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Understanding Breast Cancer and Keeping it at bay

Breast cancer is a cancer of breast tissue. It is (after lung cancer) the second most fatal cancer in women, and the number of cases has significantly increased since the 1970s, a phenomenon partly blamed on modern lifestyles in the Western world. Because the breast is composed of identical tissues in males and females, breast cancer can also occur in males, but here the incidence is very low.

Types of breast cancer

• DCIS: Ductal Carcinoma in Situ
  
• LCIS: Lobular Carcinoma in Situ
  
• Invasive ductal carcinoma
  
• Invasive lobular carcinoma
  
• Inflammatory breast cancer
  
• Paget's disease
  

Understanding Breast Cancer Risk

All women are at risk for getting breast cancer. As you get older, your risk increases. Assuming you live to age 90, your risk of getting breast cancer over your lifetime is about 14%. That might sound scary, because it means that an average of about one out of every seven women will get breast cancer over a 90-year life span.

You can also look at it another way: A 14% risk means there's an 86% chance that you WON'T get breast cancer.

How Much Do Risk Factors and Preventive Factors Change Your Risk?

Knowing what factors can increase or decrease your risk for breast cancer is important. But you probably want to know just HOW MUCH those factors change your risk.

If you hear that a certain treatment can reduce your risk by 40%, what does that mean?

To understand what the numbers mean about YOUR risk for breast cancer, the key terms to know are relative risk and absolute risk.

Relative risk is the number that tells you how much something you do, such as taking a pill, can change your risk, compared to your risk without taking that pill. Relative risk can be expressed in percentages and in "hazard ratios." If you do nothing new, your hazard ratio is 1.0—this means that your risk doesn't change. If you do something and your risk decreases by half, or goes down to 0.5, then you are half as likely to have the risk. But if your risk goes up, from 1.0 to 1.88, then you are 88% more likely to encounter the risk. If your risk goes up to 3.0, then you have a threefold (300%) increased risk of having the problem.

Absolute risk is the size of your own risk. Absolute risk reduction is the number of percentage points by which your own risk changes if you do something, like taking a pill. The size of your absolute risk reduction depends on what your risk is to begin with.

Example of Risk Going Up for a Woman with No History of Breast Cancer

Smoking is associated with an increased risk of breast cancer as well as other diseases.

Suppose your risk of breast cancer is 14%. If you smoke, your risk goes up by 32% (about a third higher risk). That means your risk of breast cancer from smoking is 32% higher than the 14% risk if you don't smoke. That's the relative risk increase from smoking.

But how big a difference does a 32% increase really make for you? To figure out the change to your absolute risk, see what happens when you make your risk of 14% go up by a third:

• Multiply your risk of 14% by the relative risk increase of 32%. You get 4% (14% x 32% = 4.48%, or 4%). 4% is the size of the increase in risk.
• Add the 4% increase to the 14% risk you started out with, and you end up with 18% risk (14% + 4% = 18%),

That means your absolute risk for breast cancer is 18% if you have no history of the disease and you smoke.

Example of Risk Going Down for a Woman with Breast Cancer History

Suppose you have had breast cancer and had lumpectomy with clear margins (meaning no cancer was found between the tumor and the edge of the surrounding tissue that was removed along with it).

After lumpectomy with clear margins, your risk of the breast cancer coming back in the same breast is about 30%. But if you choose to have radiation therapy after your lumpectomy, you can reduce your risk of the cancer coming back by two-thirds or 66%. This is the relative risk decrease.

But how much of a difference does radiation's 66% drop really make? To figure out the change to your absolute risk, take two-thirds off your risk of 30%:

• Multiply your risk of the cancer coming back (30%) by the relative risk decrease from radiation therapy (66%), and you get a decrease of 20% (30% x 66% = 19.80% or 20%).
• To figure out your remaining risk of recurrence after radiation, subtract the 20% from the 30% risk of recurrence that you started out with (30% - 20% = 10%). So your absolute risk of the cancer coming back falls to 10% if you have radiation therapy.

