​Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered podcast. I'm Dr Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. Very often, conversations on this podcast highlight the power of small, everyday choices to improve our health and wellbeing. Today's conversation might be one of the most important reminders of why that matters.
We're talking about the intersection of biology and lifestyle, because here's what the science is telling us: preserving our health and avoiding disease are two sides of the same coin, and we have far more agency over both of those things than we realize.
We'll specifically touch on endometrial cancer, a cancer of the lining of the uterus, a disease which we may not realize we have a lot of agency over because many of the risk factors are modifiable. For example, how much we move, what we eat, how we manage our stress, and how connected we feel to the people around us all can have a major impact on changing our biology to protect our health.
So many of us wait until we see a concerning lab result, a rising number on the scale, or a symptom we can no longer ignore before we take action. But we should know that small, consistent changes can work best when they begin before there's a very clear and obvious warning sign that we're responding to.
So with the help of our guest, we'll explore the very real biological effects of chronic stress on inflammation, immune function, and hormonal balance, and explore evidence-based strategies for managing it in ways that genuinely protect our long-term health.

But first, let me introduce my guest. Dr Immaculata De Vivo is a professor of medicine at Harvard Medical School, a professor in the Department of Epidemiology at the Harvard School of Public Health, and she is the Melanie Mason Nemec '71 faculty co-director of the sciences at Harvard Radcliffe Institute.
And she's also the author of "The Biology of Kindness: Daily Choices for Health, Wellbeing, and Longevity." Welcome to the WebMD Health Discovered podcast, Dr De Vivo.

Immaculata De Vivo, PhD: Thank you so much for having me. It's a pleasure.

Pathak: Well, I am really excited to dig into our topic for today and our conversation. But before we start exploring our topic, I'd love to ask about your own personal health discovery when it comes to the work that you do.

De Vivo: Well, that's a really great question. One of my early aha moments came when I was told by a senior physician that I wanted to focus my research on endometrial cancer. His reaction was somewhat dismissive. It was almost as if it wasn't seen as a priority area. I was really stunned by his reaction.
That really stayed with me because it highlighted how under-recognized this disease is, was, and in many ways, that experience motivated me to pursue this work on an even more serious level. And it has been my primary research area since 1998.

Pathak: So let's take a big step back and start at the beginning. Help us understand what an epidemiologist does and why this work is so important.

De Vivo: Yes, great question. Everybody always wants to know, what is an epidemiologist? At its core, epidemiology is about understanding patterns—who gets a disease, why, and how we can prevent it. We study large populations to identify risk factors, whether they're biological, environmental, or behavioral. And what makes this work so powerful is that it allows us to move upstream.
Instead of only treating disease after it happens, we can identify ways to reduce risk before it develops. And that's especially important for cancers like endometrial cancer, where prevention is possible.

Pathak: That's really important, and it speaks to not just the importance of understanding what might be happening with one person individually, but recognizing patterns so that you can talk to large groups of people to say, you know, "This is what we're understanding about a particular disease. This is what might put one person at risk more than another." So really, really important. Another thing that we like to highlight on this podcast is the importance of lifestyle and making small, consistent changes to improve health on a broader scale, so our health and our wellbeing beyond just focusing on an individual condition or an individual potential risk for a disease.
So I was really excited to read your book The Biology of Kindness, and again, that's six daily choices for health, wellbeing, and longevity, where you dig into five fundamental values: kindness, optimism, forgiveness, gratitude, and happiness. And then you go further and describe six essential strategies for cultivating those values, and that's relationships, nutrition, physical activity, meditation, music, and connection with nature, which I find really meaningful as a lifestyle medicine physician, where we have six pillars that we know the science shows are beneficial not just to treat a particular issue or condition or disease, but to help us get to root causes.
So help us understand what you hope readers will take away from this book and how you hope they'll apply these lessons when it comes to wellbeing and longevity.

