Category Archives: Breast Cancer

Summary of: Breast Implants, Self-Esteem, Quality of Life, and the Risk of Suicide

May 2, 2016Breast Cancer, Breast Cancer, In the News, New Cancer ResearchCPTFeditor

Diana Zuckerman, PhD, Women’s Health Issues: August, 2016

Breast augmentation is the most common cosmetic surgery in the United States, and many women are also encouraged to choose breast implants for reconstruction after a mastectomy. However, studies in the United States and Scandinavian countries have shown that suicide rates are higher for women with implants.

These studies raise a key question: Do implants increase the risk of suicide or do pre-existing mental health problems increase the likelihood of undergoing breast implant surgery and also increase suicide risk? And is the link between implants and suicide different for women undergoing reconstruction after a mastectomy than it is for women considering breast implants to augment the size of healthy breasts?

Several researchers and plastic surgeons have suggested that women undergoing breast augmentation tend to have lower self-esteem and that explains higher suicide rates. This article is the first to take a comprehensive look at implants and suicide, by considering information from studies measuring self-esteem, self-concept, mental health, and quality of life among women before and after getting breast implants for either augmentation or reconstruction.

Which Comes First: Breast Implants or Depression?

There are six studies that found that suicide rates are between two times and 12 times higher for augmentation patients than for similar women without breast implants, including other cosmetic surgery patients. There is one study that found that mastectomy patients were 10 times as likely to kill themselves if they have breast implants.

Suicide rates are relatively high for breast cancer patients, but this study shows that it is much higher for mastectomy patients with implants than for mastectomy patients without implants.

Research also shows that women who decide to get breast implants tend to have higher self-esteem than average women before getting breast implants and do not show any other signs of poor mental health. However, two years after getting breast implants, women tend to report feeling worse about themselves and to describe themselves as less healthy. Those results are similar whether the women are augmentation patients or reconstruction patients.

In other words, the confident women who get breast implants tend to be less confident and have a less positive self-image afterwards – except in terms of how they feel about their breasts. In addition, they are more likely to kill themselves. That is true whether they got implants for augmentation or for reconstruction after a mastectomy.

In conclusion, scientific evidence suggests that breast implants may have risks to mental health. Although suicide among women with implants is below 1% in every study, the rates ranging from 0.24% to 0.68% are significantly higher statistically and clinically than rates for comparable women without implants.

Many plastic surgeons tell patients that breast augmentation will make them feel better about themselves, and that reconstruction after a mastectomy will make women feel “whole” again. Instead, the research suggests that breast implants tend to have a negative impact on women, and that any women who feel depressed or have low self-esteem prior to getting breast implants should never be encouraged to get breast implants.

In order to understand the relationship between breast implants and suicide, studies are needed that provide appropriate mental health testing before surgery and years afterwards, with interviews used to ask the women themselves about their experiences with implants and how they feel about themselves and their lives.

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

January 30, 2016Breast Cancer, Prevention, Uncategorizedbreast cancer, breast implant, mammographyCPTFeditor

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, the U.S. Preventive Services Task Force recommends screening every two years for women ages 50-74 who have an average risk of breast cancer. Women at high risk because of family history, BRCA gene mutations, or other reasons should discuss a screening schedule with their doctor. But, what does this mean for women who have breast implants? Are women with breast implants faced with different risks when undergoing a mammography screening? 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.¹ 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.²

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.³,⁴

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.⁵ 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.⁶ 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.⁷ 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,⁸ 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.⁹, ¹⁰ 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.¹¹ 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, ¹² 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.

Why do mastectomy patients with breast implants commit suicide?

January 11, 2016Breast Cancer, Breast Cancer, CostCPTFeditor

Diana Zuckerman, PhD

Breast cancer patients often describe having a new appreciation for life. It is important for women and their friends and family members to know that women who have breast cancer have an increased likelihood of committing suicide for up to 15 years after their cancer diagnosis [1].

Even more surprising, one study among women who got breast implants after mastectomy found that their suicide rate was 10 times higher compared to other mastectomy patients [2]. More research is needed, but this study has received little attention. No other studies were conducted to learn more. However, it is important to note that all the women in the study had early-stage breast cancer – which experts agree does not require a mastectomy. In fact, the latest research on mastectomies indicates that women who undergo mastectomy do not live as long as women of the same age and diagnosis who undergo lumpectomy and radiation instead.

The Bottom Line

If mastectomy is not medically necessary, it is a bad choice since cancer patients who undergo mastectomy don’t live as long as lumpectomy patients and additionally, are more likely to commit suicide.

Sources

[1] Misono, S., Weiss, N.S., Fann, J.R., Redman, M., & Yueh, B. (2008). Incidence of suicide in persons with cancer. Journal of Clinical Oncology,26, 4731-4738. doi: 10.1200/JCO.2007.13.8941] [end Riihimäki, M., Thomsen, H., Brandt, A., Sundquist, J., & Hemminki, K. (2012). Death causes in breast cancer patients.Annals of Oncology, 23, 604-601. doi: 10.1093/annonc/mdr160

[2] Le, G.M., O’Malley, C.D., Glaser, S.L., Lynch, C.F., Stanford, J.L., Keegan, T.H.M., & West, D.W. (2005). Breast implants following mastectomy in women with early-stage breast cancer: Prevalence and impact on survival. Breast Cancer Research, 7, R184-R193. doi: 10.1186/bcr974

Can a handful of nuts a day keep cancer away?

