Understanding Breast Cancer Risk

All women are at risk for breast cancer -- and most of us think our risk is higher than it actually is.

The commonly cited statistic – that women have a 1 in 8 lifetime risk of breast cancer – is a bit misleading because 1 in 8 women in the United States do not actually get breast cancer. The 1 in 8 number is an estimate of lifetime risk. A woman with average risk has a 1 in 8 chance of getting breast cancer sometime during her life if she lives to be 90. Some women are less likely to get breast cancer, and some have a greater risk. Some will not live to be 90.

A more meaningful way to look at risk is the chance of getting breast cancer during each decade of life. A woman in her twenties has a 1 in 1,837 (0.05%) risk of getting breast cancer, and her risk increases as she ages to a maximum in her seventies of 1 in 26 (3.88%). If you add up the percentages for each decade, you get 13% lifetime risk (1 in 8). During no ten-year period during her lifetime, though, does a woman face a risk of getting breast cancer as high as 1 in 8.

Of course, some women are at greater risk of developing breast cancer. And they, too, overestimate their risk for getting this disease.

Women with a faulty breast cancer gene are said to have “up to” an 85% lifetime risk of getting breast cancer, but according to the National Cancer Institute, the risk ranges from 36% to 87%. As with women who have an average risk, their chance of getting breast cancer increases as they age. (The exception to this is women with close relatives who got breast cancer when they were young.)

Others with a higher than average risk for breast cancer are women diagnosed with precancerous conditions like lobular carcinoma in situ or atypical hyperplasia. Women who have had breast cancer or ductal carcinoma in situ, a noninvasive cancer, are also at increased risk.
It should be noted that many women who are high risk will never get breast cancer. No one knows why they don’t or why some women get breast cancer even though they have no risk factors. The interplay of genetic make-up, age, reproductive history, environmental exposures, and lifestyle determines whether or not we develop breast cancer.

But those of us who are high risk can’t help feeling we’re destined to get breast cancer. Some choose overly aggressive treatment because they can’t live with the possibility that they might get this disease. They get bilateral mastectomies, reducing their risk by 90%. In some cases, this surgery is more drastic treatment than is necessary, and it does not guarantee they will never get breast cancer.

Women do it to ease their fears. Being high risk for breast cancer is more frightening than it should be because of misperceptions about the level of risk for the average woman.

Putting Breast Cancer Awareness To Work

October was the month to raise our awareness about breast cancer – as if we weren’t aware enough. We bought all sorts of pink products so that money would go for breast cancer research, and maybe we were reminded to schedule a mammogram. But there's more we can do to fight breast cancer. We can make changes in our lifestyle to lower our risk for this disease.

It may seem inconceivable that healthy living could protect anyone from breast cancer, but scientists have done hundreds of studies that demonstrate a link between certain behaviors and breast cancer risk. They don’t know which of us can hope to stop this dreaded disease, but we don’t need to wait for all the answers to use what they’ve learned about reducing breast cancer risk and recurrence:

• Eat wisely. Base your diet on vegetables, fruits and whole grains. Limit fats, sugar and anything made with white flour.
• Get moving! Moderate physical activity is enough to reduce breast cancer risk and recurrence. It can be as simple as brisk fifteen-minute walks twice a day, but any amount of exercise helps.
• Keep your weight under control. Eat moderate portions of healthy foods and exercise regularly to keep weight down.
• Limit alcohol consumption to one drink per day -- less is better.
• Breastfeed for six months or more, if possible.
• Avoid hormone replacement therapy. The hormones in these pills are known to fuel the growth of some types of breast tumors.
• Guard your environment. Avoid exposure to chemicals like pesticides and some ingredients in cosmetics and toiletries that might play a role in increasing breast cancer risk.
• Control stress. It dampens your immune system, and there's nothing like stress to make you eat and drink more than you should.
• Don't smoke. And avoid second-hand smoke.
• Get regular mammograms and breast exams. Treatment is more likely to be successful when breast cancer is caught early.

Of course, some women do everything possible to reduce breast cancer risk and still get breast cancer. But there are some of us who might be able to stop this disease.

Overestimating Breast Cancer Risk

Whenever I hear that a woman has a 1 in 8 risk of being diagnosed with breast cancer, I cringe. First, because this is a scary statistic. And second, because it is misleading.

