Category Archives: Breast Cancer

Buy a Nice Sleep Mask! It’s an Investment in your Health

Jessica Becker, Cancer Prevention and Treatment Fund

Research shows that sleeping in total darkness allows your body to produce as much of the hormone melatonin as possible. This is good because when your production of melatonin drops, you are at greater risk of breast and/or colorectal cancer and other health risks.

What is Melatonin?

Melatonin is a hormone that is naturally produced in your body. It is secreted by the pineal gland, which is buried deep in the brain. Melatonin is only produced at night and only when it is dark, which means that melatonin production peaks between 3:00 a.m. and 5:00 a.m. for most people. This hormone helps to regulate your circadian rhythm, which is like your body’s natural clock. When melatonin and several other chemicals are released, you feel drowsy and your body temperature lowers. In addition to this sleep-cycle function, melatonin also works as an antioxidant. This means that it can help prevent damage to your DNA that can result from aging, exposure to cancer-causing chemicals, or harmful rays from the sun. Preventing damage to DNA is important because DNA damage can cause cancer.

Doesn’t My Body Produce Enough Melatonin?

There have been major advancements in technology over the last two centuries, one being the light bulb. Because of the light bulb (and electricity, in general), we are able to stay awake and active much later, so the night is not as dark as it used to be. Think of New York City: the city that never sleeps. Cities are so lit up at night that it can be hard to see the stars. This is referred to as “light pollution.” And, of course, even in the middle of nowhere, you can keep your lights on all night in your house.

Our ability to turn night into day has allowed for more night shift work, often called “the graveyard shift.” Even if you don’t work on the late shift, you may be working at home late at night or staying up late watching TV or using the internet. Unfortunately, this kind of schedule has many effects on your body, including reducing the amount of melatonin produced. But it is not just night owls or shift workers who suffer from a decreased production of melatonin. Sleep studies show that almost everyone wakes up at some point during the night, even if we do not remember it. Unless you have blackout shades on your windows, there is a good chance that some light is coming into your bedroom and that your eyes are registering this light during those wakeful periods.[2]

New technology is compounding the effects of light pollution. Early incandescent light bulbs that were dim and yellow and did not affect melatonin production very much. Now, artificial light emits more blue wavelengths. For example “Cool White” fluorescent bulbs are a very popular choice of light bulb because they are bright, moderately energy efficient, and relatively inexpensive. They also produce a lot of blue light which is why they have a “cool” effect. Maybe you have noticed while driving that certain people’s headlights appear to be very bright and have a blue tint to them. These new headlights produce blue wavelengths of light. Unfortunately, research shows that blue wavelengths of light are especially effective at reducing melatonin production in humans.[3] All types of computer monitors and television screens also emit blue light.

Why Is Having Less Melatonin A Bad Thing?

Believe it or not, the International Agency for Research on Cancer (IRAC) classified shift work as a probable human carcinogen in 2007. There have been numerous studies showing a link between night shift work and an increased incidence of breast cancer. For instance, a study done in the Netherlands found that by working half a year at night, a person’s risk of breast cancer increased 150%.[3] A major study found that nurses who worked night shifts at least 3 times a month for 15 years or more had a 35% increased risk of colorectal cancer.[3] If you’re still unconvinced, a study conducted in 147 communities in Israel found that women who lived in neighborhoods where it was bright enough to read a book outside at midnight had a 73% higher risk of developing breast cancer than women living in areas without outdoor lighting.[2]

What Can I Do To Limit My Chances Of Getting Cancer Because of Light At Night?

The good news is that there are easy and inexpensive ways to limit the amount of light you are exposed to at night. For starters, if you have electronic appliances in your bedroom that produce light (like a clock radio or cable box), pick those that have red lights as opposed to green or blue lights. Walmart, Target, Best Buy, and many other stores all carry alarm clocks and radios that display the time in red numbers. These brands are not more expensive than their blue numbered counter-parts. Studies show that red lights don’t cause as much of a decrease in the amount of melatonin produced by your body.[4] Also, if you have a television or computer in your bedroom, turn it off before you go to sleep.

