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Reason to Fear, Reason to Hope
by Karen Matthee

We don’t need to know the statistics to understand that breast cancer is a major health threat to women. We all know one woman, if not a dozen, who has faced the disease. But with National Breast Cancer Awareness Month celebrating its 20th year, it’s time to be diligent about our own breast health, and to reflect on how far we’ve come and how far we need to go in detecting and curing breast cancer.

Facts and statistics about breast cancer are only effective if they motivate us to be more diligent about our efforts at early detection. It’s important to know, for example, that breast cancer is the second leading cause of death among women. Another underreported fact is that Washington state has the highest rate of breast cancer in the country. And Seattle leads U.S. cities in the number of breast cancer cases.

The latest figures available from the U.S. Centers for Disease Control and Prevention and the National Cancer Institute show “we are consistently above the national average,” according to Dr. Juliet VanEenwyk, state epidemiologist for noninfectious conditions. These numbers are based on incident reports for 1999 and 2000. State comparisons for the past three years have not yet been released.

VanEenwyk has studied the results closely, particularly those for 1999. “We had 500 excess cases over the national rate,” she says. Oregon came in second followed by Connecticut. Utah and New Mexico had the lowest rates of incidence, and many southern states had incidence rates below the national average. Rates were calculated based on information from state cancer registries. Visitors to this state for medical or other reasons were not included in Washington’s count.

Is there an explanation for our state’s high ranking? “The short answer is no,” says VanEenwyk. She says she has ruled out all the obvious reasons: It’s not a matter of collecting better data or doing more screening. Nor are hormone-replacement therapy and obesity – both shown to place women at risk for breast cancer – factors, VanEenwyk says. The type of breast cancer linked to hormone therapy, she notes, is not the type that accounts for the state’s higher incidence of breast cancer. And Washington’s rates for obesity are lower than the national average. Questions of race were also ruled out. Breast cancer occurs more in Caucasians than in African-Americans. When the study compared breast cancer rates among whites only, Washington still ranked higher.

“There are only two hypotheses that haven’t bitten the dust,” VanEenwyk says. One is that women in Washington tend to have their first children at an older age than women nationwide. Looking at data from 1970 on, VanEenwyk says, a pattern emerged: The numbers of women who had their first children between ages 15 and 24 were lower in Washington than in the nation as a whole. “We don’t want to encourage teenage pregnancy, but the literature indicates that earlier is better,” she says. According to the American Cancer Society, women who had their first child after age 30 have a higher risk of breast cancer.

First pregnancies later in life “probably does explain a portion of the excess, maybe 15 to 20 percent of it, but not 100 percent,” VanEenwyk adds.

The other possible explanation, she says, involves the role of vitamin D in helping to prevent breast cancer. Vitamin D is manufactured in the skin when it is exposed to sunlight, and research suggests it may protect against certain kinds of cancers by preventing the overproduction of cells. Early this year, British researchers announced they had discovered an enzyme in breast tissue that converts vitamin D into a cancer-fighting compound called calcitrol. It had been believed that this enzyme was only present in the kidneys. The researchers suggested women living in cloudy climates might not have enough vitamin D to combat breast cancer. Given the dangers of too much sun exposure, they said dietary intake might be improved by fortifying more foods with vitamin D.

However, the evidence linking vitamin D to breast cancer is inconclusive, says Dr. Julie Gralow, a medical oncologist specializing in breast cancer at the Seattle Cancer Care Alliance and the University of Washington. “It’s an interesting hypothesis, but it’s not confirmed at all.” Attempts to measure intake of vitamin D have been “far from perfect,” she adds. “It’s a renewed area of interest, but there are no [human] trials for breast cancer.”

“It’s clear there’s an association between vitamin D and breast cancer, although proving it is another thing,” says Dr. Michael Hunter, director of the cancer program at Evergreen Hospital Medical Center and a radiation oncologist at Virginia Mason Medical Center. “It really comes down to latitude. The top 33 states for breast cancer incidence are all northern states, everyone of them.”

