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Preventing Breast Cancer with Hormonal Therapy

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

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

What is Hormonal Therapy?

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

How Effective Are Tamoxifen and Raloxifine?

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

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

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

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

The initial results of the STAR study found that tamoxifen and raloxifene were equally effective in preventing breast cancer after four years of treatment. However, after 5 years of treatment and 2 years of follow-up after the treatment ended, women taking tamoxifen were 1.1% less likely to develop breast cancer while women taking raloxifene were less than half a percent less likely to develop breast cancer (0.4%).[5] So, for example, if your 7-year risk of getting breast cancer was 4% (considered an increased risk), taking tamoxifen may decrease your risk to just under 3% and raloxifene to about 3.6%. This decrease in risk for women taking tamoxifen is very similar to the results of studies conducted more than 5 years earlier, which when combined found a 1.2% decreased risk of breast cancer for pre- and post-menopausal women at average or high risk of breast cancer.[6]

Hormonal therapy is even less beneficial to prevent breast cancer in pre-menopausal women, so it is only recommended for women who have mutations in the “breast cancer genes” (BRCA1 or BRCA2) or if they are older than 35 and have a very high risk of breast cancer.[7]

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

Side Effects

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

Here are the known side effects of tamoxifen:

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

Known side effects of raloxifene:

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

Sources: [3], [8]

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

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

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

Bottom Line

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

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

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

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

References:

  1. What Is Hormonal Therapy for Breast Cancer? (2016, July 20). Retrieved from http://www.breastcancer.org/treatment/hormonal/what_is
  2. The Study of Tamoxifen and Raloxifene (STAR): Questions and Answers. (2010, April 9). Retrieved from https://www.cancer.gov/types/breast/research/star-trial-results-qa
  3. About the Tool. (n.d.). Retrieved from https://www.cancer.gov/bcrisktool/about-tool.aspx
  4. Jones ME. et al. Smoking and risk of breast cancer in the Generations Study cohort. Breast Cancer Research. 2017;19:118. https://doi.org/10.1186/s13058-017-0908-4
  5. Vogel, V. G., Costantino, J. P., Wickerham, D. L., & Cronin, W. M. (2010). Re: Tamoxifen for Prevention of Breast Cancer: Report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. Cancer Prevention Research, 3(63), 1504-1504. doi:10.1093/jnci/94.19.1504
  6. Tan-Chiu, E., Wang, J., Costantino, J. P., Paik, S., Butch, C., Wickerham, D. L., . . . Wolmark, N. (2003). Effects of Tamoxifen on Benign Breast Disease in Women at High Risk for Breast Cancer. JNCI Journal of the National Cancer Institute, 95(4), 302-307. doi:10.1093/jnci/95.4.302
  7. Vogel, V. G. (2018). Primary Prevention of Breast Cancer. The Breast, 219-236. doi:10.1016/b978-0-323-35955-9.00016-7
  8. Bushnell, C. D., & Goldstein, L. B. (2004). Risk of ischemic stroke with tamoxifen treatment for breast cancer: A meta-analysis. Neurology, 63(7), 1230-1233. doi:10.1212/01.wnl.0000140491.54664.50
  9. Cancer Stat Facts: Uterine Cancer. (n.d.). Retrieved from https://seer.cancer.gov/statfacts/html/corp.html
  10. Swerdlow, A. J., & Jones, M. E. (2005). Tamoxifen Treatment for Breast Cancer and Risk of Endometrial Cancer: A Case-Control Study. JNCI Journal of the National Cancer Institute, 97(5), 375-384. doi:10.1093/jnci/dji057

 

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

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

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

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

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

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

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

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

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

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

Who Should Consider PBI?

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

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

Who should not be given PBI?

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

What are the Types of PBI?

PBI can be given in the following ways:

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

What are the Benefits and Harms of PBI?

Advantages of PBI:

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

Disadvantages of PBI:

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

The Bottom Line

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

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

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

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

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

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

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

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

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

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

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

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

Breast Cancer
Krista Kleczewski, Cancer Prevention and Treatment Fund

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

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

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

Peanut Butter and Benign Breast Disease

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

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

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

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

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

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

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

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

 

Drugs to Avoid for Women Taking Tamoxifen

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

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

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

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

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

 

Classes of drugs Drugs that are likely to interfere with tamoxifen

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

The Bottom Line

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

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

Reference:

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

Can Aspirin Prevent Cancer?

