Exclusive previews from
"The Breast Cancer Prevention Program"

Part I
Breast Cancer

Determining Your Risk
More is known about the causes and prevention of breast cancer than you may realize. Knowing the Twelve Common but Unpublicized Risks for Breast Cancer, or the "Dirty Dozen," on page 9 is your first step toward preventing breast cancer from developing in the future.The current statistics about breast cancer are shocking: n Breast cancer is the leading cause of death in women between the ages of 35 and 54.

n Breast cancer is the second largest cause of cancer deaths (after lung cancer) among women of all ages.

n In 1971, when President Richard Nixon declared the "War on Cancer," a woman’s lifetime risk for contracting breast cancer was one in fourteen. Today it is one in eight.

n American women are now twice as likely to develop breast cancer than they were a century ago, and most of this increase in incidence has occurred over the past thirty years.

n From 1950 to 1992 the incidence of breast cancer rates among white women (data from black women were not compiled until the 1970s) increased by 55 percent.

n From 1973 to 1992 the incidence of breast cancer among white women increased by 34 percent, and among black women by 47 percent.

n In 1996 alone, 186,000 women learned they had breast cancer and about 46,000 died from it.

n Since 1960, more than 960,000 American women—double the number of Americans (male and female) who died in World Wars I and II and in the Korean, Vietnam, and Persian Gulf wars combined—have died from breast cancer.

It would be comforting if a statistical anomaly or glitch could explain away such frightening figures. Unfortunately, these numbers reflect a stark truth: Today, more people are at risk for developing cancer—and more women are at higher risk for developing breast cancer—than ever before in history. Indeed, the general cancer statistics are at least as alarming as are those of breast cancer: One or another type of cancer now strikes more than one in three Americans, and kills more than one in four. Without question, cancer represents the greatest and most urgent medical challenge of the late twentieth century.

Yet many Americans—even well-meaning physicians—mistakenly believe that we are winning the war on cancer, that we have gotten a handle on increasing rates, and that mortality rates are actually decreasing rapidly because of improved diagnostic and treatment methods. Nothing could be further from the truth. Although there is some good news on the mortality front (from 1990 to 1995 the mortality rates for breast cancer decreased by 6.6 percent in white women and 1.6 percent in black women), most of the improvement is due to better health care access and earlier diagnosis rather than to any success in preventing the disease. In fact, the incidence rates—the numbers of older women being diagnosed with breast cancer—increased steadily during this same period. The truth is that until prevention becomes the top priority, breast cancer will continue to damage the lives of increasing numbers of women.

Before we delve further into the very real risks you may face, there are several other myths worth exploding about our perception of breast cancer.

MYTH #1: Breast cancer rates are increasing only because women are living longer.

You may have heard that the increase in breast cancer rates merely reflects an increase in life expectancy. Because most women who develop breast cancer do so after menopause, it is possible that a longer life span might explain today’s marked increases in breast cancer rates. It is true that women now live approximately thirty-five years longer than they did at the beginning of this century. In fact, up until about 1920, most women died before or shortly after reaching menopause.

Unfortunately, increased longevity is not the explanation. We know this because while life expectancy rates have remained relatively stable since 1950, the incidence of breast cancer has increased by about 55 percent. Furthermore, rates of cancer and other diseases are age-adjusted, meaning that epidemiologists—scientists who study diseases, their causes, and their trends over time—reconcile changes in rates to reflect and exclude longevity factors.

MYTH #2: Breast cancer rates are increasing only because the disease can be detected sooner and better than ever before.

Although it is impossible to completely discount the contribution improved screening methods have made to the increase in breast cancer rates, this claim, too, fails to hold up under scrutiny. Much of the increase in breast cancer rates preceded 1980, before large-scale mammography screening began in the United States. In addition, similar increases in breast cancer rates exist in countries that still do not conduct large-scale screening programs, such as Great Britain and France.

MYTH #3: Breast cancer rates are leveling off.

The opposite is true: Today, one in eight women in the United States will develop breast cancer in her lifetime—a risk that was one in twenty in 1960. Next year, about 1 percent more women will develop breast cancer than did this year, and unless we find ways to prevent breast cancer the rates will continue to increase.

