All posts by CPTFeditor

Alcohol and Cancer

Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

The link between and alcohol and cancer may surprise you. A 2017 statement by the American Society of Clinical Oncology (ASCO) reports that drinking alcohol increases the risk of cancer of the mouth and throat, vocal cords, esophagus, liver, breast, and colon. The risks are greatest in those with heavy and long-term alcohol use. Even so, moderate drinking can add up over a lifetime, which could be harmful.[1]

What is Moderate Drinking? Heavy Drinking?

According to the National institute of Alcohol Abuse and Alcoholism (NIAAA), “moderate” drinking is 1 drink per day for women and 2 drinks per day for men, but not all “drinks” are equal. A drink is defined as approximately 14g of alcohol, which equals: 1.5 ounces of distilled spirits (e.g., vodka, gin, tequila, etc), 5 ounces of wine, 12 ounces of beer, and 8 ounces of malt liquor.[1,2] (Click here to see the CDC’s fact sheet.)

Heavy drinking is defined as 8 or more drinks per week OR 3 or more drinks per day for women and 15 or more drinks per week OR 4 or more drink per day for men. Most adults who engage in high-risk drinking started as teens.[1] (Click here to see our article on teen drinking.)

Drinking Amount and Cancer Risk

According to the International Agency for Research on Cancer (IARC), a branch of the World Health Organization (WHO), alcohol is a “group 1 carcinogen.” That means it can cause cancer in humans. Group 1 carcinogens include cigarette smoke, UV solar radiation, radon, and asbestos, for example.[3] Alcohol is known to cause six types of cancer, including cancer of the mouth and throat, vocal cords, esophagus (squamous cell), liver, female breast, and colon/rectum. Alcohol may also be tied to cancer of the pancreas, stomach, and lung, but more research is needed to find out for certain.[4] (Click here to see the National Cancer Institute’s Fact Sheet.)

Some of these cancers, such as mouth and throat cancer, are rare (about 1% lifetime risk), while colon cancer and breast cancer are much more common. [7] Depending on the amount a person drinks, he or she can increase the risk for even rare cancers. For example, moderate drinkers can almost double their lifetime risk of mouth and throat cancer to almost 2%, while heavy drinkers have a 500% increased risk of having mouth or throat cancer, from 1% to 5%.

Scientists believe that when alcohol comes into direct contact with tissue through drinking and swallowing, it causes more damage. For example, in the heaviest drinkers, alcohol raises the lifetime risk of esophagus cancer from about 0.5% to about 2.5%.[1,7]

Women need to be more cautious when drinking any amount of alcohol. The World Cancer Research Fund estimates that for every additional average drink per day, breast cancer risk goes up by 5% pre-menopause and up by 9% after menopause. Alcohol affects the amounts of certain sex hormones circulating in the body. For women who have had hormone receptor-positive breast cancer, 7 or more weekly drinks increased the chances of having a new cancer diagnosed in the other breast from about 5% to about 10%.[1]

How Alcohol Causes Cancer

Scientists believe that alcohol causes cancer in several ways:[1, 4]

  • Alcohol (ethanol) is broken down into a toxic substance called acetaldehyde. Acetaldehyde is directly toxic to the body’s cells.
  • Alcohol causes damage to cells through a process called free-radical oxidation.
  • Alcohol causes the body to absorb less folate (an important B vitamin) and other nutrients (antioxidant vitamins A, C, and E), which naturally repair damage and fight off cancers.
  • Alcohol increases the body’s level of estrogen (a sex hormone associated with breast cancer).

Does Quitting Change Your Chances of Developing Cancer or Cancer Recurrence?

Yes, drinking less alcohol on a regular basis reduces cancer risk, even in people who were already diagnosed with cancer. Research has shown that heavy or moderate drinkers who substantially reduce their alcohol consumption will slowly reduce their risk of developing mouth, throat, vocal cord, and esophagus cancer, but it would take 20 years of abstention to reduce the chances of developing those cancers to the lower chances of someone who never drank so frequently.  It is not clear whether reducing or giving up drinking after years of moderate or heavy drinking will have much impact for other alcohol-related cancers.[1]

In those who survived an esophagus cancer, drinkers tripled their risk for a new primary cancer diagnosis. On average, the risk of a new cancer diagnosis after esophagus cancer is removed is 8 % to 27%, and continuing heavy drinking will triple that risk.[5]

Among all cancer survivors, heavy drinking caused an 8% increased risk in dying and a 17% increased risk of cancer recurrence. Patients with cancer who abuse alcohol do worse because alcohol causes poorer nutrition, a suppressed immune system, and a weaker heart.[1]

What You Can Do to Lower Cancer Risk for You and Your Family

  1. . If you drink alcohol, limit drinks to an average of 1 a day for women and 2 a day for men.
  2. Recognize heavy drinking in a loved one, because the more a person drinks, the greater his or her chances of developing cancer. The “CAGE” questionnaire can help spot heavy drinking. Has the person tried to Cut back? Has the person been Annoyed when asked about drinking? Has the person felt bad or Guilty? Has the person needed a drink first thing in the morning (Eye opener)? Each “yes” counts as 1 point. A score of 2 or more suggests problem drinking.[6]
  3. Talk with your doctor about your risk. Doctors can refer or offer counseling and treatment services to patients with risky drinking habits.
  4. Seek help early. Problem drinking can’t be wished away. There are many resources to access information and help. The Substance Abuse and Mental Health Services Administration (SAMHSA), which is part of the U.S. Department of Health and Human Services (HHS) has a toll free hot-line and website. Call 1-800-662-HELP (4357) or visit https://findtreatment.samhsa.gov/  today.
  5. Practice healthy habits. Eating a diet rich in cancer-fighting nutrients (i.e., fruits and vegetables), exercising, maintaining a healthy weight, reducing stress, and getting restful sleep can all help to lower cancer risk. Don’t smoke, and quit if you do. Drinking and smoking increases cancer risk more than either one alone.

The Bottom Line

To prevent cancer, try to limit your drinking by sticking to a maximum average of 1 a day if you’re a woman and 2 a day if you’re a man.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

Footnotes:

  1. LoConte, NK. et al. Alcohol and Cancer: A Statement of the American Society of Clinical Oncology. Journal of Clinical Oncology. published online before print November 7, 2017. DOI: 10.1200/JCO.2017.76.1155. Available online: http://ascopubs.org/doi/full/10.1200/JCO.2017.76.1155
  2. Centers for Disease Control and Prevention. Alcohol and Public Health. Fact Sheets- Moderate Drinking. Accessed November 16, 2017. Available online: https://www.cdc.gov/alcohol/fact-sheets/moderate-drinking.htm

 

Hormonal Therapy for Ductal Carcinoma In Situ (DCIS)

Diana Zuckerman, PhD and Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

In recent years, ductal carcinoma in situ (DCIS) has become one of the most commonly diagnosed breast conditions. It is often referred to as “stage zero breast cancer” or a “pre-cancer.” It is a non-invasive breast condition that is usually diagnosed on a mammogram when it is so small that it has not formed a lump. In DCIS, some of the cells lining the ducts (the parts of the breast that secrete milk) have developed abnormally, but the abnormality has not spread to other breast cells.

DCIS is not painful or dangerous, but it sometimes develops into breast cancer in the future if it is not treated. If it develops into breast cancer, it can spread, at which point it is called invasive. The goal of treating invasive cancer is to prevent it from spreading to the lungs, bones, brain, or other parts of the body, where it can be fatal. Since DCIS is not an invasive cancer, it is even less of a threat than Stage 1 or Stage 2 breast cancer, which are the earliest types of invasive cancer.[1]  For more information, see our free DCIS booklet, and our other articles on DCIS.