Breast Cancer, Colon Cancer, news-you-can-use, Prevention, Prostate Cancer
Diana Zuckerman, PhD: Cancer Prevention and Treatment Fund

Many Americans take low-dose aspirin, also called baby aspirin, to prevent cancer and heart disease. Taking daily aspirin increases the risk of bleeding, so it is important to compare the risks and benefits.  By 2019, research suggested that aspirin does not reduce the chances of developing most types of cancer, but may reduce the chances of colorectal cancer.

In a study published in JAMA Oncology in 2024, women and men who took daily low-dose aspirin were less likely to develop colorectal cancer in the next 10 years.1  The benefits were greatest for people with the unhealthiest lifestyles, as measured by BMI, smoking, alcohol use, and lack of exercise.

In 2016, the U.S. Preventive Service Task Force (USPSTF), an independent group of medical experts, recommended low-dose aspirin “for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk [risk of developing cardiovascular disease], are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years”.2   They did not recommend aspirin to prevent all types of cancer, only colorectal cancer.

Primary prevention means preventing a disease that a person has not yet developed. As you can see above, there were quite a few caveats on who might benefit from “baby” low dose aspirin (typically 81mg).  For example, patients with an increased risk of bleeding due to certain medications, or with a history of other medical conditions such as stomach or intestinal ulcers, kidney disease, or severe liver disease.2

Recommended Guidelines in 2019 from the American College of Cardiology (ACC) and the American Heart Association were not as enthusiastic about aspirin for primary prevention of heart disease, saying that “low-dose aspirin might be considered” for certain patients.3 They did not comment on aspirin to prevent cancer.

The latest research is quite consistent with earlier studies. Studies published more than a decade ago had mixed results for cancer prevention. One study suggested that a daily dose of at least 75mg aspirin taken for several years could reduce the risk of developing colorectal cancer or dying from it.4 Other studies suggested that aspirin may reduce mortality from other cancers, as well as reducing the chances of cancer spreading.5,6 However, a 2019 meta-analysis that combined results from several studies found aspirin did not significantly affect overall cancer mortality.7  One clinical trial known as ASPREE (Aspirin in Reducing Events in the Elderly) found that individuals who took aspirin were more likely to die from cancer.

In conclusion, more research is needed to conclusively determine whether daily baby aspirin can help to prevent cancer, but the benefits seem conclusive for preventing colorectal cancer, especially for men and women with unhealthy habits.

Bottomline: Do I Need Aspirin?

Some patients think they may as well take aspirin, because it might help and won’t harm.  That’s not an accurate assumption.  Aspirin can have risks even at low doses. You should discuss aspirin therapy with your doctor and let him or her know:

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

Other Ways to Prevent Heart Disease and Cancer

To reduce your risk of colorectal cancer, don’t smoke, don’t drink alcohol in excess, have a healthy diet, stay physically active, and maintain a healthy weight.  Being older, and having a family history of colon cancer, Crohn’s disease, or ulcerative colitis are the risk factors you can’t control.8

To reduce your risk of heart disease, don’t smoke, keep your cholesterol and blood pressure under control, and do what you need to do to prevent diabetes.  Being a man and older are risk factors you can’t control.9

 

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

References:

  1. Sikavi DR, Wang K, Ma W, et al. Aspirin Use and Incidence of Colorectal Cancer According to Lifestyle Risk. JAMA Oncol. 2024;10(10):1354–1361. doi:10.1001/jamaoncol.2024.2503
  2. Final recommendation statement: Aspirin use to prevent cardiovascular disease and colorectal cancer: Preventive Mmedication. U.S. Preventive Services Task Force. 2017. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer
  3. Donna K. Arnett, Roger S. Blumenthal,  Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. Journal of the American College of Cardiology. 2019;17:CIR0000000000000678.   http://www.onlinejacc.org/content/early/2019/03/07/j.jacc.2019.03.010?_ga=2.223365151.502443893.1555427130-1631669420.1554414836
  4. Rothwell PM, Wilson M, Elwin CE, et al.  Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials. Lancet. 2010;376(9754): 1741-50. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61543-7/fulltext
  5. Rothwell PM, Folkes FG, Belch JF, et al.  Effect of daily aspirin on long-term risk of death due to cancer: Analysis of individual patient data from randomised trials. Lancet. 2011;377(9759): 31-41. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62110-1/fulltext
  6. Rothwell PM, Wilson M, Price JF, et al. Effect of daily aspirin on risk of cancer metastasis: A study of incident cancers during randomised controlled trials. Lancet. 2012;379(9826): 1591-1601.   https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60209-8/fulltext
  7. Zheng SL, Roddick AJ.  Association of aspirin use for primary prevention with cardiovascular events and bleeding events: A systematic review and meta-analysis. JAMA. 2019;321(3):277-287. https://www.ncbi.nlm.nih.gov/pubmed/30667501
  8. Colorectal Cancer Risk Factors. American Cancer Society. https://www.cancer.org/cancer/colon-rectal-cancer/causes-risks-prevention/risk-factors.html
  9. How to Prevent Heart Disease. Medline Plus.  Last reviewed 2015.   https://medlineplus.gov/howtopreventheartdisease.html

