E71: The Environmental Domain of Stress

Kirtly: Wow. Sometimes we do things that are harmful to the environment and sometimes the environment has harmful consequences for us. And you can hear it in my voice right now in that I'm a little bit sick. Anyway, this is stressful, and becoming increasingly so. Not my voice, but the fact that the environment is under stress and so are we.

Whether the weather is too hot or too dry or too wet, or the water we drink or the air we breathe is too polluted, or there are microplastics in everything and in our bodies, this is stressful.

Welcome back to the 7 Domains of Stress, and we're talking about the environmental causes of stress.

I'm Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah, and I'm a reproductive endocrinologist. So I've been thinking about the environmental stresses on fertility and pregnancy for over 30 years, and I am stressed out about it, but I'm getting better.

With me is my co-host in stress, Katie Ward. She is professor in the College of Nursing with a doctorate in nursing practice, and a specialty clinical interest in midlife women's health. All about health.

Katie, what are your thoughts about environmental stressors?

Katie: I love the way you've framed that, Kirtly. I think a lot about my responsibility to the environment, and it is a little bit different to think about really taking that on personally for my own health.

I love to travel and then I feel guilty about the carbon footprint that I'm creating when I do travel. So as a consequence, I've kind of taken a personal mission of doing everything I can when I'm at home to produce a smaller carbon footprint.

So I've put solar on my house and I generate my own electricity for my house. I've swapped out all of my yard equipment for little battery-operated machines that don't produce the air. Even my snowblower, which was a bit of a downgrade, but I feel good about it when I use it. And also better for my own health, because I'm the person using the machine that's polluting.

Then I ride my bike to work as much as I can. So I do make adjustments in terms of thinking about my contribution to the environment. But we're going to talk a little bit more about when the environment comes home to you.

Kirtly: Right. Well, we could talk about the existential threat and stress of climate change. We've had a podcast on climate grief in the 7 Domains of Grieving. So if you're grieving the environment is stressed out, you may want to check that one out.

But those climate changes have some immediate risks to our health, and there are risks in our environmental exposure to air and the things around us that are personal.

I'm the daughter of a uranium geologist who worked underground in uranium mines before the mines were ventilated here in Utah. And my dad had high radon exposure the way all the miners and geologists did. Many of those men developed lung cancer on average 15 years after working in the mines. And my dad died young of lung cancer 15 years after working in the mines.

So I am pretty stressed about the risks to my health and the health of people I love, and the women I took care of from the stuff we breathe, including air pollution.

So to talk about this in a very personal way, we are joined today by Ann Deneris. Ann is a Clinical Professor Emeritus from the College of Nursing, Nurse Midwifery, and Women's Health Nurse Practitioner programs. And she's a practicing certified nurse midwife for 40 years, recently retired for reasons she'll go into.

She has a PhD in health education, which has guided her teaching, clinical, and personal life. And she's been a teacher and friend and inspiration to Katie and me for many years.

Kirtly: Thanks for joining us, Ann.

Ann: Thank you.

Kirtly: Ann, can you talk to us about your own experience with lung cancer?

Ann: Well, it was December of 2018 and I was feeling a lot more fatigue, exercise intolerance. I'd always walked up four flights of stairs from where I parked to my office and was finding that more difficult. Hikes were getting harder to do, and then this odd cough. And it wasn't like a cough you have when you have a cold. It was almost like somebody was squeezing my lungs.

Then you invited me to join you at your table with Utah Physicians for a Healthy Environment. And the speaker that night was Dr. Pope from BYU, who had done some worldwide studies on air pollution and lung cancer. So that really struck home because how I reduce stress is by walking or hiking just about every day.

So I had a trip planned to Iceland. I wasn't going to go to a doctor before that. Well, it just started mid-July and we had all those horrific fires in California, and so the smoke was here. I thought maybe the cough was due to the air pollution.

So when I got back, I made an appointment. Well, actually, I made the appointment before I left. Went in September to my family practice doctor, and she did an X-ray, which showed that my upper left lobe was a complete white-out with a ground glass appearance.

