Tag Archives: breast cancer

Less Radical Surgery Is a Healthier Choice for Women with Breast Cancer

Brandel France de Bravo, MPH and Diana Zuckerman, PhD, Cancer Prevention & Treatment Fund

Experts have long advised that lumpectomy patients live as long as mastectomy patients.  But the latest research, based on hundreds of thousands of women, indicates that women with DCIS or early-stage breast cancer are more likely to live longer, healthier lives if they choose less radical surgery.

Four studies indicate that lumpectomy patients live longer.

In a study of almost half a million women with breast cancer in one breast, Harvard cancer surgeon Dr Mehra Golshan  reported in 2016 that those undergoing double mastectomies did not live longer than women undergoing a mastectomy in only one breast.[1] On average, women who underwent a lumpectomy instead of mastectomy lived longer than women undergoing either a single or double mastectomy for cancer in only one breast.

Similarly, a study of more than 37,000 women, also published in 2016, women with early-stage breast cancer who underwent lumpectomy with radiation were more likely to be alive 10 years later, compared to women who underwent mastectomies.[2] They were also less likely to have died of breast cancer or of other causes.  This was true even when age and factors that could influence survival were taken into account.

Dr. Shelly Hwang and her colleagues found similar results in a 2013 study of more than 112,000 California women who had lumpectomies to remove their early-stage breast cancer were more likely to be alive and free of breast cancer 5 years after surgery than women who had mastectomies.[3] The women had been diagnosed between 1990 and 2004 with either Stage 1 or 2 breast cancer. All of them had either a lumpectomy with radiation or a mastectomy. After surgery, their health was monitored for an average of 9 years (the women were all studied for 5-14 years). The women who had a lumpectomy and radiation tended to live longer than the women who had mastectomies, when controlling for age at diagnosis, race, income, education levels, tumor grade or the number of lymph nodes with cancer. Lumpectomy with radiation was especially effective for women who were 50 years and older with hormone-receptor positive tumors: they were 19% less likely to die of any cause during the study than women just like them who had mastectomies. Perhaps more surprising, they were 13% less likely to die of breast cancer than women just like them who had mastectomies.

In a study published in 2014, Dr Allison Kurian and her colleagues at Stanford studied 189,734 California patients diagnosed from 1998 to 2011 with early-stage breast cancer in one breast, ranging from Stage 0 (DCIS) to Stage 3.[4The study showed that the percentage of women having both breasts when only one breast had cancer (called bilateral mastectomies) increased dramatically, but there was no advantage to that more radical approach.  Instead, the women who underwent lumpectomies (removing only the cancer, not the entire breast) lived longer and were more likely to be alive 10 years after diagnosis compared to women undergoing a mastectomy.  Women who had both breasts surgically removed did not live longer than those undergoing a mastectomy on one breast.

Compared to women in other countries, women in the U.S. who are diagnosed with early-stage breast cancer are more likely to remove both breasts even if only one has cancer. It is not known why bilateral mastectomy provides no medical advantage, but a study of more than 4,000 cancer patients by Dr. Fahima Osman at the University of Toronto indicates that having a healthy breast removed in addition to the breast with cancer increases the chances of medical complications.[5] Removing the healthy breast (“contralateral breast”) doubled the chances of having wound complications in the first month after surgery: from about 3% for women who had only the breast with cancer removed to about 6% for women who also had the healthy breast removed. About 4% of women who had a single mastectomy experienced some kind of complication (not necessarily wound-related) in the 30 days after surgery, compared to 8% of women who had both breasts removed. The risk of cancer in that healthy breast was already less than 1% per year unless the woman has a BRCA gene or some other very high risk factor.[6] Hormone pills such as tamoxifen or aromatase inhibitors can further reduce that already low risk.

The Bottom Line: these enormous studies of women in the U.S. and other countries make it clear that women with DCIS or early-stage breast cancer should undergo surgery to remove only the DCIS lesion or cancer, not the entire breast.   The women who undergo lumpectomy with radiation usually live longer than those who undergo mastectomy or bilateral mastectomy.  In addition, mastectomy patients who have breast implants are more likely to kill themselves compared to mastectomy patients without implants. Unfortunately, the fear of breast cancer and desire to “get rid of the problem” has resulted in too many women undergoing mastectomies or bilateral mastectomies that threaten their lives.  Physicians and breast cancer advocacy groups need to make sure that patients understand why lumpectomy with radiation is a better idea.

For a free booklet on treatment options for DCIS, click here.  For a free booklet on treatment options for early-stage breast cancer, click here.