 

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

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

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

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

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

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

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

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

What Happens after Ovarian Cancer Surgery?

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

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

How can you Detect Ovarian Cancer Early?

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

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

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

The Bottom Line

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

 

Footnotes:

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

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

Hormone Therapy and Menopause

Breast Cancer, Medical Treatments with Cancer Risks, ,
Anna E. Mazzucco, PhD, Elizabeth Santoro, RN, MPH, Maushami DeSoto, PhD, and Jae Hong Lee, MD, MPH

Do women need to “replace” hormones as they age? Millions of women struggle with the decision about hormones during and after menopause: should I go on, should I stay on, or should I go off?

For decades, women were told that hormone therapy was like a fountain of youth that would protect them against many of the diseases and symptoms of aging that increase after menopause. Since estrogen alone was known to increase the risk of uterine cancer, doctors usually prescribed a combination of estrogen and progestin, unless a woman had a hysterectomy and therefore was at no risk of uterine cancer.

In addition to its proven effectiveness for decreasing hot flashes, night sweats, and vaginal dryness, in the 1980’s and 1990’s hormone therapy was thought to decrease osteoporosis, prevent heart disease, improve memory and concentration, reduce wrinkles, and improve mood. Women were encouraged to start hormone therapy before menopause started and to continue to take it for years, if not decades, in order to improve their health and their quality of life.

However, the research evidence is now clear: the risks of hormones outweigh the benefits for the vast majority of women.

What the Research Says

In December 2017, the experts at the U.S. Preventive Services Task Force issued a clear recommendation:  post-menopausal women should NOT take hormones to prevent chronic health conditions, such as increasing bone strength to avoid fractures. The reason is that the risks of these hormones outweigh the benefits.1

This recommendation is just the latest evidence that taking hormones to “replace” those that are reduced in menopause if often bad for your health. Previous evidence came from the Women’s Health Initiative (WHI), sponsored by the National Institutes of Health (NIH), which included more than 27,000 women in three different trials to study the effect of hormones on women’s bodies.2,3,4 The 3 trials were: 1) the Estrogen Plus Progestin Trial, 2) the Women’s Health Initiative Memory Study, and 3) the Estrogen-alone Trial.

The researchers found that women taking a combination of estrogen and progesterone hormones were more likely to develop breast cancer, stroke, and blood clots, and at least as likely to develop heart disease, compared to women taking placebo. Those on estrogen alone were at an increased risk for strokes and at a significantly increased risk for deep vein, thrombosis.† The Memory Study revealed that women taking a combination of estrogen plus progesterone were twice as likely to develop Alzheimer’s Disease and other forms of dementia compared to women on placebo.

All the three trials were stopped early for ethical reasons when it became clear that women taking hormones were more likely to be harmed than helped. While there are some short-term benefits to taking hormones, the researchers concluded that for most women, the risks of hormone therapy outweigh the benefits.

Following release of these findings, use of hormone therapy in the U.S. dropped significantly.  Since then, several large studies have pointed out that breast cancer incidence also dropped a few years after the decline in hormone use for menopause.5,6 This unexpected and unprecedented drop in breast cancer incidence suggests that HRT has a more dramatic impact on breast cancer risk than previously thought.7 In 2021, a meta-analysis of more than 4,000 women in 4 different studies of women previously being treated for breast cancer, found that those who subsequently took hormone therapy (combined estrogen plus progesterone) were much more likely to have a recurrence of cancer than breast cancer survivors who took a placebo.8 The women who had estrogen receptor positive breast cancer prior to hormone therapy were 80% more likely to have a recurrence than women taking placebo, which was a statistically significant difference that did not occur by chance. The women who had estrogen receptor negative breast cancer were 19% more likely to have a recurrence than the women taking placebo, which was a small difference that might have occurred by chance.