It is also a good idea to limit the amount of time you spend in front of a screen at night. If you spend a few hours a night in front of your computer, whether or not you’re not in your bedroom, you are decreasing the amount of melatonin that is being produced in your brain. Most screens today offer a “night mode” which reduces the amount of blue light used and creates an orange tint. This is a recommended setting to use before bed.

Also, since melatonin production is highest between the hours of 3:00 am and 5:00 am, make sure you’re in bed and asleep by 3:00 a.m., and if at all possible, sleep until at least 5:00 am. While you probably will not be able to petition your community to get the street light in front of your house turned off, you can buy blackout shades to block the light. Most department stores sell blackout shades, and they are relatively inexpensive. If you don’t want to invest a penny more in “window treatments,” consider using a sleep mask. Airlines sometimes give them away in travel kits, but you can also treat yourself to a nice one that is sold online or in a department store. Besides lowering the risk of getting certain cancers, sleep masks can also lower your stress and help you fall asleep faster. Now that’s a “three-for!”

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

  1. Navara J, Nelson R. The Dark Side Of Light At Night: Physiological, Epidemiological, and ecological consequences. Journal of Pineal Research. 2007, (43)
  2. Chepesiuk R. Missing the Dark: Health Effects of Light Pollution. Environmental Health Perspectives. 2009, (117)
  3. Pauley S. Lighting For The Human Circadian Clock: Recent Research Indicated That Lighting Has Become A Public Health Issue. Medical Hypotheses. 2003
  4. Reiter R. Circadian Disruption and Cancer: Making the Connection. The New York Academy of Sciences. 2009

DCIS, LCIS, and other Pre-Cancers: Are Women Getting Mastectomies They Don’t Need?

Susan Dudley, PhD and Diana Zuckerman, PhD, Cancer Prevention and Treatment Fund

Thanks to heightened awareness of breast cancer screening, women are being diagnosed earlier than ever before. However, that has also resulted in what some experts consider an epidemic of women diagnosed with abnormal breast conditions that are not cancer or may never develop into invasive cancer. Some of these conditions are not at all dangerous, and the others have survival rates near 99%; nevertheless, these diagnoses often sound very frightening. In fact, research shows that these women are often just as worried about whether they will survive as women with the much more dangerous, invasive forms of breast cancer.

There is a wide range of treatment for women with these “stage zero” conditions. Although mastectomies are almost never necessary or recommended by experts, many women undergo mastectomies nevertheless. Research suggests that this is especially likely in the South, Midwest, and Southwest parts of the United States, in certain types of medical facilities, and with older doctors.

Knowing the Facts Will Reduce the Fear

It can be extremely upsetting for a woman to learn that she has any condition that increases her breast cancer risk. Too often, such news leaves women feeling that they must rush into surgery. They agree to – or even insist upon – undergoing mastectomies that they do not really need, in hopes that it will increase their chances of survival. In fact, their chances of survival are already very high, and having a mastectomy will not make it higher.

The good news is that most women with “pre-cancerous” conditions or other non-cancerous breast conditions will never get invasive breast cancer. For example, only 1 in 12 breast lumps is cancerous, and 1 in 5 cases of micro-calcification (white spots seen on mammograms that alert doctors that follow-up diagnosis is needed) are related to cancer, so most women get good news after a breast biopsy. For many women, however, anxiety levels soar when they learn that they might possibly be at risk for breast cancer because of abnormal changes in their breasts.

This issue brief will describe two conditions that are often referred to as “stage zero breast cancer” as well as other non-cancerous abnormal breast conditions.

Ductal Cancinoma in Situ (DCIS)

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.” It is a non-invasive breast cancer 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 invasive cancer in the future if it is not treated. That is why surgical removal of the abnormal cells, followed by radiation, is usually recommended.

What makes most cancers dangerous is that they are invasive, which means they are not restricted to one spot, but have spread to other cells within the organ where they arose. Once that happens, cancer can metastasize, which means that it spreads to other organs in the body. DCIS is not an invasive type of cancer and DCIS can not metastasize unless it first develops into invasive cancer.

The goal of treating invasive cancer while it is still confined to the breast 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 an early-stage invasive cancer (usually called Stage 1 or Stage 2 cancer).