Most women with DCIS will never develop invasive cancer whether they are treated or not, but it is impossible to predict which women with DCIS will develop cancer and which ones won’t. That’s why treatment is recommended. A woman with DCIS does not need all the same treatments as a woman diagnosed with invasive breast cancer, but surgery is almost always recommended. Most DCIS patients will choose a lumpectomy (which removes the DCIS but does not remove the entire breast), and radiation therapy is usually recommended for those women to destroy any stray abnormal cells in the same breast.[1]

Some women also try hormone therapy such as tamoxifen or aromatase inhibitors. That is the focus of this article.

DCIS does not need to be treated immediately. A woman can spend a few weeks after her diagnosis to talk with her doctors, learn the facts about her treatment choices, and think about what is important to her before she chooses which kind of treatment to have.

Hormonal Therapy

Hormonal therapy is recommended for some women with DCIS to help prevent breast cancer from developing and to prevent DCIS from returning after it has been surgically removed.  It is only effective for women whose DCIS is “estrogen receptor positive”, which DCIS usually is.

Hormonal therapy is taken as a pill every day for at least 5 years. Side effects include increased risk of endometrial cancer, severe circulatory problems, or stroke. In addition, hot flashes, vaginal dryness, abnormal vaginal bleeding, and a possibility of premature menopause are common for women who were not yet menopausal when they started treatment.[1]

What is the benefit of hormone therapy for women also undergoing radiation therapy?

Tamoxifen blocks the effects of estrogen on breast cells, which can stop the growth of cancer cells that are sensitive to estrogen. A study of more than 1,800 pre-menopausal and post-menopausal women with DCIS evaluated the benefits of tamoxifen for women who had lumpectomy and radiation treatment. These women were randomly assigned to take tamoxifen for 5 years or a placebo (sugar pill). The study found that after 5 years, women who took tamoxifen were about 5% less likely to develop either DCIS or cancer in the same breast, cancer in the opposite breast, or distant cancer spread (8.2% in women taking tamoxifen vs. 13.4% in placebo). However, the vast majority of women survived and they did not live any longer whether they took tamoxifen or not.[1]

For postmenopausal women, aromatase inhibitors may be used instead of tamoxifen. Aromatase inhibitors block the body’s ability to make estrogen. A study of more than 3,000 post-menopausal women with DCIS evaluated the benefits of hormone treatment for women who had lumpectomy and radiation treatment. These women were randomly assigned to take tamoxifen or anastrozole for 5 years. The study found that after 5 years, compared to women taking tamoxifen, the women taking anastrozole were 2% less likely to develop either DCIS or cancer in the same breast, cancer in the opposite breast, or distant cancer spread (from about 8% of women taking tamoxifen compared to 6% taking anastrozole).  As in the previous study, the vast majority of women survived and those taking anastrozole did not live any longer than women taking tamoxifen.[2]

That was a very small benefit for anastrozole compared to tamoxifen, and another study of post-menopausal women with DCIS found no difference between the two hormone treatments.[3]

What is the benefit of hormone therapy for lumpectomy patients who do not undergo radiation therapy?

Although radiation therapy is usually recommended for lumpectomy patients, it is inconvenient and many women prefer to avoid it.  In addition, radiation is only beneficial for preventing cancer in the one breast, while hormone therapy helps prevent cancer in both breasts. A study of more than 1,700 women with DCIS who underwent a lumpectomy evaluated radiation and/or tamoxifen.  The women were randomly assigned either to radiation, tamoxifen, radiation plus tamoxifen, or no treatment after surgery. For women who did not have radiation therapy, tamoxifen reduced the chances of developing DCIS within 10 years in the same breast by about 3% and the chances of developing DCIS in the other breast by about 1%. Interestingly, tamoxifen did not significantly decrease the chances of developing invasive breast cancer in the same breast, and only reduced the chances of developing invasive cancer in the opposite breast by about 1%.[4]

In women treated with radiation, about 10% developed DCIS or breast cancer within the next 10 years after surgery, and it made no difference whether these women took tamoxifen or not. And while the vast majority of women were alive 10 years later, their chances of survival were no different whether they were treated with radiation, tamoxifen, both, or neither.[4]

Side Effects

While there are benefits to using hormonal therapy, tamoxifen and aromatase inhibitors carry risks of serious harms. Because estrogen plays an important role in maintaining strong bones and healthy cholesterol, blocking estrogen can put healthy women at greater risk for heart disease and osteoporosis.

Tamoxifen:

  • endometrial (uterine) cancer- for every 1,000 women, 2 more will develop uterine cancer
  • blood clots- for every 1,000 women, 3 more will develop potentially dangerous blood clots
  • strokes-  for every 100 women, 1 will develop a stroke
  • cataracts
  • hot flashes
  • vaginal discharge
  • vaginal bleeding

source: Medscape

Aromatase Inhibitors:

  • uterine cancer-  for every 1000 women, 20 more will develop uterine cancer
  • blood clots- for every 1,000 women, 20 more will develop a blood clot
  • strokes- for every 100 women, 2 more will develop a stroke
  • Joint pain for every 1000 women, 20 to 100 more will develop joint pains
  • hot flashes
  • vaginal bleeding
  • vaginal discharge

source: Medscape

The Bottom Line

In women diagnosed with DCIS, hormonal therapy can help prevent DCIS from recurring.  If a woman doesn’t undergo radiation therapy, hormonal therapy can reduce her chances of  invasive cancer in the opposite breast, but not invasive cancer in the same breast. And, hormonal therapy used in addition to radiation treatment apparently has no benefit, but does have added risks.

Perhaps most important, women who take hormonal therapies do not live any longer than women who don’t.

Too often, women with DCIS are encouraged to undergo radiation as well as hormonal therapy, but as you can see, the benefits of doing both are not greater than the benefits of choosing one or the other. And, the benefits of either radiation or hormonal therapy are primarily for reducing the chances of recurrence, but there is no benefit in terms of living longer.  Fortunately, almost all women with DCIS will live regardless of which of these treatments they have.

Talk to your doctor about which treatment options may be right for you.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

Footnotes:

  1. National Cancer Institute. Breast Cancer Treatment PDQ. (Feb. 2018). Available online: https://www.cancer.gov/types/breast/hp/breast-treatment-pdq#link/_1576_toc
  2. Margolese, Richard G et al. Anastrozole versus tamoxifen in postmenopausal women with ductal carcinoma in situ undergoing lumpectomy plus radiotherapy (NSABP B-35): a randomised, double-blind, phase 3 clinical trial.The Lancet. 2016;387(10021): 849 – 856.
  3. Forbes, John F et al. Anastrozole versus tamoxifen for the prevention of locoregional and contralateral breast cancer in postmenopausal women with locally excised ductal carcinoma in situ (IBIS-II DCIS): a double-blind, randomised controlled trial. The Lancet.2016;387(10021): 866 – 873.
  4. Cuzick, Jack et al. Effect of tamoxifen and radiotherapy in women with locally excised ductal carcinoma in situ: long-term results from the UK/ANZ DCIS trial. The Lancet Oncology. 2011; 12(1): 21 – 29
  5. Medscape. Drugs & Diseases. Available online: https://reference.medscape.com/drug/soltamox-tamoxifen-342183#4 and https://reference.medscape.com/drug/arimidex-anastrozole-342208#4

Beginner’s Guide to Developing an Exercise Routine

Morgan Wharton and Caitlin Kennedy, Cancer Prevention and Treatment Fund

Exercise is one of NCHR’s seven recommended ways to maximize your health. If you want to exercise but aren’t sure where to begin, we can help! If you feel like your daily life doesn’t allow you to get fit (not enough time, no money for a gym membership, etc.), we have some “work-arounds” that may help.

Benefits of Exercise

Everyone knows that exercise helps keep you healthy by preventing weight gain, but did you know that it also lowers your risk of heart disease, stroke, high blood pressure, unhealthy cholesterol, type 2 diabetes, colon cancer, breast cancer, and depression? Exercising to improve muscle strength improves balance, and reduces the risk of falling, fractures, and arthritis. Overall, regular exercise improves your chances of living a longer, healthier life.[1] Even people who have been diagnosed with cancer can benefit from exercise. Click here to read more how exercise can help cancer patients.

How Much Should I Exercise?