MYTH #4: Breast cancer cannot be prevented.

It is time to dispel conclusively this dangerous yet deeply entrenched myth. To do so means refuting the position taken by the cancer establishment represented by the American Cancer Society (ACS) and the National Cancer Institute (NCI). In their 1997 publication, Cancer Facts and Figures, for instance, the American Cancer Society wrote:

To date, knowledge about risk factors has not trans-lated into practical ways to prevent breast cancer. Since women may not be able to alter their personal risk factors, the best opportunity for reducing mortality is through early detection. The cancer establishment has long insisted that the only risk factors known to cause breast cancer are hereditary (genetic) and biological (early menses and late menopause), both discussed in chapter 2, as well as dietary (a high-fat diet, discussed in chapter 9). We now know, however, that these so-called traditional risk factors account for less than 30 percent of breast cancer cases. With pervasive ties to the pharmaceutical and radiological industries, however, the ACS has a financial incentive to continue this policy of ignoring preventive strategies, and both the ACS and the NCI have an ingrained conservative mind-set against exploring environmental and dietary contaminants as causes of cancer—a mind-set reflected in their publications that blanket waiting rooms in hospitals, clinics, and doctors’ offices across the country.

This leaves the average woman with the mistaken impression that scientists know nothing about the causes of breast cancer or how to prevent it (which, as you will see throughout this book, is untrue), and that the only subjects worth studying are those perceived to be ones with more attainable goals: better detection, early treatment, and genetic screening methods. Unfortunately, this attitude sets a vicious cycle in motion: Urged by the establishment’s rhetoric, the public continues to fund research into genetic causes, chemoprevention (the use of drugs to prevent breast cancer), and diagnostic and treatment methods. The media then faithfully report the results of this research, which only encourages more funding for similar studies. Meanwhile, investigation into the more avoidable causes of breast cancer fails to receive proper funding or attention, and the rates of breast cancer continue to increase year after year.

In chapter 13, "The Politics of Breast Cancer," you will learn more about why this bias in research and reporting exists, how it leads to countless human tragedies every year, and what you can do to make other women and men aware of the truth. For now, you can start to reverse the cycle by gaining an understanding of your own risks and how to reduce them.

From a later chapter


Breast Cancer Risk Factors:
The Whole Story

Thanks to advances in the biological sciences, we now have an increasingly clearer picture of our most dreaded and pervasive enemy: the cancer cell. In the wide range of diseases called cancer, a cell—the smallest unit of living matter in the body—becomes deranged and begins to grow abnormally. This corruption can occur spontaneously through some internal malfunction of the cell itself, or it can occur when the cell comes into contact with a carcinogen that triggers a disruption of the cell’s normal activity. (The tar in cigarettes contains one such group of carcinogens; ultraviolet rays from the sun are carcinogenic as well.) By definition, a cancer is a group of malignant cells that multiply uncontrollably, invade local tissues, and sometimes spread (or metastasize) to other sites in the body.

What happens to a cell when something triggers it to grow uncontrollably? Normally, every cell in the body "knows" how often and under which circumstances it is to reproduce and the rate at which it will be destroyed or lost in the body. Most cells have a finite life span that is part of their genetic code. When a carcinogen or internal malfunction alters this genetic code, the cells lose their innate control over growth processes and divide without internal restraint. These cells also fail to die at a normal time, but instead continue to live and divide until a cancer forms.

Breast cancer is a malignant tumor that arises in the breast. It may also invade nearby tissues (such as the lymph glands) and then metastasize through the bloodstream, most often to the lungs, bone, liver, and brain. Scientists continue to search for the identity of the cancer-causing triggers (carcinogens), the substances or conditions under which a breast cell becomes deranged and starts to reproduce without control.

Without question, the story that receives the most press when it comes to breast cancer is the search for a genetic cause of the disease. During the 1980s, advances in molecular biology techniques triggered an explosion in genetic research, leading to several breakthroughs in the 1990s. One reason public funds are used to continue such research is the hope that when genetic therapy techniques become more sophisticated, doctors may be able to dismantle breast cancer genes and thus prevent women born with them from developing the disease.

