Breast Cancer Risk

I opted for a bilateral. I only had cancer on the right side, but after finding that and getting my MRI, something popped on the left. We weren't sure what it was. I could have had it tested, but at that point I just knew I wanted to have both sides removed. So I chose to not get that side tested and proceed with a bilateral mastectomy.

After surgery, pathology showed it was not cancer, but I don't regret
making that decision. It was 100% correct for me.

That said, what is right for me, may not be right for you. And it's a hard decision to make. And I wish you best of luck making it. You have to do what you think is right for you, and only you. ((hugs))

Breast and ovarian cancer survivors, especially those with, hormone-sensitive cancers, may worry about using ovarian stimulating hormones either during fertility preservation prior to cancer treatment or during survivorship. For fertility preservation purposes, embryo or egg banking are options for many young women. In this process, hormones are used to induce the ovaries to produce multiple eggs in one month (normally an ovary produces a single egg per month). Clinical hormonal stimulation protocols have been modified to work for women with hormone-sensitive cancers. The one study that looked at cancer recurrence rates for breast cancer survivors who underwent this procedure, found that these women did not have an increased risk for cancer recurrence compared to those who did not have ovarian stimulation.

Survivors of hormone-sensitive cancers may also discuss using this protocol with their fertility specialist. However, they may first wish to examine their ovarian reserve, the number of immature eggs in their ovaries, as chemotherapy, radiation, and surgery for cancer treatment may have significantly reduced this number.

Having one gynecologic cancer does not increase your risk of having other types of gynecologic cancer. However, women with a hereditary cancer syndrome are at increased risk of developing a gynecologic cancer. These syndromes include Hereditary Breast and Ovarian Cancer (HBOC) caused by a BRCA mutation as well as Lynch syndrome, also called hereditary nonpolyposis colorectal cancer (HNPCC). Women with HBOC syndrome have markedly elevated risks of breast cancer and ovarian cancer, with a lifetime risk of breast cancer of 50 to 85 percent and a 15 to 40 percent chance of developing ovarian cancer. There is also an increased risk of a second breast cancer diagnosis.

Lynch syndrome is associated with cancer diagnosis at an early age and the development of multiple cancer types, particularly colon and endometrial cancer. Until recently, the majority of attention and research related to Lynch syndrome has focused on colorectal cancer. However, women with Lynch syndrome have a 27 to 71% risk of endometrial cancer, which equals or exceeds their risk of colorectal cancer. This is significantly higher than the 3% risk of endometrial cancer in the general population. In addition, women with Lynch syndrome have a 8-11% risk of ovarian cancer, compared with 1.5% in the general population. The management of endometrial and ovarian cancer risks in women with HBOC or Lynch syndrome includes surveillance, chemoprevention and risk-reducing surgery.

The HALO Breast Pap Test is a non-invasive way of retrieving breast duct cells for pathologic examination. It is NOT a diagnositc test (meaning it will not find a cancer int he breast) but is only used as another way to assess a woman's risk of developing breast cancer in the future. Suction cups are applied to the breast (similar to a breast milk pump) and fluid is obtained from the ducts at the nipple. Approximately 2/3 of the women will have fluid obtained (so 1 in 3 women will not have fluid for examination) and the cells can look normal, hyperplastic, atypical and very rarely frankly cancerous. Hyperplastic cells raises a woman's risk by ~1.5-2x above her known risk (as assessed by the Gail or Tyrer-Cusick models) and atypical cells raise her risk by 4-5x. If cancerous cells are found, advanced imaging must be done to determine where the cells originated. The HALO Breast Pap can be done on any woman over 30-35 years of age and is typically done yearly (just as the cervical Pap test is done).

Americans get risk screening all the time but we generally don't think of these tests in those terms. Assessment of cholesterol levels in the blood and blood pressure are risk assessments for heart disease and stroke. These are offered to essentially everyone and help to direct additional testing (advanced cardiac/vascular examinations) and treatment (cholesterol and blood pressure lowering medicines). There is no downside to risk assessment in all women and can help direct advanced breast imaging and closer follow ups as well as alleviating fear in some women who overestimate their risk of developing breast cancer. The risk assessment requires no blood draws and can be done in less than 5 minutes by a trained medical assistant.

Breast cysts are completely benign, in other words, not related to breast cancer. Think of them like little "water balloons" in the breast - they develop due to enlargement of an area of the milk duct that fills with fluid. They will often enlarge and may become painful right before the menstrual period, and then often decrease without any intervention. An ultrasound can be used to ensure that a lump is indeed a fluid filled cyst and not a solid tumor. "Simple" cysts, which have a thin wall and no solid growth associated with them can safely be observed, but sometimes fine needle aspiration is recommended if a cyst is large or painful.