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


  1. Wong, S., Freedman, R., Sagara, Y., Aydogan, F., Barry, W., & Golshan, M. Growing Use of Contralateral Prophylactic Mastectomy Despite no Improvement in Long-term Survival for Invasive Breast Cancer. Annals of Surgery. 2016 March; doi:10.1097/SLA.0000000000001698
  2. Marissa C. van Maaren, et al, “10 year survival after breast-conserving surgery plus radiotherapy compared with mastectomy in early breast cancer in the Netherlands: a population-based study”. Lancet Oncol. 2016 Aug; 17(8): 1158–1170. Published online 2016 Jun 22. doi: 10.1016/S1470-2045(16)30067-5
  3. Hwang ES, et al “Survival after lumpectomy and mastectomy for early stage invasive breast cancer: The effect of age and hormone receptor status” Cancer 2013 April 1; 119(7); DOI: 10.1002/cncr.27795.
  4. Kurian, Allison W., Daphne Y. Lichtensztajn, Theresa H. M. Keegan, David O. Nelson, Christina A. Clarke, and Scarlett L. Gomez. “Use of and Mortality After Bilateral Mastectomy Compared With Other Surgical Treatments for Breast Cancer in California, 1998-2011.” The Journal of the American Medical Association 2014; 312(9): 902-914. DOI:10.1001/jama.2014.10707
  5. Osman, Fahima, et al “Increased postoperative complications in bilateral mastectomy patients compared to unilateral mastectomy: an analysis of the NSQIP database.” 2013 Oct; 20(10): 3212–3217. Published online 2013 Jul 12. doi: 10.1245/s10434-013-3116-1
  6. National Cancer Institute. Breast Cancer Treatment (PDQ®). http://www.cancer.gov/cancertopics/pdq/treatment/breast/healthprofessional/page1

Breast implants and mammography: what we know and what we don’t know

Elizabeth Santoro, RN, MPH and Dr. Diana Zuckerman

There has been a lot of attention given to mammography screening in recent years. Some of this information has been confusing to women—at what age should I first have a mammogram, how frequently should I have repeat mammograms, and are mammograms even effective? These are questions that women both with and without breast implants have been trying to understand. Despite this confusion, experts continue to recommend that the average woman have mammograms every two years starting at age 50, while women with a great risk consider having mammograms every year or two starting at age 40.1 But, what does this mean for women who have breast implants? Are women with breast implants faced with different risks when undergoing a mammogram? Will women with implants require special considerations during the procedure?

Delayed Breast Cancer Detection

Breast implants can interfere with the detection of breast cancer, because the implants can obscure the mammography image of a tumor. Implants therefore have the potential to delay the diagnosis of breast cancer. Although mammography can be performed in ways that minimize the interference of the implants, as described below, Miglioretti and her colleagues found that even so, 55% of breast tumors were missed, compared to 33% of tumors for women without implants.2  They also found that among newly diagnosed breast cancer patients who did not have any symptoms, the augmented women had larger tumors than those who did not have implants.

What is the impact of this possible delay in diagnosis?  Research findings have been inconsistent, but a 2013 Canadian systematic review of 12 studies found that women with breast cancer who had breast implants are diagnosed with later-stage cancers than women with breast cancer who did not have implants.3

A delay in diagnosis could result in the woman needing more radical surgery or the delay could be fatal.  A 2013 Canadian meta-analysis of five studies found that if women who had breast augmentation later developed breast cancer, they were more likely to die from it than women diagnosed with breast cancer who did not have breast augmentation.3

These studies indicate that for an individual woman, a delay in diagnosis could potentially result in death, and more research is needed to determine how often that happens, and under what circumstances. From a public health perspective, delays in diagnosis could potentially necessitate more radical surgery: a cancer that could have been treated at an earlier stage with breast-sparing treatments, such as lumpectomy, may instead require a mastectomy.4,5

What are the other possible problems that implants can cause regarding mammography?

A study by FDA scientist Dr. S. Lori Brown and colleagues describes problems that were reported to the FDA related to breast implants and mammography screening.6 The authors found 66 adverse events that were reported as either occurring during the mammogram or involving breast implants interfering with the mammogram. Forty-one reports of either silicone or saline breast implants- – almost two out of three reports– pertained to ruptures that were suspected as happening during mammography. The other 25 reports included delayed breast cancer detection, inability to perform the mammogram due to capsular contracture or because of fear that the implant would rupture, and pain/soreness during and after the procedure.

Description of the FDA Study

This study examined data from the Manufacturer and User Facility Device Experience (MAUDE) database. This FDA database collects mandatory or voluntary reports of medical device adverse events from physicians, breast implant manufactures, consumers, and others. The reports were received between June 1992 and October 2002 for events that occurred between June 1972 and June 2002. The mean age of the implant was 14.5 years, and ranged from 2-29 years.

The use of the MAUDE database has limitations. The FDA does not verify the information that is provided. Therefore, the FDA cannot guarantee that the information is accurate and complete. In addition, in some cases, a doctor and a patient could potentially report the same problem.  On the other hand, most problems are not reported even once, since patient and physician reporting is voluntary. It is well-documented that the vast majority of problems arising from medical products are not reported to the FDA. As a result of these shortcomings, these data cannot be used to calculate the number of new adverse events expected for a given number of people in a defined time period.