In 2009, a study found that hormone therapy increased the risk of dying of lung cancer among women who smoked or previously smoked, compared to smokers or former smokers who did not take hormone therapy. For more information click here.

In 2010 the University of California at San Francisco did a study of nearly 700,000 women. The researchers found that taking hormones may actually promote the growth of tumors in the breast which increases the incidence of invasive cancer and the risk of ductal carcinoma in situ (DCIS), a form of non-invasive pre-cancer. You can read more about that study by clicking here.

Experts who promote the use of HRT have criticized the WHI for enrolling women after menopause rather than just before or in the earliest stages.  So, it is important to note that in 2014, a study of 727 women in early menopause showed that hormone therapy did not prevent atherosclerosis (artery thickening), as had been claimed previously.  Following women on HRT for 4 years, the researchers from the Kronos Longevity Research Institute, a pro-HRT research institute, and other institutions, found no difference in artery thickening between the women who took HRT and those who didn’t.9 In 2015, the same group published an article admitting that hormone therapy also had no impact on “cognitive decline,” despite claims that it would prevent Alzheimer’s and memory loss.10 Although the authors focused on a small improvement in mood related to using hormone pills for 4 years (but not found with hormone creams), they downplayed the more important finding: no impact on depression as measured by the valid and reliable Beck Depression Inventory.

What are the Risks and Benefits of Hormone Therapy?

To emphasize that lost hormones don’t necessarily need to be replaced, the term “hormone replacement therapy” has been changed to “hormone therapy.” Experts now advise women to use hormone therapy only for severe symptoms of menopause that reduce the quality of life, such as severe hot flashes, night sweats, insomnia, and vaginal dryness. Women are urged to take hormones at the lowest dose that is effective and for the shortest possible period of time. However, even short-term use (less than one year) increases some risks; for example, the increase in heart disease comes primarily from the first year of hormone use.

Hormone therapy may be recommended in severe cases of vulvar and vaginal atrophy‡ as well as for treating severe postmenopausal osteoporosis when non-estrogen medications or other strategies are unsuccessful or impossible. A decision to use any combination of estrogen and progestin should be discussed with a physician who is expert on the topic, and specific criteria for the indication, dose, and duration of these hormones must be met prior to their prescription and administration.

Risks:

Compared to women taking placebo, within 5 years the women who received estrogen plus progestin experienced:

— 41% more strokes

— 29% more heart attacks

— twice as many blood clots

— 22% more heart disease of all types

— 26% more breast cancer

— 37% fewer cases of colorectal cancer

— one-third fewer hip fractures

— 24% fewer bone fractures of any type

— no difference in the overall death rate

It’s important to note that only 2.5% of the women in the study experienced health problems. So, while the percentage increase in some diseases was rather large, the risk for most patients remained relatively small. That does not mean these risks are not important however.

To provide a better sense of the additional risks that come with combination hormone therapy, the study data can be summarized more simply. Compared to a group of 10,000 women taking placebo, 10,000 women taking combination hormone therapy will experience:

— 7 more heart attacks

— 8 more strokes

— 8 more cases of breast cancer

— 18 more blood clots

— 6 fewer cases of colorectal cancer

— 5 fewer hip fractures

Research Evidence

The Women’s Health Initiative was a major 15-year research program to address the most common causes of death, disability and poor quality of life in post-menopausal women – cardiovascular disease, cancer, and osteoporosis. The WHI was launched in 1991 and consisted of a set of clinical trials and an observational study. The clinical trials were designed to test the effects of post-menopausal hormone therapy, diet modification, and calcium and vitamin D supplements on heart disease, fractures, and breast and colorectal cancer.

The hormone trial had two studies: the estrogen-plus-progestin study of women with a uterus and the estrogen-alone study of women without a uterus. (Women with a uterus were given progestin in combination with estrogen, a practice known to prevent endometrial cancer.) In both hormone therapy studies, women were randomly assigned to either the hormone medication being studied or to placebo. Those studies ended several years ago, and the women are now participating in a follow-up phase, which will last until 2010.