As vital and exciting as this research is, it represents just a small part of the breast cancer picture. Indeed, as we will explain further, only a very small percentage of all breast cancer cases have a direct genetic cause. Genetic factors obviously cannot account for the startling increases in breast cancer incidence over the past few decades. By concentrating on genetic research, then, the cancer establishment takes the hope of prevention out of the hands of most women. By far the vast majority of breast cancer cases are linked to one or more environmental, medical, or personal risk factors over which you have far more control than you might think (the Dirty Dozen)

Personal Protection

As you can see, ERT has many risks and benefits that you must carefully weigh for yourself before deciding whether to take it. Every woman has a different set of risk factors and concerns: You may have such a strong family history of heart disease and osteoporosis, for instance, that the benefits of ERT may outweigh its risks for you. However, keep in mind that there are several safe, effective diet and lifestyle changes you can make to help you through the passage into later life and keep you healthy and vital during the second half of your life—even if your doctor may fail to mention them unless directly asked.

In 1995, the Physicians’ Committee for Responsible Medicine stated:

It is patronizing to assume that every postmenopausal woman is too wedded to her current diet and lifestyle to listen to competent advice. The real problem is, she is not likely to find such advice. Most doctors know little about how diet affects health, even when a mountain of research has already been done [and] is gathering dust in medical libraries. They rely instead on knee-jerk prescribing [ERT], which is continually encouraged by drug manufacturers’ aggressive promotion. When doctors learn how to use all the tools their medical bags could really offer—including prescriptions for diet and lifestyle changes—their patients will be much better off. In chapters 9 and 10, we will describe in detail the connection between cancer and what you eat, drink, and inhale, how much you exercise, and how much stress you endure. Meanwhile, here are some safe and effective ways to protect yourself against the sometimes unpleasant and potentially dangerous problems that result from the loss of estrogen at menopause—without taking ERT and increasing your risk of breast cancer, other cancers, and other complications. What You Can Do n Avoid using ERT, or use it only in low doses for short periods of time.

n Avoid alcohol if you use ERT.

n Maintain your health during menopause without ERT

n Stop smoking, eat a healthful diet, exercise, and maintain a normal weight. n Take advantage of nonhormonal solutions.
Avoid Estrogen Replacement Therapy or Use in Low Doses for a Short Time

As we have discussed, the risks of breast cancer increase considerably with the use of ERT over long periods of time. Many women pass through menopause without experiencing serious menopausal symptoms or developing osteoporosis or heart disease, especially if they eat a healthful diet and exercise regularly. However, if you suffer from uncomfortable hot flashes, mood swings, or other symptoms, you may decide that taking a short course of ERT will help you through the most difficult months of menopause without putting you at a much higher risk for developing breast cancer.

Another reason to consider taking ERT is to prevent osteoporosis. If you have a family history of osteoporosis or you are otherwise at high risk for this bone-thinning disease, talk to your doctor about taking ERT starting at the age of 65 or so, when fractures related to the disease usually begin to occur. Recent evidence published in the February 1997 Journal of the American Medical Association shows that women who put off using estrogen for ten years or more after menopause still receive "nearly equal bone-conserving benefits as women who began in their late 40s or early 50s."

Avoid Alcohol

Studies show that alcohol consumption—even only four drinks a week—significantly increases the levels of estrogen (and thus the risk of breast cancer) in women who take ERT. When taking ERT it is best to eliminate or at least severely restrict your intake of alcohol.

Maintain Your Health During Menopause without Estrogen Replacement Therapy

By changing your lifestyle, or reinforcing healthful habits, you can avoid many of the conditions that tend to develop in women after menopause, including cardiovascular disease and osteoporosis.

Stop Smoking

According to the United States Surgeon General, cigarette smoking is the single most preventable cause of heart disease and is responsible for at least 30 percent of all deaths related to heart disease annually. The Framingham Heart Study found that the mortality rate of women smokers is fivefold over that of women nonsmokers. The dangers from cigarette smoke start with just one cigarette a day and increase with every cigarette smoked: Smoking one to ten cigarettes per day doubles the mortality rate from heart disease. Smoking ten to twenty cigarettes per day increases the mortality another 25 percent. Altogether, smokers have a stunning 70 percent higher rate of death from heart disease than do nonsmokers.