Key Implications of the Studies on Implants and Mammograms

Potential Implant Rupture

The FDA warns that all implants will eventually break, and research shows that most women who have implants for ten years or longer will have at least one broken implant.7 The risk of breast implant rupture is known to increase as the implant ages. A study by Holmich and colleagues suggested that during the first ten years a woman has implants, most implants do not break, between 11-20 years most will break, and by the time they are more than 20 years almost all have broken.8 Women with implants have been told that mammography is safe for them, but the results of the Brown study suggest that the risk of rupture can be exacerbated by mammography.

Brown and her colleagues also reviewed the published research on implant rupture during mammography and found an additional 17 cases reported in medical journals. According to the American Society of Plastic Surgery, approximately half of the women who get breast implants are in their 20′s or early 30′s,9 which means that the implants are already broken or vulnerable by the time these women are old enough for screening mammograms.

Mammography may therefore increase the risk of a rupture earlier in the typical lifespan of implants, and the squeezing involved in mammography probably increases the risk of leakage in implants that are already ruptured. The potential risk of rupture or leakage needs to be weighed against the benefits of mammography by each individual woman. For women who are concerned about breast cancer, knowledge of mammography problems might discourage women from getting breast implants, or encourage them to have their implants removed and not replaced. Current guidelines encourage women with breast implants to have regular mammograms provided that the technician knows the woman has implants prior to the procedure and that special techniques are utilized.6 In light of this new research, those guidelines need to be reconsidered, especially for women with silicone gel breast implants, where leakage can cause permanent disfigurement and has unknown health risks.

Avoidance of Mammography

The Brown study also found that implants sometimes make it impossible to perform a mammogram. This can happen for two reasons. First, conditions such as capsular contracture, where the scar tissue around the implant tightens and causes the breast to become hard and misshapen, can make it very difficult or even impossible to perform the mammogram.10, 11 The compression of the breast that is required in order to perform the mammogram can be extremely painful if there is capsular contracture, and in some cases the hardness of the breast makes it impossible to compress the breast for the mammogram. Some women avoid getting mammograms because they are afraid of rupture and the latest research indicates that this is a reasonable concern.

Biomaterials testing of breast implants indicates that implants should only break under the most traumatic circumstances, and yet implants break for no apparent reason, as well as under pressure from mammograms.12 It is difficult to know how much risk a mammogram increases the risk of rupture since so little is understood about why implants break and under what circumstances.

What Does this Mean for Women?

Women considering breast implants and women with breast implants need to be informed consumers, and that includes knowing about the problems that arise from having mammograms with breast implants. This is true for all women, but especially breast cancer patients who may use implants on a healthy breast so that it will match the reconstructed breast after a mastectomy. (Detection of cancer in the reconstructed breast is unlikely to be a problem because mammography is not used after a mastectomy. Since breast cancer survivors are at greater risk for breast cancer in the breast that was not removed, compared to women who have not had breast cancer, survivors should have regular mammograms of the surviving breast, and need to know the risks.

Women with breast implants and those considering breast implants need to know that they will have a different mammography experience than women without implants, to try to improve the accuracy. The special techniques used will push the implant back to try to move it out of the way, and extra views will be taken. Even so, as reported earlier in this article, mammograms performed on women with implants will still miss more tumors than is typical of mammograms for women who do not have implants.7, 13 In addition, women with implants should expect that mammography will require more views and take longer, thus costing more and exposing them to increased levels of radiation. Unfortunately, the most common problem, capsular contracture, can make mammography more painful, less accurate, or even impossible to perform. In such cases other, more expensive tests, such as an MRI or ultrasound, may be required.

Women also need to understand that even if breast implants do not cause contracture or other problems, they will still interfere with mammography and mammograms might still cause rupture and leakage.

The bottom line is that women considering breast implants and those who already have them need to be informed about potential problems with mammography so that they can make the decisions that will help them reduce the risk of breast cancer and avoid the problems that arise with implant breakage and leakage.

For more information on breast implants, see www.breastimplantinfo.org.

Related Content:
What you need to know: Breast cancer, suicide, mastectomy, and breast implants
Summary of: Breast Implants, Self-Esteem, Quality of Life, and the Risk of Suicide
2016 Update: When should women start regular mammograms? 40? 50? And how often is “regular”?


Can a handful of nuts a day keep cancer away?

By Krista Kleczewski and Claire Karlsson

Evidence is growing about the many ways in which eating nuts, seeds, and legumes can improve your health. These foods have been linked to healthier hearts and a lower risk of diabetes, but now studies show they may also cut your risk of getting cancer! Here’s what we know and don’t know.