De Vivo: Thank you for mentioning a book that was written during COVID, by the way. Something that I never wrote a trade book, and I'm so glad I did it because it has really opened up many, many areas of collaboration and discussions. And essentially what I hope readers take away from the book is that health is not just about avoiding disease, it's about actively cultivating wellbeing.
I was motivated as a biologist to understand the biological underpinnings—what is the impact of behavior on your biology? And in this book, the values I talk about, kindness, as you mentioned, optimism, gratitude, these are considered prosocial behaviors, and they may sound abstract, but they have real biological effects.
And the strategies, as you mentioned, like relationships, nutrition, physical activity, meditation, and connection with nature, are ways people can bring these values into their daily lives. And the key message is that, yes, small, consistent choices really do add up over time.

Pathak: Help us understand, when it comes to endometrial cancer, what modifiable risk factors are and why it's important to know these so that you can make some of these changes over time that can really make an impact on your health.

De Vivo: So let me define modifiable risk factors. When we talk about modifiable risk factors, we're talking about things individuals can actually change to influence their risk. For endometrial cancer, the most important ones are obesity, physical inactivity, and hormonal factors, particularly prolonged exposure to estrogens without progesterones, because this disease is defined by long-term exposure to estrogens unopposed, as we say, by progesterone.
And we estimate that about 70 to 80% of endometrial cancers are linked to excess body weight, so this is one of the cancers where lifestyle truly plays a central role. And I want to also bring up, if I may, some misconceptions about endometrial cancer, because this is really important. One of the most common misconceptions is people confuse endometrial cancer with cervical cancer. This came out of a focus group that we did many years ago with women who had endometrial cancer.
And because cervical cancer is associated with HPV, there can be stigma or shame attached to it, and unfortunately, that confusion can sometimes lead women to dismiss symptoms or delay seeking care. So awareness is critical, especially recognizing that abnormal uterine bleeding is not something to ignore.

Pathak: So I'd love to then dig into something that you talk a lot about in the book, which is stress. So help us understand how stress plays a role in endometrial cancer and just chronic disease in general.

De Vivo: Stress. We all know it. We all experience it, and a little stress is good, but a lot of stress is not good. And you know, over the years with a lot of peer-reviewed research showing that the concept of stress is not just something that is in your mind, it's really quite poisonous. And stress is something we all experience.
And again, the science really shows that chronic stress has very real biological effects. It can influence inflammation, immune function, and hormonal balance, all of which are relevant to long-term health generally, and in terms of endometrial cancer, the hormonal balance is upset. So the goal isn't to eliminate stress—that's not realistic—but to develop ways to manage it.
Things like physical activity, mindfulness yoga, social connections, even time in nature can help regulate the body's stress response. So, you know, there's a saying attributed to many different people, so I won't attribute it to anyone other than to say this is not my saying, but a saying that's very applicable: "You can't change the direction of the wind, but you can adjust the sails."
And so that's really true about stress. There's no realistic way to eliminate stress. But you can definitely diminish it in ways I offer in the book. But, as a lifestyle physician, you know yourself, there are many ways in which one can manage their stress. Physical activity, for instance—not a lot of physical activity, but 150 minutes, the U.S. requirements for physical activity.
You know, physical activity is something that turns on 1,000 genes—very good stuff. And so you can imagine how you can benefit from lowering your stress by participating in a walk, a walk with friends, a yoga class, et cetera. So the biological impacts of stress are well defined, peer-reviewed, established.
I like to be very assertive in research and say that that's one way to eliminate or decrease chronic disease by really lowering your stress in the way that works best for the individual.

Pathak: So then let's shift a little bit to talk about what we know about certain cancers being on the rise. What are some of the very important trends that you are seeing when it comes to that, especially in the United States?