And she said, "Well, it could be that you've got an infection." So lung cancer was not mentioned. She said, "We'll repeat your X-ray in a month." Came back, still there. She scheduled a CT scan, which then showed a four-centimeter tumor.

Kirtly: That's big.

Ann: Yeah, it's pretty big. I was not an advocate for myself during this time. Katie, a colleague, friend, and my provider, came to my office shortly after that second X-ray and said, "This could be lung cancer."

Kirtly: Oh, Katie, you did it.

Ann: And I looked at her and I said, "There's no way. I've never been a smoker. I test my house for radon. I am completely healthy."

Katie: And pretty much the healthiest person I know, really. Your health habits are always just exemplary and always have been.

Ann: Thank you. Of course, then they scheduled a bronchial biopsy and they didn't get any cancer cells. So then they scheduled a chest wall biopsy, which is a lot scarier.

Kirtly: So hold on. That's where they take a needle and they put it through your chest. I mean, through your skin, into your lung, so they can take some tissue. And that's moderately terrifying.

Ann: Yeah, at that point I'm beginning to realize this is a lot more serious than I ever thought. And this was the week of Thanksgiving that they did the bronchial biopsy, so I couldn't get the results.

The pulmonologist right after Thanksgiving said, "Well, we need to do this chest wall biopsy." That took place around the 1st of December. And then on December 7th that year, I found out I had lung cancer, which was a complete and total shock to me.

So even though I was beginning to think, "Okay, this is something serious," I still hadn't wrapped my brain around it. I was still in some denial. It was pretty shocking.

I still had to finish out the semester. And I was interim program director, so it was a lot of work.

Fortunately, there was a cancellation on the schedule. Initially, they told me it would be five to six weeks before they could do surgery, but fortunately they had an opening on December 27th, so two days after Christmas.

Oh, they also did a PET scan in that time. A PET scan is a scan of your entire body. And again, this is where the four-centimeter mass was found, but they didn't see anything else. So they told me that I was either stage 1A or 2B before going into surgery. They also told me they had a brand-new procedure where you'd make three little tiny incisions and by robotics take the entire lobe out.

Well, unfortunately, they punctured my pulmonary artery.

Kirtly: Oh, Ann.

Ann: And fortunately, repaired it before I bled out. But my family was waiting for me, and what was supposed to be an hour-and-a-half surgery turned into five hours. Ended up with two chest tubes, which were in for three weeks. My hematocrit plummeted, so I was pretty anemic. And that led to a difficult recovery as well. Then instead of a 3-day stay, it was a 10-day stay at Huntsman and they were excellent.

But I will never forget the surgeon coming in to talk to me on about Day 3. I was alone, and of course, lots of narcotics. He sits down to talk to me, and again, I'm expecting Stage 1 or 2. And he said to me, "We found a positive node in your mediastinal area," which is the center of your chest, "and this particular node acts like a Stage 2A." So in my adult brain, I didn't wrap my head around the fact that I'm actually 3A.

Kirtly: Which means that the cancer had gone from this walnut-size lump, which is kind of big in your lungs, and it had spread, and it spread to your lymph node. So that upgrades your cancer grade or stage.

Ann: Yeah, but I didn't understand it. I mean, I really didn't. So to colleagues, I told them I was Stage 2A. And it wasn't until I saw my oncologist about two and a half weeks later that I actually was able to wrap my head around it was 3A. I'm still in shock. I'm pretty ill during this time. I just wasn't processing. I should have known as a healthcare provider, of course, it's in your lymph nodes. It's not Stage 2 anymore.

What I realized after that initial diagnosis while I was waiting for surgery, knowing that the environment can actually cause mutations in our cells within our body, was that I wanted the tumor tested for genetics, the genetic markers of the tumor.

That's when I found out that I had EGFR, which is epidermal growth factor receptor, that is somehow activated by the environmental pollutants.

And we know now in women that they're much higher risk for this type of non-small cell lung cancer than men are. Asian women are particularly at risk.

There was a treatment for it called TAGRISSO. And I asked about it, but at the time the FDA did not approve it for anything more than Stage 4 because it hadn't been out that long. It was also $18,000 a month.

