An NCI-designated Comprehensive Cancer Center
By Stephanie Smith | March 4, 2017
When the plain white envelope arrived in the mail, it was addressed to “Professor Bridget Marshall.” It was 1995 and Marshall, who at the time taught retail management at a community college, had no idea what it contained.
California Teachers Study Marshall white bg Bridget Marshall
Still, the reference to her as a “professor” made her giddy — and curious.

“Being addressed that way made my day,” said Marshall, an adjunct instructor for two years at Orange Coast College in Costa Mesa, California. “When I was teaching, I would joke with my students, ‘I am Professor Bridget Marshall — eat it up because I am.’”

Marshall laughs at the irony today because, although she taught college, she was not a professor, and had not attended a university. But she was a potent and caring teacher, with 30 years’ professional retail experience to share, who touched young people’s lives.

“I used to ask students, ‘What is it you really want to do with your life?’” said Marshall. “I had one student in my class who said, ‘Nobody has ever taken the time to ask me that question and you did.’

“That made me feel like, ‘Wow, OK, you couldn’t be a professor but you did something for people.’”

The letter she received that day was from researchers with the California Teachers Study, a newly formed, ambitious research project whose goal was to build understanding about lifestyle and other factors fueling breast cancer — and how to reduce them.
California Teachers Study Deapen White BG Dennis Deapen, Dr.P.H.
“We had this group that was willing, they were proud to be teachers, they worked really hard as teachers,” said Dennis Deapen, Dr.P.H., one of the founders of the study.

“They didn’t even have to leave their home, just fill out some questionnaires, provide some information for us over the years and they might be able to provide life-changing information about health outcomes for future teachers — if not all women.”

More than 133,000 teachers, administrators, school nurses — all current or recently retired members of the teaching profession — signed up. The study, which is ongoing, involves quizzing participants like Marshall, over several years, about the details of their lifestyle and overall health.

“They would ask questions like, 'Are you active? Are you involved in sports? What is your nutrition like?'” said Marshall. “My answers were something like 'I’m active but not sporty,' and 'I’m probably not getting The Fives’ — you know, five fruits and vegetables a day.

“At that time of my life I was more like the ‘Mary Tyler Moore Show,’ when she’s at the market and pulls out something from the frozen food section and tosses it into her shopping cart.”

Over the years, a narrative about Marshall’s lifestyle and health began taking shape, at least on paper. She is a world traveler — a lively, jovial and active person — someone on whom stress sometimes weighs heavily — a lover of dining out and, she says, an occasional “junk-food junkie.”

Those details may have lacked context in Marshall’s mind as she bubbled in surveys, but when married to data from tens of thousands of other teachers, a compelling picture of the cohort’s breast cancer risks began to materialize.

Years of surveys suggested some interesting distinctions for women in the study.

When it came to diet, they tended to eat a tinge too much fat and too little fiber, their vitamin intake was good and their cholesterol intake below average. None of the group’s eating habits, however, could be linked back as connected with or protective against breast cancer — but drinking too much alcohol did raise the risk.

Findings about other cancers emerged from the study: Teachers had slightly higher rates of cancers like lymphoma and melanoma, but lower rates of lung and cervical cancer.

And teachers, it turns out, are more likely to have a mammogram than most women.

In 2006, about 10 years after filling out her first Teachers Study survey, after getting a routine mammogram, Marshall was diagnosed with breast cancer.

“When you hear you have cancer, your mind goes into an altered state,” said Marshall in a previous interview. “Your world literally turns upside down.”

She had two tumors — one at Stage 1 and the other at Stage 2. She was treated at City of Hope with a lumpectomy, followed by chemotherapy. The good news, according to her doctor, was that her cancer could be treated successfully. “He said, ‘It’s curable, we can take care of this. You’re going to live for another 20 years,’” said Marshall.

The good news notwithstanding, Marshall’s diagnosis reflected a discomfiting fact about the cohort. Teachers, for some reason, were more likely to get breast cancer — something that may explain the group’s strong initial willingness to participate in the study.

“Teachers had complained that they thought they had more cancer than anybody else,” said Leslie Bernstein, Ph.D., professor in the Division of Biomarkers of Early Detection and Prevention at City of Hope. “And they were worried about it.”