De Vivo: Great question, and this comes up with oncologists that I work with, who will often email or call and say, "Hey, Immaculata, in the clinic we're seeing this incredible shift in endometrial cancer incidence, and it's about 1% to 2% per year, especially among young women." And particularly concerning is that the mortality is also rising.
So we're not just seeing more cases, but outcomes are not improving as much as we hope among certain populations. So the younger women trends, the trend is remarkable in a bad sense, in a negative sense. You know, when I started focusing on this topic, it was mostly considered a post-menopausal disease.
And if young women got it, they were part of the Lynch syndrome, which is a cancer syndrome. It's a Mendelian inherited type of endometrial cancer. It was extremely rare—like super rare. So now, what was considered a traditionally post-menopausal disease, the shift to younger women is significant, and it likely reflects earlier and more prolonged exposure to risk factors like obesity and metabolic health issues.
And again, this really underscores the importance of thinking about prevention early in life. We have several papers coming out of my group showing the data because in our field, to really have findings that you can stand by, you need a particular sample size, right? Enough. And so now, unfortunately or fortunately, depending on how you view this, we were able to amass enough women under the age of 50—that's how we defined younger here—to look at the risk factors and to look at the trends.
And it's startling that, yes, oncologists are seeing women in their 30s and 20s that are not related to a cancer syndrome that are getting endometrial cancer. And from an epidemiologic standpoint, the link between obesity and endometrial cancer is one of the strongest we've ever seen among cancers.
You know, adipose tissue produces estrogen, and when that estrogen isn't balanced by progesterone, it can stimulate the lining of the uterus in ways that increase cancer risk, and that's what endometrial cancer is. It's cancer of the lining of the uterus. And women with obesity can have two to four times the risk compared to those at a healthy weight.

Pathak: So let's talk then about something that isn't really modifiable, but racial inequities. So what do we understand about those inequities when it comes to risk for developing endometrial cancer? And is that something that should be modifiable? Is it really because of lack of access and barriers to care?

De Vivo: Yes, and thank you for asking me that. That is the focus of my group's current research. We are now looking at racial inequalities with respect to endometrial cancer incidence and mortality. It's one of the most important and urgent parts of this conversation. Black women, for example, have significantly higher mortality rates—about twice that of white women, even though the incidence rates might be very similar.
And this tells us that it's not just about biology, okay? It reflects differences in access to care, delays in diagnosis, treatment patterns, and the impact of systemic bias. And addressing these inequities requires both better science and meaningful change in how care is delivered. There is a term that I use often, which is there's access to care, and then there's access to care.
So not all access to care is equal, is basically what I'm saying. So even though we saw reports and papers that I cite in my own work to say, "Well, it can't be access to care because look at these graphs. Women of color get the same adjuvant," and this and that. It turns out that when you really look deep and you look at the data, the access to care is not equal, and this makes a huge difference.
And in the grant we're in the process now of looking at tumor biology as well as all these other questions—lifestyle, access to care—we will have really great robust findings because the sample size is really huge. Enough to make some solid, let's say, suggestions towards one way or the other.
Environmental factors are sort of like a catch-all for cultural pollution. We're going to look at everything clinical. But yes, the truth is that Black women get the most aggressive type of endometrial cancer.

Pathak: And from a population health standpoint, you talked about some of the risk factors which are linked to lifestyle and environment. So what are some of the most effective modifiable things that people can do in their own lives to help stack the odds in their favor and potentially lower the risk?

De Vivo: From a population health standpoint, the most effective strategies are relatively straightforward, but very powerful. I don't want to use the word boring, but they have been described as boring, but incredibly powerful. Maintaining a healthy weight, staying physically active, eating a balanced diet, managing stress, and staying socially connected, you know, all contribute to lowering risk. And what's really important is consistency over time. That's really where it... And I think you mentioned that as well. It's really being consistent.

Pathak: I would love to sort of, as we come to a close in our time together, really talk about, given these rising rates and disparities, can you help us understand where and why increased research funding and public health awareness is so critical? And where do you see some of the biggest gaps that you'd like to see more research done in?