And my oncologist at the time said, "It only works for a certain period of time and then it stops working and the cancer comes back, and we need to save it until you perhaps become Stage 4." He told me also that at 3A, my risk was 50/50 of it coming back.

Kirtly: Well, before everybody starts crying, for those of you who didn't do the arithmetic when Ann started, this all happened about seven years ago, plus a couple of months for all this to happen. So she's still smiling, looking great, beautiful as always. There's a story. I don't want people to get so depressed that they don't want to listen anymore. So keep going.

Katie: It's a happy ending.

Ann: So I was supposed to be interim program director until the end of the school year, but I was so sick through chemo and radiation, I just couldn't come back. I was just too ill. Katie and another colleague had to pick up my workload, which I still feel guilty about these days . . .

Katie: No, don't.

Ann: . . . as women often do when there's a burden to others.

Fly forward two years, it was now December of 2021. I was having every two- to three-month CT scans at that point. And the CT scan in December showed tumors in the contralateral lung, which is the opposite lung, in the lobes on the right side everywhere. They were pretty small.

I got the CT scan report before my physician read it, Dr. Akerley, and I knew what it meant. So I was prepared when he and I spoke about next steps.

Tumor cells, for them to actually make the diagnosis of cancer, have to be about five to six millimeters or bigger. Mine were four millimeters or less. So they hadn't called it as Stage 4 at that point, but I knew that's where it was heading.

Coincidentally, that month, the FDA approved TAGRISSO for both Stage 2 and Stage 3. So when Dr. Akerley and I spoke, I said, "I want to go on to TAGRISSO immediately."

This December, if my CT scan is negative in December, it will be four years since I was diagnosed with Stage 4 and still in remission.

The unfortunate part about it after three years, because that's when usually TAGRISSO has failed, I asked Dr. Akerley, "Does this mean that I am less likely going forward having lung cancer in the future?" And he said, "Oh, no, it's just the opposite with lung cancer. Each CT scan that's clear means the next one has a higher risk for being positive."

Kirtly: Oh, that's heavy.

Ann: Yeah, that's pretty heavy. I have to have a brain scan once a year, and I know if that's ever positive that it's pretty much over, because there aren't any good treatments for brain cancer.

Kirtly: For brain cancer that's metastasized, that's grown from lung cancer.

Yeah, I remember when I heard your original diagnosis and my own family . . . My father and my stepfather had lung cancer, the kind that happens to guys and it happens with radon. Of course, this was years ago, but it was lethal immediately. I mean five or six months.

I just couldn't get my heart around losing you. You're so young, and every time I saw you, you looked so great. So I've got my fingers crossed, of course.

Ann: Dr. Akerley told me at the last visit if I can hang in there for another 18 months, there are some really exciting therapies that are coming, which are geared more towards a cure for lung cancer. How about that? Instead of just treatment and hanging on as long as you can.

It still is the deadliest cancer not only in our country, but around the world. And one of the reasons why is that the symptoms are so subtle until it gets to its later stages.

Kirtly: I think I'm going to step here just a little second and remind listeners that although women are deathly afraid of breast cancer, in fact the number one cancer killer for women is lung cancer. And the majority of those women were not smokers.

Women always think that lung cancer is a guy's thing or a smoker's thing. And in fact, no, it's a girl's thing. We need to treat women's lung cancer diagnostically and therapeutically a little differently, as yours was. Yours was treated differently.

Katie: It's one of those things about your story, Ann, that sort of breaks my heart, is I know how much time you spent researching your cancer and learning about it and advocating for yourself. I think for a lot of women, they don't have the access to that information.

Kirtly: But they have this podcast.

Katie: They do.

Kirtly: So right now, are you in between therapies? You're still on TAGRISSO? Where are you now in your therapy?

Ann: So I'm still on TAGRISSO and it's a tough medication to be on. It dries your skin. It's epithelial cells that are being reduced, so my skin is dry. My nails are really brittle, my hair. My mouth is constantly dry. So it's not the most pleasant drug to be on, but I'll happily take all those symptoms.

Kirtly: Right. Well, we talk about risk for cancer as being one-third genetic and one-third environmental and one-third bad luck. So where do you think you fall when you think about your particular risks? Where do you think your cancer came from? Just bad luck, bad genes, bad environment? All three?