December 10, 2015Breast Cancer, Colon Cancer, Diet, Habits, & Other Behaviors, Ovarian Cancer, Pancreatic Cancer, Preventionbreast cancer, diet, nuts, peanut butterCPTFeditor

By Krista Kleczewski, Claire Karlsson, and Edyth Dwyer

Evidence is growing about the many ways in which eating nuts, seeds, and legumes can improve your health. Eating walnuts or legumes like peanuts, beans, or lentils 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.

In addition to erroneously thinking that peanuts are nuts, many people think almonds, cashews, and pecans as nuts, but they are actually types of seeds. The difference is based on the plant they grow on, where peanuts grow underground below the plant roots, nuts and seeds grow inside or outside the plant’s fruit. Although this article uses the term “nuts,” the studies we describe include many combinations of nuts, seeds, and legumes. It’s also important to note that each study has different methods, and they need to be interpreted differently. Some studies looked at fewer than 100 people and closely tracked their diet and health, while others were meta-analyses that collected results from many studies of thousands of people and summarized their findings.

What are some health benefits of nuts?

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.[1] 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 serving of nuts is about the size of 30 almonds, and a study found that eating several servings a week had health benefits. 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.[2] Another study similarly found eating nuts – especially walnuts — reduces the risk of developing cancers, diabetes and heart disease when eaten as a part of the Mediterranean Diet, which also emphasizes fruits, vegetables, whole grains, and legumes.[3] 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.[4] The researchers compared the lifetime consumption of peanuts, walnuts and almonds among 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, legumes and seeds and those who ate none at all, suggesting that a person needs to consume a substantial amount of these over their lifetime to reduce their chances of developing breast cancer.

Another study looked at the risk of breast cancer for people who ate nuts and peanuts compared to people who did not. Some types of breast cancers respond to the body’s natural hormone estrogen, growing faster when exposed to estrogen. These are called Estrogen Receptor (ER) positive cancers. ER negative cancers are not influenced by exposure to estrogen. In a study of over 4,000 women in the Netherlands, those who ate 10 grams (a large handful) of nuts per day had a 45% lower risk of developing ER negative breast cancer when compared to those who ate no nuts, but it did not significantly affect ER positive breast cancer.[5,6] Since ER negative breast cancer occurs in only a third of the 12% of women who are diagnosed with breast cancer, the risk to the average person decreased overall by about half of 1% when their diet included that many nuts.

Girls who regularly eat nuts in their diet may be less likely to develop breast cancer as adults. A 2020 study of more than 9,000 girls between the ages of 9-15, and found that girls who regularly ate peanut butter or any kind of nuts were 36% less likely than girls who did not to have developed benign breast conditions when followed up with 10 years later. Although not dangerous, benign breast conditions (such as breast cysts or hyperplasia) increase a woman’s chances of eventually getting breast cancer. [7]

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.[8] The researchers reported in 2006 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.

A 2021 meta-analysis collected results from over 40 studies, and it examined whether eating more nuts would have an impact on colon cancer risk. Researchers found that eating 5 grams of nuts per day could decrease the risk of colon cancer by 25%.[9] Since the lifetime risk of colon cancer is about 4%, a 25% reduction would mean a decrease from 4% to 3% of the overall risk of colon cancer for people regularly eating nuts. Five grams is about 5-6 almonds, and this study found that the benefits of eating nuts started for people averaging just 2 grams per day and continued to decrease for people eating up to 9 grams per day. After that, the effects leveled off, so eating more than 9 grams was not more beneficial than eating 9 grams. A meta-analysis combines results from many studies, so the 2-9 grams per day were average amounts, whether the person eats them all in one day or spread out over the course of a week.

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.[10] 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.

Researchers have also investigated whether a diet containing nuts and peanuts can improve patient chances of survival for those who have already been diagnosed with colon cancer. In a study of over 800 patients with advanced (stage III) colon cancer, patients who ate more nuts were more likely to survive after treatment, without being re-diagnosed with colon cancer.[11] This study measured a serving of nuts to be one ounce, or about 15 cashews. When compared to those who ate no nuts, those who ate 2 or more servings of nuts per week had 46% lower risk of re-diagnosis of their cancer, as well as a 53% lower risk of dying from the cancer. This study has several important limitations to keep in mind. Not only was it a relatively small study, but it only examined Stage III colon cancer patients, comparing cancer patients who ate nuts to those who did not eat nuts. This means that the results cannot be generalized to the average American’s risk of colon cancer.

Pancreatic Cancer

Eating nuts also seems to lower the risk of developing diabetes, which may then lower the risk of developing pancreatic cancer.[12] In addition, a large study of women found that frequently eating nuts was associated with less chance of developing pancreatic cancer,13 one of the most deadly cancers.

A 2021 meta-analysis that examined results from over 30 studies, found that the chances of developing pancreatic cancer risk decreased for those who ate more nuts. The average lifetime risk of developing pancreatic cancer is about 1.5%. Because the results show a 6% lower risk for those eating nuts, this means the overall risk of pancreatic cancer may lower from 1.5% to 1.4% for people who regularly eat nuts.[9]

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.[15] 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.