Now, after lumpectomy and radiation, is there something else you can do to knock down the 10% risk further? You may also choose to take hormonal therapy (for example, tamoxifen or an aromatase inhibitor) for five years. Learn more about hormonal therapy choices. If you do that, you can reduce your risk by another 50%. By taking hormonal therapy for five years, you lower your relative risk of the cancer coming back in the same breast by half or 50%. To see how big a difference hormonal therapy makes in your absolute risk, take half off your risk:

• Multiply your risk by the relative risk decrease from tamoxifen (10% x 50% = 5%).
• Then subtract that 5% from your risk (10%–5% = 5%).

Now your absolute risk of the cancer coming back is 5%. So by having radiation therapy and taking hormonal therapy for five years, you have reduced your risk of the breast cancer recurring from 30% to 5%.

Knowing how much your breast cancer risk changes with lifestyle changes and treatment options can help you and your doctor make the best decisions for YOU.

Genetics and Breast Cancer Risk

• To date, most inherited cases of breast cancer have been associated with two genes: BRCA1, which stands for BReast CAncer gene one, and BRCA2, or BReast CAncer gene two. Get more information about genetic abnormities and breast cancer.
• The function of these genes is to keep breast cells growing normally and to prevent any cancer cell growth. But when these genes contain abnormalities, or mutations, they are associated with an increased breast cancer risk. Abnormal BRCA1 and BRCA2 genes may account for up to 10% of all breast cancers.
• Women diagnosed with breast cancer who have an abnormal BRCA1 or BRCA2 gene often have a family history of breast cancer, ovarian cancer, or both. But it's also important to remember that most women with breast cancer have no family history of the disease.
• Identifying BRCA1 and BRCA2 has led to new techniques for lowering detecting and treating breast cancer and lowering the risk for the disease. For women who wish to be tested, we can now establish whether the two genes are normal or not.
• But there's still a lot more to learn about these genes. And other genes probably also play a role in the development of breast cancer, for women both with and without a family history of the disease.

Environmental Factors and Breast Cancer Risk

• The world that surrounds us; including the air we breathe, the food we eat, and the water we drink; is full of toxins. Many of these toxins are known carcinogens (they cause cancer), and the vast majority have never been studied for their effects on humans.
• While many argue that all of this exposure to toxins is sure to increase our risk for breast cancer and many other diseases, it is important to find scientific evidence to back up what seems like common sense.

Lowering Risk For Everyone

• Every woman wants to know what she can do to lower her risk of developing breast cancer. If you have no personal history of the disease, you want to do what you can to stay clear of it. And if you have had breast cancer, you never want to get it again. You want to know how to lower your risk of the cancer coming back, and you want to reduce your risk of getting an unrelated new breast cancer.
• The best defense against breast cancer is a good offense. There are no perfect solutions, but you can do many things to reduce your risk.
• Regular screening tests for breast cancer, such as an annual mammogram and a breast exam during your annual checkup, allow you and your doctor to ensure that your breasts are as healthy as they can be. Screening also increases the likelihood that your doctor will find breast cancer early, when it's most treatable.

Risk Factors You Can Control

Many factors might affect your risk for breast cancer and other diseases. You may be able to control and modify some of these, including:

• what you eat
• how much you weigh, and maintaining a healthy weight
• how much you exercise
• whether you smoke
• whether you drink alcohol and if so, how much and how frequently
• the types of chemicals in your environment, and
• whether you took hormone replacement therapy (HRT) for menopausal symptoms for five years or longer

Making these changes in your life can be quite difficult. But it becomes easier to make these changes when you understand each factor, the importance of the changes, and practical ways to make the changes. And when it comes to the factors that can't be controlled, we'll help you work around them.

Risk Factors You Can't Control

Some of the factors that increase your risk for getting breast cancer are things you can't control:

• Age: Just as with many other diseases, the chance of getting breast cancer goes up as you get older. Your average risk of getting breast cancer over your lifetime is 1 in 7, assuming you live to age 90. But each 20 or so years of your life is associated with a different level of risk:
• From birth to age 39, your risk is 1 in 229.
• From age 40 to 59, your risk is 1 in 24.
• From age 60 to 79, your risk is 1 in 13.

