You
wake one morning and find a lump in your breast or
you go for a screening mammogram and get recalled
for additional views.
Welcome
to the roller coaster of breast disease. However,
this process need not be frightening, as you are
in control and you determine where you are going.
What you need now is information.
Where
do you begin this daunting task?
The
most important thing to do is to get the answers
to all of your questions. A mass in your breast or
an abnormality on your mammogram will require further
evaluation. An ultrasound is often required to further
characterize a mass as solid, requiring biopsy, or
cystic which may or may not require aspiration.
There
are also microscopic findings on mammograms called
calcifications that may require spot magnification
views. Depending upon the findings of your radiologic
studies, you may be referred to a surgeon or radiologist
for a biopsy.
Most
procedures to biopsy the breast can be performed
in an out patient setting, which will allow you to
have the procedure performed more quickly. Oftentimes
an ultrasound or mammogram is used to guide your
surgeon to the abnormal area of your breast. If the
lump in your breast is not apparent on any studies,
it still needs to be evaluated and likely require
a biopsy to determine whether it is or is not cancerous.
Remember, 20% of all cancers are not seen on mammograms
or ultrasounds; therefore, palpable masses with negative
x-ray studies need to be thoroughly evaluated.
The
bottom line with an abnormal mammogram or ultrasound
or a palpable mass is that a tissue biopsy is the
gold standard to determine whether the mass is benign
(not cancer) or malignant (cancer). If your questions
are not adequately answered, get a second opinion.
In
order to prevent breast cancer from occurring we
must understand what causes it to begin and what
causes it to grow. Ultimately all breast cancer is “genetic”.
It does not mean that everyone who is diagnosed with
breast cancer has had a relative affected by breast
cancer as only 25% of all women or men diagnosed
have a positive family history. It means in the other 75% of
breast cancers diagnosed, there is a change in the
genes that control the cells growth and division.
Once altered, the cells begin to divide in a “chaotic” or
disorganized manor forming a mass or a cancerous
growth.
Not
all cancers grow at the same rate. Some are very
rapidly dividing tumors and others may take years
to become evident on mammography or on clinical exam.
There are many factors that play a role in the growth
and development of breast cancer.
Although
genetics plays a role in all cancers, one single
genetic alteration is not enough for a cancer to
form. Even women with BRCA-1 and BRCA-2 gene alterations
are not guaranteed to develop cancer. They are clearly
at a much greater risk for the development of breast
and ovarian cancer but other factors still come into
play. Women who test positive for the BRCA-1 and
BRCA-2 genes have an 80 to 90% chance of developing
cancer. But this gene alteration accounts for only
5 to 9 % of all breast cancers diagnosed. Other internal
and external factors are involved in the formation
of a cancer.
Your
physician can determine your individual risk for
the development of cancer in the future. The most
widely used formula is called the GAIL risk model
and takes into consideration many factors. This is
only an estimate and can be used to assess your risk
profile.
The
most prominent factor in the risk assessment is having
been born a woman. Only 1% of breast cancers are
diagnosed in men, therefore being female is the most
obvious risk factor. The next factor that comes into
play is age. The preponderance of breast cancers
are diagnosed in women over 60 but cancer can occur
at any age. (80% of all breast cancers occur in women
over 50 with no family history) The next factor we
look at is how many first-degree family members (mother,
sister or daughter) have been diagnosed with this
disease.
A
history of multiple breast biopsies, particularly
those with atypical changes is a significant factor.
Estrogen exposure is the next factor that has many
components. Estrogen does not cause a cancer to form,
but it can promote the growth and progression of
the disease. Menarche, the age of your first menstrual
period, is a factor that you cannot control. The
earlier your period begins the higher the risk. Being
nulliparus, never having given birth, and having
your first child after the age of thirty, also increases
your risk profile.
The
GAIL risk assessment allows your physician to determine
your five year and lifetime risk and can become an
important factor in your decision making process
when it comes to breast cancer prevention.