What makes nuts good for your health?

There is still some debate about why nuts might be so beneficial. Omega-3 fatty acids are found in peanuts, walnuts, and some seeds, and researchers think their health benefits may help to prevent cancer.[16] The omega-3 acids can help protect cell structures and walls, and since they are anti-inflammatory; that might reduce the risk of cancer for people who regularly eat peanuts, walnuts, and seeds. [17]

Some research has shown that walnuts can also improve your gut biome, meaning it helps you grow healthy bacteria in your gut.[18] To test this, an experiment was done on 18 people, where some were assigned to eat walnuts and others ate no nuts. Blood and fecal samples were tested, and researchers were able to see changes in the bacteria, and lower levels of “secondary bile” which suggests the nuts decreased inflammation in their intestines. This experiment studied a very small group of people, so more research is needed to understand why these nuts, seeds, and legumes improve the risk of cancer over a lifetime.

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. Researchers are still investigating whether the health benefits of nuts are because people who eat nuts have a healthier overall diet, but tree nuts seem to have some health benefits on their own. Peanuts and peanut butter may also have benefits, but the higher levels of fat and sodium could explain why these legume products show fewer health benefits. Peanuts, walnuts, almonds, and other 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.

Brandt, P., & Schouten, L. Relationship of tree nut, peanut and peanut butter intake with total and cause-specific mortality: A cohort study and meta-analysis. (2015). International Journal of Epidemiology, 44(3), 1038-1049. doi:10.1093/ije/dyv039
Guasch-Ferré, M., Bulló, M., Martínez-González, M.A., Ros, E., Corella, D., et al. Frequency of nut consumption and mortality risk in the PREDIMED nutrition intervention trial. (2013). BMC Med; 11: 164. doi: 10.1186/1741-7015-11-164
Toner, CD., Communicating clinical research to reduce cancer risk through diet: Walnuts as a case example (2014). Nutr Res Pract. 8(4): 347–351. doi: 10.4162/nrp.2014.8.4.347
Soriano-Hernandez, A.D., Madrigal-Perez D.G., Galvan-Salazar H.R., Arreola-Cruz A., Briseño-Gomez L., Guzmán-Esquivel J., Dobrovinskaya O., Lara-Esqueda A., Rodríguez-Sanchez I.P., Baltazar-Rodriguez L.M., Espinoza-Gomez F., Martinez-Fierro M.L., de-Leon-Zaragoza L., Olmedo-Buenrostro B.A., Delgado-Enciso I. (2015). The Protective Effect of Peanut, Walnut, and Almond Consumption on the Development of Breast Cancer. 2015;80(2):89-92. doi: 10.1159/000369997.
van den Brandt P.A., Nieuwenhuis L. Tree nut, peanut, and peanut butter intake and risk of postmenopausal breast cancer: The Netherlands Cohort Study. Cancer Causes Control, (2018). 29(1):63–75.
Putti T.C., El-Rehim D.M.A., Rakha E.A., Paish C.E., Lee A.H.S., Pinder S.E., et al. Estrogen receptor-negative breast carcinomas: a review of morphology and immunophenotypical analysis. (2005). Mod Pathol, 18(1):26–35.
Berkey C.S., Tamimi R.M., Willett W.C., Rosner B., Hickey M., Toriola A.T., et al. Adolescent alcohol, nuts, and fiber: combined effects on benign breast disease risk in young women. (2020). NPJ Breast Cancer;6(1):61.
Yeh, C. C., You, S. L., Chen, C. J., & Sung, F. C. Peanut consumption and reduced risk of colorectal cancer in women: a prospective study in Taiwan. (2006). World Journal of Gastroenterology, 12(2), 222.
Naghshi, S., Sadeghian, M., Nasiri, M., Mobarak, S., Asadi, M., Sadeghi, O. Association of total nut, tree nut, peanut, and peanut butter consumption with cancer incidence and mortality: A comprehensive systematic review and dose-response meta-analysis of observational studies. (2021). Adv Nutr, 12(3):793–808.
Jenab, M., Ferrari, P., Slimani, N., Norat, T., Casagrande, C., Overad, K., Riboli, E. et al. Association of nut and seed intake with colorectal cancer risk in the European Prospective Investigation into Cancer and Nutrition. (2004). Cancer Epidemiology Biomarkers & Prevention, 13(10), 1595-1603.
Fadelu T., Zhang S., Niedzwiecki D., Ye X., Saltz L.B., Mayer R.J., et al. Nut consumption and survival in patients with stage III colon cancer: Results from CALGB 89803 (alliance). (2018). J Clin Oncol,36(11):1112–20.
Jenkins, D. J., Kendall, C. W., Banach, M. S., Srichaikul, K., Vidgen, E., Mitchell, S., Josse, R. G., et al. Nuts as a replacement for carbohydrates in the diabetic diet. (2011). Diabetes care, 34(8), 1706-1711.
Bao, Y., Hu, F. B., Giovannucci, E. L., Wolpin, B. M., Stampfer, M. J., Willett, W. C., & Fuchs, C. S. Nut consumption and risk of pancreatic cancer in women. (2013). British journal of cancer.
Lee J.T., Lai G.Y., Liao L.M., Subar A.F., Bertazzi P.A., Pesatori A.C., et al. Nut consumption and lung cancer risk: Results from two large observational studies. (2017). Cancer Epidemiol Biomarkers Prev,26(6):826–36.
Hedelin, M., Löf, M., Andersson, T. M. L., Adlercreutz, H., & Weiderpass, E. Dietary phytoestrogens and the risk of ovarian cancer in the women’s lifestyle and health cohort study. (2011). Cancer Epidemiology Biomarkers & Prevention, 20(2), 308-317.
Fabian C.J., Kimler BF, Hursting S.D.. Omega-3 fatty acids for breast cancer prevention and survivorship. (2015) Breast Cancer Res;17(1):62. https://breast-cancer-research.biomedcentral.com/articles/10.1186/s13058-015-0571-6
Freitas R.D.S., Campos M.M.. Protective effects of omega-3 fatty acids in cancer-related complications. (2019). Nutrients;11(5):945. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6566772/#:~:text=Omega%2D3%20polyunsaturated%20fatty%20acids,structure%20and%20fluidity%20of%20membranes
Holscher H.D., Guetterman H.M., Swanson K.S., An R., Matthan N.R., Lichtenstein A.H., et al. Walnut consumption alters the gastrointestinal Microbiota, microbially derived secondary bile acids, and health markers in healthy adults: A randomized controlled trial. (2018). J Nutr;148(6):861–7.