The 1 in 7 statistic comes from averaging all the different risk levels. So the overall risk will always be higher than the risk associated with any one age bracket.

• Personal history of breast cancer: If you have had breast cancer already, you are at risk of it coming back. That risk might be low or high, depending on your situation. And you are at higher risk of getting a NEW breast cancer compared to someone else who has never had the disease.
• Family history: Breast cancer in your family can have a significant impact on your risk. But this doesn't ALWAYS mean that you are at high risk just because someone in your family had breast cancer. For example, if your grandmother was diagnosed with breast cancer at age 75, this may not increase your risk of the disease. Your grandmother was most likely just 1 of the 13 women who gets breast cancer between the ages of 60 and 79.
• Certain breast changes: Normal breast cells can sometimes get overexcited and start to misbehave. These changes can show up as a lump, thickness, or calcifications on a mammogram. If a biopsy is done, these changes can be seen under a microscope. When the breast duct cells are overactive and appear unusual, the pathology report may describe these findings with the term atypical ductal hyperplasia. An uncontrolled growth of breast cells in the lobule (the part of the breast that makes milk) is called lobular carcinoma in situ or LCIS. (Even though the word “carcinoma” is part of the term LCIS, it is not considered a true cancer.). These two types of breast changes are associated with an increased risk of breast cancer in the future. But these abnormalities are not themselves cancerous.
• Genetic alterations: To date, most inherited cases of breast cancer have been associated with two genes: BRCA1, which stands for BReast CAncer gene one, and BRCA2, or BReast CAncer gene two. The function of these genes is to keep breast cells growing normally and to prevent any cancer cell growth. But when these genes contain abnormalities, or mutations, they are associated with an increased breast cancer risk. Abnormal BRCA1 and BRCA2 genes may account for up to 10% of all breast cancers. Women diagnosed with breast cancer who have an abnormal BRCA1 or BRCA2 gene often have a family history of breast cancer, ovarian cancer, or both. There are also women with a strong family history of breast cancer who might have another kind of genetic abnormality that's not yet been identified. But it's also important to remember that most women with breast cancer have no significant family history of the disease.
• Menstrual history: You have no control over the amount of estrogen that your ovaries produce over time. If you were very young when you got your first period, or you had a late menopause, or both, you have had more years of exposure to estrogen and other hormones produced by your ovaries. Women who had their first period before they were 12 years old or went through menopause after 55 have a higher risk of breast cancer than women with fewer years of exposure to hormones made by the ovaries.
• Race: Breast cancer in the United States occurs more often in white women than Latina, Asian, or African American women. But in women 40 and younger, African American women have the highest risk.
• Radiation therapy to the chest before you were 30 years old: If you had radiation therapy to your chest before you were 30 years old and particularly during adolescence, you may have a higher risk of developing breast cancer. This has been seen in young women receiving radiation to treat Hodgkin's disease. (This does NOT include radiation therapy to treat breast cancer.)
• Breast density: Past research has shown that women with “dense” breasts, which contain more glandular and connective tissue, are more likely to be diagnosed with breast cancer than women whose breasts are less dense (mainly made up of fat tissue). Breast cancer itself is dense and starts from glandular tissue. Estrogen makes breast tissue more dense. So the connection between breast density and breast cancer may be related to higher levels of estrogen in the body. On a mammogram, a cancer is harder to spot in dense tissue than in fatty tissue. That's because the cancer looks a lot like the glandular tissue around it.
• Exposure to DES (diethylstilbestrol): DES is an estrogen-like hormone used in the past to help women prevent miscarriage. Daughters of women who used DES have an increased risk of cancer of the vagina. This drug may also increase the risk of breast cancer in women who used it and in their daughters who were also exposed to it.
• Late pregnancy or no pregnancy: Women who had their first full-term pregnancy after age 30 and women who never had a full-term pregnancy are at higher risk for breast cancer than those who gave birth earlier in life. A full-term pregnancy, which stops your menstrual cycle for nine months, seems to offer protection against breast cancer.

If you weigh uncontrollable factors against those that CAN be changed, you'll see that you can do a lot to lower your risk of breast cancer. And while it's very hard to pin down specific foods or chemicals that are firmly linked to a higher or lower risk of breast cancer, researchers are working hard to find out whatever they can about specific lifestyle and environmental factors that may be within your control.