Having DCIS means that a woman has an increased risk for developing invasive breast cancer in the future, unless she has treatment. With appropriate treatment, DCIS is unlikely to develop into invasive cancer. A woman with DCIS does not need all the same treatment as a woman diagnosed with invasive breast cancer, but she does need surgery to remove the DCIS, and radiation to ensure that any stray, abnormal cells are destroyed. This lowers the risk that the DCIS will recur or that invasive breast cancer will develop.

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.

Treatment Choices for DCIS

DCIS patients have three surgery choices. They are 1) lumpectomy followed by radiation therapy 2) mastectomy or 3) mastectomy with breast reconstruction surgery. Most women with DCIS can choose lumpectomy.

Lumpectomy means that the surgeon removes only the cancer and some normal tissue around it. This kind of surgery keeps a woman’s breast intact – looking a lot like it did before surgery. Under most circumstances, mastectomy does not increase survival time for women with DCIS, and would only be considered under unusual circumstances, such as cases where the breast is very small or the area of DCIS is very large.

Radiation therapy is also recommended for almost all women with DCIS after lumpectomy. This type of treatment is very important because it could keep more DCIS or invasive cancer from developing in the same breast. DCIS patients who choose lumpectomy with radiation live just as long as they would with mastectomy.

Tamoxifen or another hormonal therapy is recommended for some women with DCIS to help prevent breast cancer. The benefit is that it can further decrease the risk of recurrence of DCIS or the development of invasive breast cancer. However, these medicines can have potentially dangerous side effects, such as 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.

Unlike women with invasive breast cancer, women with DCIS do not undergo chemotherapy and they usually do not need to have their lymph nodes tested or removed. Experts are not sure whether all women with DCIS would eventually develop invasive breast cancer if they live for a long time and are not treated. They do know that most women with DCIS who undergo surgery and radiation can put fears of breast cancer behind them.

Lobular Carcinoma in Situ (LCIS)

Lobular carcinoma in situ (LCIS) is also sometimes referred to as stage zero breast cancer. But we shouldn’t let the words “carcinoma” or “cancer” scare women. LCIS got its name many years ago, before doctors realized that it is not breast cancer at all.

Unlike breast cancer, LCIS does not form a tumor. Unlike DCIS, it does not form abnormal cells that can develop into invasive cancer. That is why no surgery is needed to remove LCIS. Instead, LCIS is one of several conditions that may indicate an increased risk for a woman to develop breast cancer in the future. Even though most women who have LCIS never develop breast cancer, a woman with LCIS should talk to her physician to evaluate all her risk factors and to set up a plan to monitor her breast health, such as regular mammograms. This will ensure that any changes in her breast health can be detected and evaluated very early.

How is LCIS different from breast cancer?
In LCIS, some of the cells lining the lobules (the parts of the breast that can make milk) have developed abnormally. LCIS is not cancer. It does not cause pain or produce a lump. In fact, by itself, LCIS is not a dangerous condition.

How does LCIS affect breast cancer risk?
There is no way for doctors to predict whether a woman with LCIS will develop breast cancer in the future. Most won’t, but if they do, it could be in either breast (not just the one where the LCIS was found) and in any part of the breast (not just in the area near where the LCIS was discovered).

What is the treatment for LCIS?

LCIS has no symptoms, and is first suspected because of an abnormal mammogram. A biopsy is needed to confirm the diagnosis. After a diagnosis is made, no more surgery or other treatment is needed, even if the affected area is large.

The abnormally developing cells that make up LCIS are often spread around in more than one location in the breast. It may even be in several areas and both breasts. If LCIS is diagnosed in one breast, it is not necessary to search for it or biopsy the second breast or to try to locate each area of affected lobules. That’s because no treatment is necessary regardless of the spread or location.

Women diagnosed with LCIS may question why no treatment is necessary, but experts agree that LCIS is a condition that should be managed rather than a disease to be treated. You can think of it like being overweight, which is a condition that puts a person at risk for heart disease but is not itself heart disease – and people who are overweight do not always develop heart disease.