While it’s not a good idea to forgo sunscreen for longer periods outdoors, 10 to 15 minutes a day without sunscreen is “allowable and probably safe,” says Hunter. He also recommends eating foods rich in vitamin D, including fish, cod liver oil, cheese, eggs and fortified breakfast cereals.

While Washington’s number-one ranking for breast cancer is cause for concern and further study, VanEenwyk says, there’s no need to panic. “At this point, making a public health recommendation is premature. We need more time to see if a recommendation is worthwhile. It takes resources and a pretty solid evidence base.”

On a more positive note, she notes that mortality rates for breast cancer are dropping across the country, and fewer women are dying from breast cancer in Washington state than in the nation as a whole. “Survival rates are very good.”

The Washington State Cancer Registry reports that in 2001, there were 5,577 women diagnosed with breast cancer and 756 women who died from the disease.

As Washingtonians, there are other reasons to feel hopeful about breast cancer. We have state-of-the-art screening and treatment facilities. We also have an excellent support network for women who are newly diagnosed and for breast cancer survivors. And local institutions such as the Fred Hutchinson Cancer Research Center and the University of Washington are researching better ways to prevent, diagnose, treat and cure breast cancer.

Risk and Prevention

It seems that what we know about breast cancer is constantly changing. We’re told certain things may increase our risk of cancer, only to discover later that those things might not be so bad after all – or the other way around. This can be frustrating. But that’s not necessarily bad, says Dr. J. David Beatty, who leads the breast cancer program at the Swedish Cancer Institute of Swedish Medical Center. “I don’t think we should apologize for changing information. As our understanding improves, new questions come up.”

What we know for sure is that it’s often a number of factors that put a person at risk for breast cancer – some of which we can control and some of which we cannot. Research has identified the following risk factors as important in the development of breast cancer.

Family History: Risk is higher among women whose close blood relatives had or have breast cancer. Some studies suggest the risk is even higher for women whose first-degree relatives (mother, sister, daughter) had cancer in both breasts or were diagnosed before menopause.

• Personal History: A woman with cancer in one breast has a three- to four-fold increased risk of developing new cancer in the other breast.

• Race: White women are more likely than black women to develop breast cancer, but recent research suggests that African-American women are more likely to be diagnosed at a more advanced and difficult-to-treat stage.

• Estrogen Exposure: A prolonged exposure to estrogen, either natural or synthetic, increases risk. Women with an early onset of menstruation, a late menopause, and no pregnancies or a first pregnancy after age 30 have a longer exposure to estrogen. Synthetic estrogens are found in oral contraceptives (although the increased risk is small) and are administered in hormone-replacement therapy. Long-term use of hormone-replacement therapy after menopause may increase breast cancer risk. And several large studies, including the Women’s Health Initiative, have found an increased risk related to the use of both estrogen and progesterone – combined hormone-replacement therapy.

• Obesity and Diet: Studies have shown that overweight women have a greater risk. A high-fat diet is considered a possible risk as well, as is regular consumption of alcohol.

• Exercise: Recent studies indicate that strenuous exercise while young and moderate to vigorous physical activity as an adult can protect against breast cancer.

• Age: Risk for breast cancer increases with age, peaks at about age 75, and declines again at 85.

For a thorough listing of risk factors for breast cancer, visit the American Cancer Society’s Web site at www.cancer.org.

While we can’t control factors like our genetics or, in many instances, when and if we have children, we can choose to eat healthier and exercise more. The link between exercise and breast cancer has been studied in depth by Dr. Anne McTiernan, a breast cancer specialist at the Fred Hutchinson Cancer Research Center and the author of Breast Fitness: An Optimal Exercise and Health Plan for Reducing Your Risk of Breast Cancer (St. Martin’s Press, 2000). She is also a professor at the University of Washington. McTiernan found that women who do regular, high-intensity exercise have a 30 percent lower risk of developing breast cancer than sedentary women.