DCIS: Mostly good news

September 15, 2015Breast Cancer, Breast CancerCPTFeditor

By Diana Zuckerman, Ph.D.

Thanks to widespread use of and technical improvements to screening mammography, there has been a dramatic increase in women diagnosed with ductal carcinoma in situ (DCIS), which is also called Stage 0 breast cancer. DCIS accounts for 20-25% of new breast cancer cases diagnosed each year.¹³ The National Cancer Institute no longer refers to DCIS as breast cancer.

It’s important for doctors to do a better job of explaining DCIS to patients, because the number of cases of DCIS has increased by 750% over the last two decades. This has resulted in thousands of women being upset by a DCIS diagnosis that in many cases frightened them as much as a diagnosis of invasive breast cancer would have.

This epidemic is good news and bad news

The epidemic seems like good news because it means that a lesion that can cause breast cancer is being diagnosed very early, before it is life-threatening and before the radical treatments that women most dread (mastectomy and chemotherapy) are necessary. It is bad news because many women are not fully informed or do not clearly understand the difference between DCIS and invasive cancer, and as a result of their fear of cancer, many undergo mastectomies that are not medically necessary.

Standard treatment for DCIS is mastectomy or lumpectomy with radiation. Sometimes patients also have hormonal treatment. In most cases, lumpectomy with radiation is as safe and effective as mastectomy or bilateral mastectomy. And the latest research suggests that for most women, being treated for DCIS instead of waiting to be treated for breast cancer is not saving lives.¹⁴

A diagnosis of DCIS means that cancerous cells were found in the lining of the breast duct, and will not spread. The fact that DCIS can’t spread means that it is not harmful to patients. However, DCIS can change to Stage 1 breast cancer, which can spread and can be fatal. DCIS is much less dangerous than other breast cancers, but patients are frightened by a diagnosis of cancer, often resulting in over-treatment.

Is it necessary to have any kind of treatment for most types of DCIS? Some women choose not to get any treatment. That used to be considered risky because it was difficult to predict if DCIS would ever change to breast cancer or not. However, as experts have learned to diagnose the most risky types of DCIS, experts in the field are now encouraging some women to consider not undergoing treatment, or considering hormonal treatment instead of surgery.

Although early detection of breast cancer can save lives, DCIS is not life-threatening the way invasive breast cancer can be, and so the benefits of detecting it is controversial.

Unfortunately, many women diagnosed with DCIS undergo unnecessarily radical surgery and treatment. Over-treatment is expensive and can be harmful and debilitating to patients and their loved ones. And, when women diagnosed with DCIS undergo mastectomies just like women with later-stage breast cancer, it may discourage other women from having regular mammograms, since there seems to be no noticeable benefit to early diagnosis.

At a DCIS conference at the National Institutes of Health (NIH) in 2009, experts concluded that breast-conserving surgery is as safe and effective as mastectomy, although mastectomy is more likely to be recommended if the DCIS is in more than one location in the breast. Combining radiation therapy with lumpectomy helps prevent recurrence and the development of invasive breast cancer, and other hormonal treatment is sometimes used in combination with one of these surgical treatments. According to the NIH, the long-term disease-free survival of women treated for DCIS is between 96% and 98%. Despite the high survival rate, the NIH concluded that the “current diagnosis and treatment of DCIS have considerable emotional and physical impact for women diagnosed” making it important “for the medical community to consider eliminating the inclusion of the term ‘carcinoma’ in this disease, as DCIS is by definition not invasive—a classic hallmark of cancer.”

Research published in 2015 reported that the death rate for women with DCIS is very low – about 3% over the next 20 years after diagnosis, compared to about 1.5% for the general population of women.¹⁵ However, the risks are higher for black women with DCIS than for white women.

