Breast Cancer

Present State of the Art Re: Hormones and Diagnosis

A lot has been written on breast cancer (BrCa) and many women are savvy on the disease and its diagnosis. But there is a lot of misinformation. In "1,000 words or less" here is the latest update:

I. Who Gets It?

Anyone can. The average woman's risk of getting breast cancer (BrCa) before she dies (usually of other things) is 1:10. Most women (80%) who get BrCa have no "risk factors" (but obviously, the other 20% of BrCa sufferers come from a much smaller segment of the population).

What puts a woman at higher risk: "First generation relatives" (mother, sisters) with the disease; very early menarche and/or late menopause (because of the longer time exposed to the higher estrogen milieu of one's own ovaries); no (or fewer) children--especially if they weren't breastfed; history of breast biopsies, especially with "atypical" findings. Also at higher risk are women with a strong family history of colon and ovarian cancer.

There are dietary and other predispositions: women with diets high in fresh fruits, veggies, grain and soy are less likely targets compared to their "fast food/processed foods/meat'n'potatoes counterparts. (Here again, you are what you eat!) Excess weight (releases more estrogen), cigarette smoking, alcohol excess and physical inactivity are also risk factors.

II. Types of Breast Cancer

Luckily, most BrCa is very slow growing (taking many years from "first seed" to distant spread), making possible early diagnosis by mammography and self palpation and prompt therapy before distant spread. A couple of rare forms differ from this norm (most notably "inflammatory BrCa", which can spread distantly in a matter of months of its first notice as a firm, reddened area in the breast).

Very interestingly, the type of BrCa that may manifest itself secondary to post-menopausal hormone stimulation is the most benign and easy to cure.

III. Prevention

It's hard to argue with genes and bad luck. That said, there are a few things women can do to level the playing field:

1. Diets that are low in processed foods and saturated fats and high in soy, grains, fresh fruits and veggies are protective.
2. Breastfeeding (for at least 6 months) offers protection. Whether this is secondary to some physical or neuro-chemical reason, or simply because breast feeding lowers internal estrogen levels for a time is uncertain.
3. Not smoking or drinking alcohol to excess is protective.

Although this is not really prevention, you can further even the odds by early diagnosis, this is the place for mammography and frequent self examination.

Interestingly, taking low-dose estrogen supplementation for a short (under 5 year) period of time around or just after menopause may offer a degree of protection, especially from the more virulent forms of BrCa.

IV. Diagnosis

The operative word here is EARLY.

Mammography, frequently leading to directed biopsy, picks up BrCa early, frequently prior to manifestation by palpation.

Conversely, however, if a mass "feels disturbing" to a qualified health care examiner, a "negative" mammogram should never delay biopsy diagnosis.

Coupled with mammography, breast ultrasound can help distinguish cystic (usually benign) from solid (more worrisome) masses.

Most early BrCa's are picked up by breast self-exam (BSE). 60% of masses picked up relatively early are done so by the woman herself; the remaining 40% by health care personnel. The ideal is a "daily" shower or bath palpation (to familiarize oneself with the usual feel of her breasts), plus a periodic (every 1-2 months) careful go-over and visual inspection.

A new, available, and scientifically proven procedure called ductal lavage can be added to the diagnostic armamentarium for high risk women. In this procedure (which can only be done in women who are able to express a small amount of milk or liquid from their nipples with vigorous self-expression), a tiny catheter is threaded through a duct in the nipple into the breast, and actual cells are rinsed out, frequently leading to diagnosis in the "precancerous" stage.

Who should be genetically tested for BrCa? Women with two first generation relatives (or one first generation relative plus other high risk factors), or women with strong family histories of ovarian and colon cancer may benefit from the (expensive) testing for BrCa-I and BrCa-II, the genes which place their "owners" at significantly higher risk for breast cancer.

A couple of different "quasi-radiographic" diagnostic procedures are in the investigational pipeline and may offer additional hope for early diagnosis--this remains to be seen.

Hormones and Breast Cancer

Traditional medical dictum is that "hormones" (estrogens) are a risk factor for BrCa and that is partially true. After a woman's own ovaries and comparatively high level of estrogens they secrete (and of course genetics) long term and high dose estrogens (via birth control pills or traditional HRT at/after the time a woman's own ovaries cease functioning) are a somewhat positive risk factor for BrCa. The key words are: a woman's own ovaries, and "long term--high dose."

It is now known (from meta analyses of over 45 long term studies involving more than 750,000 women) that, as a blanket statement, estrogens do not cause BrCa. In fact, if a woman with a previous history of BrCa ("breast cancer survivor") takes short-term (for sure 2 years or less and probably less than 5 years) low dose HRT (e.g., to help with severe peri–menopausal symptoms), she has a decreased risk of dying from both BrCa and cardiovascular diseases than a woman who does not take estrogens!

They key is: short-term, and low dose. The key is understanding and individualization. The hormones a woman's own ovaries secrete are far greater risk factors for BrCa than short-term, low dose estrogen supplementation. But this new knowledge will take a while to "sink in." For a woman who is truly worried about a negative impact of estrogen on her breasts, the negative psychic stress effect of a daily hormone dose on her immune system certainly may outweigh any possible beneficial effects of the hormone.

Certainly also, there is great promise in SERM's (Selective Estrogen Receptive Modulators), synthetic compounds which certainly give the same bone and cardiac protection as estrogens and at the same time significantly lower the risk of BrCa. The problem is, the presently available SERM's (Raloxifen, Tamoxifen) do not in any way help menopausal symptoms--in fact, they make them worse.

However...the whole ballgame will soon be different with FDA approval (expected in 1-2 years) of a new generation of SERM's. One of these, Tibolone, has been used in Europe (under the trade name Livial) for more than a decade. Not only does it have the same protection as other SERM's, but it helps with menopausal symptoms as well.

It is certainly hoped the FDA will approve it soon (it's been in the "pipeline" for years...)