Dodging cancer with diet.

You're more likely to die of a heart attack. But you're more afraid of cancer.

And with good reason.

Heart attacks are sometimes swift and fairly painless, Cancer never is.

You can cut your risk of heart disease with a healthy lifestyle. Cancer feels beyond your control.

Deaths due to heart disease are in the midst of a 25-year free-fall. The number-one killer of Americans now claims lives at half the rate it did at its 1965 peak. Cancer deaths have risen seven percent in the last twenty years.

Fearing cancer won't help you. Learning more about it may. And there's lots to learn.

Cancer isn't one disease, it's many. Each has its own high-risk groups, its own attack and cure rates, its own causes. And a healthier diet may cut your risk more than you think.

"I am afraid it's malignant."

Two out of every five Americans will hear that diagnosis sometime in their lifetimes. One in five will have "cancer" written on his or her death certificate.

Medical science hasn't conquered cancer. But it has learned a tremendous amount about who, when, and where cancer strikes. For example:

* Half of all cancers are diagnosed in people under age 67.

* U.S. men are less likely to die of cancer than men in England, Germany, France, or Italy. American women are more likely to die of cancer than German, French, or Italian--but not English--women. English women lead the world in breast cancer deaths.

* Four cancer sites--lung, colon, breast, and prostate--account for more than half of all cancer deaths. Lung alone comprises more than a quarter (see chart on page 6).

[CHART OMITTED]

In a way, that's encouraging, because healthier diets may help cut the risk of each of the top four killers. Take fruits and vegetables.

"Compared to people who eat two or fewer fruits and vegetables a day, those who eat at least five a day have about a 40 percent decrease in risk for lung, colon, stomach, esophagus, and oral cancers," says Tim Byers of the Centers for Disease Control in Atlanta. "That's a fairly big effect for a fairly achievable change in diet."

Our rundown of 13 diet-related cancers--ranked according to how many lives each claims--tells you how to minimize your risk.

LUNG

It strikes fewer people than prostate, breast, or colon cancer. But it's the biggest cancer killer, because only 13 percent of patients live more than five years after being diagnosed. Death rates are falling only for men younger than 55.

Who's most at risk? Cigarettes contribute to an estimated 85 percent of lung cancer deaths. Radon, asbestos, arsenic, radiation, secondary smoke, and air pollution cause most of the rest.

Smokers who eat fruits and vegetables, especially those rich in beta-carotene, have half the risk of other smokers (see page 8). But something other than beta-carotene in those foods may be protective, because so far, smokers who have taken beta-carotene supplements for five to seven years have had no lower risk.

And even with an optimal diet, cautions Regina Ziegler, a researcher with the National Cancer Institute (NCI), "smoking would still cause a ten-fold, rather than a 20-fold, increased risk of lung cancer."

Warning signs: Persistent cough, bloody sputum, chest pain, recurring pneumonia or bronchitis.

COLON, RECTUM

One out of three cases is found when the cancer is still localized, which means that the patient has a 90 percent chance of surviving five years or more.

Who's most at risk? People who eat diets that are high in fat, heavy on red meats, and low on fruits and vegetables. Anyone with a family history of colon or rectal cancer, polyps, or inflammatory bowel disease.

In a recent trial, beta-carotene, vitamin E, and vitamin C did not cut the risk of potentially precancerous polyps.

Warning signs: Rectal bleeding, bloody stool, change in bowel habits.

BREAST

By far the most common cancer in women...and it's still inching upward.

Who's most at risk? The risk rises with: age, a family history of breast cancer, early menarche or late menopause, age at which the first child is born, never having had children, higher education and income, obesity, and, possibly, hormone replacement therapy and oral contraceptives.

The typical high-fat American diet may increase the risk. Even moderate drinking is linked to breast cancer.

Warning signs: Any lump, thickening, swelling, dimpling, skin irritation, or pain in or discharge from the breast.

PROSTATE

One out of every eight men will get prostate cancer in his lifetime. Half of all deaths are in men aged 77 or older.

Who's most at risk? African-American men are twice as likely to die of it. People who eat diets rich in fat, especially red meat, have a greater risk. Vasectomy is linked to a higher risk, but only in some studies.

A recent trial suggested that vitamin E (50 mg a day) protected Finnish smokers. As a result, says the NCI's Richard Hayes, "researchers will be looking at vitamin E."

Warning signs: Difficult, painful, or frequent urination, bloody urine, pain in the lower back, pelvis, or upper thighs (all can also be caused by an infection or an enlarged prostate).

PANCREAS

It's one of the worst cancers to get. Only three out of every 100 patients survive five years.

Who's most at risk? Smokers have double the risk of non-smokers, but smoking accounts for only about a quarter of the risk. Beyond that, says NCI researcher Debra Silverman, "we can't draw any strong conclusions."