Several studies show a great benefit from eating nuts, seeds, and legumes. In 2015, a Dutch study of 120,000 men and women between the ages of 55-69 found that those who ate about half a handful of nuts or peanuts each day were less likely to die from respiratory disease, neurodegenerative diseases, diabetes, cardiovascular diseases, or cancer than those who consumed no nuts or seeds.14 The same benefit was not seen for peanut butter, however, which suggests that the salt, vegetable oils, and trans fatty acids in peanut butter may counterbalance the benefits of the peanuts. A 5-year study conducted in Spain of 7,000 men and women aged 55 to 80 years old found that eating at least three servings of nuts per week reduced the risk of cardiovascular and cancer death.15 Another study similarly found eating nuts – especially walnuts — reduces the risk of developing cancers, diabetes and heart disease when eaten in conjunction with the Mediterranean Diet, which also emphasizes fruits, vegetables, whole grains, and legumes.16 Walnuts were highlighted by the study as reducing inflammation associated with certain cancers and other conditions like diabetes and heart disease. More evidence is needed, however, to determine the specific impact of walnuts on cancer risk.

Breast Cancer

Eating large amounts of peanuts, walnuts, or almonds can reduce the risk of developing breast cancer, according to a 2015 study of 97 breast cancer patients. 17 The researchers compared the lifetime consumption of nuts and seeds among the breast cancer patients with the consumption of those without breast cancer, finding that women who ate large quantities were half to one-third as likely to develop breast cancer. No difference was found between people who ate a small amount of nuts and seeds and those who ate none at all, suggesting that a person needs to consume a substantial amount of nuts and seeds over their lifetime to reduce their chances of developing breast cancer.

Girls who regularly eat peanuts and nuts may be less likely to develop breast cancer as adults. In a study published in 2013, girls between the ages of 9-15 who regularly ate peanut butter or any kind of nuts had almost a 40% lower chance of developing benign breast conditions as adults.18 Although not dangerous, benign breast conditions increase a woman’s chances of eventually getting breast cancer.

Many people think of peanuts as nuts, but they are actually a type of legume. Researchers found that eating legumes, which include beans, lentils, soybeans, and corn, may all reduce the risk of benign breast conditions (and therefore, breast cancer).

Can eating nuts, legumes and seeds reduce colorectal cancer risk?

To find out whether snacking on foods with peanuts lowers your chances of getting colorectal cancer (also called colon cancer), researchers studied more than 23,000 adults in Taiwan, ages 30 and older.19 The researchers found that women who ate meals with peanut products at least twice each week were less likely to develop colorectal cancer. More research is needed to see if this benefit is actually from the peanuts.

In one of the largest studies of diet and cancer, which was conducted in 10 European countries, researchers discovered that eating nuts and seeds reduced women’s chances of developing colon cancer, but did not lower the risk for men.20 Women who ate a modest daily amount of nuts and seeds (about 16 peanuts or a small handful of nuts or seeds) every day were less likely to develop colon cancer, and women who ate the largest quantities of these foods were the least likely to develop colon cancer. Again, more research is needed to understand these findings.

Pancreatic Cancer

Eating nuts also seems to lower the risk of developing diabetes,21 which may then lower the risk of developing pancreatic cancer. In addition, a large study of women found that frequently eating nuts was associated with less chance of developing pancreatic cancer,22 one of the most deadly cancers.

What about ovarian cancer?

A 2010 study examined the possible link between ovarian cancer and foods high in phytoestrogens and/or fiber, including nuts, beans, and soy. They found that these foods seemed to help prevent “borderline ovarian cancer”—slow-growing tumors that are less dangerous and more likely to affect younger women. However, these foods did not seem to protect against the more aggressive types of ovarian cancer.23

The Bottom Line

There is growing evidence that nuts, legumes, and seeds reduce the risk for several types of cancer, as well as having other health benefits. Nuts are high in calories, so don’t overdo it. It seems safe to assume that adding these foods to your diet, in small quantities several times a week, is a good idea, especially if you use them to replace less healthy snacks.

This gives new meaning to the name “health nut”!


Tamoxifen and other hormonal therapies for treating early stage breast cancer and preventing it

By Diana Zuckerman, Ph.D., Anna Mazzucco, Ph.D., and Brandel France de Bravo, MPH
Updated 2014

Breast cancer is the most common type of cancer in women around the world, and the second leading cause of cancer deaths among U.S. women.

Women who are diagnosed with early-stage breast cancer almost always undergo surgery to remove the cancer (either lumpectomy or mastectomy). Most will also choose at least one other treatment in addition to surgery:

1) If they have a lumpectomy, they usually undergo radiation to shrink the tumor before surgery or to kill any cancer cells in the breast that were missed during surgery;

2) About 1 in 3 women undergochemotherapy to reduce the size of the tumor before surgery or to reduce the chances of the cancer coming back after surgery.24,25 Chemotherapy is more likely for women whose tumors are larger (1 centimeter or larger), high grade, or less common or more aggressive types.