It does not mean that 1 in 8 women in the United States will actually get breast cancer. It is an estimation that a woman has a 1 in 8 (12.3%) chance of getting breast cancer during her entire lifetime -- if she lives to the age of 85. Of course, some women die from other causes before they reach 85. The leading cause of death in women is heart disease and the leading cause of cancer death in women is lung cancer, not breast cancer.

The 12.3% figure comes from adding up the average risk women face during each decade of their lives. Some women face a higher or lower risk than average, but according to the American Cancer Society, a woman’s chance of being diagnosed with breast cancer is:

Age
20-29...........0.05%..........1 in 1,837
30-39...........0.43%.............1 in 234
40-49...........1.43%...............1 in 70
50-59...........2.51%...............1 in 40
60-69...........3.51%...............1 in 28
70-79............3.88%..............1 in 26
----------------------------------------------
Lifetime......12.28%.................1 in 8

The lifetime risk is roughly the sum of the risk in each decade. (The math whizzes among us may have noticed that the percentages for each decade do not add up to 12.28%, but to 11.81%. These numbers were taken directly from the American Cancer Society’s Breast Cancer Facts and Figures 2007-2008, and do not include risk to age 85.) What is clear – though a bit mysterious mathematically – is that at no time during her life does a woman face a risk of getting breast cancer as high as 1 in 8. No one should be mislead to think that if she’s sitting in a room with 8 women, one of them is destined to get breast cancer.

I am not among the mathematically inclined, but I do have to question whether it’s valid to add up the risk during different periods to get a picture of overall risk. Suppose we were trying to predict the weather instead of the likelihood of getting breast cancer. If the forecast next week was for a 10% chance of rain each day, you’d expect pleasant weather. But if you added up the risk for each day and estimated that there was a 70% chance of rain next week, you’d be sure to take your umbrella.

Carrying around an umbrella is one thing, but when women are made unduly anxious about breast cancer, they may opt for overly aggressive treatment – prophylactic mastectomy -- when they are diagnosed with precancerous conditions, ductal carcinoma in situ (DCIS), or the breast cancer gene. Hearing you’re high risk for breast cancer becomes even more frightening when you have an inaccurate perception of what average risk is.

Awareness Reality Check

Awareness of breast cancer, as I mentioned in an earlier post, is a double-edged sword. There is too much awareness when it raises fears about breast cancer to the point where women overestimate their risk. But a certain level of awareness is necessary for women to understand how they might protect themselves.

An interview with Nancy Brinker, founder of the Susan G. Komen Foundation and the Race for the Cure, on the October 1st Oprah show reminded me of a different era when there was too little awareness. When Brinker's sister was diagnosed in the late 70's, no one talked openly about breast cancer, there were no support groups for women with the disease, and little information was available. Brinker says that if they'd known more about breast cancer, her sister might have considered going outside of their small town to get a second opinion at a large cancer center instead of putting her faith in the local doctors. She believes her sister's outcome might have been different if she'd been treated by knowledgeable specialists from the beginning.

Women need to be aware that they should get a second opinion when they're uncertain about the first one. Doctors may have different ideas about what follow-up a woman with a suspicious lump should have or which treatment is best for any particular breast cancer patient.

There is a list of cancer centers on the National Cancer Institute web site as well as a wealth of information. If none of these cancer centers are close enough for even a one-time consultation, it may be helpful to speak to doctors or call local hospitals to find a breast surgeon or an oncologist who is known to treat a lot of patients with breast cancer.

We should be aware that early detection is important because treating breast cancer at its earliest stages is simplest and most effective. Mammograms are not pleasant, but the small amount of discomfort is well worth the peace of mind they bring. We also need to get breast exams as part of our regular check-ups, and check our own breasts occasionally in between.

We should keep in mind that our risk for breast cancer is probably lower than we think, and that if further tests are necessary after having a mammogram, they're most likely to come out negative. Call-backs after a mammogram are common simply for getting clearer views of dense areas in the breast. And 80% of breast biopsies end up being negative.