The Centers for Disease Control and Prevention (CDC) recommend that adults should aim for 150 minutes of moderate-intensity exercise every week (such as walking quickly) or 75 minutes of high-intensity activity per week (such as running), plus two days of strength training (training with weights or resistance bands). If you haven’t been very active, start exercising at a low intensity, then slowly increase the amount and intensity of exercise each week.[2]

How Do I Create an Exercise Routine?

Regardless of your fitness goals, start small to avoid discouragement or burnout: if you set your initial goals too high and aim for perfection, you’ll be more likely to abandon your exercise plans before they improve your health. Follow these exercise routines from the CDC to create a balanced, varied routine.

To prevent injury, always start your workout with a good warm up-short aerobic activity followed by dynamic stretching. Dynamic stretching involves moving different muscle groups through a full range of motion and is the best form of stretching before exercise because it warms up groups of muscles rather than individual muscles. Static stretching, such as holding a muscle in a position of resistance for up to 30 seconds, is helpful for improving flexibility and muscle imbalance over time, but is not beneficial just before exercising.[3] Investing in good running shoes will also help with preventing injuries such as shin splints that can develop after running on hard surfaces with the wrong kind of footwear.

If you don’t feel up to completing a full workout or are too busy on a given day, even taking the stairs instead of an elevator or escalator, walking around while you make phone calls, or walking to work or during your break can make up your exercise for the day. Try to have some physical activity each day, and you’ll find that’s more likely if you get co-workers involved.[4] Form a walking group and walk to work with people who live near you, or walk together on your daily breaks. If you don’t have a group of people to exercise with at work, consider using social media to benefit from peer pressure. You can download the HealthyShare app on Facebook to get people from your social network involved and use Nike+ to track your workouts and upload your progress to sites like Facebook and Twitter.

Keeping track of your fitness goals and exercise can help you develop a routine so exercise becomes a habit. If you don’t want to use mobile technology to keep track of your exercising, click here to check out some tools designed by the U.S. Department of Health & Human services for other ways to track your fitness goals and routines.

In addition to running- and movement-based exercise, weight training is very valuable. If you enjoy weight lifting, joining a gym can add a financial incentive to working out: if you’ve already paid for a membership, you’ll have more reason to go and get your workout in! If you need more motivation to get to the gym, check out GymPact – you can get paid just for completing workouts at your gym! If you aren’t sure how to use the machines in the gym, check out these instructional videos and these tips for better technique.

Whether or not you go to a gym, there are plenty of ways to get a good workout at home! You can get a great workout with bodyweight exercises alone. Use this guide from the National Institutes of Health to begin resistance training and weight lifting at home. Investing in a jump rope, balance ball, medicine ball, resistance bands, and 5-pound dumbbells can give you more flexibility with your workouts. Variation is important to get the most benefits from exercise and prevent boredom from the same routines. The Nike Training Club app for smartphones has free workouts, sorted by difficulty, which can be done with these basic training tools. The app also tracks your progress and adds new workouts once you reach specific milestones based on the number of minutes you’ve exercised.

Signing up for a race is a great way to motivate you to begin an exercise routine. It gives you a deadline to work towards – the date of the race – and a concrete goal to train for – the length of the race.  A 5k is a great first race to train for because it’s only 3.14 miles.

Avoiding the Risks of Exercise

Dehydration

People who exercise outside and do not drink enough water put themselves at risk for heat stroke and exhaustion. Drink plenty of water beginning the day before you exercise, and drink 10 ounces of water for every 20 minutes of exercise (a can of soda is 12 ounces). Drink before you get thirsty, because thirst is the first sign of dehydration.[5] Finally, beware of the dangers of water bottles containing BPA. Be sure to select a stainless steel bottle or a plastic water bottle that is labeled “BPA free.” Read more about the harmful effects of BPA here.

Skin Cancer

While running and exercising outside, remember to apply sunscreen of SPF 30 or higher that offers full spectrum protection (protection against both UVA and UVB rays) and is water-resistant. Apply at least fifteen minutes before going outside to allow your skin to soak up the sunscreen. Reapply often-every two hours and after swimming and excessive sweating. You should also apply lip balm of at least SPF 30. This will reduce your risk of sunburn, skin cancer, and premature aging of the skin.[6] Read more about running and skin cancer here.

Overtraining

Overtraining can put too much stress on the immune system and keep it from doing its job, which is to keep you from getting sick! People who overtrain put themselves at risk of developing illnesses like colds and the flu because their immune systems are “run down.” You may feel fatigued all the time, or find yourself getting injured.  Some soreness and fatigue is a normal part of training, but if your discomfort becomes excessive, increase your rest/recovery time in between workouts.[7]

Regular endurance exercise may be risky, as well.  Running more than 30 miles per week may lessen or erase the health benefits, including a longer life, which moderate levels of running provide.  People who run a lot of marathons have been found to have higher levels of coronary plaque, a type of heart disease and a cause of heart attacks.[8] Therefore, moderate levels of regular exercise are recommended.

The Bottom Line

The potential benefits far outweigh the potential risks of regular exercise. Grab a friend, use social media, and register for a race to keep your motivation levels high until exercise becomes a part of your daily routine. Regular physical activity can improve your physical health, and also your mood and overall mental well-being. Maybe you’ve heard of a “runner’s high” – well, you don’t have to be a runner to experience the calming effects of exercise.  If you want to experience these health benefits and live a longer, healthier life, now is the time to begin a fitness routine!

All articles on our website have been approved by Dr. Diana Zuckerman and other senior staff.

References:

  1. Physical activity and health. Division of Nutrition, Physical Activity and Obesity 2011; Available from: http://www.cdc.gov/physicalactivity/everyone/health/index.html.
  2. Health, O.o.W.s. Physical activity (exercise) fact sheet. 2009.
  3. How much physical activity do adults need? 2011; Available from: http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html.
  4. O’Donovan, G., Lee, I., Hamer, M., et al. (2017). Association of “Weekend Warrior” and Other Leisure Time Physical Activity Patterns with Risk for All-Cause, Cardiovascular Disease, and Cancer Mortality. JAMA Intern Med. 177(3): 335-342. Retrieved from https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2596007?utm_source=silverchair&utm_campaign=altmetric&utm_content=2017_year-end&cmp=1&utm_medium=email&redirect=true. Accessed on January 5, 2018.
  5. Parracino, L., A Simple Guide to Stretching, 2002, National Academy of Sports Medicine.
  6. Make Physical Activity Fun, in Overcoming Barriers to Physical Activity, W. Can!, Editor, U.S. Department of Health & Human Services.
  7. Healthy Hydration. 2012; Available from: http://www.acefitness.org/fitfacts/fitfacts_display.aspx?itemid=173.
  8. Sunscreens. 2012; Available from: http://www.aad.org/media-resources/stats-and-facts/prevention-and-care/sunscreens.
  9. Kellmann, M., Preventing overtraining in athletes in high-intensity sports and stress/recovery monitoring. Scand J Med Sci Sports, 2010. 20 Suppl 2: p. 95-102.
  10. Mohlenkamp S, Lehmann N , Breuckmann F, Brocker-Preuss M, Nassenstein K, Halle M, Budde T, Mann K, Barkhausen J, Heusch G, Jockel K, & Erbel R. Running: The risk of coronary events. Prevalence and prognostic relevance of coronary atherosclerosis in marathon runners. European Heart Journal, 2008. 29(15): p. 1903-1910.

The Unknown Health Risks of Air Pollution

Hannah Kalvin and Alex Pew, Cancer Prevention & Treatment Fund

Air pollution is a hot topic in the media. Here is what you need to know about the causes of air pollution and how it can increase the risk of cancer and other serious diseases in adults and children.

Types of Air Pollution and the Impact on Your Health

The Environmental Protection Agency (EPA) has classified six air pollutants that are the most common and the most dangerous. They are:[1]Air pollution

  • Ozone
  • Particulate Matter
  • Carbon Monoxide
  • Nitrogen Oxides
  • Sulfur Dioxides
  • Lead

Each of these can cause breathing problems and can increase asthma symptoms. Children, the elderly, and people with asthma are the most likely to be harmed by air pollutants.