Low-income women with DCIS have been more likely to undergo mastectomy instead of breast-conserving surgery with radiation, compared to higher income women with the same diagnosis. One possible explanation for this is that mastectomy is less expensive than lumpectomy with radiation in the short-term. Treatment choices are often more influenced by the information a woman has about DCIS and her understanding or confusion regarding that information, rather than her actual diagnosis.¹⁶ Physicians’ recommendations are the most influential factor in a woman’s treatment choice.¹⁷

Tackling the DCIS Epidemic

The Cancer Prevention and Treatment Fund of the National Center for Health Research has worked on the forefront of patient education on this issue. We have also educated health professionals through a popular continuing medical education course. Several years before the NIH Consensus Conference, we received federal grants to convene two conferences at NIH for experts to discuss the most effective treatment options for early-stage breast cancer and DCIS, as well as how to improve patients’ understanding of their treatment options. The result of these meetings was a patient booklet for women with several different types of early-stage breast cancer, developed by our Center in partnership with the National Cancer Institute and NIH, and the NIH Consensus Conference on DCIS.

With support from the Jacob and Hilda Blaustein Foundation, we developed a free patient booklet for women with DCIS.

Prophylactic or optional mastectomies

May 28, 2015Breast Cancer, Breast Cancer, news-you-can-useCPTFeditor

Diana Zuckerman, PhD, and Brandel France de Bravo, MPH

Every year, thousands of women choose to undergo a mastectomy (surgery to remove the breast tissue) when lumpectomy (removal of only a small part of the breast) would be an equally effective option for them. Some women choose a bilateral mastectomy (removal of both breasts, also called a double mastectomy) when there is cancer in only one breast. Even women who do not have breast cancer may undergo mastectomies as a preventive measure because of their high risk of breast cancer, as was the situation with Angelina Jolie. If either one or two breasts without cancer are removed, the surgery is called a “prophylactic mastectomy.”

Helping patients make an informed decision about whether to have a mastectomy is an important aspect of the physician-patient relationship. Unfortunately, many patients are not able to get the information they need from their physicians. A patient who is seriously considering a mastectomy or bilateral mastectomy that is not medically necessary may be basing her decision more on fear than on information. They may benefit from unbiased information, counseling, or from a second opinion before making a final decision.

The purpose of this article is to provide information that patients and family members can use to help them discuss their options with their physicians.

Should I remove one breast or both?

Women in the U.S. who are diagnosed with early-stage breast cancer sometimes remove both breasts even if only one has cancer. However, new research indicates that having a healthy breast removed in addition to the breast with cancer increases the chances of medical complications. Even though removing a healthy breast lowers the risk of getting cancer in that breast in the future, 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.¹⁸ Hormone pills such as tamoxifen or aromatase inhibitors can further reduce that already low risk. In a study of more than 4,000 women, 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. Dr. Fahima Osman of the University of Toronto presented these findings at the 2013 meeting of the American Society of Breast Surgeons.¹⁹

What if I have a breast cancer gene (BRCA1 and BRCA2)?

Women with known mutations in the BRCA1 and BRCA2 genes have a lifetime risk of breast cancer ranging from 40% to 65% on average, compared to 12% for women in the general population. Women with BRCA1 or BRCA2 mutations often develop breast cancer before age 50 and have a high risk of bilateral breast cancer and ovarian cancer.²⁰ Removing breasts with no sign of cancer is called a prophylactic (preventive) mastectomy. Prophylactic mastectomy and prophylactic oophorectomy (removal of the ovaries) have both been shown to greatly reduce – but not eliminate – the risk of breast cancer in BRCA mutation carriers.³Among women with strong family histories of breast cancer, individuals of Ashkenazi Jewish descent have an 8 times greater frequency of carrying these mutations in BRCA1 or BRCA2 compared with other women.²¹

Lumpectomy with radiation therapy is just as effective for preventing same-breast tumor recurrence in breast cancer patients with BRCA mutations as it is for other women. Questions remain, however, about how other adjuvant treatments (such as chemotherapy) affect survival of women with these gene mutations.⁴

For women with the BRCA1 or BRCA2 genes, it is important to remember that the risk of breast cancer in the next 5 or 10 years is much lower than the lifetime risk of breast cancer. For example, the risk of breast cancer in her 20s is very low, even with BRCA1 (less than 3%) or BRCA2 (approximately 1%). For a 30-year old woman, the risk by age 39 is higher (10% for women with BRCA1 and 8% for BRCA2). For a 40-year-old woman, the risk by age 49 is 16% for women with BRCA1 and 13% for women with BRCA2.⁴ Although these 10-year risk levels are much higher than for most women, they are much lower than the life-time risk that is so frightening. It is also important to remember that cancer treatments and prevention strategies are improving, so the risks of cancer may decrease and the survival rates are improving.

Is there something I can do other than Prophylactic Mastectomies?

Prophylactic mastectomies can prevent breast cancer, but many women who undergo prophylactic mastectomies would never have developed breast cancer, even without the surgery. To make an informed decision about whether to undergo a prophylactic mastectomy, women need a clear understanding of the risks and benefits as well as other strategies that also reduce risk.

Tamoxifen and raloxifene have both been shown to reduce the risk of breast cancer for women who have not had cancer but are at greater risk. These drugs can also reduce the risk of breast cancer for women with BRCA1 or BRCA2 mutations.

