Category Archives: Breast Cancer

Summary of Published Study by MD Anderson Physicians on the Increase in Rare Diseases Among Women with Breast Implants

National Center for Health Research: September 17, 2018.


A study published in September 2018 in the medical journal Annals of Surgery, entitled US FDA Breast Implant Postapproval Studies: Long-term Outcomes in 99,993 Patients, concluded that “silicone implants are associated with an increased risk of certain rare harms” and that further study is needed “to inform patient and surgeon decision-making.”  The study is important because it is largest study to date, but it has limitations because it is based on data from flawed studies conducted by two implant companies, Mentor and Allergan.

The data collected from the two studies were supposed to be very similar, but because of how poorly the studies were conducted, they are not comparable.  Mentor’s data are focused on patients’ self-reporting on questionnaires, primarily on data of only 20% of the patients collected 7 years after the study was started. Allergan’s data are based on physicians’ diagnoses during the first two years after the patients had implant surgery.  Since patients’ self-reports at 7 years would be expected to include more complications than physicians’ diagnoses after 2 years, it is impossible to make meaningful comparisons between the two manufacturers. Nevertheless, it is important to note that the MD Anderson researchers found that the risks of certain autoimmune diseases increased by 800% (Sjogren syndrome), 700% (scleroderma), and 600% (arthritis) for the women with Mentor silicone gel breast implants compared to the general population of women of the same age and demographics.  Stillbirths increased by 450% in the women who became pregnant.  Other autoimmune and rare diseases were also significantly higher among women with Mentor silicone gel implants.  These diagnoses were also statistically significantly higher (although not as dramatically increased) for women with Allergan implants compared to the general population of women of similar demographics. Given the large percentage of women who were not in the study for more than 1 year, it is not possible to know how representative these findings are. However, these results certainly deserve careful attention.

It is also important to note that the women with saline breast implants who were in the Mentor and Allergan studies were not analyzed in the MD Anderson study.

FDA Response

In response to this important study, Dr. Binita Ashar of the FDA published an editorial in the same issue of the same medical journal, claiming that the MD Anderson study “failed to account for methodologic differences between studies, inconsistencies in the data, differential loss to follow-up, confound and other potential sources of bias.”  That is true.  However, Dr. Ashar did not mention that the FDA should take responsibility for all the shortcomings of the data that MD Anderson analyzed.  She did not mention that the flawed data were based on studies that were required by the FDA as a condition of approval for the breast implants made by Allergan and Mentor.  The data were flawed because women soon disappeared from the study, and the FDA did not require the companies to finish the studies, as they should have,

As a result of the FDA’s failure to enforce the study requirements, the large Allergan and Mentor studies used as the basis of the MD Anderson analyses were very flawed short-term studies rather than the 10-year studies that FDA had proudly said they were requiring.  Whereas the companies blamed the study shortcomings on the enormous number of women who “dropped out” of the study shortly after enrolling (including 80% of the women with Mentor implants after only 1 year), we have interviewed women who were enrolled in those studies who told us that they did not drop out of the studies – rather they were “dropped” from the study by the researchers without their consent.  They never heard from the researchers and hence had no opportunity to tell the researchers how sick they had become after getting breast implants.   Instead, several of those women went to the FDA this month to explain to FDA scientists what happened.  They told Dr. Ashar and other FDA officials that they were dropped from the studies.  They told Dr. Ashar and other FDA officials that they had suffered from autoimmune and connective tissue symptoms such as the ones reported in the MD Anderson study.  They told Dr. Ashar and the other FDA officials that despite being sick for years, they were unaware that breast implants could be the cause because neither the FDA nor their plastic surgeons had warned them of the risks.  When they finally found each other on social media (on Facebook pages joined by more than 50,000 women harmed by breast implants), they realized that removing their implants might help.  Much to their surprise, they experienced almost miraculous recoveries after their implants were removed by experienced explant surgeons.   The women told Dr. Ashar and other FDA officials that their symptoms disappeared entirely or improved by 85%.

The FDA editorial was written before Dr. Ashar met with the former implant patients this month, but she had previously met with several of the same women who had reported these same problems and recoveries after explant surgery.  So it is very discouraging that FDA staff have been and continue to be so close-minded about the risk of breast implants despite the MD Anderson analyses.

What Have we Learned from the MD Anderson Study?