Estrogen plus Progestin Trial (stopped in July 2002)

Compared with women in the placebo those on estrogen plus progestin had:

  • Increased risk of heart attack
  • Increased risk of stroke
  • Increased risk of blood clots
  • Increased risk of breast cancer
  • Reduced risk of colorectal cancer
  • Fewer fractures
  • No protection against mild cognitive impairment and increased risk of dementia (study included only women 65 and older)
  • Increased risk of dying of lung cancer

Women’s Health Initiative Memory Study (stopped in May 2003)

  • Women taking hormones had twice the risk for developing dementia
  • Hormones provided no protection against mild cognitive impairment/memory loss

Estrogen-alone Trial (stopped in February 2004)

  • Estrogen increased risk for stroke
  • Estrogen decreased risk for hip fracture
  • No positive or negative effect on breast cancer

Compared to placebo women on estrogen alone had:

  • Increased risk of stroke
  • Increased risk of blood clots
  • Uncertain effect for breast cancer
  • No difference in risk for colorectal cancer
  • No difference in risk for heart attack
  • Reduced risk of fracture

Links to Research summaries of the Women’s Health Initiative studies  –

Estrogen Plus Progestin Trial: 2002

The Women’s Health Initiative Memory Study: 2005

The Estrogen-alone Trial: 2004

_______________________________________________

† Deep vein thrombosis refers to a blood clot deep inside the veins, usually in the legs.

‡ Symptoms include thinning and inflammation of the vaginal walls and changes in the vulva.

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

The National Center for Health Research is a nonprofit, nonpartisan research, education and advocacy organization that analyzes and explains the latest medical research and speaks out on policies and programs. We do not accept funding from pharmaceutical companies or medical device manufacturers. Find out how you can support us here.

References:

  1. Jin J. Hormone therapy for primary prevention of chronic conditions in postmenopausal women. JAMA. 2017;318(22):2265-.
  2. Writing Group for the Women’s Health Initiative Investigators, Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-33.
  3. Craig MC, Maki PM, Murphy DG. The Women’s Health Initiative Memory Study: findings and implications for treatment. The Lancet Neurology. 2005;4(3):190-4.
  4. Anderson GL, Limacher M, Assaf AR, Bassford T, Beresford SA, Black H, Bonds D, Brunner R, Brzyski R, Caan B, Chlebowski R. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial. JAMA. 2004;291(14):1701-12.
  5. Ravdin PM, Cronin KA, Howlader N, Berg CD, Chlebowski RT, Feuer EJ, Edwards BK, Berry DA. The decrease in breast-cancer incidence in 2003 in the United States. New England Journal of Medicine. 2007;356(16):1670-4.
  6. Katalinic A, Rawal R. Decline in breast cancer incidence after decrease in utilisation of hormone replacement therapy. Breast Cancer Research and Treatment. 2008;107(3):427-30.
  7. Colditz GA. Decline in breast cancer incidence due to removal of promoter: combination estrogen plus progestin. Breast Cancer Research. 2007;9(4):1-3.
  8. Poggio F, Del Mastro L, Bruzzone M, Ceppi M, Razeti MG, Fregatti P, Ruelle T, Pronzato P, Massarotti C, Franzoi MA, Lambertini M. Safety of systemic hormone replacement therapy in breast cancer survivors: a systematic review and meta-analysis. Breast Cancer Research and Treatment. 2021:1-7.
  9. Harman SM, Black DM, Naftolin F, Brinton EA, Budoff MJ, Cedars MI, Hopkins PN, Lobo RA, Manson JE, Merriam GR, Miller VM. Arterial imaging outcomes and cardiovascular risk factors in recently menopausal women: a randomized trial. Annals of Internal Medicine. 2014;161(4):249-60.
  10. Gleason CE, Dowling NM, Wharton W, Manson JE, Miller VM, Atwood CS, Brinton EA, Cedars MI, Lobo RA, Merriam GR, Neal-Perry G. Effects of hormone therapy on cognition and mood in recently postmenopausal women: findings from the randomized, controlled KEEPS–cognitive and affective study. PLoS Medicine. 2015;12(6):e1001833.

 

Nearly a Dozen Artificial Turf Fields in DC Failed Last Round of Safety Tests

In the News, News Stories & Editorials
Evan Lambert, Fox 5 News: September 18, 2017

A parents’ group known as Tireless DC tells FOX 5 that 11 artificial turf fields in the District have failed their most recent round of testing, leading to closures and replacements, and igniting another debate over the safety of synthetic turf.

D.C.’s Department of General Services (DGS) maintains and tests the 50 synthetic turf fields in the city. DGS did not make a list of the 11 failing fields available to FOX 5, but a task order from DGS shared with us shows the city is spending nearly $1 million to replace four turf fields at Janney, Eaton, Ross and Tubman elementary schools.