Women with LCIS who are especially worried and want to “do something” can consider a low calorie or low-fat diet, as well as an increase in fresh fruits and vegetables to reduce their risk of future breast cancer. Although the research is not conclusive, those kinds of dietary changes may reduce the risk of breast cancer, and also have the potential to prevent other diseases. Hormonal therapy (with a drug such as tamoxifen) is also sometimes recommended to reduce the risk of future breast cancer, although it has the potentially dangerous side effects mentioned earlier, such as increasing the risk of stroke and endometrial cancer, and can cause unpleasant symptoms such as hot flashes and vaginal dryness. However, if a woman is very worried and does not feel comfortable without treatment, hormonal therapy is a less radical prevention method that bilateral mastectomies.

Other Non-Cancerous Breast Conditions.

Many women who find lumps on their breasts do not have cancer, DCIS, or LCIS. Non-cancerous lumps can be cysts that are filled with fluid, or fibroadenomas, which are smooth, and hard, often feeling like a marble under the skin. Thickened but harmless areas called pseudo-lumps also fall into this category. Cysts are sometimes but not always drained, but otherwise, these conditions usually require no further treatment. Fibrocystic breasts (also called mammary dysplasia, benign breast disease, or diffuse cystic mastopathy) feel bumpy or lumpy and sometimes painful. This condition used to be considered a pre-cancerous disease, but experts now realize that it is not a disease and does not increase the risk of breast cancer.

What About Mastectomy to Prevent Future Breast Cancer?

Ten or 20 years ago, when breast conditions like these were diagnosed, they were often treated with mastectomy, surgery which completely removes the affected breast. Sometimes a healthy second breast was also removed (prophylactic mastectomy), even when there was no sign of cancer or other abnormalities in the other breast.

Today, thanks to advances in scientists’ understanding of breast cancer and of these other conditions, along with the development of better diagnostic, surgical, and treatment techniques, mastectomy is often unnecessary. In fact, we now know that a less radical treatment (lumpectomy followed by radiation therapy for most DCIS or Stage 1 or Stage 2 cancers) or no treatment (for cysts, fibroadenomas, fibrocystic breasts, and LCIS) is just as effective. Except in unusual circumstances, mastectomy does not increase survival time for these conditions, and the risks of mastectomy usually outweigh any benefits.

Should I “Upgrade” to Digital or 3D? A Mammography Guide

Christina Silcox, PhD, and Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

Woman_receives_mammogram

When breast cancer is detected early—before it has spread—it is easier to treat and women have a much better chance of living a long life.  Screening refers to tests that are given to people who have no symptoms, to find out if they might have a disease.  Mammograms are the best way to screen women for breast cancer.

Forty million mammograms are performed each year,2 but the technology is evolving. Depending on where a woman lives, she may be able to choose from among three different types of mammography. Does it matter what kind of mammogram she gets?

A New Type of Digital Test: 3D Mammography

3D mammograms, also known as tomosynthesis or “tomo,” use the same x-ray technology as regular “2D” mammograms. The procedure is the same from the patient’s point-of-view, although it will take a few seconds longer. In both 3D and 2D mammograms, the breast is compressed between two plates. In 2D mammograms, which take images only from the front and side, this may create images with overlapping breast tissue. Because 3D mammography provides images of the breast in “slices” from many different angles, finding abnormalities and determining which abnormalities seem potentially worrisome may be easier with 3D tests. On the other hand, 3D mammography is more expensive than 2D, and your insurance may charge you more if you use 3D.

Since 2013, the FDA has concluded that a low-dose 3D digital mammography is at least as accurate as 2D mammography. 2D digital images can also be obtained from the 3D mammography data.

Differences between 2D and 3D Mammograms

Because it was initially not known how accurate 3D mammograms would be, most research compared 2D mammograms to a combination of 3D mammograms and 2D mammograms.  That was the information that Hologic, the company that developed the first 3D mammography machines, needed to provide to the FDA when they applied for FDA approval.  The studies were funded by Hologic and evaluated the mammograms from their machines.  We do not know if the results would be similar to other companies’ mammography machines.