We agree with the FDA and the MD Anderson researchers that these results can’t be considered conclusive, but the FDA needs to look at the data more carefully and require better studies so that they can reconsider their repeated claim that breast implants are only proven to cause local complications, such as leaking and painful implants.  Although the FDA admits that breast implants can cause a cancer of the immune system known as ALCL, they continue to quote industry-funded studies claiming that implants do not cause other systemic illnesses.  It should be obvious to open-minded scientists that if breast implants can cause cancer of the immune system, they can probably cause other serious immune system diseases and symptoms.  Moreover, the results of the MD Anderson study supports those concerns about autoimmune symptoms and diseases.

What should be the key information of importance to women considering breast implants or women who have them in their bodies? Clearly, these studies indicate that patients should report any new symptoms that develop after getting their implants, whether involving their breasts or other parts of their body.  Breast implant patients should know that the FDA recommends MRI imaging of silicone breast implants 3 years after the augmentation or reconstructive surgery and every 2 years thereafter.

  

Statement of Dr. Diana Zuckerman, President of the National Center for Health Research Regarding the New Study of 100,000 Women with Breast Implants

Dr. Diana Zuckerman, President of the NCHR: September 17, 2018.


In the largest study ever conducted of long-term health risks for patients with breast implants, researchers at The University of Texas MD Anderson Cancer Center have reported that women with silicone implants are more likely to be diagnosed with several rare diseases, autoimmune disorders, and other conditions.  These results are consistent with numerous previously published studies, but contradict the conclusions of studies funded by implant manufacturers or plastic surgery medical societies.

The study, published in the medical journal Annals of Surgery, is by researchers in MD Anderson’s Department of Plastic Surgery and is based on analyses of almost 100,000 patients with either saline or silicone implants. The information was derived from the FDA’s database dating back to 2005.  When the FDA approved silicone gel breast implants made by two manufacturers in 2006, the agency required that each of the manufacturers study at least 40,000 women for 10 years.  Those studies were started but never completed, making it impossible to determine the long-term risks of breast implants.  In the absence of such crucial studies, patients report that they were not warned about the risks when they decided to get breast implants.

We thank Mark W. Clemens, M.D., associate professor, Plastic Surgery, the senior investigator of this very important study.  The findings are consistent with what thousands of women with breast implants have reported in Facebook groups and other social media, and directly challenge the FDA’s claims that breast implants do not cause such diseases.  We urge the FDA to be more patient-centered and finally require independent studies be conducted of women before and after their breast implants are removed.  Many women have reported that their debilitating autoimmune symptoms decreased or disappeared after their breast implants were removed, but scientific data is needed to establish the rate of recovery.

Radiation Therapy for Ductal Carcinoma In Situ (DCIS)

Diana Zuckerman, PhD, 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.  If that happens, it is called invasive breast cancer. 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.  Unfortunately, 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]

Is Radiation Necessary?

Doctors usually recommend radiation therapy for lumpectomy patients, but since it is inconvenient and has some side effects, many women prefer to avoid it.  In fact, some DCIS patients decide to have a mastectomy because they do not want to undergo radiation.  However, mastectomy is a much more radical surgery and is very rarely a good idea for DCIS patients. That’s because almost all women with DCIS live long lives, and undergoing radiation does not affect whether DCIS patients live a long life or not.

Instead, the main advantage of radiation for DCIS is to prevent recurrence of DCIS in the breast where the DCIS was removed. A study of more than 1,700 women with DCIS who underwent a lumpectomy evaluated different treatment options.  The women were randomly assigned either to radiation, tamoxifen, radiation plus tamoxifen, or no treatment after surgery.  Undergoing radiation had a very small benefit for women in general, and has little impact on your chances of living a cancer-free life.

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]  

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%. 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]

So why do doctors so strongly recommend radiation and hormone therapy for DCIS?  Doctors tend to focus on reducing “relative risk” rather than actual risk. So, if a  treatment decreases the chances of recurrence by about 50% that sounds impressive — but 50% of a 16% chance is 8%, for example, and that isn’t much of a difference. And 50% of a 6% chance of recurrence is even less meaningful.  Most important, it doesn’t affect survival so women can skip radiation now and choose it later if they have a recurrence. In contrast, if a woman has radiation after a lumpectomy and later has a recurrence anyway, she can’t undergo radiation again.

When is radiation most important for DCIS?  It is more likely to benefit younger women (especially women diagnosed before age 40), women with more serious types of DCIS (a high grade DCIS called comedo), and women with a family history of breast cancer.

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.  The difference was 8 of women taking tamoxifen compared to 13% of women taking 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.  The difference was 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].

Bottom Line:  Radiation and hormone therapy both have benefits for most women who undergo lumpectomy, because they decrease the chances of DCIS returning after surgery.  However, the benefits are quite modest and neither of these treatments affect how long women live, because almost all women diagnosed with DCIS are still alive 20 years later.

References:

  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

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.