3) If their cancer is estrogen receptor positive, many women will try to take hormonal therapy for at least five years after surgery to lower the chance of cancer coming back in the future.

Types of Hormonal Therapies for Early Stage Breast Cancer

Hormonal therapy (also called hormone treatment/therapy or anti-estrogen therapy) is the opposite of the type of hormones women sometimes take to reduce the symptoms of menopause.  It lowers your estrogen levels instead of increasing them.

Hormonal therapy is recommended for most women with breast cancer, and sometimes it is taken by women who have not been diagnosed with breast cancer but are at high risk for it based on their genes or family history. When hormonal therapy is used before developing breast cancer, it is called “primary prevention” or “chemoprevention,” even though it is very different from the drugs used in chemotherapy to treat breast cancer.

Four types of hormonal therapy are FDA-approved for early-stage breast cancer treatment: tamoxifen, exemestane, letrozole, and anastrozole. Tamoxifen is also approved for preventing breast cancer in high-risk women, along with a fifth drug, raloxifene. There are other hormonal therapies that a doctor may prescribe, but they have not yet been sufficiently studied or approved by the FDA as safe and effective to either prevent breast cancer or treat early-stage breast cancer.

There are risks as well as benefits to hormonal treatment, and tamoxifen, the most widely used and studied type of hormonal treatment, is no longer considered the first choice treatment for most postmenopausal women. Some breast cancer patients experience such bad side effects from tamoxifen that they stop taking it after a few years. A study published in 2013 in the British Journal of Cancer found that 1 in 4 women didn’t complete the recommended five years of tamoxifen.26

How does Hormonal Therapy work?

Hormonal treatment for breast cancer is sometimes called “anti-estrogen therapy,” is used to starve the breast cancer cells of the hormone they thrive on, which is estrogen. Hormonal treatment is effective for women with estrogen receptor-positive breast cancer (the most common type of breast cancer) and estrogen-receptor positive ductal carcinoma in situ (DCIS), which is a type of lesion that increases a women’s risk of breast cancer. Approximately 3 out of 4 breast cancers are estrogen-receptor positive.27 Hormonal therapy is not effective for women with estrogen-receptor negative breast cancer.

There are other hormonal therapies being studied, including those for women whose cancers are fed by the hormone progesterone. These women have progesterone receptor-positive breast cancer, but most are estrogen-receptor positive as well, and can also benefit from anti-estrogen therapy.

All hormonal therapy is taken as a daily pill for a minimum of 5 years. For some types of hormonal therapy, such as tamoxifen, recent research has shown that breast cancer patients can reduce their chances of recurrence a little bit more by increasing the number of years they take the therapy.

For women with breast cancer who have already gone through menopause, hormonal therapy using aromatase inhibitors seems to be more effective than tamoxifen or raloxifene, which belong to a class of drugs known as selective estrogen receptor modulators (SERMs).  Once a woman has gone through menopause, her ovaries no longer produce estrogen but the enzyme aromatase still produces some estrogen.  Interfering with the production of estrogen is another way of starving breast cancer cells that feed off of estrogen. Since aromatase inhibitors do not block the production of estrogen from the ovaries, they are not usually used by premenopausal women. Studies are being done but it is still too early to say whether or not aromatase inhibitors should be given in addition to tamoxifen to premenopausal women with breast cancer or DCIS.28

How effective is hormonal therapy for women with early-stage breast cancer?

Tamoxifen.  A study published in 2013 in Lancet showed that taking tamoxifen for 10 years results in slightly lower recurrence rates and slightly better survival rates, compared to taking it for 5 years. This study, which followed breast cancer patients taking tamoxifen for longer than other studies, found that 25% of the women who took tamoxifen for 5 years had their cancer return within 15 years of surgery, whereas 21% of women who took tamoxifen for 10 years had a breast cancer recurrence within 15 years. Survival was also slightly better: over 81% of women who took tamoxifen for 10 years were alive 15 years after surgery compared to just under 79% of the women who took tamoxifen for only 5 years. While longer treatment with tamoxifen resulted in 2.5% more patients surviving for 15 years, it also resulted in 1.5% more women developing uterine cancer, one of the more serious risks linked to tamoxifen.29,30

Tamoxifen is the only hormonal therapy approved for use in women with DCIS. It reduces a woman’s risk of getting DCIS again or developing breast cancer in either breast.  According to a 2011 study published in the Journal of the National Cancer Institute, 10% of women treated with lumpectomy and radiation had a recurrence of DCIS or developed breast cancer in the same breast within 15 years of surgery, as compared with 8.5% in the women who also took tamoxifen. Among the women who took tamoxifen, only 7.3% developed DCIS or breast cancer in the other, previously healthy, breast whereas 10.8% of the women who didn’t take tamoxifen in addition to lumpectomy and radiation were diagnosed with DCIS or breast cancer in the other breast.31

Raloxifene. This drug was first approved to treat osteoporosis, a condition where bones become more porous and breakable, in women after menopause. In 2007, raloxifene was approved as a hormonal treatment to prevent breast cancer—not to treat it. For prevention, it works very much like tamoxifen, and is almost as effective,32 but has fewer side effects (see “Side Effects of Hormonal Therapy” below). In addition, it has the benefit of increasing bone density.