We should also be aware that it is better to contribute to breast cancer charities directly than to buy pink promotional items. An excellent and informative article in the Minneapolis Star Tribune -- Which pink products really help fight breast cancer? -- addresses the issue of companies using Breast Cancer Awareness Month as a marketing tool. Of course, some companies contribute significant amounts to breast cancer charities, but others do not. The article links to a Guide to buying pink that offers suggestions on what to look for in a pink product to be sure the manufacturer is really using profits to support the fight against breast cancer.

Above all, we need to be aware that one of the best ways to fight this disease is to protect ourselves by using what scientists know about reducing breast cancer risk and recurrence through lifestyle.

Too Much Breast Cancer Awareness?

October is Breast Cancer Awareness month, and we can brace ourselves for a deluge of pink. There will be countless promotional products from companies trying to demonstrate their commitment to fighting breast cancer. Some will profit from their association with the cause and end up contributing a miniscule amount to breast cancer research.
We can also expect a barrage of articles about how we're making progress understanding and treating this disease, but women today will get many of the same treatments their mothers did. And we still have no idea what causes this disease.
The unfortunate result of all this awareness is a pervasive and unrealistic fear of breast cancer. Heart disease is the leading killer of women -- and lung cancer is the leading cause of death from cancer in women. Yet, most women believe their greatest threat is breast cancer.
The average woman faces a 1 in 8 risk of getting breast cancer at some point during her lifetime. This number sounds alarming, but it is important to note that risk increases with age, and at any particular age, a woman's risk of getting breast cancer is actually lower than 1 in 8. According to the American Cancer Society, the risk of getting breast cancer for a woman between the ages of 40 and 50 is 1 in 70 while the risk for a woman between 60 and 70 is 1 in 28. The risk for a woman in her 20's is 1 in 1,837, and though breast cancer is extremely rare in anyone under 20, concerns about it are not.
Breast cancer specialist and author Marisa Weiss recently published a book about breast cancer for teens and young girls because she sees growing fears about the disease in this age group. It's bad enough that grown women overestimate their risk for getting breast cancer, but when there is so much focus on this disease that young girls start worrying about breast cancer, it is clear there's too much awareness.
One effect of this misperception about breast cancer risk is that women are choosing mastectomy over less drastic treatment even when it is not known to provide any advantage for survival. Women with a gene that increases susceptibility to breast cancer are choosing to have both breasts removed even though there is uncertainty as to who would benefit from it. The number of women being diagnosed with these genes is increasing because the company that does genetic testing has started the questionable practice of advertising directly to consumers. Again, too much awareness.
Some women with early stage breast cancer are opting to have both breasts removed instead of facing a small risk that they will have a recurrence. There is no known survival advantage for those who have both breasts removed. By the time a cancer is diagnosed, it may have already started spreading to distant organs, and it is these metastases that lead to cancer deaths. But most women who are diagnosed at an early stage do not have the cancer spread outside the breast and will never have a recurrence.
It is not enough to wear pink ribbons, buy pink products, and spend a month becoming more aware of breast cancer -- and more fearful. We need to push Congress to support cancer research instead of hindering it as they have this year. They reduced the budget for the National Cancer Institute and blocked legislation to fund research on environmental causes of breast cancer. We also need to press for more research on breast cancer prevention instead of having so much of the research budget devoted to searching for that elusive cure.