The results of the studies showed that the combination of 3D and 2D was more accurate than 2D digital or film mammograms, although the difference in accuracy was tiny for each patient.6,7,8,9,10,11  In addition, women who undergo screening with 3D+2D mammography are less likely to be called back for more testing due to a suspicious finding that turns out not to be cancer. This means fewer false alarms caused by inaccurate findings.7,8,12  But, using two tests is not practical and can be harmful because it exposes women to more radiation. The important question is: Do the 3D tests hold up on their own?

An article published in 2017 in the prestigious medical journal JAMA examined the benefits of 3D mammograms. The study compared the number of call backs and the numbers of cancers diagnosed before the next scheduled screening in women who had 3D mammograms vs. standard 2D mammograms. For the more than 23,000 women undergoing an initial 2D mammogram followed by 3 years of annual 3D mammograms, the use of 3D tests slightly reduced the number of women who got called back (10% in the 2D group vs. 9% in the 3D group) and the number of cancers detected in the months between the annual mammograms. Following 2D mammography, about 7 out of 10,000 women were diagnosed with cancer before their next annual mammography, compared to 5 out of 10,000 of the women who underwent 3D mammography screening.[16]  Although the differences are very small, they are statistically significant, which means they did not happen by chance.

Even though the differences are small, 3D tests seem to have a small advantage over 2D tests because they are slightly better at finding dangerous cancers, reducing the number of repeat tests, and reducing the amount of time a woman has to wait to find out.

While the benefits of 3D mammograms appear to be tiny for an individual woman, the benefits of the 3D test could add up for a large population of women.  For example, a study examining over 44,000 screening tests, including over 28,000 3D mammograms, over 5 years found that 3D screening detected significantly smaller invasive breast cancers (about 1.5 cm (about ½ inch) vs. 2.3 cm (about 1 inch). And, the cancers that were detected by 3D tests were less likely to have spread to the lymph nodes (about 15% vs. 31%).[17] Finding a cancer that is smaller and hasn’t spread to the lymph nodes means that a woman would require less aggressive treatment of her cancer, such as less radical surgery and fewer chances of needing chemotherapy.

Even if 3D mammography is more accurate, does it save lives?

Experts used to believe that mammograms reduced breast cancer deaths by about 14% to 32%, based on very old studies.  Newer studies conclude that screening mammography has a smaller impact, decreasing breast cancer deaths by about 2%.[19] It is important to keep in mind that these studies include data up to the year 2005 when it was common practice to recommend mammograms every year. Experts now recommend screening be done every 2 years for women of average risk and believe it will not increase the percentage of women dying from breast cancer, but we don’t yet know exactly what impact this new screening practice will have.

Why would mammography save fewer lives today than in previous years?  It may be because cancer treatments have gotten better, even for more advanced cancers. Also, as mammography has improved, it is detecting abnormalities and cancers that may not be fatal. Even if 3D mammograms can detect invasive cancers when they are smaller and less dangerous, more research is needed to determine if 3D mammography saves more lives.

Harms of 3D screening:

Radiation exposure

The 3D test takes a few seconds longer than 2D digital or film mammography (adding a few seconds of discomfort). The newer, low-dose 3D mammography uses less radiation than a 2D mammography.

Because digital mammography—2D and 3D—is relatively new, no one has figured out exactly what all the health risks and benefits are.

Cost

2D screening mammograms are free for patients covered by healthcare insurance under the Affordable Care Act. Some insurers will not cover 3D mammograms, and others charge women a surcharge. However, Medicare began covering 3D mammography in 2015 and some states are beginning to mandate coverage.13

The Bottom Line

On average, 3D mammography is slightly better at detecting cancer, but it is not clear how much that benefits the average woman.

It is important to remember that experts now agree that most women under 50 or over 75 do not need to undergo screening mammography and that the average woman only needs to undergo screening mammography every two years instead of annually. See our article When should women start regular mammograms? 40? 50? And how often is “regular”? for more information.