In a handful of studies, patients appeared to have eaten fewer fruits and vegetables or more fat than others. But the typical patient only survives for three months, she explains, "and their eating habits may be colored by their illness."

Warning signs: None...until it has spread. That's why it's so deadly.

STOMACH

Worldwide, deaths from stomach cancer are still second only to deaths from lung cancer. But the U.S. death rate is only one-fourth what it was in the early 1900s. Unfortunately, tumors of the upper stomach are climbing in white American men.

Who's most at risk? For lower-stomach cancer, smokers, men, African-Americans, people with a family history of stomach cancer, and those who eat few fruits and vegetables or whose stomachs are infected with Helicobacter pylori bacteria have a higher risk.

Highly salted, cured, or smoked foods may also increase the risk by creating cancer-causing nitrosamines in the stomach, though "it's never been definitively demonstrated in humans," says Joseph McLaughlin of the International Epidemiology Institute (IEI) in Rockville, Maryland.

As for upper-stomach cancer, he adds, "no one knows what's causing the dramatic increase in white men."

Warning signs: Indigestion (gas, slight nausea, heartburn, etc.) persisting over weeks.

OVARY

Often there are no warning signs, so less than a quarter of cases are detected early. Only 41 out of every 100 patients are alive five years after they are diagnosed.

Who's most at risk? A family history of ovarian cancer is the strongest risk factor, but it accounts for only three out of every 100 cases. Infertility increases the risk, especially in women who have taken fertility drugs. Pregnancies, whether failed or successful, cut the risk, as do oral contraceptives, tubal ligations, hysterectomies, and breastfeeding.

In a recent study, women with ovarian cancer reported eating diets high in saturated fat and low in vegetable fiber. "We found no association with lactose [milk sugar] intolerance or intake," as earlier studies had suggested, says Harvey Risch of Yale University School of Medicine.

Warning signs: Enlarged abdomen (caused by fluid accumulation), vague persistent digestive problems (gas, bloating).

LIVER

Deadly, but rare in the U.S. Many other tumors that spread to the liver are mistaken for liver cancer.

Who's most at risk? People who have alcoholic cirrhosis or chronic hepatitis B or C, especially if they are also HIV positive.

Warning signs: Weight loss, fatigue, vague upper abdominal pain.

BLADDER

If it's caught early, more than 90 percent of patients survive at least five years.

Who's most at risk? Smokers, especially men. "Fresh fruits and vegetables were protective in five out of six studies," says the NCI's Debra Silverman.

Warning signs: Bloody urine, more frequent urination.

ESOPHAGUS

Fairly uncommon, except among low-income African-American men. Only nine percent of patients survive five or more years. Cancers of the lower esophagus--like those of the upper stomach--are on the rise in white men.

Who's most at risk? Alcohol and smoking cigarettes, cigars, or pipes are responsible for 80 to 90 percent of esophageal cancers, most of which strike the upper esophagus. "The risk is also high in heavy drinkers who don't smoke," says the IEI's Joseph McLaughlin.

A diet low in vitamins and minerals is also suspect. Cancer of the lower esophagus is still a mystery.

Warning signs: Difficulty swallowing foods, weight loss, diminished appetite.

MOUTH, THROAT, TONGUE, LIP

Oral cancer is uncommon, except among tobacco users and heavy drinkers.

Who's most at risk? Three out of four cases are due to alcohol or tobacco (cigarettes, cigars, pipes, and smokeless tobacco, especially snuff). The risk soars for people who smoke and drink. Two packs of cigarettes and four drinks a day, for example, means a 35 times greater risk. The human papilloma virus is also suspect.

There's "pretty strong" evidence that vegetables, and especially fruits, are protective, says Deborah Winn of the National Institute of Dental Research.

"We found a higher risk in people who use high-alcohol mouthwashes at least once a week for six months or more," she adds. "High" means at least 25 percent alcohol.

Of the national brands we looked at, only regular Listerine had more than 25 percent. Lavoris and Listermint were among the lowest--below eight percent. Check the label.

Warning signs: A sore or red or white patch that doesn't heal, a lump, or thickening in the lip, tongue, mouth, or throat.

UTERUS (ENDOMETRIUM)

The number of cases peaked during the 1970s in women who had taken "unopposed" estrogens to treat menopausal symptoms during the 1960s. (Women who take hormone replacement therapy now get estrogen that's "opposed" by progestins.)

Who's most at risk? Women who are 40 percent or more overweight, who had early menarche or late menopause, or who have a history of infertility or failure to ovulate. Also women who take tamoxifen (an antiestrogen drug used to treat breast cancer) or unopposed estrogens.

Warning signs: Abnormal uterine bleeding, especially in postmenopausal women.

UTERUS (CERVIX)

Rates have nosedived since Pap smears made it easy to detect abnormal cells.