In a recently completed study, McTiernan says, she found that overweight, postmenopausal women who engaged in aerobic exercise for 45 minutes, five days a week, lowered their blood estrogen levels when they lost body fat. A new study starting this month will explore the link between breast cancer and a low-calorie diet, as well as exercise. McTiernan says she hopes to recruit healthy, postmenopausal women who are overweight and have not had hormone-replacement therapy in the past six months. (For more information about the study, call 206-667-6444.)

Excessive body fat predisposes women to different types of reproductive system cancers because fat cells can produce estrogen, says Dr. Jane Guiltinan, dean of clinical affairs at the Bastyr Center for Natural Health. Diet and exercise do appear to reduce the risk of breast cancer, particularly a diet containing certain kinds of foods, she adds. Studies suggest, says Guiltinan, that a diet rich in beta-carotene, folic acid, olive oil, soy (during childhood or adolescence), lycopene (found in tomatoes) and vitamin B12 may reduce the risk of breast cancer. “Green tea seems to reduce the risk of breast cancer reoccurring,” she adds.

There is growing concern, Guiltinan notes, about the effects of xenoestrogens found in some plastics, pesticides, fuels and drugs. Naturally occurring xenoestrogens, such as those in broccoli and soy products, can protect against estrogen’s effects. But synthetic compounds can mimic the behavior of estrogen in the body and add to its impact.

We get exposed, Guiltinan says, by eating foods sprayed with certain pesticides and eating or drinking water out of heated plastic containers. “I tell our patients not to microwave food in plastic containers, and not to reuse water containers. If they get hot, plastic can begin to leach into the water.” Although research does not show a clear link between breast cancer and exposure to these environmental contaminants, “there’s enough anecdotal evidence out there to suggest we may have a problem with xenoestrogens,” Guiltinan says.

The risks associated with hormone-replacement therapy have been highly publicized, and as a result many women are looking for safer alternatives to help them cope with menopause. “There’s a whole lot of hoopla about Suzanne Somer’s book, The Sexy Years,” Guiltinan says. In it, Somers advocates the use of natural, bioidentical hormonal replacement, available through a variety of creams and supplements. Derived from plants and processed in labs, bioidentical hormones mimic the actions of human hormones.

“They’re identical to the estrogens our ovaries make,” Guiltinan says. “But I caution that any time you’re dealing with hormones, you need to be careful. I use them in the smallest doses for the shortest amount of time.” She advises patients that exercise helps relieve hot flashes and other menopausal symptoms, as do certain herbs such as black cohosh. Vitamin E, she adds, has been shown to help as well.

A non-natural substance – tamoxifen – has been used for more than 25 years to prevent and treat breast cancer. “It’s shown tremendous preventive value for people who are high-risk,” says Dr. Beatty of the Swedish Cancer Institute. Taken as a pill, tamoxifen battles breast cancer, in part, by disrupting the estrogen activity. As a treatment, the drug slows or stops the growth of cancer cells that are already present.

In the largest study on tamoxifen, sponsored by the National Cancer Institute, 13,000 women considered at high risk for breast cancer were assigned to take a pill each day for nearly five years. The pill contained either tamoxifen or a placebo, but the women weren’t told which pill they were taking. Among the women who took tamoxifen there were almost 50 percent fewer cases of breast cancer. Tamoxifen has not been studied in healthy women at average risk.

As with many drugs, there are also risks associated with taking tamoxifen. It can increase the risk for some cancers of the reproductive system, as well as blood clots in the lungs or major veins. Other possible side effects of the drug, such as vaginal dryness, fatigue and weight gain, are more easily treated. The American Cancer Society states that women with a history of blood clots, high blood pressure, smoking, obesity, and diabetes, and those who are pregnant, planning a pregnancy, breast feeding or taking hormone-replacement therapy, should not take tamoxifen to reduce breast cancer risk. The ACS also cautions that woman should discuss all benefits and risks with their physicians before deciding to take the drug.