Tireless DC tells FOX 5 those schools are among the 11 fields that failed an annual test by DGS, which essentially measures how hard the fields are. A number under 200G is considered safe by some industry experts and that is the guideline DGS uses. […]

Janney Elementary School’s principal sent a letter to parents at the start of the school year letting them know the field failed a safety test and that it would be closed for replacement. The field is nearing completion, according to a DGS spokeswoman.

Parents expressed frustration over not learning of the test results sooner and the timing of the repair during the school year.

“The timing is really what was the biggest frustration because if it was known last spring, there was a lot of downtime during the summer, and at this point, it has impacted the practices,” said Janney Elementary School parent Christine Lucy.

Dr. Diana Zuckerman, president of the National Center for Health Research, expressed concern about the fact that the synthetic turf industry faces little government regulation.

“We really know very little about what is in artificial turf, but when studies have been done, they find a wide range of very toxic materials, including materials that can cause children to have attention deficit problems, can exacerbate asthma or obesity and can even in the long run cause cancer,” Dr. Zuckerman said.

In Montgomery County, seven artificial turf fields used by the school system are tested twice yearly by the manufacturers.

Read the original article here.

Question: I Have Been Diagnosed with Breast Cancer. What Are My Options so That I Can Still Have Breasts?

Breast Cancer

Q: I have been diagnosed with breast cancer. What are my options so that I can still have breasts?

A. We’re not doctors and we don’t provide medical advice, but I can tell you what we know based on research and from speaking with many experts and with women who have had breast implants. If you have been diagnosed with early stage breast cancer (stage I, IIa, IIb, or IIIa) , you probably can keep your breasts, and have a lumpectomy rather than a mastectomy (which removes the entire breast). Early-stage breast cancer patients who undergo a lumpectomy (which removes only the cancer and a small area around it) that is followed by radiation will live just as long as women who have a mastectomy instead.  In fact, the latest research indicates that women with early-stage breast cancer who have a lumpectomy live significantly longer than women of the same age and diagnosis who undergo mastectomy.

Experts recommend a lumpectomy with radiation for most women because it is less traumatic physically and emotionally, and avoids the problems from reconstructing a breast. For more information about this, see a booklet printed by the National Cancer Institute, the NIH, AHRQ, and the National Research Center for Women & Families here.

If you have been diagnosed with a pre-cancerous condition such as Stage 0 breast cancer, including ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS), it is very unlikely that you need a mastectomy. Women with LCIS do not have breast cancer and most will never get breast cancer. They do not need a mastectomy or even a lumpectomy, although they do need regular mammograms. Most women with DCIS can choose lumpectomy with radiation, rather than mastectomy. For more information, see our booklet here.

For women with breast cancer who want to have breasts, the preferred choice is usually to keep their breasts (rather than remove their breasts and create new ones). Although a lumpectomy can make the breast smaller or change the shape, it will still have the sensation of a natural breast. In contrast, a woman who has a mastectomy with reconstruction, either with implants or with tissue transferred from elsewhere in her body, will have “breast shapes” that do not have any feeling. They are numb. Reconstruction also requires at least two surgeries. Reconstructed breasts may look fuller or “younger” but when the options are explained to them, many women would prefer to have sensation in their breast (or breasts), and would prefer not to have to worry about complications and the need for additional surgery.

If a woman needs to have a mastectomy, because the DCIS has spread throughout the breast or the cancer is large, there are several choices for reconstruction: saline breast implants, silicone breast implants, and moving tissue to create a new breast, such as a TRAM flap (Transverse Rectus Abdominis Myocutaneous flap) or DIEP flap (Deep Inferior Epigastric Perforator flap).

Many plastic surgeons know how to reconstruct breasts using breast implants, but few are skilled at moving tissue (which is called autologous tissue transfer). That is one of the reasons why so many plastic surgeons recommend breast implants.

Saline or Silicone? Some surgeons prefer silicone gel breast implants to saline, because they feel more natural. However, saline breast implants are approved by the FDA as “reasonably safe” and silicone gel implants are not. That is why women getting silicone gel breast implants must agree to be in a study. The goal is to find out how many complications or problems arise in these women in order to decide whether they are safe enough to approve. You would be part of an experiment to find out if the implants are “safe enough” for other women.

One problem with silicone breast implants is that they can break without a patient knowing it. Although less embarrassing than an instant deflation (which is likely with saline), breakage without symptoms is a bad thing, not a good thing. If silicone gel breast implants break and leak, the silicone can get into lymph nodes and travel to the lungs, liver, and brain. No research has been done on those risks, but a study by scientists at the National Cancer Institute found that women with breast implants were twice as likely to die from brain cancer or lung cancer compared to other plastic surgery patients. More research is needed, but those findings are cause for concern.

