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Breast health: Your questions answered

Don't let doctors rush you. A deliberate approach to prevention and treatment is best

Published: October 2008

Anxiety about breast cancer can prompt many women to make rushed decisions about prevention and screening. For example, they might make drastic changes to their diet or opt for aggressive tests without adequately researching the pros and cons.

Even more disturbing are the quick decisions made by many of the estimated 240,000 American women diagnosed with breast cancer this year. Many had to choose between getting a mastectomy or lumpectomy, or had to select among various chemotherapy and radiation treatments. Women often make those decisions during their first visit to a cancer doctor, but that's usually too soon, contends Steven J. Katz, M.D., a professor of health management and policy at the University of Michigan. "Too often, it's a rush job," Katz says, adding that breast cancer is rarely "an imminent danger" that requires immediate treatment.

Here are the key questions about breast cancer prevention, screening, and treatment for which it's especially important to use a slow, deliberative approach to reach the right answer for you.

Prevention

Can dietary steps help prevent breast cancer?
Cutting back on alcohol, red meat, and fat, especially trans fats, are three possible steps. Even a drink or two a day of beer, hard liquor, or wine might slightly increase the risk, possibly by affecting estrogen levels, and two to five daily drinks raises the risk 1.5 times that of teetotalers. Cutting total fat intake to about 15 percent of total calories might also slightly lower breast-cancer risk, especially among high-risk women, according to a study from the National Cancer Institute.

Reducing trans fat, which comes mainly from partially hydrogenated vegetable oil, might be particularly important. European researchers collected blood samples from nearly 20,000 women, then followed them for up to seven years. Women with a high level of trans fat in their blood had up to twice the risk of those with a low level. To limit your intake, check food labels, especially on processed foods, for the trans-fat content.

Consuming more than five servings of red meat a week might also boost risk, according to a recent study that followed more than 90,000 women for 12 years. Women who did were 42 percent more likely to develop the most common kind of breast cancer than women who ate fewer than three servings.

Certain other foods may help ward off breast cancer. Cruciferous vegetables such as broccoli and cabbage, for example, are high in indoles, compounds that may protect against breast cancer by lowering levels of estrogen, a hormone that fuels many tumors. But the best bet is simply a balanced diet high in a variety of produce, lots of whole grains, and moderate amounts of fish.

What about soy products?
The evidence is contradictory. Soybeans contain estrogen-like compounds called isoflavones that, in animal studies at least, fuel the growth of cancer cells and reverse the inhibitory effects that drugs such as tamoxifen (Nolvadex and generic) have on that growth. Yet Asian women, who tend to consume lots of soy foods, have a lower incidence of breast cancer than do women in Western countries. On balance, it's probably safe for most women to consume soy products as long as they don't go overboard (no more than about 100 mg of isoflavones a day). But women who already have breast cancer or are at high risk for it should limit their consumption.

Can certain medications prevent breast cancer?
Yes, but the risks make it worthwhile only for very high-risk women. Researchers have long known that tamoxifen can cut the risk of breast cancer in half. And a manufacturer-funded study published in June found that the related drug raloxifene (Evista) is nearly as effective. Other research suggests it is slightly less likely to cause cataracts.

But rates of heart attacks and strokes remain unacceptably high for most people. Research suggests that the risk-benefit ratio is favorable for women younger than 50 whose five-year risk of breast cancer is at least 2.5 percent. In older women, the ratio generally favors only white women in their 50s with a five-year risk of at least 4.5 percent. One way to determine your five-year risk is with the National Cancer Institute's risk calculator, and discussing the results with your physician. But don't feel pressured into taking a drug. Everyone's tolerance for risk differs, so there's no right or wrong approach, even if the calculator indicates a possible benefit for you.

Screening

Is mammography worthwhile if I'm in my 40s?
While annual screening for women over age 50 clearly saves lives, the benefits for younger women are less clear. Young women are much less likely than older ones to develop the cancer.

And the greater density of their breasts makes it harder to spot tumors. As a result, mammography for them may produce less benefit. And that can make the test's risks-mainly false alarms and the anxiety and biopsies they trigger-more disturbing. On the other hand, breast cancer in younger women tends to be especially aggressive. The more breast-cancer risk factors you have the more sensible testing in your 40s becomes.

