Breast Health Fundamentals
Few health concerns create as much fear, confusion, and misunderstanding as breast cancer. But the best approach is to familiarize ourselves with valid information so we are armed with knowledge, not fear! Understanding individual risks, embracing science-based information, and separating the hype-filled information from the help-filled, are all critical.
While breast cancer is scary, cardiovascular disease kills the most women and lung cancer is the deadliest cancer. Besides skin cancers, breast cancer is the most common cancer for American women. The fear associated with breast cancer may be its randomness. We know (or think) that there are modifiable risk factors for heart and lung disease, but breast cancer can strike us all, young or old, saint or sinner.
The good news is that although the number of cases is rising as the population ages, deaths are decreasing. And the rise in incidence seems to be leveling off. We must be making progress in detection and treatment.
The truth is most breast lumps are benign, and benign breast conditions are very common. Nearly 90 percent of all women experience some symptoms such as breast pain, lumps, or nipple discharge by the time they reach menopause.
The most common benign breast conditions are: breast pain, benign breast tumors and solitary lumps, fibrocystic changes, nipple problems and discharge, and infections or inflammation. Normal physiological changes, such as minor tenderness, swelling, and lumpiness before or after their menstrual periods is quite common.
When should you see a doctor? If there is a lump or thick, firm tissue in or near the breast or under the arm that is new and lasts through a menstrual cycle; a bloody or clear nipple discharge; an inverted nipple that doesn’t spontaneously evert; itching or skin changes such as redness, scales, dimples, puckers, or a change in the size or shape of the breast. Nipple discharge that you express doesn’t count, nor does “colored opaque” discharges, like green, yellow and white. These are NEVER cancer. The nipple discharge that needs attention is marked by blood or clear fluid that is just in your bra at the end of the day. Most of these are not malignant, but need to be evaluated.
Examining Risk Factors
Breast cancer risk factors include a family history, atypical hyperplasia, delaying pregnancy until after age 30 or never becoming pregnant, early menstruation (before age 12), late menopause (after age 55), current use or use in the last ten years of oral contraceptives, and daily consumption of alcohol. Other factors include chest exposure to radiation, especially when young. Women who received radiation for childhood Hodgkin’s lymphoma, for example, are at a greater risk for breast cancer later in life. Weight gain after menopause, especially after natural menopause and/or after age 60, is also linked to increased breast cancer risk.
The family history that counts is pre-menopausal breast cancer in a first degree relative (mother, sister, daughter), BUT it is still true that most women who get breast cancer do not have a significant family history, and that most women with a significant family history do not get breast cancer! A prior biopsy that shows lobular neoplasia (“LCIS”) or atypical ductal hyperplasia is associated with increased risk , as is radiation to the head, neck and chest. Risks increase if a person is female, as they age, and if there is a known inherited genetic predisposition for breast cancer. BRCA genes are the most common—and increased risk applies to men and women with one of these genes).
Most risk factors are reported as increases in relative risk—or the incidence of a particular condition in 2 different populations, and an estimate of whether this association would hold up in repeated testing. Even if it does, the association does not mean “causation”. For instance, if you looked at a group who takes a lot of aspirin vs. one where people rarely take aspirin, you might see many more headache sufferers in the first population. Does that mean that aspirin causes headaches? Probably not. But people troubled by headaches reading the report might think that they had better stay away from aspirin. That would be premature.
Because there is so much “noise” in epidemiologic studies that report in relative risk, most epidemiologists caution that the relative risk, or the strength of the association, should be 3.0 or higher to be significant clinically. Observations that are less strongly associated, but confirmed on repeat testing and statistically significant, mean that there is a question here that needs to be researched further. It is interesting, but not yet ready to be applied to the population as a whole.
First term pregnancy over 30; menarche before 12; menopause after 55; no term pregnancies; no breast feeding; recent oral contraceptive use; recent and long term HRT; postmenopausal obesity; personal history of endometrial, colon and ovarian cancer; alcohol consumption; tall stature; high socioeconomic status; and Ashkenazi Jewish heritage all have relative risks between 1.1 and 2.0. That means that there is insufficient strength in the association to say that there is causation, or even a statistically significant association, which is good, since many of these factors are not modifiable by the patient anyway. But they may be clues. For instance, is there something that happens to the breast tissue with a first term pregnancy that can tell us something about how genetic mistakes accumulate, and how they are eliminated? Is there a common mechanism with some of the associated cancers? What is it about being financially well-off that could possibly have anything to do with breast cancer? Is that real, or just a function of better detection? Moderate alcohol use is associated with a decrease in heart disease, and heart disease is our biggest killer…so we don’t want to discourage a glass of wine before we are SURE that it is linked to breast cancer…and if it were, what is the mechanism to be researched? Do women who drink a lot avoid the doctor and therefore screening? Or does alcohol truly interfere with the immune system, or cause more of the dangerous estrogen receptors to be made by cells? We just don’t know…so we have to be cautious in what we tell women.
Diet is being studied as a risk factor for breast cancer. Although a diet low in fat or high in fruits and vegetables has not been proven to prevent breast cancer, studies have shown that eating foods rich in beta-carotene (apricots, carrots, papaya, cantaloupe, spinach, pumpkin, sweet potatoes and mangoes) may decrease the risk of breast cancer. A diet rich in beta-carotene, folate, and vitamins A and C may reverse the higher risk of breast cancer linked to alcohol use. So making healthy foods choices just makes sense for our overall well being!
And we know that a healthy low fat diet with lots of fruits and vegetables is good for the heart, and remember, that is our biggest risk!