For women at high risk of breast cancer for any reason, routine screening starting at a young age can be an alternative to prophylactic mastectomy. Options include clinical breast exams, mammograms, ultrasounds, and MRIs. MRIs are much more accurate than mammograms for young women and women with dense breast tissue, and avoid the additional risks associated with radiation — risks that should be avoided by women who already are susceptible to breast cancer. A 2012 study of women with BRCA1/2 mutations who were under 30 years old showed that the increased radiation they were exposed to from early, frequent mammograms increased their risk of breast cancer. Women with the most radiation exposure had the highest risk of breast cancer, compared to other women with the same gene mutations.²² Those risks can be avoided by replacing early mammograms with MRIs instead. However, it is important to note that MRIs used for screening tend to result in overtreatment, including unnecessary biopsies and mastectomies.²³

Research indicates that a low-fat diet, weight control, and exercise may reduce the risk of breast cancer for all women, including women at high risk and women who previously were treated for breast cancer.²⁴ ²⁵

Hormone replacement therapy and breast cancer

February 1, 2015Breast Cancer, Medical Treatments with Cancer RisksCPTFeditor

By 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

Research shows that, “replacing” the hormones women lose as they age is not only unnecessary, but it can bad for your health. The Women’s Health Initiative (WHI), sponsored by the National Institutes of Health (NIH), enrolled over 27,000 women in three different trials to study the effect of hormones on women’s bodies. 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 HRT use. ²⁶, ²⁷ This unexpected and unprecedented drop in breast cancer incidence suggests that HRT has a more dramatic impact on breast cancer risk than previously thought. ²⁸ 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 incidents 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. ²⁹ 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. ³⁰ 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.

To learn more about the debate about hormone therapy for menopause, click here.

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 Information

Estrogen Plus Progestin Trial: July 2002
The Women’s Health Initiative Memory Study: May 2003
The Estrogen-alone Trial: February 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.

Does abortion cause breast cancer?

January 26, 2015Breast Cancer, Medical Treatments with Cancer RisksCPTFeditor

No. Although there has been a great deal of controversy on this topic, scientists have agreed that abortion does not cause breast cancer.

The world’s leading experts, including epidemiologists, clinical researchers, and basic scientists, have discussed the scientific data on reproductive events in a woman’s life that could affect her risk of developing breast cancer. They evaluated the research that has been done on this topic and concluded that abortion and miscarriage do not increase a woman’s risk of breast cancer.

Breast cancer is related to reproductive experiences such as age of puberty and age of motherhood, and for years anti-abortion activists have cited research showing a link between abortion and breast cancer. That research has been quoted by some politicians as evidence that should be provided to women to discourage abortions. A workshop was held in 2003 (during the Bush Administration) at the National Cancer Institute (NCI) as a result of this controversy, and despite political pressures it concluded that the research linking breast cancer and abortion is flawed and not as credible as research indicating that there is no link between breast cancer and either abortion or miscarriage.

A medical journal article published in 2015³¹ evaluated 15 studies on this issue, which included 31,816 women with breast cancer from seven studies in the U.S., seven studies in Europe, and one in China, conducted between 1986 and 2013. The scientists only evaluated studies which used the most reliable research design (what is known as a “prospective study”) and concluded that the evidence does not show a link between cancer and abortion.

The fact that abortion does not increase the risk of breast cancer is also supported by, among others, the World Health Organization (WHO), the National Cancer Institute and the American Cancer Society, as well as many women’s health advocacy organizations, including the National Breast Cancer Coalition, the National Women’s Health Network and Our Bodies Ourselves.

For more information on the NCI workshop and early reproductive events and breast cancer, please see: http://cancer.gov/cancerinfo/ere.

Can wearing a bra cause breast cancer?

September 8, 2014Breast Cancer, PreventionCPTFeditor

Caroline Novas

There are several persistent email and internet rumors about potential causes of breast cancer. One is that wearing a bra, or wearing an underwire bra, causes the disease.

The idea that bras may cause cancer was fueled by the 1995 book called Dressed to Kill by Sydney Ross Singer and Soma Grismaijer. It claims that women who wear underwire bras for 12 hours a day have a much higher risk of developing breast cancer than women who do not wear bras.They maintain that bras restrict the lymph system, which results in a build-up of toxins in the breasts.³² However, according to the American Cancer Society, there is no evidence that compression of the lymph nodes by bras causes breast cancer; in reality, body fluids travel up and into the underarm lymph nodes, not towards the underwire.³³ Similarly, there is no sufficient evidence that any types of bras cause breast cancer.

In Dr. Susan Love’s Breast Book, Love claims that the hypothesis about bras causing cancer stems from our desire to have control over areas of life where we have a lot of uncertainty or fear. People want something to blame, and also hope that by avoiding bras they can avoid breast cancer.³⁴ While there are geographic variations in breast cancer rates, there are many, many factors, including diet, exercise, lifestyle, childbearing practices, as well as other behaviors and exposures that are more plausible explanations for these regional differences in breast cancer than bras. In places where people have less access to medical care, breast cancer will not be diagnosed as often, even though it might be present. And because the risk of breast cancer increases as women get older, breast cancer rates will be lower in parts of the world where people die of other causes at younger ages, whether they have worn bras or not.

Even if women who wear underwire bras are more likely to be diagnosed with breast cancer, a likely explanation would be that many women with larger breasts also tend to be heavier. Being overweight or having a lot of body fat puts a woman at increased risk for breast cancer.³⁵ It would make sense that women with larger breasts are both more likely to wear underwire bras and more likely to develop breast cancer. But this doesn’t mean that underwire bras cause breast cancer!