But most cancers occur in women with no known risk factors. If you're in that group, the decision boils down to how worried you are about breast cancer and how prepared you are for the possibility of a false-positive result.

Are manual exams worthwhile?
A July 2008 review found that breast self-exams have no overall benefit and make needless biopsies more likely. But that's probably because women don't perform the tests properly. Our consultants still say that women should be familiar with the terrain of their breasts and report any lumps or changes to their physician. Talk with your doctor about the proper timing and technique for the exams. Similarly, while there's little evidence backing up manual exams by doctors or nurses, a careful clinical exam by a skilled practitioner might catch some tumors missed by mammography.

Consider having it done before your mammogram so that the radiologist will be aware of suspicious areas.

Do I need other screening tests if I'm at high risk?
People at high risk of breast cancer should consider a breast MRI. Ultrasound screening, as it becomes increasingly available, might be the answer for women who are at somewhat lower risk as well as for those who can't undergo MRIs because they're too claustrophobic or too large to enter the machines, or because they can't have the test for medical reasons. Breast ultrasounds, combined with standard mammography, find 3 to 4 additional cancers per 1,000 women at intermediate risk, according to a recent study. But neither ultrasound nor MRI is appropriate for average-risk women, since they both increase the risk of a false-positive result.

Treatment

If I'm diagnosed with breast cancer, what should I do first?
Consider getting a second opinion, preferably from a cancer center that coordinates care using a team that includes surgeons, oncologists, radiologists, pathologists, and nurses. Consulting such specialists changed the original surgery recommendations for more than half of the breast-cancer patients in a recent study from the University of Michigan.

In several cases the team found that the original doctor failed to follow treatment guidelines and proposed overly aggressive surgery. For example, five patients advised to undergo a mastectomy could instead get a breast-conserving lumpectomy.

And 19 could have just one lymph node removed, at least initially, rather than several. Second opinions also disclosed problems missed by the first physician. In 43 women, radiologists spotted signs of tumors that required additional biopsies or imaging tests. In addition, the team found that two women who were originally told to undergo a lumpectomy could not tolerate the follow-up radiation, so a mastectomy was recommended instead. You're likely to find such a team at a large medical center, especially one affiliated with a medical school.

If the prognosis is particularly worrisome or the cancer doesn't respond to aggressive measures, consider modifying treatment to preserve your quality of life. A consult with a palliative-care specialist can help. Such professionals are trained to consider the patient's entire medical and personal situation and to focus on symptom management and pain relief along with curative treatments.

What does a diagnosis of ductal carcinoma in situ mean?
It's a relatively unaggressive form of breast cancer in which abnormal cells are confined within the walls of ducts in the breast and lack the ability to invade other parts of the body. Eventually, however, some of those lesions become invasive.

The problem is that doctors can't predict which DCIS will progress to invasive cancer, says Monica Morrow, M.D., chief of breast surgery at Memorial Sloan-Kettering Cancer Center in New York. So although some experts tentatively question the need for surgical removal, DCIS is currently treated very much like more clearly dangerous tumors. Most women opt for lumpectomies often followed by radiation.

But more aggressive care, including mastectomy and one of a new class of drugs called aromatase inhibitors, can be reasonable if you have extensive areas affected by DCIS.

Should I consider reconstructive surgery?
Yes, though surgeons who perform lumpectomy and mastectomy often don't discuss that option with their patients. Indeed, only about 17 percent of mastectomies, and even fewer lumpectomies, are followed by breast reconstruction.

If you choose it, try to schedule both surgeries on the same day. For mastectomies, surgeons can use silicone implants or tissue from other parts of your body. The so-called "TRAM flap" involves shifting skin, fat, and abdominal muscle into the chest area without removing them from the body. The "DIEP flap" transplants skin and fat, often from your stomach, and leaves the muscle intact.

But it is slightly riskier than the TRAM flap, and fewer centers offer it. Mastectomy that spares the nipple is also available, though keeping the nipple might allow cancer to recur. After lumpectomies, plastic surgeons say that they can enhance the appearance of the breast by rearranging its architecture or adding tissue. The key, they stress, is to make the changes before radiation creates further changes in the breast. Benefits from such reconstruction may be more than cosmetic. A recent survey of more than 600 women post-lumpectomy found that those with pronounced breast asymmetry were far likelier to have depressive symptoms than those with less asymmetry.


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