Cigarette smoking also has an impact on the development of osteoporosis because it inhibits bone repair and depletes valuable nutrients. Women who smoke lose bone mass more quickly and the loss is much more severe than in those who do not smoke, largely because smoking affects both estrogen production and the way in which the body metabolizes estrogen. (We will discuss smoking in further detail in chapter 10.)

Design a Healthful Diet

The cliché, "You are what you eat" is apt when it comes to your health. Scientists have discovered many important links between what we eat and both cardiovascular disease and osteoporosis. We recommend four dietary guidelines for menopausal women:

1. Lower your fat intake: Cutting down on fatty meat and dairy products may be the most important step you can take in creating a healthful diet for yourself. Leading heart disease specialist Dean Ornish, M.D., demonstrated that a nearly vegetarian diet—one that contains little or no fat—can dramatically lower heart disease risk and even reverse existing damage to the cardiovascular system. Replacing meat and dairy products as sources of protein with complex carbohydrates, such as grains, beans, and soy products, will help lower cholesterol levels and reduce caloric intake.

2. Add complex carbohydrates to your diet: The United States Department of Agriculture recommends that you eat from six to eleven servings of cereals and grains, three to five servings of vegetables, and two to four servings of fruits per day. Most complex carbohydrates also contain high amounts of fiber, which lowers cholesterol by helping the body excrete fat more quickly and thus reduce its absorption into the bloodstream. Fresh fruits and vegetables, especially dark green, leafy vegetables, tend to be rich in folic acid and other B vitamins that help reduce levels of the toxic amino acid called homocysteine. According to a January 3, 1996 article in the New York Times, "just a small decline in homocysteine levels could save 35,000 lives a year in this country."

3. Add antioxidants to your diet: Fruits and vegetables also contain high amounts of nutrients known as antioxidants, including the vitamins C, E, beta carotene (a precursor of vitamin A), and the minerals magnesium, zinc, and selenium. These nutrients have the ability to destroy certain harmful molecules in the body called free radicals. Free radicals are unstable molecules that may damage both cell membranes and internal cells structures, including DNA. Scientists have linked free radicals to the development of several diseases and conditions, including heart disease, osteoporosis, and several types of cancer. (We will discuss free radicals and breast cancer in more detail in chapter 9.)

4. Increase your intake of bone-strengthening and heart-healthy nutrients: When it comes to osteoporosis, the most important vitamins and minerals are calcium, magnesium, and vitamins C and E. Found in grains, vegetables, fruits, and dairy products, these nutrients help bone tissue maintain its strength and resiliency, even as the effects of aging progress. Listed here are the vitamins and minerals you need every day to keep your heart and musculoskeletal system healthy:

n Calcium: Approximately 80 percent of women eat less than the recommended daily allowance of 800 milligrams of calcium. Not only is calcium essential to the health of your bones, it also helps to lower blood lipids and make other blood components less sticky, thereby helping to prevent cardiovascular disease. Food sources rich in calcium include green leafy vegetables, sardines, salmon, soybeans, and dairy products such as milk, yogurt, and cheese. Most doctors recommend that postmenopausal women consume about 1,000 to 1,500 milligrams of calcium per day.

n Magnesium: Magnesium is a mineral that works in tandem with calcium to help keep both the musculoskeletal and cardiovascular systems healthy. A recent Israeli study published in the Medical World News, for instance, showed that women who take supplemental magnesium can increase their bone density up to 8 percent, whereas those who did not take extra magnesium lost bone density. Although magnesium is found in a wide variety of foods, including wheat bran, raw leafy vegetables, nuts, and bananas, few women obtain enough magnesium from their diets. If you decide to take magnesium, you should balance the amount you take one for one with calcium. You can safely take about 600 to 800 milligrams of magnesium daily.

n Vitamin B3 (niacin): Niacin is often prescribed to lower blood lipids and increase HDL cholesterol and homocysteine. However, because use of niacin may result in serious side effects, you should take supplements only under the care of an experienced health care provider. Always use free-form niacin, avoiding time-release forms that tend to cause the most serious side effects.