In a study published in 2014, researchers interviewed postmenopausal female participants about their lifetime bra wearing patterns. Evaluating more than 1,000 women with breast cancer and almost 500 who did not have breast cancer, the researchers found no evidence of a connection between the number of hours spent wearing a bra or wearing an underwire bra and increased breast cancer risk.³⁶

The bottom line: well-designed studies have not convinced experts that wearing bras or underwire bras increase your chances of developing breast cancer. Here are some factors that are associated with increased risk of breast cancer:³⁷

Risk factors you can’t control

Sex: Women represent 99% of all breast cancer patients and have a 12.1% chance of being diagnosed with breast cancer during their lifetime.
Age: The chances of getting breast cancer increase with age. About 65% of women are over 55 years old when they are diagnosed.
Race: After age 45, white women are more likely to get breast cancer than black women, but black women have a higher incidence before age 45 and are more likely to die from breast cancer.
Family history: Certain inherited gene mutations (BRCA1 and BRCA2) increase the risk of developing breast cancer. However, these genes account for only 5-10% of overall cases. Even without those genes, having a grandmother, mother, sister, or daughter diagnosed with breast or ovarian cancer increases the risk.
A previous history of breast cancer, abnormal breast cells (atypical hyperplasia) or certain non-invasive “pre-cancers” like lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS) increase the risk of developing invasive cancer.
Beginning menstruation early (before age 12) increases the risk of breast cancer by affecting the level of reproductive hormones a woman is exposed to during her lifetime.
Starting menopause late (after age 55) increases the risk of breast cancer.
Dense breast tissue (including fibrocystic breasts) increases the risk of breast cancer

Risk factors you can (possibly) control

Women who delay having their first child until later in life or who never have children are at a higher risk for breast cancer.In contrast, having children at a younger age and breastfeeding decrease the risk of developing breast cancer
Women who take hormonal therapy for menopause are at an increased risk for breast cancer.
Being overweight or obese increases the risk of postmenopausal breast cancer
Physical inactivity increases risk.
Women who drink an average of 2 alcoholic beverages per day increase their breast cancer risk by 21%. The more a woman drinks, the greater her risk.
High levels of radiation in the chest area before the age of 30 increase the risk.
Women who took DES during pregnancy (this drug was mainly used in the 40s, 50s, 60s, and 70s) are at an increased risk of breast cancer. The risk to their daughters is still being studied.
There is growing evidence that smoking and exposure to tobacco smoke probably increase breast cancer risk.
The use of oral contraceptives may slightly increase the risk of developing breast cancer. Some studies have found no increased risk from taking birth control pills and others have shown an increased risk.

If you are worried about your risk of breast cancer, you should discuss your concerns with a health care professional and find out about ways to cut your risk. Knowing the real risk factors and making healthy lifestyle choices can help you reduce your risks. Going braless won’t.

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

BRCA1 and BRCA2 mutations: when your genes increase your cancer risk

April 17, 2014Breast Cancer, Breast Cancer, Ovarian Cancer, PreventionCPTFeditor

Laurén A. Doamekpor, MPH

When Angelina Jolie announced that she had removed both of her healthy breasts to reduce her risk of breast cancer, she explained that she had inherited the BRCA1 gene mutation, which increases her chances of someday developing breast cancer. This is why she decided to have a preventive (or prophylactic) double mastectomy. Angelina’s public decision drew attention to women with BRCA1 and BRCA2 mutations and the choices they make. Click here to read our response to Angelina’s double mastectomy, published in the Huffington Post.

BRCA1 and BRCA2 gene mutations also increase a woman’s chances of having ovarian cancer. Ms. Jolie has not yet had her ovaries removed.

What are BRCA1 and BRCA2?

BRCA1 and BRCA2 are human genes that produce proteins that suppress tumors and repair damage to our DNA. If there is a mutation in one of these genes and they do not work properly, DNA damage may not be repaired. This can eventually cause cancer.

If you have a BRCA1 or BRCA2 mutation, what are the chances of getting breast or ovarian cancer?

Women who have no family history of breast cancer and don’t carry the BRCA1 or 2 gene mutation, have only a 12% chance of getting breast cancer in their lifetime.³⁸ But women with BRCA1 have about a 55% to 65% chance of developing it by the time they turn 70; the likelihood is a little lower for women with BRCA2 at 45%.³⁹ ⁴⁰

Even though women with BRCA1 or BRCA2 are about 5 times more likely to get breast cancer than the average woman, women with these mutations make up only 5% to 10% of all breast cancer cases. In other words, fewer than 1 in 10 women with breast cancer have either BRCA1 or BRCA2.⁴¹

Ovarian cancer is less common than breast cancer. Fewer than 2% of women who have neither BRCA1 or BRCA2, nor a family history of ovarian cancer, will develop ovarian cancer. But, 39% of women with BRCA1 will develop ovarian cancer by age 70, and approximately 11%-17% with BRCA2 will develop ovarian cancer by 70.² ³

Doctors will often suggest testing for the BRCA1 and BRCA2 genes in women with family members diagnosed with breast or ovarian cancer before age 50, family members with cancer in both breasts or multiple breast cancers, and women who come from Ashkenazi Jewish backgrounds.