De Vivo: Funding, especially for this cancer, is critical. This is a cancer that is increasing, has clear opportunities for prevention, and still does not receive the level of attention or funding it deserves. Greater awareness and research investment are essential if we want to reverse these trends and reduce inequities in outcomes. We've done this with many other cancers. We've made great strides in blood cancers, pediatric cancers, lung cancer, breast cancer. From when I was a student to now, we are living where man— we're living with cancer. And so I think that this cancer, you know, a little late to the ball, in my view, deserves and requires funding and true investment because this is, has been and continues to be an underserved and understudied cancer, and it's on the rise.

Pathak: And I'd love to close our time together by asking you to speak directly to our audience. Can you share a few examples about how someone can talk to their healthcare provider about their concerns when it comes to endometrial cancer and risk? And what steps can someone take in order to reduce their risk?

De Vivo: Yes, I would be happy to. I really would encourage patients to feel empowered in their healthcare visits. You have agency. Don't be intimidated. You need to ask questions like, "What is my risk? What can I do to lower it?" And most importantly, don't ignore symptoms, especially abnormal bleeding. It's not your fault. It's not shameful. It's okay to go to your doctor and have an open discussion about your health. This is a disease that, if caught early, is treatable. You never use the word curable, but it's a disease that's completely manageable. It is a disease for which you have a lot of agency because the risk factors are modifiable, okay? Early evaluation can make a meaningful difference. And a few other points I'd like to make to our listeners is that endometrial cancer is increasing, okay? But many of its risk factors are modifiable. Lifestyle factors like weight, activity, and stress play a major role. And third, disparities in outcomes highlight the need for better awareness, access, and research.

And I hope that this discussion will empower women to seek proper care and they deserve the right to take care of themselves. And if you don't do it, no one's gonna do it for you.

Pathak: I love every point that you made. And I think, again, it sort of speaks to the importance of understanding the science. So if we didn't know that these trends were shifting and changing and in what direction, then we can't really sort of shift our focus to meet the moment. So I think that's critical. Then I think the other piece that's so critical is just, again, more and more data for what, like you said, one prescription, which is a prescription for exercise, activating thousands of healthy modification in your diet, and I don't know any pill that can make that same sort of level of impact with one...

De Vivo: Yeah. Thank you very much for summarizing that so well.

Pathak: I'd like to share my three key takeaways from our discussion. First, health is not just about avoiding disease. It's about actively cultivating wellbeing. We don't need to wait for a warning sign from our body to start making healthy lifestyle changes. The lifestyle changes that lower our risk for endometrial cancer and so many other chronic diseases work best when they're started early and practiced consistently over time. This is a way to demonstrate agency over our health. It's important to start now making small changes wherever we are, but it's also important to recognize it's never too late to make those changes.

Second, chronic stress has very real biological effects, particularly when it comes to things like endometrial cancer. Stress can influence inflammation, immune function, and hormonal balance, all of which are relevant to long-term health. The takeaway today is that it's impossible to eliminate stress entirely, but it's important to develop ways to manage it. Find what works for you and make sure you make that management strategy a consistent part of your life.

Finally, Dr De Vivo's message focused on ways listeners can feel empowered in their healthcare visits. You have agency. Don't be intimidated. It's important to have an open discussion with your healthcare provider with questions like, "What is my risk for something like endometrial cancer, and what can I do to lower that risk?" And most importantly, don't ignore symptoms. If you're having irregular vaginal bleeding, that's an important piece of information to bring to your next doctor's appointment, and it might be a reason to schedule that appointment if you haven't made one already.

To find out more information about Dr De Vivo's work, make sure to check out our show notes. Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you'd like to send me an email about topics you're interested in or questions for future guests, please send me a note at webmdpodcast at webmd.net.

This is Dr Neha Pathak for the WebMD Health Discovered podcast.