Aromatase inhibitors (exemestane, letrozole,or anastrozole). The three FDA-approved aromatase inhibitors can be used by postmenopausal women in any of the following ways: 1) they can be taken for 5 years; 2) they can be taken for 2-3 years after having taken tamoxifen for 2-3 years; or 3) they can be taken for 5 years after 5 years of tamoxifen. In general, each of the aromatase inhibitors seems to work about equally well.  Some studies have suggested that aromatase inhibitors—whether taken alone or after tamoxifen—may be more effective than tamoxifen alone at preventing cancer recurrence in postmenopausal women.  But there has not been a clear advantage for aromatase inhibitors over tamoxifen in helping breast cancer patients live longer (see below for more details).33

Aromatase inhibitors instead of tamoxifen. For example, in one study lasting almost 9 years, taking letrozole for 5 years reduced the chance of cancer recurrence more than taking tamoxifen for the same amount of time.  Of the women taking letrozole, 24% had a recurrence of breast cancer, compared to 28% of women taking tamoxifen. In addition, 85% of the women who took letrozole were alive after almost 9 years, compared to 81% of the women who took tamoxifen.34  A different study comparing another aromatase inhibitor, anastrozole, with tamoxifen also found that the aromatase inhibitor was more effective in preventing recurrence.  In that study, 30% of the women taking anastrozole had a cancer recurrence, compared to 33% of women taking tamoxifen.  However, the women who took anastrozole were not significantly more likely to be alive 9 years after surgery than the women who took tamoxifen.35

Aromatase inhibitors after tamoxifen. When used for 2-5 years after taking tamoxifen, aromatase inhibitors have been shown to prevent breast cancer recurrence more than just taking tamoxifen for 5 years.36,37 For example, 6% of women who took the aromatase inhibitor letrozole for about 30 months after 5 years of tamoxifen had a cancer recurrence, compared to 10% among women who did not take anything after tamoxifen.  Among women who took the aromatase inhibitor anastrozole for about 5 years after 5 years of tamoxifen, 8% had a cancer recurrence, compared to 12% of women who took only tamoxifen.38

However, in terms of overall survival—living longer whether or not the cancer returns—most studies have not shown a clear benefit to following tamoxifen with an aromatase inhibitor.39 Nevertheless, a few studies showed that taking both forms of hormonal therapy might help some women live longer.  For example, women with breast cancer in their lymph nodes (“lymph node-positive”) who took letrozole after taking tamoxifen reduced their chance of dying by 39% over 30 months compared to women who took tamoxifen alone.40

For now, the American Society of Clinical Oncologists advises postmenopausal women to take aromatase inhibitors, either alone or in combination with tamoxifen.41 Because some women might tolerate one drug better than another, the best treatment strategy will vary from woman to woman. This is why it is important to discuss side effects with your doctor. If side effects are making it difficult to continue taking a particular hormonal therapy, you may want to try a different one.

See the table at the end of this article for a summary of all the different hormonal therapy options.

Side effects and Risks of Hormonal Therapy

Tamoxifen increases the chances of a woman developing endometrial cancer and blood clots in legs and lungs, especially for women over 50 years of age.42,43  Women taking tamoxifen are about twice as likely to get endometrial cancer, although the overall risk is still low; about 2 women out of 1,000 taking tamoxifen will get endometrial cancer each year.44  Women taking tamoxifen are also about twice as likely to suffer blood clots; for example, in one of the longest term studies, 7% of women taking tamoxifen experienced blood clots.45  Moreover, tamoxifen therapy often causes side effects similar to those experienced in menopause, including hot flashes and irregular periods.46  In one study, 41% of women taking tamoxifen experienced hot flashes, and 10% experienced vaginal bleeding.47

 Like tamoxifen,  Raloxifene increases the risk of blood clots, but it does not increase a woman’s risk of endometrial cancer the way tamoxifen does.

Aromatase inhibitors increase the risk for osteoporosis compared with tamoxifen or taking no hormonal therapy at all.  Exemestane, a commonly used aromatase inhibitor (brand name Aromasin), also increases the risk for visual disturbances, joint pain, an allergic reaction to medication, or diarrhea.  In one of the longest term studies, almost 19% of women experienced joint pain while taking exemestane.48

In very rare cases, the side effects of hormonal therapy can be fatal or can harm a patient’s quality of life.  Close monitoring of women for symptoms, such as abnormal uterine bleeding, is needed, and women taking tamoxifen should receive annual pelvic exams.49

Different women respond differently to the various forms of hormonal therapy, which is why it is not uncommon for women to switch to different hormonal treatments after starting.