If you have BRCA1 and BRCA2, what can you do to lower your risk for breast or ovarian cancer?

If you find out that you have the BRCA1 or BRCA2 mutation, it doesn’t mean you will definitely get breast or ovarian cancer.

There are a few ways you can lower your risk of breast cancer:

1) More frequent breast exams to detect cancer as early as possible. Some experts recommend that women with BRCA1 or BRCA2 begin breast cancer screening as early as age 25 ⁴, but that doesn’t mean mammograms should start at such an early age. Young women with BRCA mutations should get screened using magnetic resonance imaging (MRI). MRIs are more accurate than mammograms for young women and do not expose breasts to as much radiation as mammograms do. While early screening can be helpful, if a woman’s genes place her at higher risk, she needs to realize that regular radiation to the breasts at an early age could increase her risk of cancer.

2) Take an estrogen-blocking pill such as tamoxifen. Many breast cancers feed off the estrogen produced naturally by a woman’s body so interrupting the production and flow of estrogen can reduce a woman’s risk of getting breast cancer. Taking tamoxifen after being treated for breast cancer, for instance, usually cuts the risk of breast cancer recurring by about half. However, the effectiveness of raloxifene or tamoxifen in women with BRCA1 and BRCA2 has not been studied specifically yet. ⁴

3) Preventive mastectomy (removal of the breasts). When a woman with BRCA1 or BRCA2 gets both of her breasts surgically removed, she reduces her chances of getting breast cancer by as much as 95%.⁴² Why is there still some risk? Because some breast tissue is left behind after surgery, and cancer can develop in that tissue or on the nearby chest wall.⁴³

4) The removal of both ovaries and the fallopian tubes, called salpingo-oophorectomy. The ovaries produce estrogen which make the more common breast cancers more likely to grow, so removing the ovaries and fallopian tubes works much like tamoxifen. Research shows that women with BRCA1 or BRCA2 can reduce their breast cancer risk up to 50% by removing just their ovaries. ⁵ Removing the ovaries and fallopian tubes is the only known method of reducing the risk of ovarian cancer.

What about having children? While having children reduces the chances of developing the most common types of breast cancer, research published in 2014 found that women with BRCA1 or BRCA2 mutations who decide not to have children are no more likely to develop breast cancer than women with the mutations who do have children. For women with BRCA1 who want to have children, it’s helpful to know waiting until after 30 to have a child and breastfeeding longer—for at least 1-2 years—seems to lower their risk of breast cancer. Delayed childbearing and longer breastfeeding did nothing to lower breast cancer risk among women with BRCA2, however.⁴⁴

Maintaining a healthy weight and exercising regularly can reduce the chances of breast and ovarian cancer. For women with BRCA1 or BRCA2, some studies show that women who were overweight (BMI>25) at age 18 and lose at least 10 lbs between age 18 and 30 are less likely to develop early-onset breast cancers.⁴⁵

What women with BRCA 1 and BRCA2 can do to reduce their risk of ovarian cancer

Other than getting a salpingo—oophorectomy (removing the ovaries and fallopian tubes), which can reduce a woman’s risk of ovarian cancer by 90% ⁴⁶, there is little else a woman with BRCA mutations can do to lower her risk of ovarian cancer. Even after having her ovaries removed, a woman with BRCA mutations will still have a small chance of getting ovarian cancer in the peritoneum (a thin layer of tissue that lines the inside of the abdomen). This can happen if some ovarian tissue is left behind after surgery or if ovarian cancer cells have already spread to that part of the body before surgery.⁴⁷

The drawback to getting your ovaries and fallopian tubes surgically removed is that you won’t be able to have children naturally and will have to adopt or use some form of assisted reproductive technology like IVF with frozen embryos or frozen eggs. Moreover, studies show that women who have had their ovaries removed are more likely to suffer heart disease, stroke, lung cancer, and depression or anxiety disorders. And the risk of these illnesses is higher the younger the woman is when her ovaries are taken out. Also, if a woman has her ovaries removed before going through menopause, the surgery will cause a sudden drop in estrogen and bring on early menopause.⁴⁸

There is no widely accepted screening to detect ovarian cancer early. In fact, the U.S Preventative Services Tasks Force recommends against yearly screenings for ovarian cancer in women except those with BRCA1, BRCA2 or a family history of ovarian cancer. Some medical groups recommend transvaginal ultrasound examinations and the CA-125 blood test. But research shows that these screening tools are not very accurate and do not reduce a woman’s chances of dying from ovarian cancer.

Bottom Line

For any woman—whether she is a BRCA carrier or not–maintaining a healthy weight and exercising regularly can reduce the chances of breast and ovarian cancer. You can learn more about ovarian cancer here and more about the risks and benefits of preventive mastectomies to reduce the risk of breast cancer here.

There are other ways women with BRCA1 or BRCA2 mutations can lower their risk of breast and ovarian cancer, such as screening to detect cancer early, surgery to remove breasts, ovaries, and fallopian tubes, estrogen-blocking drugs, and losing weight if they are overweight. While screening regularly for breast cancer with MRIs is safe, surgery and drugs have side effects and risks. Women with the BRCA mutations will want to consult with several different doctors to discuss what is important to them at each phase of their reproductive lives, and weigh the risks and benefits of each prevention strategy.