Changes You Can Make to Lower Your Risk

Making the following changes in your life will improve your overall health and also MAY SIGNIFICANTLY REDUCE your risk for breast cancer.

• Stop smoking. You should use every resource you can find to help you quit smoking—for good! Research shows that smoking causes many diseases, and it is associated with an increased risk of developing breast cancer. Smoking can also increase complications from breast cancer treatment. It can worsen radiation damage to the lung, cause difficulty healing after surgery, and increase risk of blood clots with hormonal therapy. But even knowing about all of the dangers isn't always enough to make you quit. Smoking is a habit that's very hard to break.
  • Medications to help you quit can be taken as a pill, chewed as gum, or worn as a patch on the skin.
  • Acupuncture and meditation can also help.
  • It's also easier if you have a friend or “buddy” who can either stop with you or cheer you on when you're feeling you can't make it on your own.
• Get more exercise. Exercise has many healthy benefits. Research has shown that four hours of exercise a week may lower the risk of breast cancer. Over time, exercise may be able to lower the estrogen levels in your body. With less estrogen around, there is less stimulation of breast cell growth, which is associated with a lower risk of breast cancer. Other research on exercise and breast cancer has found that exercise also can help boost the immune system, limit weight gain from chemotherapy, and help ease treatment side effects.
• Maintain a healthy weight. Overweight women have an increased risk of getting breast cancer after menopause. And being overweight can increase the risk of breast cancer coming back in women who have had the disease. There are probably several reasons that being overweight is associated with an increased risk of breast cancer. Extra fat cells make extra estrogen that might stimulate breast cell growth. Plus, overweight women tend to exercise less and eat higher-fat foods. Regular exercise can reduce fat in the body and help with weight loss. As we age, it's harder to keep weight under control because our metabolism slows down and we tend to get less exercise. But if you can stick to a low-fat, low-calorie diet and stay physically active, weight is much easier to control. Our Ask-the-Expert Online Conference from January 2005 has some good general tips on losing weight.
• Reduce your exposure to estrogen. Prolonged exposure to estrogen without a break can increase your risk for breast cancer. To reduce or eliminate sources of extra estrogen from your diet and environment, try the following steps:
• Shed any extra pounds, and try to keep those pounds off. Extra fat cells make extra estrogen. At a healthy weight, estrogen levels tend to be lower.
• If you have already had breast cancer, avoid taking estrogen-like and progesterone-like products such as menopausal hormone replacement therapy (HRT) and DHEA (dehydroepiandrosterone). So far the increased risk of breast cancer is most closely associated with the combination of estrogen and progesterone pills. Little is known about the relative safety of vaginal creams, gels, rings (such as Estring), “natural” hormones, and herbal hormone-like remedies. Your doctor may prescribe vaginal hormones to help with vaginal dryness and discomfort. Hormone preparations used in the vagina mostly stay in the vagina. But some of these hormones can be absorbed into your bloodstream and get to your breasts. Blood levels of estrogen depend on the dose, frequency of use, the type of estrogen preparation, and your body's ability to absorb the hormone. If you decide to use estrogen with your doctor's advice, try to use the lowest dose possible.
• Limit alcohol use. You may choose to stop drinking alcohol completely. But if you enjoy alcoholic beverages and plan to continue using them, try to have fewer than five alcoholic drinks a week. Significant alcohol use is unhealthy for your liver, which helps regulate estrogen levels in your system. So limiting your alcohol use helps your liver keep blood estrogen levels low.
• Restrict sources of red meat and other animal fats (including dairy fat in cheese, milk, and ice cream), because they may contain hormones, other growth factors, antibiotics, and pesticides. Some researchers believe that eating too much cholesterol and other fats are risk factors for cancer.
• If circumstances allow, consider having children sooner rather than later in life. A full-term pregnancy, which stops your menstrual cycle for nine months, seems to offer protection against breast cancer. Pregnancy produces a blend of several hormones that forces breast cells to “grow up” and learn how to make milk. When breast cells mature and have a job to do, they have less time to act out and cause problems—like starting a cancer. Estrogen is in the mix of the hormonal blend, but the other hormones seem to balance out its effects.
• Learn about good nutrition and start eating for good health. Everything your body does—from healing a wound to fighting cancer cells—is affected by what you eat. Bad nutrition seriously hampers your body's ability to function in top form. Good nutrition increases general wellness.
• Eat your fruits and vegetables! Researchers disagree on whether certain vegetables or fruits reduce risk for breast cancer. One report that combined many dietary studies showed no clear decrease in risk of breast cancer from diets high in vegetables and fruits. But a diet full of produce can help you lose weight or maintain a good weight. So through this indirect result, this type of diet may also be able to help lower breast cancer risk.
• Here are some easy ways to make sure you get at least five servings of vegetables and fruit in a day (nine is better):
  • Add chopped squash and carrots to jarred or fresh spaghetti sauce (serve on pasta for a great dinner).
  • Eat tomatoes, tomatoes, tomatoes—raw in salad, sandwiches, salsa, juice, alone (like a piece of fruit), cooked in sauces.
  • Eat whole fruit rather than drink juice, to reduce calories, add fiber, and increase feelings of fullness.
  • Snack on baby carrots and celery (keep a cooler of them in the car).
  • Throw handfuls of spinach into stews and soups
  • Add shredded lettuce to potato salad.
  • Add broccoli, tomatoes, or zucchini to scrambled eggs or omelets.
  • Freeze grapes and berries in single-serving containers for a cool treat during summer months.
• Relax. Anything you can do to reduce your stress and to enhance your comfort, joy, and satisfaction will have a major effect on your quality of life. So-called “mindful measures” (such as meditation, yoga, visualization exercises, and prayer) may be valuable additions to your daily or weekly routine. Intriguing new studies suggest that these fundamental but non-traditional interventions may strengthen the immune system. And if your immune system is strong, it's better able to fight disease. For example, improved immune cell function has been documented after people with melanoma, a malignant skin cancer, attended regular support group meetings. Another study found that women in breast cancer support groups had a better quality of life and more immune cells in the blood than those who don't join such groups. The power of support goes a long way to reduce stress and make people feel connected—not alone—in their fight against cancer.