Ozone is commonly known as the layer of gas that protects the Earth from UV rays. However, only ozone in the atmosphere has this protective effect. Ozone located on the ground level is a health hazard. Ground level ozone is the result of industrial plants, electric utilities, motor vehicle exhaust, gasoline vapors, and chemical solvents. Each of these causes the release of invisible molecules that react with each other and create ozone on the ground level when it is warm and sunny outside.[2] Inhaling ozone can cause chest pain, coughing, throat irritation, and congestion. If someone has bronchitis, emphysema, or asthma, ground level ozone makes it even more difficult to breathe. Eventually, repeated exposure to ground level ozone can scar the lungs.[3]

Particulate Matter is made up of very small particles and liquid droplets. They can be acids, organic chemicals, metals, soil, or dust particles. Particulate matter forms when gasses from power plants, industries, and/or automobiles react in the air. This form of air pollution is found near roads, in smoke, in haze, and in forest fires. When these particles are 10 micrometers or less in diameter, they are small enough to go through the nose or throat, resulting in major health problems.[4] When inhaled, particulate matter can cause serious lung damage, since the particles are small enough to go deep into the lungs. Particulate matter can cause premature death in people with heart or lung disease. Particulate matter has also been linked to nonfatal heart attacks, irregular heartbeat, and difficulty breathing. While individuals who already have health problems are more likely to be harmed by particulate matter, healthy people can be injured by these small particles as well.[5]

Carbon Monoxide is a gas that you cannot see or smell. It is released into the air by motor vehicles, so it is more likely in cities where there are many motor vehicles.[6] Carbon Monoxide is harmful when inhaled because it results in blood not being able to carry as much oxygen. Since we need oxygen to live, carbon monoxide pollution can be harmful to anyone, but it is most harmful for people with already low oxygen levels.[7]

Nitrogen Oxides are another type of air pollutant, also from emissions from cars, trucks, buses, power plants, and off-road equipment.[8] Nitrogen oxide can cause inflammation of the airways in healthy people, breathing problems in people who have asthma or other lung problems, and worsen existing heart disease. Anyone who lives within 300 feet of a major highway, railroad, or airport, will be exposed to higher levels of Nitrogen Oxides. Unfortunately, that includes about 16% of housing in the United States.[9]

Sulfur Dioxides are gases created from the burning of fossil fuels at power plants and industrial facilities. They also result from burning fuels containing high levels of sulfur, by locomotives, large ships, non-road equipment, and other industrial processes.[10] They cause breathing problems and increase other asthma symptoms.[11]

Lead is also considered to be a type of air pollutant. Lead used to be released into the air from gasoline, but while laws currently prevent lead from being in gasoline, lead from past pollution is still commonly found in dirt, especially in urban areas.[12] Lead is especially dangerous for children, and can cause behavioral problems, lower IQ, and learning problems. In adults, lead exposure is linked to high blood pressure and heart disease.[13]

Often, smog is mentioned as a sign of air pollution. While it is an obvious sign of air pollution, most smog is invisible to the human eye.

Recent Findings

In 2015, researchers used mathematical models to find out how many deaths were caused by air pollution in 2010. They concluded that particulate matter air pollution caused adults to die earlier from chronic obstructive pulmonary disease (COPD), heart disease, and lung cancer, and for infants to die from acute lower respiratory illnesses (such as pneumonia, bronchitis, or flu). They estimated that 3.3 million deaths in 2010 were a result of particulate matter air pollution. If nothing is done to reduce particulate matter air pollution, the authors anticipated that in 2050 6.6 million people will die earlier as a result of air pollution. The authors found that “residential and commercial energy use” contributed most to the amount of deaths worldwide from particulate matter air pollution in 2010. However, the major contributors to particulate matter air pollution in the United States are emissions from vehicles and power generation.[14] This is the first study to calculate the number of deaths caused by a type of air pollution.

A different study published in late 2015 concluded that airborne coal particles result in more fatal heart attacks than other particles in the air.[15]

In 2017, a Harvard study that looked at 22 million deaths in the U.S. found that people 65 and older are more likely to die on days when air quality is poor. This means that even short-term exposure to air pollution can be dangerous as we get older. The EPA’s Clean Air Act Amendments have decreased the levels of pollutants in the air, which experts estimate has saved at least 30,000 lives in the U.S. Keeping and improving these amendments could save more lives and improve air quality even more.[16,17]

The Bottom Line

Air pollution will continue to harm adults and children unless drastic changes are made. While some air pollution is visible to the human eye, most cannot be seen. You can use a website or an app to monitor air quality, in order to reduce your exposure to all types of air pollution. Below are some websites and apps for monitoring air quality. On days when the air quality index is bad, it is best to avoid the risks and stay indoors. While pollution is risky for everyone, children, elderly, and people with heart or lung problems need to be especially careful.

If you would like to learn more about how you can reduce air pollution, click here.

Air Quality Index Websites

http://www.airnow.gov/

http://aqicn.org/map/world/

Air Quality Index Apps

EPA AIRNow

Global Air Quality Monitoring & Forecast

Air Bubbles: Air Quality in Real Time

Global Air Quality – Real Time Air Pollution Indices

All articles on our website have been approved by Dr. Diana Zuckerman and other senior staff.

References

  1. What Are the Six Common Air Pollutants? (2015, September 18). Retrieved December 4, 2015, from http://www3.epa.gov/airquality/urbanair/
  2. Ground Level Ozone | US Environmental Protection Agency. (2015, October 1). Retrieved December 4, 2015, from http://www3.epa.gov/ozonepollution/
  3. Health Effects- Ozone Pollution. (2015, October 1). Retrieved December 4, 2015, from http://www3.epa.gov/ozonepollution/health.html
  4. Particulate Matter | US Environmental Protection Agency. (2015, September 10). Retrieved December 4, 2015 from http://www3.epa.gov/pm/
  5. Health Effects- Particulate Matter. (2015, September 10). Retrieved December 4, 2015, from http://www3.epa.gov/pm/health.html
  6. Carbon Monoxide | US Environmental Protection Agency. (2015, September 10). Retrieved December 4, 2015 from http://www3.epa.gov/airquality/carbonmonoxide/
  7. Health Effects- Carbon Monoxide. (2015, September 10). Retrieved December 4, 2015, from l http://www3.epa.gov/airquality/carbonmonoxide/health.html
  8. Nitrogen Oxides | US Environmental Protection Agency. (2015, September 10). Retrieved December 4, 2015 from http://www3.epa.gov/airquality/nitrogenoxides/
  9. Health Effects- Nitrogen Oxides. (2015, September 10). Retrieved December 4, 2015, from http://www3.epa.gov/airquality/nitrogenoxides/health.html
  10. Sulfur Dioxide | US Environmental Protection Agency. (2015, September 10). Retrieved December 4, 2015 from http://www3.epa.gov/airquality/sulfurdioxide/
  11. Health Effects- Sulfur Dioxide. (2015, September 10). Retrieved December 4, 2015, from http://www3.epa.gov/airquality/sulfurdioxide/health.html
  12. Lead | US Environmental Protection Agency. (2015, September 10). Retrieved December 4, 2015 from http://www3.epa.gov/airquality/lead/
  13. Health Effects- Lead. (2015, September 10). Retrieved December 4, 2015, from http://www3.epa.gov/airquality/lead/health.html
  14. Lelieveld, J., Evans, J., Fnais, M., Giannadaki, D., & Pozzer, A. (2015). The contribution of outdoor air pollution sources to premature mortality on a global scale. Nature, 367-371. Retrieved December 4, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/26381985
  15. Thurston, G., Burnett, R., & Turner, M. (2015). Ischemic Heart Disease Mortality and Long-Term Exposure to Source-Related Components of U.S. Fine Particle Air Pollution. Environ Health Perspect. doi:DOI:10.1289/ehp.1509777
  16. Di, Q., Dai, L., Wang, Y., et al. (2017). Association of Short-Term Exposure to Air Pollution with Mortality in Older Adults. JAMA. 318(24): 2446-2456. Retrieved from https://jamanetwork.com/journals/jama/article-abstract/2667069?redirect=true. Accessed on January 5, 2018.
  17. Ridley, D., Heald, C., Ridley, K., and Kroll, J. (2017). Causes and Consequences of Decreasing Atmospheric Organic Aerosol in the United States. PNAS. doi.org/10.1073/pnas.1700387115. Retrieved from http://www.pnas.org/content/early/2017/12/18/1700387115. Accessed on January 5, 2018.