Early Detection, Still the Best Defense

Because there is no guaranteed prevention against breast cancer, a woman can greatly increase her chances for survival by detecting the disease as early as possible. The ACS recommends that women 40 and older have a mammogram and a clinical breast exam every year and that younger women have a breast exam by a health professional every three years. Women should report immediately to their physician any changes they find in their breasts.

Recent research has cast doubt on the role of breast self-exams in helping to reduce the risk of dying from breast cancer. A major study, led by Dr. David Thomas of the Fred Hutchinson Cancer Research Center, involved 266,000 women factory workers from Shanghai, China, who were randomly assigned to a group training in breast self-examination, or BSE, or to a control group with no instruction. Women who underwent the intensive BSE instruction did not find their tumors when they were smaller or at a less-advanced state than women who did not receive instruction. After a decade or more of follow-up, women in the instruction group suffered no fewer deaths from breast cancer than women in the control group. Researchers also found that women who received breast self-exam training had more benign breast biopsies. Still, they did not discourage women from doing their own breast exams, particularly women who are high risk for breast cancer. But researchers did question the wisdom of spending funds earmarked for prevention on breast self-exam instruction programs.

Controversy also has arisen over the value of mammography in helping to save lives. Given that screening method’s less-than-perfect success rate, magnetic resonance imaging, or MRI, is gaining notice as a more sensitive screening technique for early detection of breast cancer. But Dr. Connie Lehman, a leading MRI expert and director of breast imaging at the University of Washington and the Seattle Cancer Care Alliance, says breast MR imaging should be used to complement mammography, not to replace it. Studies, including one conducted by Lehman, have shown that mammograms missed 50 percent of breast cancers detected by MRI scans. On the other hand, she says, “Mammograms catch cancers that MRIs cannot. It is still the best tool that we have to consistently catch breast cancer early.”

Lehman and other cancer specialists say breast MRI isn’t ready for widespread use. It’s expensive – around $2,000 – and sometimes yields false alarms that can lead to unnecessary biopsies or even mastectomies. Insurance companies are paying the bills only when physicians can show the patient is at greater risk for breast cancer. And so far, MRI studies for breast cancer have been done only with women who have a confirmed genetic mutation for breast cancer or a strong family history of the disease.

“It’s an excellent tool for harder-to-diagnose tumors and for people who have breast cancer and are looking at different forms of treatment,” says Beatty. “It’s good for further diagnosis, for determining how big a tumor is, for making sure there’s no others.”

He too feels breast MRI is not ready for use on the average-risk population. Beyond issues of cost and false positives, he believes the local medical community may not be up to the challenge. “There’s less than a handful of centers in Seattle that are really good and experienced,” Beatty says. “A number are starting to do breast MRIs, but the standard has not been achieved across the board. The technology is there, but we’re not at the point of disseminating it broadly.”

While it is not yet the magic bullet for early detection, Lehman is optimistic about the future of breast MRI. “I think we’re going to get better at identifying high-risk women and women at risk for cancers being missed by mammograms. I think the cost will come down.”

In the meantime, we who need mammograms can do better about making sure we get them. According to the most recent ACS report on cancer prevention and early detection, Washington state lags far behind other states for recent mammograms. In 2000, only 57.8 percent of Washington women ages 40 to 64 had had a mammogram within the past 12 months. That puts us in 42nd place. Compared to states like Delaware, where 75.8 percent of women had had recent mammograms, we are clearly behind in our efforts at early detection.

Beatty notes that mammograms work particularly well in older women – the age group most at risk for breast cancer – whose breasts are no longer stimulated by ovarian hormones because the tissue is less thick, and less glandular.

So our best defense right now, and something we can control ourselves, is to take charge of our own health, be our own advocate and meet with our physicians to discuss the best screening guidelines for each of us. While this may not help us avoid the disease, we know that catching it early can save lives.

©2004 Caliope Publishing Company