The HALO test is a way to obtain fluid from the nipple which then can be analyzed to see if there are any abnormal, or atypical cells. Cellular atypia is a risk factor for the future development of breast cancer, and patients who have atypia usually are followed more closely. The HALO test is not a substitute for mammogram or other imaging as it is not meant to diagnose breast cancer - it is a way to determine if a woman might be at increased risk and therefore might need additional imaging. The HALO test is typically used in women under the age of 40, who are not yet undergoing routine screening with mammography.

I love this question because we as oncologists have changed our thinking in the past few years. My former recommendation was that patients with hormone receptor positive breast cancer avoid soy in any form. This was not necessarily based on any hard science, but rather a concern that the phytoestrogens in soy could theoretically promote breast cancer in women with hormone receptor positive tumors. Now we have some pretty convincing epidemiologic evidence that soy food consumption is beneficial in breast cancer survivors (note soy food—not supplements). In a meta-analysis done by Trock, et al.(Journal of the National Cancer Institute, 2006) soy protein intake was associated with a small but statistically significant decrease in the risk of breast cancer. Two other case-control studies (one in a European population and the other in a Japanese population) also showed no increased risk of breast cancer with soy or other phytoestrogen consumption (Am J ClinNutr, 2010, and Iwasaki, et al., JCO, 2008). The Shanghai Women’s Health Study also shed some light on the benefits of soy consumption and breast cancer prevention. In this study the highest consumption of soy was associated with the lowest risk of pre-menopausal breast cancer. In breast cancer survivors, soy intake was associated with a lower mortality and risk of recurrence with a 29% risk reduction for total mortality and 32% risk reduction for breast cancer recurrence (ER pos or neg).

I would reinforce Dr. Moore's answer that not all breast findings need an MRI. There is no way that any of us can tell based on the information provided whether or not an MRI or other imaging will be helpful or necessary in this case - an understanding of the patient's clinical situation as well as review of the mammograms and any available pathology reports is necessary. In general, calcifications do not show up on MRI. There is no question that there are cancers that will show up on MRI that are missed by other imaging, but again each case needs to be properly evaluated before a blanket recommendation for MRI is made. There is no best imaging test for the breast, but that also does not mean that every test should be done in every person.

Being a vegetarian is not a 100% guaranteed that you will not get cancer. It is a healthier lifestyle, however, there are many variables that can cause cancer and breast cancer. Add to the equation, eating meat in an earlier life, environmental factors, genetics/family history, obesity, smoking, lack of exercise and history of drinking alcohol. All these factors can cause breast caner.

Moreover, know where your fruits and vegetables come from. Many of our fruits and vegetables that we eat have been treated with pesticides, (which in turn places more estrogen in our bodies, which can cause breast cells to grow abnormally).

Be aware of what vegetables that have a high estrogen content in them. Such as sweet potatoes and “true yams” are totally different vegetables from two separate botanical families. Yams are brighter, orange color and are served more frequently in stores and restaurants, have a higher estrogen component in them. Yet women who maybe at risk for breast cancer are not aware of this factor

Furthermore, there are studies that have shown curcumin and black pepper have cancer-fighting properties to help to reduce breast cancer. Other measures that can be taken to reduce breast cancer is to lower or eliminate the consumption of alcohol. Check your Vitamin D levels, it appears that women who have a low Vitamin D level are more at risk for breast cancer.

In addition to, these factors that I have mentioned above, one must get adequate sleep, exercise, and take time for you.

Metformin, an oral medication that is commonly used to treat diabetes, may significantly reduce the risk of multiple types of cancer in diabetics, including cancers of the breast, prostate, pancreas, colon and rectum (although the published research in this area is overwhelmingly based upon retrospective, and hence less accurate, data). The vast majority of metformin cancer prevention studies have been performed in diabetics who are already taking metformin (http://doctorwascher.com/Archives/7-12-09.htm). As diabetes is, by itself, a significant risk factor for cancer, it is unclear at this time if metformin can significantly decrease cancer risk in non-diabetic patients. Therefore, the use of metformin for breast cancer risk reduction should be considered investigational at this time (in both diabetics and non-diabetics). Fortunately, there are multiple ongoing prospective clinical trials looking at the role of metformin as a cancer prevention agent in both diabetic and non-diabetic patients. Unfortunately, it will likely take 5 to 10 years before the data from these trials has been collected and analyzed.