If saline implants break they are usually easy to remove. If silicone implants break, they can leak and can be extremely difficult and expensive to remove carefully. For that reason, we believe that saline are safer than silicone, even though both have very high complication rates.

Risks. All breast implants, even saline implants, are enveloped in an outer shell made of silicone. The envelope also contains other chemicals and heavy metals, such as microscopic amounts of platinum or tin, which vary during the manufacturing process. Unfortunately, some women have a reaction to those substances. Although silicone is considered “biocompatible” and most people don’t have an immediate allergic or autoimmune response, some people do, and many more develop a response years later.

It’s impossible to predict who will have problems with breast implants, and who won’t. It’s important to know that all implants will eventually break, sometimes within a few months or years, and usually within 10 years. Sometimes women who have a mastectomy get breast implants to replace one breast and to make the other breast look more similar to the replaced breast. However, it’s important to know that either silicone or saline breast implants interfere with mammograms. They show up white on the film, hiding tumors that are above or below.

Alternatives to Implants. An alternative to breast implants is “autologous tissue transfer,” such as the TRAM flap and DIEP flap procedures. These procedures use a woman’s own fat and tissue is used to reconstruct the breast. Many women prefer it to implants because it feels more natural and apparently lasts for a very long time (possibly forever, although the procedure has mostly been done in the last 15 years so it’s impossible to say). However, both the TRAM flap and DIEP flap procedures are more expensive than implants, require an especially skilled surgeon for a good result, and the healing process usually takes at least several months and can be painful. Women are only able to get this surgery if they have enough body fat in their abdomen area or back to form breasts. And, like a breast implant reconstruction, the breast has no feeling. For a woman who has the tissue transferred from her abdomen area (in an operation that has been compared to a “tummy tuck”), there is some loss of muscle in that area. That can be a problem for athletic women, but many other women don’t mind.

The DIEP flap is a similar type of reconstruction but does not remove any muscle. Instead, for the DIEP flap, the surgeon only removes fat and other tissue and makes a small cut in the abdominal muscle. Since no part of the abdominal muscle is removed, patients are able to maintain abdominal strength, making this surgery a better option for most women, especially those who are physically active.

Fortunately, TRAM flaps and DIEP flaps are covered by some health insurance companies. These are complicated surgeries with long recovery times and you would need to find a physician who is very experienced doing these procedures, and we highly recommend asking the doctor to put you in touch with other patients who were happy with the reconstruction.

For examples of women who had less pain and other symptoms after their implants were removed, see the personal stories on our website at http://www.breastimplantinfo.org/personal-stories/. You also might want to check out www.explantation.com to hear from women who have had their implants removed and not replaced. Many felt healthier, happier, and more attractive afterwards.

We hope this information is helpful. For more information, check out http://www.breastimplantinfo.org/breast-reconstruction/surgical-alternatives/ or feel free to write to us at info@center4research.org / info@stopcancerfund.org

The comments and statements of the National Research Center for Women & Families are believed and intended to be accurate, and where applicable, based on scientific literature. NRC’s statements do not constitute medical diagnoses, medical advice, plans of treatment, or legal opinion, and we are not responsible for the use or application of this information. All medical information should be reviewed with your health care practitioner.

We hope that the information we’ve provided is helpful. In order to maintain this free service to all women and their families, we invite your tax-deductible contributions to NRC (see http://www.center4research.org/contribute/ )

Letter from NCHR about Dangerous Playgrounds and Athletic Fields to the Mayor and City Council of Washington, DC

Legislation, Policy
National Center for Health Research: July 19, 2017

Dear Mayor Bowser and Council Members,

I am writing as the president of the National Center for Health Research to express my strong concerns about the safety of the synthetic turf that the DC government has used and is continuing to use across the city, including installation that will soon be underway at Janney Elementary.

As a scientist who has worked on health policy issues for 30 years, I don’t shock easily. However, the fact that school athletic fields and playgrounds are exposing D.C. children on a daily basis to chemicals and materials that are known to increase obesity, cause early puberty, cause ADD and other attention problems, harbor deadly bacteria, and exacerbate asthma is very disturbing. Surely these are exactly the types of health problems that the DC government should be doing its best to reduce, not increase. Federal agencies are investigating the safety of these products – even during the Trump Administration – and yet neither District officials nor parents are being provided with accurate information about the products being used.

