • ingestion of milk, with it’s higher lactose content, may be linked to increase risk of disease
  • ingestion of low lactose dairy products (yogurt, cheese) is associated with a decrease of disease
  • moderate intake of milk is not associated with increased disease risk

There are some limits to this study

  • the data is based on 1 or 2 food surveys, and subject to people’s memory and answers
  • the population studied was very uniform – 2 or 3 counties in Sweden – which may limit generalizing to the population at large
  • All subjects were over 39 years old so no conclusions can be made about children and young adults
  • Lactose free milk was not evaluated

What can we take away from this?

  • High amounts of lactose may contribute to disease based on its breakdown into oxidation and inflammation promoting compounds
  • Dairy foods with low lactose contents are associated with lower death rates and illness
  • Moderation again seem to be the word of the day – it is possible to have too much of a good thing!

The path to wellness begins with a proper diagnosis

Breast Cancer Screening – In October We Wear Pink

It’s October and that means post-season baseball, (sorry Yankees), football season is in full swing and it is Breast Cancer Awareness month. Many athletes, celebrities and people affected by breast cancer in some way are sporting pink clothes or accessories and advocating for breast cancer screening. Why has breast cancer gotten such universal recognition in the US?

Breast Cancer Statistics

  • 1 in 8 women will get breast cancer in the US
  • About 300,000 women will be diagnosed this year
  • About 2300 men will be diagnosed as well
  • 40,000 women will die from their cancer this year – a death rate that is decreasing due to early diagnosis and treatment advances
  • Breast cancer is the 2nd most common cancer in women – the first is skin cancer
  • Breast cancer is the 2nd leading cause of cancer death in women – the first is lung cancer
  • 2.8 million women in the US are either living with breast cancer or post treatment
  • having a 1st degree relative with breast cancer doubles breast cancer risk
  • 85% of women diagnosed have no family history
  • 8-10% of breast cancers are linked to a genetic risk such as the BRCA gene
    • BRCA-1 carries a 55-65% risk
    • BRCA-2 carries a 45% risk as well as an increase in ovarian cancer risk

Breast Cancer Screening Guidelines

Given the number of women affected by breast cancer, as well as the high death rates and the fact that early detection and treatment have improved survival, one would think there would be little debate about the value of breast cancer screening. However, there are conflicting guidelines regarding screening – what age to start, when to stop, and how often to test.

The American Cancer Society (ACS) recommends yearly mammograms beginning at age 40 and continuing as long as a woman’s health and activity level make it feasible to continue.

In 2009 the US Preventive Services Task Force (USPSTF), a key driver of guidelines in the US, changed its recommendation from the ACS guideline to mammograms starting at age 50 and repeating them every other year, stopping after age 74, and eliminating self breast exams.

This change caused a lot of confusion and backlash, and later the USPSTF “softened” its recommendation to include a section stating that all women should discuss the risks and benefits of breast cancer screening with their doctors and make a decision based on their individual concerns.

So there are somewhat conflicting guidelines, but a decision about breast cancer screening should be based on your preference, your doctor’s assessment of your risks and likely your insurance company’s willingness to pay.  As of now, there have not been any major changes to the reimbursement of mammograms.

So how do we screen for breast cancer?

The main screening tool we use is a history!

  • What age did you start menstruating
  • Do you have a family history of breast cancer
  • Have you had breast surgery
  • Have you ever been pregnant

The answer to these questions add context to the next part of screening – a mammogram. A mammogram is an x-ray of the breast taken from 2 angles with the breast pressed against the machine to give a standard view. That image is evaluated for irregularities that suggest cancer.

There are many variables that go into a mammogram – size of the breast, age, and density are several. Density describes the ambient of breast tissue and fat in a breast. Denser breast make it harder to detect abnormalities on a mammogram. Denser breasts tend to be found in younger women, those who never had children, and athletic women. When this occurs, adding an ultrasound of the breasts can improve the reliability of the results.

MRI has been looked at recently as a screening tool – attractive because it does not use radiation, and can create very detailed images. Therefore, it can detect much smaller abnormalities. Currently this is only recommended for very high risk women.

Another technology recently developed is called Digital Tomosynthesis. Similar to a mammogram, the breast is pressed into position but 11 x-rays are taken instead of two. The images are fed into a computer and a 3-D image of the breast is created and evaluated for abnormalities.

MRI and tomosynthesis are not currently recommended for routine screening.

What do I tell my patients?

  • Every patient is unique, and needs their risk factors evaluated
  • Based on the risk assessment, a mammogram and possibly an ultrasound will be ordered
  • I reserve MRI and tomosynthesis to those women with very high risk
  • Breast implants do not change the need for a mammogram – the implants can be maneuvered out of the image so the breast can be assessed

After the study is done, we will decide when to repeat it – usually yearly based on the ACS guidelines.

One important aspect of breast cancer screening that is overlooked is communication – any test, especially one looking for cancer will provoke anxiety, and I try to get results to my patients as soon as possible. In fact, reducing test anxiety was one of the reasons the USPSTF recommended less testing!

Often there will be an area that was not well seen on the mammogram. In this situation, close up views of the area need to be done – called spot compression views. This does not mean you have cancer – it means a closer look is needed.

Regardless of which screening guideline one follows, one thing must be stressed – if you feel something that does not seem normal to you – bring it to your doctor’s attention! Breast tissue does change and often develops cysts (tender lumps) throughout the menstrual cycle, and where you are in your cycle as well as caffeine intake can influence cysts.  These changes tend to go away at the end of a period. When there is a lump – especially if it persists through a complete menstrual cycle – it is not considered screening and all guidelines stress the need to further diagnose a lump – regardless of age. When discussing self breast exams with my patients I tell them to learn what is normal for them – all breast tissue has some irregularities. If something is different from your normal, see your doctor. It may be nothing but all evidence shows early detection improves outcomes – and ignoring a lump will delay things – either peace of mind that everything is ok or the opportunity to find a cancer early.

The path to wellness begins with a proper diagnosis