Ann: Definitely environment. There's never been anyone in my family diagnosed with lung cancer, and even those who were lifelong smokers.

Genetics, I actually contacted the Huntsman Genetic Counselors and had them run my DNA that I was given by my parents, not how it's been changed by the cancer. But I wanted to know what my risks were for my kids, and that was negative. So I did not have germ cell or . . .

So it has to be the environment, and it's because I walk, hike every day. It did not matter if it was a red bad air quality day. I still got out there, and I didn't wear a mask. I remember a particularly bad day at Sugar House where I could hardly see 50 feet in front of me. The air quality was so horrific. That moment I thought about, "Maybe I shouldn't be out here."

And then studies started to come out that pollution is like smoking a pack of cigarettes a day, and I would then pull back on the red days. But otherwise, I was still out there.

We also know that women are extremely high risk for pollution and non-smoking lung cancer over men. And the studies vary about that from 30% to 60%, at least, of higher rates in women over men.

Kirtly: Ann, have you changed the way you assess your own home air quality? Do you change the way you go out on bad air days, or how you keep your home clean? Tell me what you're doing now.

Ann: So I have two air purifiers, one in my bedroom and one in my large living space, and I monitor the air every day. I have an app called AirVisual. But I've also found that my weather app will tell me what the air quality is.

I don't go out on orange or red days anymore, which is really hard for me. Or if I do, I try to go up into the mountains and I still wear a mask because it will still be up there, but not as heavy. If you have any other suggestions . . .

Kirtly: No. For me, we have a furnace filter. So for those of you who have a furnace and that you blow air and that's how you get your house warm, you have a furnace filter and they come in this MERV, meaning it's a degree of how much it filters. You can get a HEPA filter, but that's difficult to get for a furnace. But we have a MERV 16, which is the highest-grade filter.

We have a portable PM2.5 meter that I can take in my house and I can walk it outside. And I take it to this Salt Lake Sports Complex so I know what's inside. I know what's in my car. So I have this little portable PM2.5 meter. It does not measure ozone, which is another risk factor, but ozone is a much more difficult thing to measure. So wherever I go, I know what the PM2.5 is.

And remember, I'm nervous about this not just because of my family history. My family has a lot of reactive airways, as you can hear in my voice right now. But I also know that women who live in areas with bad air quality have more cognitive decline, and my brain is my one great gift. I can't sing like Barbra Streisand and I don't look like anybody gorgeous, but my brain is really important to me.

And because of this data from the Nurses' Health Study that looks at women who were all nurses who lived in areas with high and low air pollution based on their geo code, their zip code, it's really bad and your brain gets kind of polluted, and you don't think so clearly. So I am careful. Of course, I'm also careful for my husband.

Katie, what do you do in your home to keep your home as clear as you can?

Katie: Well, you guys are the exemplars here. Boy, I have not purchased an air purifier. I do have a good filter on my furnace. I have the weather app that Ann mentioned, so I do pay attention to that.

And I mentioned before I'm a bike commuter, and a runner. Like Ann, I would exercise regardless of the weather, because marathoners, if you know any, are like that. You set your training schedule and you train no matter what. That comes first. Since knowing Ann and going through this, I definitely pay more attention to it.

It always feels unfair to me that the people who are willing to get out of their cars and ride their bikes to work . . . If I choose on a bad air day to take my bike to work, I'm putting myself at much more personal risk. And if I don't get on the bike, then I'm contributing to the bad air.

So I've been grateful for Zoom. I think one of the changes I've made is to say to my class, "If it's a bad air day, let's meet on Zoom. Don't drive here."

Kirtly: Yeah. Then there are 20 people who aren't driving their car. When you make that choice, often 20 other people don't get in their car. Good for you, Katie.

Well, I manage my stress by knowing that I can choose exactly where I'm going to go, and I know where my air quality is. I can look at the Utah's Air Quality Boards website at airnow.gov, which is actually a national center, and I can look at air quality.

But I can make decisions for me and my husband. I will say I've lived with someone who shops at the fearmonger shop. He measured radon every five years. I mean, it was always, "What's the radon? What's the radon in our garage? What is it in our basement? What's in our bathroom? Is it next to the toilet so don't sit on the toilet too long?"

