Photography by Paul Nordmann
Matt Powell’s medical career started with a football injury his junior year in high school. His knee surgery fascinated him. Then, in senior year, he did assays for a research project, helping pinpoint the level at which radiation causes cell damage. (Pretty advanced stuff for a high schooler, but he lived near Hanford, Washington, where plutonium was manufactured for the world’s first nuclear bomb.)
By the time Powell reached med school, he was headed straight for surgical oncology. His future wife wanted to specialize on ob/gyn, so he figured that’d be her deal, not his. But during his ob/gyn rotation, he discovered gynecologic oncology, a field that let him be involved in all facets of care: surgery, chemo, even end-of-life. He liked the idea of getting to know his patients over time, and he liked their attitude. Instead of grumbling, resisting help, or clinging to bad habits, these women were eager to do whatever they could to be healthy.
Now a gynecologic oncologist at Washington University and Siteman Cancer Center, Powell’s followed some of his patients for a decade. He’s also made a name for himself as a surgeon: He was the first in Missouri to use the da Vinci robotic system on cancer surgeries, and he’s one of the few doing fertility-sparing surgeries for patients with cervical cancer. For prevention, he urges healthy living: ““Smoking cessation, number one. Diet and exercise, especially for those who are obese or eat too much simple sugar.” Higher insulin levels stimulate cells to grow—and that includes cancer cells.
Powell’s running a clinical trial with his patients, recording outcomes for those who eat a lot of colorful fruits and vegetables. “It’s clear that people who eat two or three servings a day tend to have less cancer. Now, does that mean they’re just people who are paying more attention to their health in general?” He’s puzzling that out empirically.
As for the wilder remedies his patients’ friends urge on them, like shark cartilage, “there’s not a lot of evidence,” he warns them. “I’m not even sure it’s true sharks don’t get cancer!” Powell resents profiteering—“Cancer’s big business”—but remains open-minded. He’s glad to see the National Institutes of Health doing serious studies of complementary medicines and second-guessing traditional recommendations, like taking calcium to prevent osteoporosis. “A lot of the supplementations we’ve been recommending may not be necessary.”
What about all the vitamin, oil, and mineral supplements touted to prevent cancer? “We’ve tried food supplements, but we haven’t found that they necessarily decrease cancers, and in some cases they increase them,” he says. “There’s just not a magic pill that can equate to healthy living.”
Yet if patients try to blame themselves after a cancer diagnosis—they shouldn’t have been so stressed out, shouldn’t have eaten so many Snickers—he stops them. “Cancer is an accumulation of gene damage, and I don’t think at this point we will know why it happened. I don’t think it’s anything you did. It’s often bad luck.”
And genes.
As we all now know, actress Angelina Jolie carries a defective gene, BRCA1, and her doctor estimated that she had an 87 percent risk of breast cancer and a 50 percent risk of ovarian cancer. When Powell heard she’d decided to have her breasts and ovaries removed, he was impressed by her courage—and glad to have her example raise awareness.
“BRCA1 and BRCA2 act like proofreaders,” he explains. “Once our cells divide, they make sure there is no error in that division. Normally, we each have two good copies of those genes. When you have a mutation, as Angelina did, you’re born with one damaged copy, so if you lose the other one, you’re in trouble.
“Women start to get ovarian cancer and cancer of the Fallopian tubes beginning around age 35,” he continues. “So she had a little bit of time to make that next decision” (to remove her ovaries). “Because she’d had a double mastectomy, she was quite protected from breast cancer, so her doctor could add back estrogen, and she wouldn’t be thrown so abruptly into menopause.”
Twenty years ago, Jolie couldn’t have known she carried a defective gene. It wasn’t until the mid-’90s that a genetic test became available. That’s when women began having “risk-reduction” surgeries—or at least regular ultrasounds and CA-125 blood tests, if they were at high risk of ovarian cancer.
“I think we’ll find that ultrasound and CA-125 are nearly useless,” Powell says. “All that’s going to do is find cancer once it’s already set in. We don’t have a good preventive test for ovarian cancer, because it arises from the end of the Fallopian tube; it’s not in a contained environment.” When he does a risk-reduction surgery, especially if his patient’s over 50, he often sees very early cancers—“They look like mold on bread, little spots that grow”—on the end of the Fallopian tube. “It would be a long time before they’d ever show up on a CAT scan or ultrasound. Often these little cells will spread throughout the abdominal cavity before we can even detect them.”
In recent years, doctors have learned to take the Fallopian tubes along with the ovaries—and sometimes take the uterus as well. It’s a radical step; I ask Powell how he’d handle the calculus of risk and loss himself. Say he had a good chance of developing cancer in his right arm? “That’s a great question,” he says slowly. “The hard part is that until you’re really faced with that situation, it’s very difficult to know how you would reply. As a surgeon, my hands are really important… I might choose to have some risk.” OK, what if the risk only involved his left foot? He sighs. “Yeah, again, these are really hard. Losing a limb—or losing your ovaries, or a portion of your intestines—there’s no one answer.”
Every situation’s different, every person’s different. Recalling patients who’ve chosen surgery, Powell says, “The fear of developing cancer—we can’t overestimate how damaging that can be to a person’s quality of life.”
Meanwhile, he encourages younger women at extra risk for ovarian cancer to have their children a little earlier than they might have done, and if they’re not trying to get pregnant, to take birth-control pills. “Five years of use cut a woman’s risk in half.”
Why?
“Probably because they turn ovulation off,” he says. “When a woman ovulates, the surface of the ovary is damaged, and there’s an inflammatory response.” Cells fly to the site, carrying enzymes that might cause chronic irritation to the cells, even as they prompt the ovary to repair itself.
Which almost makes ovulation sound a little sinister.
“It’s a normal process,” Powell says, “but the female body was not designed to ovulate nearly as much as it does in modern women.” In past centuries, women spent long stretches of their adult lives pregnant or nursing.
Powell chairs the quality outcomes committee for the Society of Gynecologic Oncology. As we went to press, they were finalizing national standards for the care of women with ovarian, uterine, and cervical cancer, in partnership with the American College of Surgeons Commission on Cancer. A study released this spring showed that almost two-thirds of women with ovarian cancer are not receiving the best possible care, “and cervical cancer care is often substandard,” Powell says, “because the centers equipped to take care of it are fewer and fewer.”
In the next five years, he’d like to see better care for women who don’t have access to the specialists at cancer centers, more data about the support genes alongside BRCA1 and BRCA2, and more knowledge about cancer prevention.
“There are plenty of other complicated conditions to treat,” he says. “When it comes to cancer, I’d like to be put out of work.”