Footnotes:

  1. National Cancer Institute. “SEER Stat Fact Sheets: Breast Cancer.” http://seer.cancer.gov/statfacts/html/breast.html (Accessed October 12, 2015).
  2. S. Food and Drug Administration. “Radiation-Emitting Products.” http://www.fda.gov/Radiation-EmittingProducts/MammographyQualityStandardsActandProgram/FacilityScorecard/ucm113858.htm (Accessed October 12, 2015).
  3. Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic Performance of Digital versus Film Mammography for Breast-Cancer Screening. New England Journal of Medicine, 2005; 353(17): 1773-1783.
  4. Rosselli del Turco M, Mantellini P, Ciatto S, Bonardi R, Martinelli F, Lazzari B, Houssami N. Full-field digital versus screen-film mammography: Comparative accuracy in concurrent screening cohorts. American Journal of Roentgenology 2007; 189(4): 860-866. doi: 10.2214/AJR.07.2303.
  5. Kerlikowske K, Hubbard RA, Miglioretti DL, Geller BM, Yankaskas BC, Lehman CD, Taplin SH, & Sickles EA. Comparative effectiveness of digital versus film-screen mammography in community practice in the United States. Annals of Internal Medicine 2011; 155: 493-502.
  6. Sharpe RE Jr, Venkataraman S, Phillips J, Dialani V, Fein-Zachary VJ, Prakash S, Slanetz PJ, Mehta TS. Increased Cancer Detection Rate and Variations in the Recall Rate Resulting from Implementation of 3D Digital Breast Tomosynthesis into a Population-based Screening Program. Radiology. 2015 Oct 9:142036
  7. Greenberg JS, Javitt MC, Katzen J, Michael S, Holland AE. Clinical performance metrics of 3D digital breast tomosynthesis compared with 2D digital mammography for breast cancer screening in community practice. AJR Am J Roentgenol 2014;203(3):687–693.
  8. Friedewald SM, Rafferty EA, Rose SL, et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA 2014;311(24):2499–2507.
  9. Lei J, Yang P, Zhang L, Wang Y, Yang K. Diagnostic accuracy of digital breast tomosynthesis versus digital mammography for benign and malignant lesions in breasts: a meta-analysis. Eur Radiol 2014;24(3):595–602.
  10. S. Food and Drug Administration. “Summary of Safety and Effectiveness Data (SSED): Selenia Dimensions 3D System.” http://www.accessdata.fda.gov/cdrh_docs/pdf8/P080003S001b.pdf (Accessed November 20, 2013).
  11. Rose S, Tidwell AL, Bujnoch LJ, Kushwaha AC, Nordmann AS, & Sexton R. Implementation of breast tomosynthesis in a routine screening practice: An observational study. AJR online; March 22, 2013. doi: 10.2214/AJR.12.9672.
  12. Skaane P, Bandos AI, Gullien R, Eben EB, Ekseth U, Haakenaasen U, Izadi M, Jebsen IN, Jahr G, Krager M, Niklason LT, Hofvind S, & Gur D. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology 2013; 267(1): 47-56. doi: 10.1148/radiol.12121373.
  13. McDonald ES, Oustimov A, Weinstein SP, Synnestvedt MB, Schnall M, Conant EF. Effectiveness of Digital Breast Tomosynthesis Compared With Digital MammographyOutcomes Analysis From 3 Years of Breast Cancer Screening. JAMA Oncol. 2016;2(6):737–743. doi:10.1001/jamaoncol.2015.5536
  14. mandates 3-D mammogram coverage. Philadelphia Inquirer. Marie McCullough October 6, 2015 http://www.philly.com/philly/health/20151006_Pa__mandates_3-D_mammogram_coverage.html
  15. Esserman LJ, Thompson IM, & Reid B. Overdiagnosis and overtreatment in cancer: An opportunity for improvement. Journal of the American Medical Association 2013: online version, E1-E2. doi:10.1001/jama.2013.108415.
  16. McDonald, E., Oustimov, A., Weinstein, S., et al. (2016). Effectiveness of Digital Breast Tomosynthesis Compared With Digital Mammography. Journal of the American Medical Association. Accessed from https://jamanetwork.com/journals/jamaoncology/fullarticle/2491465 on June 5, 2018.
  17. Neal, C. and Philpotts, L. (2017). Breast Imaging (Multimodality Screening and Breast Density). Accessed from http://archive.rsna.org/2017/17039959.pdf
  18. Kalager M, Zelen M, Langmark F, Adami H-O. Effect of screening mammography on breast-cancer mortality in Norway. N Engl J Med. 2010;363(13):1203–1210.
  19. Kaunitz, A. (2010). Just How Much Does Screening Mammography Reduce Mortality From Breast Cancer. OBG Manag. Accessed from https://www.mdedge.com/obgmanagement/article/64117/gynecologic-cancer/just-how-much-does-screening-mammography-reduce.
  20. Philpotts, L. (2017). Screening for Breast Cancer Breast Imaging. Accessed from http://ctcancerpartnership.org/wp-content/uploads/2017/09/Beast-Cancer-Liane-Philpotts.pdf.