n Vitamin C: Vitamin C is both an important antioxidant that protects against cardiovascular disease and an essential component of bone metabolism. Foods rich in vitamin C include citrus fruits, green leafy vegetables, and tomatoes, among many others. You can safely take anywhere from 250 to 3,000 milligrams of vitamin C per day (the official recommended daily allowance is about 60 milligrams). Older women who smoke require more vitamin C, because cigarettes sap the body of its vitamin C supply. Please note, however, that the more vitamin C you take, the more likely you are to suffer from the common side effect of stomach irritation.

n Vitamin D: In order for your bones to absorb enough calcium, your body needs enough vitamin D. Found in fish and fortified milk, vitamin D is also produced in the body in response to sunlight. You need about 400 IU (international units) of vitamin D per day.

n Vitamin E: According to several recent large-scale studies, vitamin E provides excellent protection against heart disease in postmenopausal women. The Harvard Nurses’ Health Study, for instance, reported that nurses who took vitamin E supplements had only two-thirds the heart disease risk compared with nurses who did not take supplements. Women who took vitamin E for more than two years cut their risk in half. A study in the American Journal of Epidemiology reported that women with the highest intake of vitamin E lowered their risk by 65 percent compared with women with the lowest intake.

Vitamin E is also known to help relieve menopausal symptoms such as hot flashes and night sweats. Back in 1950, a study published in the Annals of Western Medicine and Surgery showed that "vitamin E is undoubtedly effective in treating [menopause] and some associated symptoms." Vitamin E also helps alleviate benign breast disease in many women.

n Phytoestrogens: As we will discuss in greater detail in chapter 9, certain plants contain estrogen-like substances. Found primarily in soy products such as tofu and soybeans, phytoestrogens help protect against bone loss. Indeed, several studies that show osteoporosis is very uncommon in countries in which soy consumption is highest, such as China and Japan. You can also reduce your risk for heart disease by consuming more soy: One study published in The New England Journal of Medicine in 1995, found that eating about 47 grams of soy protein (the amount found in three-quarters of a pound of tofu) per day lowers cholesterol levels up to 20 percent in persons with high cholesterol. It also showed that phytoestrogens found in soy also appear to increase protective HDLs while lowering total cholesterol. In chapter 9, we will discuss the importance of these key chemicals to the prevention of breast cancer.

Maintain a Healthy Weight

According to a 1990 report by the Framingham Heart Study group, obesity is a major cardiovascular risk factor, especially for women after menopause. Even ten extra pounds puts a heavy burden on the heart and blood vessels; for each pound of excess weight, the heart is forced to pump blood through an additional several hundred extra miles of blood vessels a day. Even a 10 percent reduction in weight is more likely than an exercise program to improve blood pressure readings, cholesterol levels, and the ability of the body to process blood sugar, all of which influence coronary disease risks. Being overweight also places more stress on bones that may become more brittle as you age, thus increasing your risk of osteoporosis process. As you will see in chapter 9, obesity also plays a major role in the development of breast cancer.

Exercise Regularly

Without question, for a woman entering or past the age of menopause, exercise may be the single best thing she can do for her emotional and physical health. Exercise mitigates three of her most pressing health problems: cardiovascular disease, osteoporosis, and weight gain. Aerobic exercise helps keep the heart pumping and blood vessels clear, while weight-bearing exercise helps strengthen bones and muscles. Just 30 minutes of aerobic exercise three times a week helps prevent cardiovascular disease in older women. Many women also find that exercise alleviates other menopausal symptoms, including annoying hot flashes. A recent study among women at Wayne State University showed that more than 50 percent of those who suffered from hot flashes decreased the frequency and severity of their episodes by exercising regularly. A menopausal women who exercises may also notice that her skin looks and feels younger as more blood is pumped into the tiny capillaries that feed the dermis. Improved circulation will also help her digestive system stay healthy and her immune system stay strong. Exercise has a positive effect on her brain and her emotions as well. Like skin, brain tissue is fed by thousands of tiny capillaries, and the more blood coursing through them, the more mentally alert and emotionally satisfied a woman will feel. Part of the reason is that certain body chemicals called endorphins, known to dull pain and produce mild euphoria, are released during vigorous exercise. Finally, exercise helps prevent breast cancer, a matter we will take up in more detail in chapter 10.