Preventing Breast Cancer with Hormonal Therapy

Caroline Halsted and Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

About 12% of women in the United States will be diagnosed with breast cancer at some point in their lifetimes.  Although most women survive breast cancer, many women are very afraid of the disease and consider undergoing medical treatments to prevent breast cancer from ever developing.  Hormonal therapy is a popular strategy among women who are afraid of breast cancer and want to reduce the chances of ever developing it.  What are the risks and benefits?

What is hormonal therapy?

Hormonal therapy prevents breast cancer by blocking or reducing the level of female hormones that can help breast cancer cells to grow. Approximately 80% of all breast cancers are “estrogen-receptor positive” which means that they need estrogen to grow.[1] Tamoxifen and raloxifene are two hormonal treatments that block estrogen in the breast but not in other parts of the body.  They are called selective estrogen receptor modulators (SERMs), and they are sometimes prescribed for pre-menopausal and post-menopausal women who have an above-average risk of developing breast cancer.

How Effective are Tamoxifen and Raloxifine?

A study compared tamoxifen and raloxifene as prevention strategies for post-menopausal women who were at an increased risk of breast cancer.[2]  The study was called the STAR trial, which is the acronym for “The Study of Tamoxifen and Raloxifene.” Women were defined as increased risk in this study if they had a higher risk than the average 60-64 year old, which is estimated at 1.67% in the next 5 years.[3] Factors that determine a woman’s risk include:

  • age
  • number of first-degree relatives diagnosed with breast cancer
  • number of children
  • age at first delivery
  • number of breast biopsies undergone
  • whether there is presence of atypical hyperplasia
  • age at first menstrual period
  • age at menopause

A tool determining your own risk of breast cancer can be found here.

The initial results of the STAR study found that tamoxifen and raloxifene were equally effective in preventing breast cancer after four years of treatment. However, after 5 years of treatment and 2 years of follow-up after the treatment ended, women taking tamoxifen were 1.1% less likely to develop breast cancer while women taking raloxifene were less than half a percent less likely to develop breast cancer (0.4%).[4] So, for example, if your 7-year risk of getting breast cancer was 4% (considered an increased risk), taking tamoxifen may decrease your risk to just under 3% and raloxifene to about 3.6%. This decrease in risk for women taking tamoxifen is very similar to the results of studies conducted more than 5 years earlier, which when combined found a 1.2% decreased risk of breast cancer for pre- and post-menopausal women at average or high risk of breast cancer.[5]

Hormonal therapy is even less beneficial to prevent breast cancer in pre-menopausal women, so it is only recommended for women who have mutations in the “breast cancer genes” (BRCA1 or BRCA2) or if they are older than 35 and have a very high risk of breast cancer.[6]

Although about 12% of U.S. women will be diagnosed with breast cancer at some point in their lifetime, 88% won’t.  Most women at “higher than average risk” will never develop breast cancer, and there are many things women can do to reduce their risks. Here are 5 ways you can reduce your risk of getting breast cancer. When considering whether to take hormonal therapy to reduce your chances of developing breast cancer, don’t focus on what is called “relative risk” –  make sure you understand the absolute risk.  For example, a woman with a 2% risk of developing breast cancer in the next 5 years can possibly reduce that risk by 50% by taking Tamoxifen, but that is only a reduction from 2% to 1%.  To decide whether that is worth it to you, it is important to consider the side effects and risks of these treatments, and not just the benefits.

Side Effects

Tamoxifen and raloxifene can be harmful. Because estrogen plays an important role in maintaining strong bones and healthy cholesterol, blocking estrogen can put healthy women at greater risk for heart disease and osteoporosis.

Here are the known side effects of tamoxifen:

  • endometrial (uterine) cancer- for every 1,000 women, 2 more will develop uterine cancer
  • blood clots- for every 1,000 women, 3 more will develop potentially dangerous blood clots
  • strokes- for every 100 women, 1 will develop a stroke
  • cataracts
  • hot flashes
  • vaginal discharge
  • vaginal bleeding

Known side effects of raloxifene:

  • blood clots- for every 1,000 women, 2-3 will develop a potentially dangerous blood clot
  • hot flashes
  • vaginal dryness
  • joint pain
  • leg cramps

Sources: [3], [7]

Compared to raloxifene, women taking tamoxifen have a greater risk of developing serious blood clots, but both drugs have about the same increased risk for other heart-related side effects and bone fractures. Women who took tamoxifen had a more than 1% increased risk for developing cataracts compared to women who took raloxifene.

Most important, taking tamoxifen for five years can increase a woman’s lifetime risk of developing endometrial cancer from about 3% to about 7%.[8] Raloxifene does not.[9]

For premenopausal women, tamoxifen has significantly worse side effects than raloxifene. However, tamoxifen can be taken by either pre-menopausal or post-menopausal women, while raloxifene is only approved for post-menopausal women.

Bottom Line

If you are afraid of developing breast cancer because of a family history or other reasons, it is important to understand the limited benefits as well as the risks of hormonal therapy.  As noted above, the absolute benefit in terms of lower risks is often only about 1% (for example, lowering your risk from 4% to 3% chances of developing cancer, or from 2% to 1%).

Although research has consistently shown that both tamoxifen and raloxifene can decrease risk for developing breast cancer, these results have only been significant for post-menopausal women with an increased risk of getting breast cancer. The higher your risk of developing breast cancer (because of the BRCA genes, family history, or other reasons) the more likely that the benefits will outweigh the risks for you.  But even that depends on your other health risks.  For example, if you are already at high risk of developing blood clots, you probably don’t want to take a hormone treatment that increases that risk even more.

If you are not impressed by the benefits of hormonal treatment to prevent breast cancer, think about other strategies such as reducing how much alcohol you drink, losing a few pounds, eating more fresh fruit, vegetables, and whole grains, and exercising. Our articles about preventing breast cancer can be found here. These strategies reduce your chances of developing cancer as well as reducing your chances of dying from heart disease – which kills more women every year than breast cancer.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

References

  1. What Is Hormonal Therapy for Breast Cancer? (2016, July 20). Retrieved from http://www.breastcancer.org/treatment/hormonal/what_is
  2. The Study of Tamoxifen and Raloxifene (STAR): Questions and Answers. (2010, April 9). Retrieved from https://www.cancer.gov/types/breast/research/star-trial-results-qa
  3. About the Tool. (n.d.). Retrieved from https://www.cancer.gov/bcrisktool/about-tool.aspx
  4. Vogel, V. G., Costantino, J. P., Wickerham, D. L., & Cronin, W. M. (2010). Re: Tamoxifen for Prevention of Breast Cancer: Report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. Cancer Prevention Research, 3(63), 1504-1504. doi:10.1093/jnci/94.19.1504
  5. Tan-Chiu, E., Wang, J., Costantino, J. P., Paik, S., Butch, C., Wickerham, D. L., . . . Wolmark, N. (2003). Effects of Tamoxifen on Benign Breast Disease in Women at High Risk for Breast Cancer. JNCI Journal of the National Cancer Institute, 95(4), 302-307. doi:10.1093/jnci/95.4.302
  6. Vogel, V. G. (2018). Primary Prevention of Breast Cancer. The Breast, 219-236. doi:10.1016/b978-0-323-35955-9.00016-7
  7. Bushnell, C. D., & Goldstein, L. B. (2004). Risk of ischemic stroke with tamoxifen treatment for breast cancer: A meta-analysis. Neurology, 63(7), 1230-1233. doi:10.1212/01.wnl.0000140491.54664.50
  8. Cancer Stat Facts: Uterine Cancer. (n.d.). Retrieved from https://seer.cancer.gov/statfacts/html/corp.html
  9. Swerdlow, A. J., & Jones, M. E. (2005). Tamoxifen Treatment for Breast Cancer and Risk of Endometrial Cancer: A Case-Control Study. JNCI Journal of the National Cancer Institute, 97(5), 375-384. doi:10.1093/jnci/dji057

 

What are the Alternatives to Traditional Radiation Therapy for Breast Cancer?