 

 

Heart Disease and Breast Cancer

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

In a first-of-its-kind scientific statement, the American Heart Association reminds women that heart disease is the #1 killer of women and that frequently used breast cancer treatments can increase a woman’s chances of developing heart disease.  These treatments include radiation, hormone therapy, chemotherapy, and targeted therapy.

Facts that will Help you Decide your Treatment Options

Fact:  Heart disease affects almost 50 million U.S. women, and 1 in 3 deaths in women in the U.S. are due to heart disease. Breast cancer affects about 3.3 million U.S. women, and 1 in 32 deaths in women are due to breast cancer.  That means that women are about 10 times more likely to die of heart disease than to die of breast cancer.

 Fact: Women with a history of breast cancer are more likely to die from heart disease than women without a history of breast cancer.  That is because some health habits cause both heart disease and breast cancer, and because some breast cancer treatments can also increase your chances of dying of heart disease.

Fact: There are many things you can do to decrease your risks of developing both breast cancer and heart disease:  not smoking, eating a healthy diet, losing weight (if you are overweight or obese) and being physically active

Which Breast Cancer Treatments Harm the Heart?

Radiation therapy:

Radiation therapy is often recommended for women who have a lumpectomy, so it is important to know that it can cause inflammation that can damage heart muscles and blood vessels. Studies on animals show that it can also cause clots to form in the coronary arteries. The risks are higher for radiation that is directed at the left side of the chest. The effects are not immediate, but radiation can increase the chances of heart disease at any time between 5-30 years after radiation therapy.

Hormonal therapy:

Tamoxifen is a hormone therapy that is often prescribed for breast cancers that are sensitive to the hormone estrogen. Studies show that tamoxifen lowers bad cholesterol, but there is no evidence this decreased their chances of developing heart disease or dying from it. Perhaps that is because tamoxifen also increases the chances of forming blood clots, which can be dangerous if they are in the lungs, heart, or brain.

Aromatase inhibitors are a type of hormone therapy that is often prescribed for postmenopausal women with breast cancers that are sensitive to the hormone estrogen. Aromatase inhibitors increased the chances of developing heart disease by less than 1%, but the risks may be higher (about 7%) in women who already have heart disease. The U.S. Food and Drug Administration issued a warning about this for one aromatase inhibitor, anastrazole (brand name arimidex).

Chemotherapy:

Doxorubicin, a type of anthracycline-based chemotherapy, can have harmful effects on the heart, which can be permanent and irreversible. Doxorubicin can damage heart cells and cause inflammation that can weaken the heart muscles, which can lead to heart failure. Heart failure means the heart isn’t pumping well, which can cause the body to become swollen and the lungs to fill with fluid.  This can cause you to feel short of breath, tired, or weak.

5-Fluorouracil (5-FU), is a type of antimetabolite chemotherapy used for metastatic breast cancer and other cancers. Some women who take 5-FU develop chest pain caused by a blood clot or tightening in the blood vessels that feed the heart (coronary arteries). In very rare cases, the heart does not get enough blood, which can cause a heart attack.

Targeted Drugs:

Trastuzumab or pertuzumab are targeted drugs that work against breast cancer cells that make the protein HER2. These medications can cause heart failure that is reversible. Because of the risks, women should only take these medications for 1 year.  Women who are over age 50 with diagnosed heart disease, high blood pressure, reduced heart function, or prior use of doxorubicin are most likely to be harmed by this drug.

Prevention

Studies show that there are things you can change to help prevent breast cancer and heart disease.