Whether natural grass or synthetic materials, all types of turf have risks and benefits. However, some materials are well known to have substantial risks. For example, DCPS is installing synthetic turf with Envirofill at Janney Elementary and possibly other schools, even though the Department of Parks and Recreation has already determined that product to be too unsafe to install at city parks. Envirofill was slated for installation at Friendship (Turtle) Park, but after local parents briefed DC officials about problems with the product on June 9th, the District revised its plans and did not install that material. Since children play on school fields five days a week, under the direction of their teachers, this is a particularly questionable decision on the part of DCPS, for safety reasons and in terms of legal liability. How does it make sense that a product is not safe enough for a public park but is safe enough for a school field or playground?

I don’t know if you are aware of the number of synthetic turf fields across the District that have been condemned because of failing safety tests. Gmax is a score that tests for hardness to determine if a surface is safe for playing. A Gmax over 200 is considered extremely dangerous and is considered by industry to pose a death risk. The synthetic turf industry and ASTM suggest that scores should be below 165 to ensure safety comparable to a grass field. It is my understanding that there are at least six fields in the city that are over the 200 level. That information should be made public to all parents, so that they understand why fields are closed and can protect their children’s safety. Since the Gmax score varies with the weather, synthetic fields should be tested at least quarterly, all scores should be posted publicly, and scores over 165 should have warning signs in order to prevent traumatic brain injuries.

This has not happened. For example, the Gmax score at Janney Elementary tested over 200 in June, and yet that information was not made public and the field was used by camp children all summer. Despite the repeated requests of concerned parents for the last few months, the field wasn’t closed until the day before school started last week. Parents were justifiably upset that the field was closed when school started, and some parents claimed to have been told by school staff that the Mayor’s office stated that the field would be closed all year and perhaps forever. It seems unlikely to me that the Mayor’s office would have said such a thing, but it resulted in ugly and unfair accusations. The many parents who were concerned about the safety of the synthetic field were bullied into silence, and a small number of parents who wanted the field available immediately erroneously claimed that all parents agreed that synthetic field was best.

As a result of that controversy, DC officials have recently stated that Envirofill will be used at Janney. Envirofill is basically a type of infill underneath a plastic carpet. It is composed of materials resembling plastic polymer pellets (similar in appearance to tic tacs) with silica inside. Silica is classified as a hazardous material according to OSHA regulations, and the American Academy of Pediatrics specifically recommends avoiding it on playgrounds. The manufacturers and vendors of these products claim that the silica is contained inside the plastic coating. However, sunlight and the grinding force from playing on the field breaks down the plastic coating. For that reason, even the product warranty admits that only 70% of the silica will remain encapsulated. The other 30% can be very harmful as children are exposed to it in the air; here’s a screen grab from a November 2016 Patriots vs. Seahawks game, which shows how the silica sand infill is kicked up when players dive on a synthetic surface with silica sand infill.

In addition, the Envirofill pellets are coated with an antibacterial called Microban, which is a trade name for triclosan. Triclosan is registered as a pesticide with the United States Environmental Protection Agency (EPA), and last year the FDA banned triclosan from soaps because manufacturers did not prove that that the ingredients are safe for long-term use, since it is associated with liver and inhalation toxicity and hormone disruption. In addition to microscopic particles of synthetic turf infill being inhaled by children, visible and invisible particles come off of the field, ending up in shoes, socks, pockets, and hair.

I have appreciated the opportunity to meet with several Councilmembers’ staff in the last few weeks, and I commend the Council for banning crumb rubber in FY 2018. Unfortunately, however, Envirofill, “poured in place” rubber (PIP), EPDM, and all the other synthetic materials currently on the market all share some of the same health risks. While the companies that sell these products claim they are safe and meet federal safety standards, the sad truth is that there are currently no federal safety tests required to prove that these products are safe, and as noted earlier, the Gmax safety tests have until recently been ignored by DC officials. Most important, none are proven to be as safe as natural grass in well-constructed fields such as the Maryland Soccerplex. Although a well-respected grass expert offered a free consultation on how to install well-engineered grass designed to withstand rain and play. DGS did not respond to his offer.

I am one of many parents and scientists in DC that are asking DC officials to provide essential safety information about the materials being used for fields and playgrounds. We are offering our expertise on these issues and would welcome the opportunity for public meetings so that parents across the city can be informed.

Sincerely,

Diana Zuckerman, Ph.D.
President
National Center for Health Research
1001 Connecticut Ave, NW, Suite 1100
Washington, DC 20036