There
are risk factors that are under your control. The
foods you eat and the toxins that you choose to put
in your body is an area within your control. The
obvious toxins tobacco and excessive alcohol consumption
can be eliminated, as they are associated with so
many cancers and disease processes in our bodies.
Obesity,
a diet high in saturated fats, lack of exercise,
and environmental pollutants are also linked to the
development of breast cancer. Radiation exposure
(in levels much higher than mammography requires
for screening) has deleterious effects on normal
cellular function. Free radical formation is thought
to be at the root of the aforementioned factors and
therefore, vitamins, antioxidants, and a healthy
lifestyle are certainly an option for those who choose
to be proactive.
All
women may want to adopt these strategies since they
are all, by virtue of being female, at risk. The
incidence of breast cancer has increased over the
past 25 years from 1 in 15 to 1 in 8. Certainly our
lifestyles have been altered during that time period
and we have the power to alter them in a positive
manor.
In
addition to life style and dietary modification there
are several options for women at high risk. If you
are premenapausal and at a significant risk, your
physician may recommend you take a drug called tamoxifen.
In a recent study, the National Cancer Institute
and National Surgical Breast and Bowel Project were
able to show a 44% reduction in the development of
breast cancer in women at high risk. It works by
blocking estrogen receptors in the breast and therefore
prevents the cells with the potential for cancer
from dividing. The decision to go on tamoxifen should
be discussed at length with your team of physicians,
as there are potential side effects along with its
benefits.
If
you are a postmenapausal woman, you have the additional
option of participating in an ongoing clinical trial
called the STAR trial. STAR stands for the study
of tamoxifen and raloxifene. Both drugs have been
shown to be effective in protecting bones from osteoporosis
and both appear to be effective in breast cancer
prevention. Tamoxifen has been studied for over twenty
years and is approved by the FDA for reducing the
incidence of invasive breast cancer in high-risk
women. Raloxifene has been suggested to have the
same benefit with possibly fewer side effects. The
goal of this clinical trial is to establish the definitive
answers to these questions by randomizing high-risk
women into two groups.
To
locate a participating STAR center in the US and
Puerto Rico you can call 1-800-4-CANCER. In Canada
call 1-888-939-3333.
Remember: Prior
to making any changes to your health care, it is
of utmost importance to discuss your risk profile
with a physician you know and trust.
Vitamin D has recently been associated with a decreased risk of several cancers. (up to 50% decrease risk of breast cancer when blood levels are between 45 and 100 ng/ml). Vitamin D may also help to prevent diabetes and other cancers.
Our bodies manufacture Vitamin D in response to sun exposure. Possibly our adherence to wearing sunscreen has affected our ability to produce adequate levels of Vitamin D.
Sources of Vitamin D
Sun exposure- 15 min per day ~ 5 days per week (risk skin cancer)
Salmon, tuna, oily fish and milk contain Vitamin D but little enters the blood stream.
25 OH- Vitamin D level will determine the need for treatment
Vitamin D 1000 IU daily dose for therapeutic maintenance
Levels > or = to 45 ng/ml maintain dosages of 1000 IU per day
Levels 30 - 45 ng/ml2000 IU per day for 4 weeks then maintain 1000 IU per day ( retest blood @ 3 months)
Levels 20-30 ng/ml indicates insufficiency2000 IU per day for 8 weeks then maintain 1000 IU daily (retest blood @ 3 months)
Levels less then 20 ng/ml indicate a severe deficiency and should be treated with 3000 IU per day for 8 weeks then 2000 IU per day there after. Retest blood level after 4 months of treatment. This will determine maintenance.
Patients with renal disease should have levels of 30ng/ml
NEJM
Vitamin D Deficiency
Michael F Holick MD PhD
Volume 357:266-281 July19,2007 Number 3
LEARNING IF YOU HAVE BREAST CANCER