Dana Casciotti, PhD, Anna E. Mazzucco, PhD, and Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

Almost all women with early-stage breast cancer will live just as long if they choose lumpectomy (also called breast conserving surgery) instead of mastectomy. However, traditional radiation treatment is recommended for lumpectomy patients because it lowers their chances of the cancer returning.

Traditional radiation therapy is given on an outpatient basis 5 days each week for 6-8 weeks, and that is a difficult schedule for many patients. Many women living in rural areas or far from the hospital choose to get a mastectomy because daily radiation is so inconvenient.

For some women, radiation to a smaller area of the breast over a shorter period of time may be a useful alternative. These options are called partial breast irradiation (PBI).

PBI can be given with just 5-10 treatments over about a week’s time, and researchers are testing if treatments can be shortened to 2 days. According to experts, PBI can reduce the chances of a tumor coming back in the area around the lumpectomy from 10-25% to 3-4%.[1]

Based on a comprehensive 2016 research review, women who had PBI were more likely to have their tumor come back or to have a new tumor form in the same breast than women who had whole breast radiation treatment (WBRT). However, women who had PBI were not more likely to die any sooner or to later need a mastectomy.[2] 

PBI is not for everyone (see considerations below). Each type of PBI carries a different potential risk than the other types. For example, PBI with brachytherapy carries a higher risk of infection or seroma (fluid filled pocket in the breast tissue after surgery) than PBI with external beam radiation.[3] However, PBI with external beam radiation, increases risk for harmful effects to the lungs and heart. Three-dimensional models can reduce the radiation exposure to normal tissue, but do not completely eliminate risk.[4]

Across many studies, it is not clear whether PBI is more harmful to skin tissue than traditional radiation therapies.[5, 6,7] Harmful effects on the skin are rated on a scale of 1 to 4, with 4 being the worst. The changes in skin appearance include wrinkling, shrinkage, color change, red blotches, thickening, skin loss and destruction, etc.[8]  

PBI has been studied in clinical trials lasting no longer than 5 years, which isn’t really long enough to know if the therapy works the same or better than traditional radiation treatment. Traditional radiation therapy has been proven to be safe and effective for women for at least 15 years after treatment.

Who Should Consider PBI?

The American Society of Therapeutic Radiology and Oncology (ASTRO) provides the following recommendations: [9]

  1. Women aged 50 and over
  2. Early-stage breast cancer that is confined to one defined area of one breast only
  3. Estrogen receptor-positive breast cancer
  4. Women who had a breast lump removed with “clean margins” (no cancer cells were found in the area that was removed surrounding the lump)
  5. Women who did not have chemotherapy prior to surgery

Who should not be given PBI?

  1. Women aged 40 and younger
  2. Women who had the cancer removed but the margins contained cancer cells (“positive margins”)

What are the Types of PBI?

PBI can be given in the following ways:

  1. Intracavitary brachytherapy or MammoSite- A radiation bead is placed in the surgical cavity (the space left in the breast tissue after the breast lump is removed). This can be done at the time of surgery or later.
  2.  Interstitial brachytherapy- Several catheters are placed into the surgical cavity. Radioactive beads can be put in the breast through the catheters.
  3. Intra-operative technique- During the surgery, a machine is used that gives local radiation to the surgical cavity before the wound is closed.
  4. External beam radiotherapy using 3D modeling- Beams of radiation are given from different directions to match the 3D shape of the tumor. This focuses the rays on the tumor while reducing damage to the rest of the breast.

What are the Benefits and Harms of PBI?

Advantages of PBI:

  1. Smaller area of breast is given radiation, which reduces damage to normal breast tissue.
  2. Treatments can be given over days instead of weeks, making it more convenient and easier to schedule with other medical appointments.
  3. Because of the more convenient schedule, more women may be able to choose to get lumpectomy instead of mastectomy.

Disadvantages of PBI:

  1. Increased chances of tumor coming back or new tumor forming in the same breast compared to traditional radiation therapy.
  2. Because PBI can give a bigger dose of radiation, women may have later toxic effects, which affect the way the breast looks.
  3. Invasive approaches (placing beads in the surgical wound or catheters in the wound) can increase the chance of infection and can slow wound healing, which may affect the way the breast looks.

The Bottom Line

Radiation treatment can help women to conserve breast and prevent cancer spread after lumpectomy. PBI can be more convenient in the short run, but in the long run, we do not know if it is as safe or effective as traditional radiation treatment.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

References:
1. Kuznar, W. ASCO Reading Room: APBI: A Compromise Solution Following BCT–In low-risk breast cancer patients, recurrence rates equivalent to those for WBI. Medpage Today. (July 26, 2016). Available Online: https://www.medpagetoday.com/reading-room/asco/breast-cancer/59322?pop=0&ba=1&xid=tmd-md&hr=trendMD

2. Hickey BE, Lehman M, Francis DP, See AM. Partial breast irradiation for early breast cancer. Cochrane Database of Systematic Reviews 2016, Issue 7. DOI: 10.1002/14651858.CD007077.pub3.

3. Lei RY, Leonard CE, Howell KT, et al. Four-year clinical update from a prospective trial of accelerated partial breast intensity-modulated radiotherapy (APBIMRT). Breast Cancer Research and Treatment. 2013;140(1):119-133. doi:10.1007/s10549-013-2623-x.

4. Jacobson GM, Siochi RA. Low-Energy Intraoperative Radiation Therapy and Competing Risks of Local Control and Normal Tissue Toxicity. Frontiers in Oncology. 2017;7:212. doi:10.3389/fonc.2017.00212.

5. Whelan TJ, Olivotto I, Parpia S, et al. Interim toxicity results from RAPID: a randomized trial of accelerated partial breast irradiation (APBI) using 3D conformal external beam radiation therapy (3D CRT) Int J Radiat Oncol Biol Phys. 2013;85:21–22. DOI: 10.1200/JCO.2013.50.5511

6. Keshtgar MRS, Williams NR, Bulsara M, et al. Objective assessment of cosmetic outcome after targeted intraoperative radiotherapy in breast cancer: results from a randomized controlled trial. Breast Cancer Res Treat. 2013;140:519–525. DOI: 10.1007/s10549-013-2641-8.

7. Akhtari M, Abboud M, Szeja S, et al. Clinical outcomes, toxicity, and cosmesis in breast cancer patients with close skin spacing treated with accelerated partial breast irradiation (APBI) using multi-lumen/catheter applicators. Journal of Contemporary Brachytherapy. 2016;8(6):497-504. doi:10.5114/jcb.2016.64830.

8. RTOG Foundation. RTOG/EORTC Late Radiation Morbidity Scoring Schema. Available online: https://www.rtog.org/ResearchAssociates/AdverseEventReporting/RTOGEORTCLateRadiationMorbidityScoringSchema.aspx.

9. Correa C, et al. Accelerated Partial Breast Irradiation: Executive summary for the update of an ASTRO Evidence-based Consensus Statement. Practical Radiation Oncology 2017, Issue 7. DOI: 10.1016/j.prro.2016.09.007.

Can Girls Lower Their Breast Cancer Risk by Eating Peanut Butter?

