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Q&A: Complex lessons about cancer risk from Holocaust survivors

Dr. Beti Thompson discusses studying the links between extreme traumatic events and disease

July 12, 2017

Dr. Beti Thompson heads the Health Disparities Research Center at Fred Hutch.

Photo by Robert Hood / Fred Hutch News Service

Throughout her research career, Dr. Beti Thompson has explored the rough edges of our health care system, calling out the inequities that set poor people and minority groups aside and lead to disparities in disease burdens, access to care and lifespan.

At Fred Hutchinson Cancer Research Center, she heads the Health Disparities Research Center, which explores those barriers to care and searches for ways to narrow the health care divide at the community level.

As the daughter of a Dutch mother who endured famine under Nazi occupation in the final winter of World War II, she has always held an interest in the long-term health consequences of trauma and deprivation. When she learned that the journal Cancer was going to publish an Israeli study of cancer risk in Holocaust survivors, she saw a connection between that study and her lifelong work with the underserved. With Drs. Sarah Gehlert of Washington University in St. Louis and Electra Paskett of The Ohio State University, she co-authored an editorial on the topic that was just published in the same issue of the journal.

The Israeli study, the largest of its kind, found a “small but consistent increase” in cancer risk among 153,000 Holocaust survivors, with higher risk in particular for lung and colorectal cancers. In their accompanying commentary, Thompson and her co-authors reviewed the complexities of studying how war and other large-scale tragedies could influence cancer risk. They noted similarities between such intense traumatic experiences and the social, emotional and physical stress of people living in extreme poverty.

“We observe a parallel with the disproportionate exposure to stressors at the neighborhood and community level experienced by some racial minorities in the United States,” they wrote, and said more research is needed “to untangle these complex phenomena.”

In an interview following publication of the editorial, she explained how the study of the long-term health impact of one of history’s most horrendous events ties into her work today.

What lessons can we draw about cancer risk by studying this large group of Holocaust survivors?

I think we can learn that extreme stress-related events, no matter where they occur, can have implications for later cancer incidence and mortality. This group is interesting to study primarily because the scientists in Israel have done an outstanding job of keeping records, of tracking what happened to the survivors. It’s very hard to get the kind of information they did in Israel, with that kind of precision.

This Holocaust study takes us out of the lab and into a place where human beings do awful things to others. Can war be described as a kind of natural experiment, where circumstances that no one would wish for can create conditions that scientists can measure, analyze and maybe learn from?

What actually happened with this analysis of survivors was a natural experiment. All of the work we talk about in the editorial is a natural experiment, and more of these are happening every day. In Syria today, and in other places where there are many refugees, they are also experiencing this extreme stress.

Does this new paper change what we know about the impact of extreme, traumatic events on cancer?

It’s a very complicated question, and we don’t have any easy, straightforward answer to it. I wish I could say we know exactly why there are excessive cancers in these populations. But we’re not really sure why. In the cases we’ve talked about, there is a lot of stress in extreme situations. One of the things we know is that there are lots of ways that genes can be affected. One of the ways is stress. Another way is by poor nutrition, another is by environmental exposure. If you have an extreme situation, chances are that genes are affected, and that can lead to malignancies.

That study showed an increased risk for colorectal and lung cancer among Holocaust survivors, but not an increase in risk for breast cancer. A Dutch study showed a strong association between a severe famine during the war and breast cancer, while a Norwegian study did not. Why are the results so different?

It was worse for the women in the Netherlands compared to Norway. I personally think it had to do with the amount of nutritional deprivation. It was a matter of extreme vs. moderate. In Norway, women received three-quarters of their average daily nutritional intake, while in the Netherlands it was less than half what their average nutritional intake would be.

But it is very convoluted. Breast cancer involves so many factors. There is some link between breast cancer and obesity, so when you have famine, you have nutritional deprivation and less obesity. Breast cancer risk is affected by diet, by body composition, and by the age when a young girl hits puberty and starts menstruating. If she is suffering from food deprivation, it can affect when she achieves menarche, and that can shorten lifetime exposure to estrogen, reducing breast cancer risk. … That all makes the breast cancer question more complex.

The Israelis did a great job of keeping records. So did the Dutch, for the women who experienced the famine. They did a marvelous job of going back to those women, asking them how much deprivation they experienced, and they were able to link to a significant increase in incidence of breast cancer. Not all countries do this. Their increased risk is not the only issue. There are other studies of women famine survivors who were pregnant, of their offspring, and of problems their offspring experience. There is some evidence that the effects do not stop with the child but also have an impact on the subsequent generation.

You identified a parallel between the experiences of Holocaust survivors and those who live in extreme poverty in the United States. As someone who studies health disparities here, what sort of health effects have you observed that highlight those parallels?

People who are underserved are more likely to suffer from a variety of chronic diseases. The link is definitely there for cardiovascular disease and diabetes. The link between the underserved and cancer is more complicated. It varies by minority type, by level of deprivation. We know there is a lot of deprivation for people who grew up in poverty during their development years, but unfortunately, we do not keep good records.

Your mother was living in the Netherlands under Nazi occupation, during a severe famine, when she was pregnant with you. How did that shape your interest in this field?

The reason I find this field so exciting is because of my own in utero experience, of which I remember nothing! I have a son-in-law, who is a neurobiologist, and we frequently talk about the Dutch famine; so when I learned of the Israeli study, that led me to collaborate with Sara Gehlert and Electra Paskett on the editorial. The more I got into it, the more I realized it was such a complicated issue, but it can explain a lot of the disparity is cancer we see today. It fits with everything I’ve been studying for years.

Sabin Russell is a staff writer at Fred Hutchinson Cancer Research Center. For two decades he covered medical science, global health and health care economics for the San Francisco Chronicle, and wrote extensively about infectious diseases, including HIV/AIDS. He was a Knight Science Journalism Fellow at MIT, and a freelance writer for the New York Times and Health Affairs. Reach him at srussell@fredhutch.org.

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