Too little of one hormone (melatonin) may interfere with hormonal therapy

Exposure to light and insufficient night time sleep lower the amount of melatonin produced, and melatonin helps prevent breast tumors from growing.  In a 2014 study on rats, scientists showed that sleep disruptions (due to poor sleep or night shift work) and exposure to light at night can make tamoxifen less effective at blocking estrogen.50  Breast cancer patients taking tamoxifen (and possibly other hormonal therapies) should avoid work and light at night when possible using light blocking curtains and/or a sleep mask (see our article on sleep masks and health here).

Hormonal therapy to prevent breast cancer in women at high risk (primary prevention)

While the oldest form of hormonal therapy, tamoxifen, and its newer cousin, raloxifene are the only drugs approved to prevent breast cancer in women who’ve never had the disease but are at high risk, early results from long-term studies suggest that aromatase inhibitors are also effective at preventing breast cancer in postmenopausal women.51 Studies are underway to see if aromatase inhibitors can be used to prevent breast cancer in premenopausal women as well, but it is likely that they would have to be used in combination with other drugs to temporarily stop ovarian function.




The Cancer Prevention and Treatment Fund Responds to CDC study on Camp Lejeune Drinking Water Health Hazards

By Anna E. Mazzucco, PhD and Diana Zuckerman, PhD, President of the Cancer Prevention and Treatment Fund
Updated March 24, 2014

The contaminated water at the Camp Lejeune Marine Corps base is a national disgrace that has jeopardized the health of many adults and children. Now the government’s focus needs to be on assisting all those who have been harmed – and that should include preventing cancer and other diseases in those who are not currently sick but at risk because of their exposure years ago. Righting the wrong that was done to our armed service families requires more than research and passing the buck – it requires a plan of action based on solid scientific information.

The Cancer Prevention and Treatment Fund expresses its strong support for the adults and children who have been harmed by contaminated drinking water at Camp Lejeune Marine Corps Base.  This unprecedented environmental disaster has been a tragic disservice to the courageous men and women of our military.

The new analysis by the Centers for Disease Control and Prevention indicates that pregnant women who were more exposed to contaminated drinking water at Camp Lejeune were 4 times as likely to give birth to children with serious birth defects such as spina bifida, compared to women who were less exposed.  There was also a slight increase in childhood cancers such as leukemia among these children.  A study published (reported) in 2014 found increased risk of death among Camp Lejeune residents from several cancers including kidney, liver, cervical, esophageal, multiple myeloma and Hodgkin lymphoma, in comparison to residents of another military base which did not have contaminated water.  Previous reports have indicated that men living or working on the base from the mid-1950s until 1987 were much more likely to develop breast cancer than men in the general population, but that study has not yet been completed.  Breast cancer is a rare occurrence among men, and is especially dangerous because men often do not recognize the symptoms or seek treatment in a timely manner. In addition, men with breast cancer often experience unique and significant physical, social and psychological issues.

The Cancer Prevention and Treatment Fund is dedicated to helping children and adults reduce their risks of getting all types of cancer, and assists them in choosing the safest and most effective treatments. We use research-based information to encourage more effective programs, policies and medical treatments. We strongly urge the federal government to continue investigating the link between exposure to trichloroethylene (TCE) and other known contaminants in the Camp Lejeune drinking water, and an increased risk for diseases among children and adults.  It is likely that the exposures could cause several different types of cancer, but those other cancers would not be as noticeable as male breast cancer, since that is so rare.

Can girls lower their breast cancer risk by eating peanut butter?

By Krista Kleczewski

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.52 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.5354 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. 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.55

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.56

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)!

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

Choosing wisely: tests and treatments cancer patients usually DON’T need

By Jennifer Yttri, PhD

The thought of cancer is so frightening that many patients depend on their physicians to make all the decisions about screening, prevention, and treatment.  Or they may ask for whatever “new cure” they have heard about.  That can result in too many tests or treatments that do more harm than good.  Not every test, procedure, or medication is appropriate for every patient, and many are over-used. What is beneficial for one person isn’t worth the risks for another.

The best health decisions can be made when physicians take the time to talk with their patients and patients ask questions rather than just assuming the doctor always knows best.

The ABIM Foundation and Consumer Reports collaborated with specialty medical societies to create lists of “5 Things Physicians and Patients Should Question” as part of a national effort called Choosing Wisely (www.choosingwisely.org). These medical groups represent more than 500,000 physicians. The lists contain evidence-based recommendations made by experts. Here is the list of their recommendations on cancer.