Prophylactic Mastectomy: A Cautionary Tale

Hearing you're high risk for breast cancer is frightening. There is uncertainty as to what you should do about it -- and you desperately want to do something. But taking the most drastic step of having both breasts removed is not the right choice for many women. It wasn't for me.
I had no family history of breast cancer and would never have thought I was at risk until a routine mammogram showed a suspicious spot. A biopsy revealed that I had a precancerous condition that put me at high risk for getting breast cancer.
I thought my days were numbered. Adding to my concern was confusion about what this condition was and how it should be treated. Lobular carcinoma in situ (LCIS) is a cancer "in place" that has no potential for spreading outside the breast unless it undergoes a transformation. It is classified as a "Stage 0" breast cancer but is not a true cancer because it lacks the potential to metastasize, or spread.
Now there is more certainty about what women with LCIS should do, but when I was diagnosed almost twenty years ago, the medical community was evenly divided on what to recommend. Around half the doctors surveyed for a study at the time said they would carefully monitor women with LCIS with regular check-ups and mammograms. The other half said they would advise LCIS patients to have both breasts removed.
A double mastectomy for a precancerous condition seemed extreme -- since the treatment for a more threatening invasive cancer would have been a lumpectomy or a single mastectomy. LCIS indicates a potential for developing breast cancer in either breast, so to fully reduce the likelihood of breast cancer, both breasts have to be removed. But even with a double mastectomy, there is no guarantee you won't get breast cancer.
I considered the bilateral mastectomy, but followed the recommendation of my wise and progressive breast surgeon to have careful follow-up. Now most doctors favor this approach, and the women most likely to be grappling with the issue of having prophylactic bilateral mastectomy are those who have been diagnosed with a gene that causes susceptibility to breast cancer. Some are taking the initiative in deciding to have this surgery -- and in many cases, they are ignoring the recommendation of their doctors.
And why shouldn't they, you might ask. They are told their risk for getting breast cancer can be as high as 85%, and they are living with the uncertainty that breast cancer could strike at any time. Many have watched mothers or sisters struggle through surgery, radiation, and chemotherapy. They understandably want no part of that.
But there are reasons they should not rush into having this surgery.

• Some women with the gene will never get breast cancer. The risk of a woman with a susceptibility gene getting breast cancer at some point during her lifetime is 36% to 85%, as compared to a risk of 12.7% in the general population. The risk for women with the gene is often described as being "up to" 85%, but that number represents the worst case scenario.
• These estimates of risk are not etched in stone. They are likely to change as scientists learn more about how these genes lead to breast cancer, just as ideas about LCIS changed. One group has already reported that the risk may be lower than currently believed.
• Scientists are trying to learn why some women with the gene do not get breast cancer, and at some point, they may be able to predict who is at greatest risk and should consider prophylactic mastectomy.
• Women who get bilateral mastectomy can still get breast cancer. The surgery reduces risk by 90%, but does not eliminate it. Breast tissue is spread out in the chest, and some remains after mastectomy.
• There are less drastic ways to reduce breast cancer risk. Tamoxifen and Evista reduce breast cancer risk by around 50%. Some women can reduce their risk with a healthy lifestyle.
• The risk of getting breast cancer increases with age, even in women with a susceptibility gene unless they have close relatives who got breast cancer when young. For women whose mother or sister didn't get breast cancer until close to menopause, though, having breasts removed in their 30's -- as some women are doing -- may be premature.
• No surgery is free of risk, and further surgery may be necessary. Women having mastectomies can develop infections or have bad reactions to drugs, just as with any surgery. Implants need to be replaced periodically.

Of course, bilateral mastectomy may be the wisest choice for some women who have the gene, but it is too drastic a step for many others.

Improving Your Odds

It may seem inconceivable that a healthy lifestyle could protect anyone from breast cancer, but scientists have done hundreds of studies that tell us that some women can. They don't know which of us can hope to stop this dreaded disease, but we don't need to wait for all the answers before we use what they've learned about reducing breast cancer risk and recurrence:

• Eat wisely. Base your diet on vegetables, fruits and whole grains. Limit fats, sugar and anything made with white flour.
• Get moving! Moderate physical activity is enough to reduce breast cancer risk and recurrence. It can be as simple as brisk fifteen-minute walks twice a day, but any amount of exercise helps.
• Keep your weight under control. Eat moderate portions of healthy foods and exercise regularly to keep weight down.
• Limit alcohol consumption to one drink per day -- less is better.
• Breastfeed for six months or more, if possible.
• Avoid hormone replacement therapy. The hormones in these pills are known to fuel the growth of some types of breast tumors.
• Guard your environment. Avoid exposure to chemicals like pesticides and some ingredients in cosmetics and toiletries that might play a role in increasing breast cancer risk.
• Control stress. It dampens your immune system, and there's nothing like stress to make you eat and drink more than you should.
• Don't smoke. And avoid second-hand smoke.
• Get regular mammograms and breast exams. Treatment is more likely to be successful when breast cancer is caught early.

Of course, there are some women who do everything on this list and still get breast cancer. But there are some who can hope to stop this disease. Isn't it worth a try?

http://www.reducebreastcancerrrisk.com/