  1. Stop smoking
  • For heart health – Smoking increases the chances of having a heart attack or stroke.
  • For breast health – Women who start smoking at a younger age, and smoke for many years, are more likely to develop breast cancer. Smoking causes about 4 in 1000 breast cancers. Quitting decreases the chances of developing breast cancer, but it may take about 20 years to see the full benefits. To read more, click here.
  1. Maintain a healthy weight
  • For heart health – Being overweight or obese (a BMI of 25 or above) increases the chances of developing heart disease.
  • For breast health – Every extra 10 pounds over “normal” weight (BMI below 25) increases the chance of developing breast cancer by about 10%.
  1. Be physically active
  • For heart health – Sitting, watching TV, lying in bed, or driving for 10 hours or more a day while you are awake instead of 5 hours or less per day increases the chances of developing heart disease by about 18%. The AHA recommends exercising for 30 minutes or more a day 5 days each week.
  • For breast health – Those same sedentary activities for 12 hours or more a day compared to 5.5 hours or less increase the chance of developing breast cancer by about 80%. To prevent breast cancer, exercise for 30 minutes or more a day 5 days each week.
  1. Eat a healthy diet
  • For heart health – Eating a diet rich in fresh vegetables, Fresh fruit, fish, poultry, and whole grains reduces your chance of dying from heart disease by about 28% compared to eating a typical U.S. diet with many fast foods, red meats/processed meats, and packaged or processed foods.
  • For breast health – The typical U.S. diet is associated with a greater chance of developing breast cancer, but the clearest evidence is for eating at least 15 oz of red meat or processed meat each week compared to less than 9 oz. of red meat or processed meat.

Heart Health for Breast Cancer Patients and Survivors

High blood pressure, diabetes and high cholesterol increase the chances of having a heart attack or dying from one. The AHA recommends controlling blood pressure, blood sugar, and blood cholesterol with diet, exercise, and medications when needed. Exercise is good for the heart and it also fights off cancer. Studies show that exercising 30 minutes a day for 5 days out of the week decrease the chances of breast cancer returning and from dying from breast cancer.

The Bottom Line

Heart disease is a major cause of deaths in women, and remains a number one cause of death in breast cancer survivors. Women who are at a higher risk of heart disease should talk with their doctors about the risks and benefits of commonly used cancer treatments.

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

References:

Laxmi S. Mehta. et al. Cardiovascular Disease and Breast Cancer: Where These Entities Intersect: A Scientific Statement From the American Heart Association. Circulation. 2018, originally published February 1, 2018. https://doi.org/10.1161/CIR.0000000000000556

Jones ME. et al. Smoking and risk of breast cancer in the Generations Study cohort. Breast Cancer Research. 2017;19:118. https://doi.org/10.1186/s13058-017-0908-4

 

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.

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

There are other risk factors you can control, like smoking cigarettes and drinking alcohol. (Click here to read our article on alcohol and cancer). A United Kingdom study involving over 100, 000 women found a significant link between smoking and breast cancer. Over a 7-year period, about 2% of women who ever smoked developed cancer compared to about 1.6% of women who never smoked. This means that smoking causes about 4 in 1000 breast cancers. Even though that number seems small (less than half a percent), it is statistically significant. Starting smoking at a younger age, smoking 15 or more daily cigarettes, and smoking for at least 10 years increase the chances of developing breast cancer. If you smoke, you should talk to your doctor about ways to quit. Quitting decreases the chances of developing breast cancer, but it may take about 20 years to see the full benefits. To read more, click here.[4]

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%).[5] 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.[6]

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.[7]

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], [8]

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%.[9] 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. Jones ME. et al. Smoking and risk of breast cancer in the Generations Study cohort. Breast Cancer Research. 2017;19:118. https://doi.org/10.1186/s13058-017-0908-4
  5. 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
  6. 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
  7. Vogel, V. G. (2018). Primary Prevention of Breast Cancer. The Breast, 219-236. doi:10.1016/b978-0-323-35955-9.00016-7
  8. 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
  9. Cancer Stat Facts: Uterine Cancer. (n.d.). Retrieved from https://seer.cancer.gov/statfacts/html/corp.html
  10. 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

 

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)!

 

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