One-third of houses in Utah are at levels of radon that are dangerous, above the amount that's recommended by the EPA. And so we have a radon monitor and we have been measuring radon for 30 years. So I'm really glad about that.

As you make decisions, there are things that you can do to make yourself feel better. I am careful about which oil I actually cook with, because they always have you cooking with olive oil and you crank the heat on your stove up and then it just smokes because olive oil has a low smoke point. So I don't cook with olive oil anymore.

I'll pour it in a salad, but if it's going to be heated, I use avocado oil because it has a very high smoke point and it doesn't smoke up the kitchen. I know when I smoke up the kitchen because I can see it, and of course, I've got a monitor so I know it. I don't want to pollute my family.

I have choices, and I've made those choices, and I'm very careful. I gave a very special air filter for my granddaughter's bedroom, and she always has an air monitor.

So I'm feeling also better by involving myself in an organization that actually tries to move the dial a little bit.

How do we actually do something for our community? Not just for ourselves, but there are people in Salt Lake Valley who disproportionately are affected by bad air. They are poorer, they are less White, and they're right down by the center of the Valley where the interstates and the airport and all those diesel trucks are going by.

Those folks don't necessarily have the $200 to get a fancy, portable PM2.5 meter. So what do I do for everybody else? I feel good about making decisions that help people more than myself.

Katie: I mean, again, you two are such role models in this. Not just how you take care of yourselves, but how you get involved in your community.

And so I think as a way to relieve your own stress, and we've talked about this before, if you can, it's getting involved. Whether it's sharing your story, your voice, your vote, spending some time talking to your legislators, engaging in the community, all of those things are so important for all of us to do. And I think it gives you back some agency.

I know, Ann, you've told your story in many places and I'm grateful for that because it changes the people that come in contact with you. I think about it more in my role taking care of women. I'm worried about their reproductive health, and it's a reminder that there are other risks and to pay attention.

Kirtly: Yeah, as a clinician, you might be a little bit more willing to get a chest X-ray when a woman says she's had a cough for a couple of months. It's pretty low radiation, which is a risk factor of course, but maybe you're just a little more willing to get a chest X-ray for somebody rather than saying, "Oh, it's winter time. Everybody coughs in the winter."

So, Ann, what else comes to mind? What else would you like to say?

Ann: I try to stay positive, and my family and my friends are incredibly helpful with that. I try to stay socially engaged. And then I also schedule a counseling visit after each CT scan just in case there's a positive outcome. I want to be able to talk to somebody immediately.

I focus on the present as much as possible. I meditate. I do yoga. I try not to perseverate too much on the future. It's just too overwhelming. So if you can stay in the present, you can find joy every day.

I also tell everybody I meet in the healthcare profession, when I find out they spend any time outdoors, to wear a mask and to start advocating for our clean air.

And because not everybody reads your whole chart, I still get the surprise looks that I have Stage 4 lung cancer. I certainly don't look like the typical person with it.

I also just feel like programs like this that are educational, that reach such a large audience, it's really important to get involved in that as well. So that's why I said yes, because I do want my message to get out there for everyone.

Katie: Ann, thank you.

Kirtly: Thank you so much for joining us. You've always been an inspiration to me both in your clinical work and now in the way you have taken hold of your own illness and tried to learn more.

Well, this is usually where I say to just take a deep breath, but that might make you feel worse. Although this is a day . . . it's kind of a blue day, but not a perfectly blue day.

But what does make me feel better is that my home is a safe place to breathe for my husband, and son, and granddaughter, and friends. As I mentioned, I belong to organizations that advocate and educate around issues of clean air. And being with people who are working on issues is really important in decreasing my stress.

Everyone has to find their own path to a healthier environment and less stress. And I hope that joining us today will help you, as a listener, find yours.

Please share these thoughts or podcasts with friends and family so you can have a conversation.

Join us for the other 7 Domains of Stress wherever you get your podcasts, or at womens7.com.

Thank you, Ann, and thank you, Katie and everybody. Hope for clean air. Thank you.