Krista Kleczewski, Cancer Prevention and Treatment Fund

Peanut butter, a favorite food of so many kids and overwhelmed parents, may help ward off abnormal breast conditions linked to cancer, according to researchers from Harvard and Washington University School of Medicine. The study, funded by the National Institutes of Health (NIH) and the Breast Cancer Research Foundation, found that girls between the ages of 9 and 15 who regularly ate foods high in vegetable protein and fat had a significantly lower risk of developing non-cancerous (benign) breast conditions as young women than those who did not eat these foods.1 Peanut butter, peanuts and nuts were the main sources of vegetable protein and fat in the girls’ diets.

What is Benign Breast Disease and How is it Related to Breast Cancer?

Benign breast diseases are changes in the breast that sometimes have no symptoms and sometimes can cause pain or discomfort, but are not cancerous. Some benign breast diseases increase a woman’s risk of eventually developing breast cancer only slightly, while others can increase her risks more substantially.2<sup>,</sup>3 For example, women with simple cysts or fibrosis (scar-like tissue in the breasts) have almost the same risk of developing breast cancer as women who don’t have these benign breast conditions.<sup>4</sup> However, women who have fast-growing abnormal cells, called atypical hyperplasia, are 3-4 times more likely to develop breast cancer than women with normal breasts.4

Peanut Butter and Benign Breast Disease

The study enrolled 9,039 girls, ages 9 to 15, and kept in touch with them for 14 years. The girls regularly reported to the researchers what they ate and drank, and whether they had been diagnosed at any point between the ages of 18 and 30 with benign breast disease. Adolescent girls who ate peanut butter or any kind of nuts three times a week or more had a nearly 40% lower chance of developing benign breast disease.

Although all the girls who ate peanut butter and nuts were less likely to develop benign breast disease, the girls who benefited the most were those who had a family history of breast cancer. This is important because, in general, benign breast disease is riskier in women with a family history of breast cancer.

Many people think of peanuts as nuts, but they are actually legumes.  For that reason, it is not surprising that the researchers found that consumption of other legumes such as beans, lentils, soybeans, as well as corn, may help shield girls from these breast conditions. Although the researchers did not study the benefits of specific types of nuts, it is believed that regular consumption of most nuts, including tree nuts, such as almonds and walnuts, provide protection against benign breast disease. At least one study in 2011 found that a diet containing walnuts slowed breast cancer tumor growth in mice; more research is needed before we will know if this is true for humans.5

Should All Girls Eat More Peanut Butter, Nuts, and Beans?

Although this was a large study of over 9,000 girls living in all 50 states, 95% of the girls were non-Hispanic whites, primarily from middle and upper socioeconomic backgrounds. As a result, it is impossible to say whether the study’s findings would also apply to girls from other races, and ethnicities, or to girls of lower socioeconomic backgrounds.

The study had other limitations. Because the girls filled out questionnaires about their eating habits, the researchers did not observe what the girls actually ate, or how much. This means the researchers had to rely on the girls remembering and reporting their intake accurately.

Another important question is do these foods truly protect against benign breast disease and possibly even breast cancer, or do the girls who eat them eat fewer less nutritious foods that would increase the risk of cancer? Whichever the answer, it’s a good idea—particularly if you have breast cancer in your family— to eat snacks involving peanut butter or a handful of nuts instead of less healthy alternatives like cookies, candy, or chips. Nuts and nut butter are what nutritionists call “nutrient dense” foods. They are rich in protein and nutrients, but they are also high in calories. So eat them in moderation and don’t assume that the new study means you can eat Reese’s Peanut Butter Cups to your heart’s content! They are not a nutritious snack choice! Similarly, it is best to look for low-salt and peanut butter brands without added sugar or oils. Try peanut butter with an apple or banana, peanuts low in salt, or an old classic called “Ants on a Log,” which is a stick of celery with peanut butter and raisins sprinkled on top.

Spread the news, and spread the peanut butter (in moderation, of course)!

 

Drugs to Avoid for Women Taking Tamoxifen

Blossom Paravattil, Megan Cole, and Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

The female hormone estrogen makes most cancer tumor cells grow and multiply. The drug tamoxifen was developed to block estrogen and therefore stop that growth, to help treat, prevent, and stop the recurrence of most breast cancer.  Breast cancer that is sensitive to estrogen is called “estrogen receptor-positive breast cancer.”

For tamoxifen to do its job, it needs to be broken down in the body by a key protein known as CYP2D6.  Unfortunately, many common medicines can block or slow down CYP2D6, and that would make tamoxifen less effective.

Certain medications used to treat depression should be avoided by women taking tamoxifen. The antidepressants paroxetine (Paxil) and fluoxetine (Prozac) have been found to increase women’s risk of dying of cancer if they are taking tamoxifen. Women who are on these medications should talk to their doctors about switching to other medicines that don’t affect how tamoxifen works.

The table below shows a list of drugs to avoid and alternative drugs that can be taken instead.

 

Classes of drugs Drugs that are likely to interfere with tamoxifen

Alternative drugs that should be safe to take with tamoxifen

Antidepressants (SSRI/SNRIs) Paxil, Prozac, Wellbutrin, and Cymbalta Effexor, Pristiq, Edronax, Lexapro, and Remeron
Antipsychotics Mellaril, Trilafon, and Orap Navane, Clozaril, Zyprexa, Geodon, and Seroquel
Cardiac Drugs Cardioquin and Ticlid Cardizem
Allergy medications Benadryl (diphenhydramine), Unisom (doxylamine), Dimetapp (Brompheniramine), Tagamet (cimetidine) Zyrtec (cetirizine), Claritin (Loratadine), Fexofenadine (Allegra), Ranitidine (Zantac)
Medications for Infectious Diseases Seldane and Cardioquin Crixivan, Invirase, Viracept, Rescriptor, Viramune, and Sustiva

The Bottom Line

If you are taking tamoxifen, talk to your doctor about any medications  that you are taking (including over-the-counter products, such as cold and allergy medications) to be sure that they don’t interfere with tamoxifen.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

Reference:

  1. Zosia Chustecka. Medscape News. Drugs to Avoid in Women Taking Tamoxifen. May 05, 2010. Accessed December 2017 Available online: https://www.medscape.com/viewarticle/721306

Can Aspirin Prevent Cancer and Cancer Deaths?

Nyedra W. Booker, PharmD, Tracy Rupp, PharmD, MPH, RD, Laura Gottschalk, PhD, and Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

Doctors have prescribed aspirin to prevent heart attacks and stroke for many years. There is now good evidence that regular aspirin use can also prevent cancer. Experts already recommend an aspirin a day to prevent colon cancer, but aspirin may also “play a strong role in reducing death from cancer.”[1]  

Recommending Aspirin for Cancer Prevention

The U.S. Preventative Service Task Force (USPSTF), an independent group of medical experts, recommend  that people between the ages of 50 and 59 should take 81 mg of aspirin daily (which is the typical dosage of “baby” or low-dose aspirin) to prevent colon cancer. Since colon cancer develops slowly overtime, aspirin should be taken for at least 10 years.[2]

Daily aspirin is not for everyone between 50 and 59, however. For example, if you have an increased risk of bleeding because of other medication you are taking or because of a history of stomach or intestinal ulcers, kidney disease, or severe liver disease, the risks of taking aspirin daily may outweigh the benefits. 

The benefits of aspirin in preventing death from cancer are based in part on a 2016 study published in the prestigious Journal of the American Medical Association (JAMA), which looked at the rate of cancer in two large long-term studies.  The Nurse’s Health Study and the Health Professionals Follow-up study included almost 48,000 men and more than 88,000 women.[3] The study found that people who took aspirin regularly had a slightly lower risk for overall cancer and a 19% lower risk for colon cancer. These benefits were seen after just five years of use and are statistically significant, which means they are almost definitely due to the aspirin and not to other factors.