Who's most at risk? Smokers and women who have had multiple sex partners, first intercourse at an early age, or certain human papilloma viruses (which are sexually transmitted).

Some, but not all, studies find that fruits and vegetables--especially those rich in vitamin C, beta-carotene, and folic acid--are protective. Low-income women have higher rates, but "it's difficult to know whether it's their diets--or other things about their lifestyles--that are responsible," says the NCI's Regina Ziegler.

Warning signs: Abnormal uterine bleeding or abnormal vaginal discharge.

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Cutting Your Risk of Cancer

Here's what you can do to cut your risk of cancer (the names of the cancers these steps may help prevent are in bold):

* Don't smoke or use smokeless tobacco--lung, pancreas, stomach, bladder, esophagus, mouth & throat.

* If you drink alcoholic beverages, limit them to less than one a day (for wome) or two a day (for men)--breast, liver, esophagus, mouth & throat.

* Eat at least five to nine servings of fruits and vegetables every day--lung, colon, pancreas, stomach, bladder, esophagus, mouth & throat.

* Cut back on fats, especially saturated fats and red meats--colon, breast, prostate, pancreas, ovary.

* Use whole grains whenever possible--colon.

* Exercise at least four hours a week--colon, breast.

* Consider taking an aspirin every day, after checking with your doctor--colon.

* Limit cured or smoked foods like bacon, ham, lox, and hot dogs. Eat them with a glass of orange juice or another rich source of vitamin C. Limit sodium to 2,400 mg a day or less--stomach.

* Avoid obesity--breast, endometrium.

WHAT TESTS YOU NEED

Detecting cancer early is half the battle. Here's what the American Cancer Society recommends:

* Get a yearly Pap smear and pelvic exam if you are sexually active or 18 or older--endometrium, cervix.

* Do a monthly breast self-exam starting at age 20--breast.

* Get a mammogram every year or two between the ages of 40 and 49 and every year starting at age 50--breast.

* Get a digital rectal exam every year after age 40--rectum, prostate.

* Have a prostate-specific antigen (PSA) blood test every year starting at age 50--prostate.

* Have your stool tested for hidden blood once a year after age 50--colon & rectum.

* Have a sigmoidoscope exam every three to five years after age 50--colon & rectum.

* Get a dental check-up at least once a year--mouth.

Trials in Progress

What's a clinical trial? It's when investigators randomly divide people into groups that get either the vitamin, drug, or other anti-cancer agent being tested or a (inactive) placebo. Then they wait to see if one group gets fewer cancers.

A clinical trial can provide powerful evidence on diet and cancer. Here are most of the major ones that are under way.

Cancer          Participants                Diet or Nutrients
All sites       male physicians             beta-carotene (50 mg
                                            every other day)
Lung            female smokers              beta-carotene (50 mg a
                                            day)
                                            and/or vitamin E (600
                                            mg a day)
Lung            current and former smokers  beta-carotene (30 mg a
                                            day)
              and people exposed to       and vitamin A (25,000 IU
                asbestos                    a day)
Colon           people who've had polyps    low-fat, high-fiber
                                            diet with
                                            whole grains plus 5 to
                                            8 fruits
                                            and vegetables a day
Colon           people who've had polyps    wheat bran (1/4 cup a
                                            day)
Colon           people who've been treated  beta-carotene
                for colon cancer            (30 to 180 mg a day)
Colon           people who've had polyps    the B-vitamin folic
                                            acid
                                            (5 mg a day)
Colon           precancerous lesions        calcium carbonate
                                            (3,000 mg a day)
Breast & Colon  healthy postmenopausal      low-fat diet (less
                                           than 20
                women                       percent of calories
                                            from fat)
Stomach         people with precancerous    vitamin C (2,000 mg a
                                            day) and/
                lesions                     or beta-carotene (30
                                            mg a day)
Mouth & Throat  people with precancerous    beta-carotene (30 mg a
                                            day),
                lesions                     vitamin A (25,000 IU a
                                            day),
                                            and/or Accutane, a
                                            drug used to
                                            treat acne
Cervix          people with cervical        beta-carotene (30 mg a
                                            day)
                dysplasia (precancers)
Skin            people with actinic         vitamin E,
                                            epigallocatechin
                keratoses (precancers)      gallate (found in
                                            green tea),
                                            and/or the anti-cancer
                                            drug
                                            DFMO, all applied to
                                            the skin
Skin            people with actinic         vitamin A (25,000 to
                                            100,000 IU
                keratoses (precancers)      a day)

Source: National Cancer Institute.

WHERE TO FIND OUT MORE

* The National Cancer Institute. 800-4-Cancer. Get answers to questions by phone, fax, or the CancerNet computer network.

* The American Cancer Society. 800-ACS-2345.