One of the worried was a teacher who signed up for the study in the beginning, Cathie Hays. In 2000, a lump she found in her breast turned out to be cancerous. “My sons said, ‘How could you get cancer? You’re so health conscious,” said Hays, in the 2001 issue of the study’s newsletter. “‘You don’t drink or smoke.’”

Besides the seeming incongruity between her lifestyle and diagnosis, also unnerving for Hays were the cancers in her midst. “In our wing of four classrooms, four teachers have been diagnosed with breast cancer in the past three years,” said Hays in the newsletter. “It’s very frightening.”

“What they would say was, ‘Too many of our teachers in this school have gotten cancer, there must be something we’re exposed to like chalk dust or asbestos,’” said Bernstein, speaking of women in the study who expressed similar concerns.

The school district where Hays worked found no environmental causes for the “cluster” — in fact, the question about why cancer affects teachers more than others never has been fully resolved.
Suggestions about this increased risk, so far, are more speculative than satisfying — environmental and other factors have not been found by the Teachers Study to play a role, while increased income and education among teachers, ironically, may. Higher socioeconomic status has been linked in several studies to breast cancer.

While participants like Marshall got a mammogram, others were spurred to do something by simply signing on to the study.
Marie St. Pierre Finnegan, a retired school nurse, had an inkling after receiving her survey in 1995. As she sat down to complete it she decided, on a whim, to do a breast self-exam.

“I discovered a lump in my right breast,” she said in the handwritten note, published in the study’s 1996 newsletter.

Finnegan acted swiftly after discovering the lump. By 2:10 p.m. the next day she was in her doctor’s office. By 3:30 p.m. — “Less than 24 hours after receiving your survey,” she writes — her diagnosis was confirmed by a needle biopsy: She had breast cancer.

“Although I know better, I did not give myself breast exams on a regular basis, and it had been two years since my last mammogram,” she wrote. “Thank you — your study has made a difference in my life.”

Deapen remembers receiving Finnegan’s note years ago, and when asked about it recently, the moment still seemed to resonate.

“It’s exactly what I hoped would happen,” said Deapen during a recent interview in his office at the University of Southern California. “You hope that a study like this can have an impact beyond the research itself, before the research results were known.

“I don’t think I ever expressed that to anybody before, but that was the hope. And for that to happen right away, to have that immediate impact felt really good.”

For Marshall, any impact she felt from participating in the study would be residual, as would be the implicit messages embedded in the surveys about how she could lower her risk of a recurrence.

It has been more than 20 years since the white envelope landed in Marshall's mailbox. Wearing a long jacket with a scarf stuffed snuggly into her collar, she now regularly bounds across the City of Hope campus as she leads tours of new employees.

Marshall began working at City of Hope 15 years ago. Several years later, in 2007, Bernstein was appointed director of the Division of Cancer Etiology in the Division of Population Sciences at City of Hope, bringing the study with her from USC.
Leslie Bernstein Headshot Cropped Background Leslie Bernstein
It took Marshall several months to realize that Bernstein, whom she met more than once while on campus, was the person who had, in some way, helped to mold her little life story into something bigger.

“When I found out the Leslie Bernstein that came here was ‘The Leslie Bernstein’ who was in the newsletters I was getting, I thought, ‘Wow,’ said Marshall. “I’ve been (participating in the study) all this time and have been helping her get a better understanding about how lifestyle might affect women down the road with cancer.

“That’s when I realized there is a big picture to all of this.”

For Marshall, participating is both a point of pride, and what gave her a push toward a healthier life. A septuagenarian who hesitates to give her exact age, Marshall now exercises more and, after being diagnosed with prediabetes, tries to eat healthier. She also firmly believes that stress fed her cancer, so she is keeping things even-keeled emotionally, and sleeping more.

“Would I have done this 20 years ago?” said Marshall. “Probably not. But now I take things a lot more seriously because I really want to enjoy life and I certainly don’t to be sick again.”
**Research reported in this piece was supported by National Cancer Institute of the National Institutes of Health under award number R01-CA077398. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Stories of Hope is a monthly series that explores important issues in health care. This series is an inside look at the beginning, and future, of the California Teachers Study. Part 1 is a look at the statistician who would change how we view breast cancer risk and Part 2 about the lead up to the beginning of the study. Monday: The challenges of cancer prevention.




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