The new study results were presented at a national cancer conference in April 2017 and go beyond the results published in 2016.[1] Women in the studies who took aspirin regularly had a 7% lower chance of dying of any cause than women who did not take regular aspirin. Men who took aspirin regularly had an 11% lower chance of dying of any cause than men who did not take regular aspirin. Dying from cancer was 7% lower in women and 15% lower in men who regularly took aspirin. Women who regularly took aspirin had an 11% lower risk of dying from breast cancer. Men who regularly took aspirin had a 23% lower risk of dying from prostate cancer.  

Aspirin can have many benefits, but since it also has risks more studies are needed to examine who is most likely to benefit and who is most likely to be harmed. The study was observational, which means that it evaluated the health of people in the “real world,” rather than a randomized clinical trial.  Since it is not possible to know as much about all the health habits and other possible influences of the thousands of people in these huge studies as is possible in a clinical trial, the conclusions are considered less certain.

What You Need to do Before Starting Aspirin Therapy

Remember that aspirin is a drug, and it has risks even at low doses. You should talk about whether taking a daily aspirin is a good idea with your doctor, so that you can discuss:

  • Your medical history and all the medicines you are currently using, whether they are prescription or over-the-counter
  • Any allergies or sensitivities you may have to aspirin
  • Any vitamins or dietary supplements you are currently taking

Aspirin should not be taken with certain other over-the-counter pain medications such as ibuprofen (Motrin and Advil) and naproxen (Aleve) because they can increase the risk of internal bleeding. These medications are called NSAIDS.  Aspiring should also not be taken daily by those who regularly use herbs and nutritional supplements.  Vitamin E, fish oil (omega-3 fatty acids) and what’s known as the “four Gs”– garlic, ginger, gingko, and ginseng– can all increase your risk for bleeding when taken with aspirin and other blood thinners.[4]

If taking aspirin is not a safe option for you, there are other ways to reduce your chance of developing heart disease and cancer, without any side effects!  They include quitting smoking, eating a diet rich in fruits and vegetables, and getting up from your chair or couch regularly rather than sitting for hours without moving around. Walking or other exercising for at least 20-30 minutes each day is also helpful. However, for people at highest risk of heart disease or cancer, aspirin could truly be a lifesaver.

The Bottom Line

Regular aspirin use may prevent deaths from many causes including cancer, heart attacks, and strokes.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

Footnotes:

  1. American Association for Cancer Research News Release. Regular Aspirin Use in Associated with Lower Cancer Mortality. April 3, 2017. Available online: http://www.aacr.org/Newsroom/Pages/News-Release-Detail.aspx?ItemID=1036#.Wib80kqnGM9
  2. USPSTF. Final Update Summary: Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Preventive Medication. April 2016. Available online: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer
  3. Cao Y, et al. Population-wide Impact of Long-term Use of Aspirin and the Risk for Cancer. JAMA Oncol. Published online March 03, 2016. DOI: 10.1001/jamaoncol.2015.6396
  4. U.S. National Library of Medicine. MedlinePlus: Drugs, Supplements, and Herbal Information. Accessed December 2017. https://medlineplus.gov/druginfo/herb_All.html

Patients Under 50 with Early-Stage Ovarian Cancer: Safe Treatment with no Loss of Fertility

Julie Bromberg and Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

Ovarian cancer is especially traumatic for young women, because it is often diagnosed when the disease is advanced. Standard treatment usually includes having both ovaries, fallopian tubes, and the uterus removed. While this “radical” surgery was once considered the safe option, the procedure left younger women with early menopause and unable to become pregnant. Now, many young women have the option of “fertility sparing surgery,” which removes one ovary and one tube.

A 2017 study in the Journal of Obstetrics & Gynecology found that women below age 40 who have early-stage epithelial ovarian cancer can be safely treated without losing their fertility.  Women in the study had an 89% chance of surviving at least 10 years after their surgery, whether they had the standard surgery or the fertility-sparing surgery.[1]  

A similar 2017 study in the Journal of Gynecologic Oncology examined premenopausal women under age 50 with a more aggressive type of ovarian cancer called early-stage ovarian clear cell cancer. At 5 years after surgery, 90% of women who did not have their uterus removed were alive compared to 88% of women who did. Similarly, 93% of women who had one ovary removed were alive compared to 85% who had both ovaries removed.[2]

The traditional treatment approach for ovarian cancer was to remove the organs to prevent the cancer from coming back. The uterus was also removed, because it was assumed to be safer to remove a nearby organ where cancer could grow. Younger women who were treated for ovarian cancer underwent early menopause (known as surgical menopause) because of the greatly reduced level of estrogen hormones in their bodies, and lost their ability to have children.[3]

Since the 2017 studies only included pre-menopausal women under age 50 with Stage 1 ovarian cancer, it is impossible to know whether older women would have similar survival rates under similar circumstances. Fertility-preserving treatment is risky for women with stage II or later stage ovarian cancer.

Cancer surgery has evolved over the years, becoming less radical. For example, breast cancer used to be treated by removing the entire breast and the muscles underneath, instead of just the cancer and a small area of healthy tissue around it.  Eventually, research proved that women lived just as long with much less radical surgery, and now early-stage breast cancer is often treated by removing just the cancer, rather than one or both breasts. The latest research indicates that breast cancer patients’ survival is slightly better with the less radical surgeries. (Read more on breast conserving surgery here.)

What Happens after Ovarian Cancer Surgery?

After surgery, women need to see their physician frequently for clinical exams during the first 5 years. The Society of Gynecologic Oncologists (doctors specializing in women’s cancers) recommends the following [3]:

  • In the first 2 years after surgery, women should have a regular exam, including an exam of the pelvis and lymph nodes every 3 months (or 4 times a year).
  • In the third year, women should have exams every 4-6 months (or 2-3 times a year).
  • In the fourth and fifth year, women should have exams every 6 months (or twice a year).
  • After 5 years, women can resume annual exams.
  • A blood test that checks for a tumor marker (CA-125) is optional.
  • CT scan should be done only when the doctor is concerned the cancer has recurred.   

How can you Detect Ovarian Cancer Early?

For all cancers, early treatment greatly increases the chances of survival. Unfortunately, the early symptoms of ovarian cancer are easily confused with less serious problems, making it difficult for women to know if they need to be tested for ovarian cancer.

If a woman has any of the following symptoms every day for more than 2 weeks, or if the symptoms are more severe or unusual for her, she should talk to her doctor about being tested for ovarian cancer[4]:

  • Feeling bloated or swelling in the stomach area
  • Pain in the stomach area
  • Difficulty eating or feeling full
  • Gas, bloating, or constipation

The Bottom Line

Treatments that preserve the uterus and at least part of one ovary, instead of removing the uterus and both ovaries, can be safe for women younger than 50 who have Stage 1 epithelial ovarian cancer. Premenopausal women with early-stage ovarian cancer who want to preserve their fertility should find a doctor who is experienced in that treatment and find out whether it is a safe option for them.

 

Footnotes:

  1. Melamed A, Rizzo AE, Nitecki R, Gockley AA, Bregar AJ, Schorge JO, delCarmen MG, and Rauh-Hain JA. (2017). All-Cause Mortality After Fertility-Sparing Surgery for Stage I Epithelial Ovarian Cancer. Obstetrics & Gynecology, 130 (1): 71-79. doi: 10.1097/AOG.0000000000002102
  2. Nasioudis, D., Chapman-Davis, E., Frey, M. K., Witkin, S. S., & Holcomb, K. (2017). Could fertility-sparing surgery be considered for women with early stage ovarian clear cell carcinoma? Journal of Gynecologic Oncology, 28(6), e71. http://doi.org/10.3802/jgo.2017.28.e71
  3. Medscape. Ovarian Cancer Guidelines. (2016, Aug. 22). Available Online: https://emedicine.medscape.com/article/2500016-overview#showall
  4. National Cancer Institute. Ovarian Epithelial, Fallopian Tube, and Primary Peritoneal Cancer Treatment (PDQ®)–Patient Version. (2017, Oct. 13). Available Online: https://www.cancer.gov/types/ovarian/patient/ovarian-epithelial-treatment-pdq

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† 85%-90% of all ovarian cancers are epithelial