Lowering Risk for People at High Risk

• If you have a family history of breast cancer, on either your mother's or father's side, you might have a higher risk for developing breast cancer during your lifetime. The most significant family history is if women in your family were diagnosed with breast cancer before the age of 50, if they had breast cancer in both breasts, and if anyone also had ovarian cancer.
• But having a family history of breast cancer doesn't ALWAYS mean that your risk is increased. For example, if your grandmother was diagnosed with breast cancer at age 75, your risk of the disease is probably not increased. Your grandmother was most likely just one of the women who gets breast cancer in advanced age. Breast cancer risk increases as you get older.

Genetics

• Some women with a strong family history of breast cancer have inherited a specific gene abnormality that increases their risk for the disease. The BReast CAncer 1 (BRCA1) and BReast CAncer 2 (BRCA2) gene abnormalities are the most common types that are linked to a high risk for breast cancer (as well as ovarian cancer). However, BRCA1 and BRCA2 abnormalities only account for up to 10% of all breast cancers and 7% of ovarian cancers. There are other, lesser-known genetic abnormalities in some families, with less common cancer syndromes.
• Women who have an abnormal BRCA1 or BRCA2 gene have a 50–85% risk of breast cancer by the age of 70. And their lifetime risk for ovarian cancer is also increased: to 40–60% for women with BRCA1 mutations and to about 25% for women with BRCA2 mutations.
• Not all inherited forms of breast cancer are due to abnormal BRCA1 or BRCA2 genes. The CHEK2 gene may play a role in the development of some breast cancers. Having an abnormal CHEK2 gene may double a woman's risk of getting breast cancer—from the average 14% lifetime risk to about 28%. Some women may have an abnormal BRCA1 or BRCA2 gene AND an abnormal CHEK2 gene. In that case the abnormal CHEK2 gene does not further increase the risk of getting breast cancer because it is part of the same cell mechanism.

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