I really try to have them focus on 1. achieving a healthy weight 2. consuming a healthy diet 3. Avoiding chemical exposure as much as possible 4. Relieving stress in their lives 5. Making sure to manage any side effects of meds (like hormone blockers) so that they continue to take them 6. Stay up to date on all other cancer screening. My favorite book about these topics is Anti Cancer a New Way of Life by David Servan-Schrieber, MD, Phd

There is a growing recognition that pathological findings may assist in prognosis. It is unclear from your question what disease this represented. Perineural extension is often noted in prostate cancer. This may confer a higher risk of recurrence in this disease. Again, this is disease specific. A growing number of algorithms are being developed that combine histology, nuclear grade, lymphatic invasion, vascular invasion, and molecular markers to provide better information regarding risk of recurrence.

Great answers...I'd like to add that you want to aim for at least 15 servings of fruit and veges (more veges than fruit) and include at least 10 different varieties. Look for a rainbow of colors as each has its own cancer fighting properties. Limit dairy, eggs, poultry and meat, and peanuts/peanut butter as they can promote cancer friendly inflammation in the body, and in the case of the former, add unwanted hormones.

The day I was diagnosed with breast cancer my doctors told me I had to stop taking the pill. When I asked why they told me becasue, "they can cause breast cancer". I went straight home and opened up the pill pack pamphlet folded up in the lid, the one I never read for 15 years, and it says it right there in black and white. I firmly believe that the Rx manufacturers are required to disclose this for a reason and I bet if you talked to enough breast cancer survivors you would learn that this is a huge common denominator. I don't believe it is any coincidence. Dr. Malcolm Pike, epidemiologist at SLoan Kettering Cancer Institute has said he believes the risk increase is closer to 21%, not the "claimed 2%"

Hard question to answer. In addition to BRCA, did anybody undergo BART testing? This test is for large DNA rearrangements and is done through Myriad Genetics. If it has been done, then your family falls in a high-risk familial breast cancer category. I would treat y daughter's breasts as if there were a BRCA mutation in the family and offer annual MRI alternating with mammogram and sonogram every 6 months. In between I would suggest that she have clinical breast exams, one by her gynecologist and one by a breast surgeon. If she is exceedingly anxious or is hard to examine, I would consider prophylactic mastectomies with immediate reconstruction. It cannot totally eliminate the risk of cancer, but brings it down to less than that of the general public. The reason risk still exists is that a minute amount of breast tissue remains after a mastectomy and could still result in a breast cancer, but there is nothing better available at this time.

These are the guidelines:
For the general population, no family history of breast cancer:
Baseline mammogram at age 35 or 37. Mammograms every 1-2 years from 40-50, annual mammography above age 50.

I am sure that you are aware that there is a great deal of controversy regarding annual mammograms in the 40's. I believe that they should definitely be done. It is true that cancer is less common in this age group compared with women above 50, but unfortunatley we do see many cases in young women. Statistically, some argue that the mammograms are not reducing mortality, or saving lives. Well, in my opinion this is not the only criteria to measure, for example if you found an early cancer in a 46 year old women which will only require lumpectomy, but not mastectomy, or chemotherapy, (which might be the case had this only be diagnosed 4 years later), then we have done a great service to this patient and her quality of life. It is true that some of the cases diagnosed in the young women are particularly aggressive, and that the early detection may not save her life, but I do not think this is a reason for not offering it. Furthermore, some of the studies discouraging mammography discuss the anxiety related to additional workups (magnification views and spot views) and unnecessary biopsies, all valid arguments. But the anxiety can be allayed with proper discussions and education, and we are working on not biopsying findings that are not worrisome. But it is true that most biopsies are negative, still... we are doing our best with the technology we have, this may change in the future. I do not know the number of cancers I have identified in women under 50, on screening, but it is great! It is true that I have also biopsied many many benign nodules and calcifications, this is the trade-off.

In women with dense breasts and/or a family history of breast cancer, screening sonography should also be performed annually. Sonography may increase detection by 30% or so.

In women with a strong family history, or personal history of breast cancer, screening MRI should be performed, as well.

If both you and your mother have had premenopausal breast cancer, then genetic testing should probably be performed.
Good luck to you and your mom.

Most women choose close surveillance, seeing their breast specialist twice a year for breast examinations along with screening. In addition to that, you may be referred for chemoprevention or hormonal treatment such as tamoxifen or if post-menopausal (raloxifene, exemestane).
It is not necessary to have a mastectomy for ADH alone.

High risk lesions such as atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH) and LCIS (lobular carcinoma in situ) or lobular neoplasia when identified on a needle biopsy are often followed by an open excisional biopsy as there is a 10-20% incidence of an associated cancer.

Patients can be offered chemopreventive agents such as tamoxifen or raloxifene. However, most women are generally followed twice a year with physical examinations and annual mammograms.

I'm assuming you mean LCIS (lobular carcinoma in situ or lobular neoplasia) discovered by a core needle biopsy. Yes, it is advisable to the lesion removed as there is a 10-20% incidence of an associated invasive cancer.