Take Advantage of Nonhormonal Solutions

If you are like most women, stopping smoking, eating right, and exercising regularly will help you stay healthy and feeling vital and vigorous throughout menopause. However, if you remain plagued by menopausal symptoms or side effects, there are several herbal and nonhormonal remedies available to you:

n For skin changes: Avoiding the sun and using sunscreen are the very best ways to protect your skin from age-related changes, including increased dryness and wrinkling.

n For vaginal dryness: Several safe and effective lubricants are available over the counter, including almond, coconut, or vitamin E oil. Water-soluble products, such as Astroglide, gly-cerin, and K-Y Jelly, are also helpful.

n For preventing heart disease: Several recent studies show that, at least among men, taking one aspirin a day can help prevent heart disease. As yet, no such information is available for women, however. Several medications are also available that help lower high blood pressure and reduce serum cholesterol. All drugs, including aspirin, however, have their own side effects and associated risks that you must be aware of before you take them.

n For preventing or treating osteoporosis: In addition to eating a diet rich in calcium, magnesium, and vitamin D, and exercising regularly, you can also take one of several different medications developed to treat osteoporosis. Fosamax (alendronate)—manufactured by Merck and Company, Incorporated—and Miacalcin (calcitonin)—manufactured by Sandoz—may help keep bones strong after menopause; however, both have side effects and their long-term effects are unknown. Fluoride by prescription too, has side effects.

 Discuss the matter thoroughly with your doctor. It is also important that you avoid or restrict taking prescription and over-the-counter medications that increase bone loss. Indomethacin, ibuprofen, and other non-steroidal anti-inflammatory drugs (NSAIDs), anticonvulsant medications, some cholesterol-lowering drugs, corticosteroids, and the antibiotic tetracycline are some of the most common culprits. Antacids containing aluminum may also interfere with the ability of the body to use other bone-building materials and thus should be avoided. Again, talk to your doctor for more information.

n For preventing colon cancer: The Harvard Nurses’ Health Study showed that women who took two or more aspirin weekly for more than twenty years had a dramatic 44 percent reduction in colon cancer. Taking four to six aspirin per week gave the greatest protection. See your doctor before you begin taking aspirin, however, because aspirin has side effects of its own, including exacerbating osteoporosis and causing stomach irritation.

n For preventing Alzheimer’s disease: Studies released in a 1997 issue of the Journal of Neurology indicate that ibuprofen, an inexpensive over-the-counter anti-inflammatory drug, may reduce the risk of Alzheimer’s disease by as much as 60 percent. Although the findings are preliminary, and you should not take ibuprofen for this reason alone, if you are already taking it for arthritis or another inflammatory condition you can take heart in knowing that you may be protecting yourself against Alzheimer’s disease at the same time.

The Estrogen Connection

Why is estrogen-dependent breast cancer so much more common today than it was just a few decades ago? Plainly speaking, the average woman is exposed to more estrogen over a longer period of time than ever before and at the same time, she is exposed to the more carcinogenic or "bad" type of estrogen than women were in the past. This overexposure to estrogen is occurring for a variety of reasons:

n The widespread use of oral contraceptives and estrogen replacement therapy not only lengthens the amount of time women are exposed to additional estrogen, but also increases the total amount of estrogen that circulates in the bloodstream over a woman’s lifetime (chapters 3 and 4).

n Contamination of the food we eat by estrogens and estrogen-mimicking industrial chemicals (pseudoestrogens) increases the levels of estrogen in the body and exposes the body to the bad carcinogenic forms of the hormone (chapter 9).

n Poor eating habits, lack of exercise, and other detrimental life-style habits, such as the consumption of large amounts of alcohol, also increase the amount of estrogen circulating in the body (chapter 9).

n Certain reproductive choices more commonly made today, such as deciding not to have any children, bearing a first child late in life, and choosing not to breast-feed, also affect estrogen levels.


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