Breast cancer screening

Breast cancer screening is done through mammograms, which are like x-rays.  A breast cancer diagnosis involves giving the cancer a stage (0 through 4, with 4 being the most advanced) based on the size of the tumor, how advanced it is, and how likely it is to spread. Other imaging tests, like PET, CT, and bone scans are not recommended for screening early stage breast cancer (stages 0-3), patients newly diagnosed with Ductal Carcinoma In Situ (DCIS), or people without symptoms. This testing does not benefit patients, and false-positives (test results that indicate cancer when no cancer is present) can lead to unnecessary procedures and misdiagnosis. For anyone who has been treated for early-stage breast cancer and is symptom free, mammograms and regular clinical exams are the best ways to check that the cancer has not come back.  Advanced imaging tests and tumor marker tests should only be used for patients with later-stage breast cancer.

Cancer therapy

The first round of cancer therapy works best at reducing or eliminating a tumor. Multiple treatments, including chemotherapy, will not always help get rid of cancer, especially more advanced cancers or tumors that return. After three different treatments, another round is unlikely to improve quality or length of life. It is better to stop therapy and not suffer through the side effects of treatment.  (In fact, there is some evidence that patients live longer, with better quality of life, if they stop aggressive treatments earlier.)

Cervical cancer screening

Women over 65 should stop being screened for cervical cancer if they have not previously shown risk for disease. Women under 30 should not have HPV tests to screen for cervical cancer. Women with mild dysplasia or cervical intraepithelial neoplasia (CIN1) for less than two years should not be treated for cervical cancer, as CIN1 is usually caused by a short-term HPV infection and goes away within a year.   See below for information about HPV testing. Pap smears should be used to screen for cervical cancer.

Colon cancer screening

For people who are at an average risk for developing colon cancer, tests such as stool tests and sigmoidoscopy can be used instead of colonoscopy to screen for colon cancer. Abnormal results from these tests require follow-up with a colonoscopy. The plasma test named methylated Septin 9 (SEPT9) is an alternative screening test but it is not recommended unless the more conventional tests and colonoscopy are not feasible.

HPV testing

HPV testing is not recommended for low risk infections, such as for HPV associated with genital warts. HPV testing should be used to identify high risk infections in patients with abnormal Pap smears or other clinical symptoms associated with high risk HPV infections.

Ovarian cancer screening

Women at average risk who do not have symptoms should not be screened for ovarian cancer. Screening using ultrasound or blood serum testing might detect early signs of cancer, but ovarian cancer is uncommon in women of average risk without symptoms. An abnormal result that isn’t cancer might require invasive follow-up, and those risks outweigh the benefit of early detection.

Ovarian cysts

Small, simple cysts are common in women and usually won’t affect their health. If one is found, the doctor will schedule an ultrasound to determine if the cyst is benign (not cancer). If the cyst is not cancerous, a follow up ultrasound and surgery is not recommended unless the cyst causes symptoms, like pelvic pain. If the cyst is suspected to be cancerous, a follow up ultrasound is not recommended because the cyst should just be surgically removed.  A second ultrasound is only recommended for larger cysts that the doctor could not be sure about.

Palliative care for bone metastasis

Cancers that spread to bones are often very painful. Local radiation is sometimes used to treat patients with one or a few bone metastases, but some doctors question if the increased risk of cancer warrants radiation as treatment for pain. The American Society for Radiation Oncology recommends using one dose of radiation to relieve pain from any bone metastasis. While another dose might be needed in the future, starting with one dose makes sense, since patients with bone cancer have a short life expectancy.

Prostate cancer screening

Men who do not have symptoms generally should not be screened for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam as it can lead to treatments that may do more harm than good. Gleason and prostate-specific antigen (PSA) tests are used to measure how aggressive prostate cancer is and how likely it is to spread. Imaging tests can then be performed to identify exactly where cancer has spread. These imaging tests, such as bone scans, PET, and CT, are not recommended for detecting disease in men who are newly diagnosed with low-grade prostate cancer. Imaging tests are expensive, can expose men to high levels of radiation, and are unlikely to provide more information about early prostate cancer. Only men with Gleason scores above 7 and PSA levels above 10 nanograms/mL should consider imaging tests.

Prostate specific antigen (PSA)

High PSA levels may be a sign of prostate cancer. However, having a low PSA level does not prevent prostate cancer nor does it mean there is no cancer. It was thought that antibiotics might lower PSA and protect men from prostate cancer. This has not been proven in clinical tests and is not recommended as an alternative preventive therapy.

Stage 1 non-small cell lung cancer (NSCLC)

Lung cancer is the most common type of cancer to spread to the brain. However, the chance of patients with Stage 1 lung cancer developing brain metastasis is very low. Because of the rate of false positives is much higher than the actual rate of brain metastasis, brain imaging by MRI or CT is not recommended for patients with stage 1 NSCLC unless they have neurologic symptoms.

Thyroid scans

Radioactive iodine is absorbed by the thyroid and can be used to give doctors a picture of what the thyroid looks like, how it is functioning, and if there are any nodules in the area. Imaging with radioactive iodine is not recommended for determining whether thyroid nodules are benign or cancerous unless the patient is hyperthyroid. Nodules should be biopsied if the thyroid functions normally.