Can I Prevent Breast Cancer?Can I Prevent Breast Cancer?

Patty Tenofsky, MD FACSVia Christi 50+ Lunch and Learn

Wednesday, Oct. 17

2

TopicsTopics

Breast cancer risks

Breast cancer prevention

Breast cancer screening

Improving breast cancer outcomes

3

Risk FactorsRisk Factors

Risk factors that cannot be reduced Being a woman Getting older Family history Breast density Age at first menstrual cycle Age at first pregnancy Breast biopsies

4

Risk FactorsRisk Factors

Being a woman For every 99 women who get breast cancer there is

one man who gets breast cancer

Getting older The media has a tendency to focus on younger

women with breast cancer, but that is actually rare. Odds

30-39 0.43% (1 in 233) 40-49 1.45% (1 in 69) 50-59 2.38% (1 in 42) 60-69 3.45% (1 in 29) Overall lifetime risk 12.1% (1 in 8)

5

Risk FactorsRisk Factors

Family history Having one first-degree relative doubles your risk

Lifetime risk is around 20%

Two first-degree relatives give you a risk that is 5 times higher

Lifetime risk is 30-40%

Second and third-degree relatives most likely affect risk, but not as significantly as first degree relatives

Lifetime risk between 10-15%

6

Risk FactorsRisk Factors

Family history Rare for a woman to have a breast cancer

gene Only 5-10% of families have multiple women with

breast cancer There are usually a significant number of women

(and men) with breast or ovarian cancer, especially under age 50

Lifetime risk of breast cancer — 80% Gene can be tested for if criteria is met

7

Risk FactorsRisk Factors

Breast density Having a higher amount of breast tissue and

connective tissue (the tissue between the breast tissue) compared to fat increases risk

Relatively new risk factor Increases risk 4-5 times Harder to screen with mammograms

• Definitely need digital mammograms

• Possibly sonogram and MRI as well — being studied Probably inherited Cannot be determined by breast size or exam — it’s a

mammogram finding

8

Risk FactorsRisk Factors

Breast density

9

Risk Factors — Small Risk Factors — Small

Menstrual cycle/pregnancies/biopsies Women who are exposed to less estrogen in their

lifetime have a lower risk of cancer Girls who start their menstrual cycle at a later age (15-16)

(This rarely happens anymore.) Women who bear children at a young age (less estrogen

when pregnant)• Women who have children late or do not have children have a

higher risk Women who breast feed for more than six months (less

estrogen when breast feeding) Studies show a slightly higher risk if a woman has

biopsies even if they are benign. The reason is unknown.

10

Risk FactorsRisk Factors

Options for women with risks that cannot be reduced

Digital mammograms Additional testing depending on your risk,

such as sonograms or MRI Medications that can lower your risk — such

as tamoxifen or raloxifene (Evista) Try to minimize risks that may be reduced

11

Risk FactorsRisk Factors

Risk factors that can potentially be reduced Maintaining a healthy weight Exercise Limiting alcohol Avoiding hormone replacement medications

or staying on them for only a short period of time

Environmental factors

12

Risk FactorsRisk Factors

Weight Being overweight increases the risk of breast cancer,

especially after menopause Both an increase in body weight as an adult and

gaining weight as you age increases risk Most likely because fat produces low levels of estrogen and

stores it, making estrogen levels higher in heavier women

Higher weight also increases the risk of recurrence of breast cancer once diagnosed and decreases survival if the breast cancer is sensitive to hormones (most are)

13

Risk FactorsRisk Factors

Exercise Women who exercise have a lower risk of breast

cancer Possibly because it reduces weight or it may decrease it

simply on its own

Estrogen levels tend to be lower with regular exercise 150 minutes of moderate exercise or 75 minutes of

vigorous exercise/week at a minimum to reduce risk Strength training may also be beneficial Women who exercise are also better able to tolerate

the treatment of breast cancer if they are diagnosed

14

Risk FactorsRisk Factors

Limiting alcohol The more you drink, the higher your risk Try to limit yourself to one drink per day or

less to lower your risk

15

Risk FactorsRisk Factors

Hormone replacement medications Long term combination therapy (estrogen &

progesterone) increases the risk of breast cancer. Long term is considered more than 5 years

Combination is given to women who still have a uterus because estrogen alone increases the risk of uterine cancer

Estrogen alone probably does not increase the risk of breast cancer too much, especially if on it fewer than 10 years

No research studies on bio-identical hormones and their risk

Do not assume they are safer (American Cancer Society)

Birth control pills — no link to breast cancer

16

Risk FactorsRisk Factors

Environmental pollution Possible link to polycyclic aromatic

hydrocarbons (vehicle exhaust, air pollution) No real research shows this

Water bottles: Polyethylene terephthalate (PET)

No real research linking this either

Deodorant — no link

17

Risk FactorsRisk Factors

Miscellaneous risk factors Diet

What you eat doesn’t seem to be as important as weight control

No particular food seems to increase or decrease risk

• Soy is okay

Birth control pills No increased risk of breast cancer Does lower risk of ovarian cancer

18

Risk ReductionRisk Reduction

Chemoprevention medications, given to help prevent cancer from occurring, can lower risk

SERMS — Selective estrogen receptor modulators

Tamoxifen and raloxifen (Evista)

19

Risk ReductionRisk Reduction

Tamoxifene results Dark circles —

tamoxifene Open circles —

placebo Left — invasive Right —

noninvasive Risk decrease by

1/2

20

Risk FactorsRisk Factors

Risk for invasive breast cancer reduced by 49% when using tamoxifen

At 69 months: incidence was 43.4 vs. 22 per 1000 in placebo vs. tamoxifen

19% reduction in hip, radius and spine fractures

Adverse affects: Increased risk of uterine cancer Increased risk of pulmonary embolism, DVT,

stroke and cataracts

21

Risk ReductionRisk Reduction

Raloxifen: Only for postmenopausal women As effective as tamoxifen for preventing

invasive cancer and probably not as effective for noninvasive cancer

Used for osteoporosis and breast cancer reduction

Side effects are probably not as severe as tamoxifen

22

Risk ReductionRisk Reduction

Who are candidates for these medicines? Strong family history Previous biopsy showing lesions (such as

Atypical cells, Papillomas, or LCIS) that make your risk higher

23

ScreeningScreening

Early detection and treatment Best strategy since lifestyle methods are not

easy and only reduce the risk slightly 98.4% five year survival when cancers are

detected early Before they can be felt on exam Cancers are detected earlier and our treatment is

better

24

ScreeningScreening

Normal risk women Mammograms starting at age 40 Continue if the woman is in good health

High risk women Strong family history; BRCA positive; radiation

to chest wall Mammograms starting 10 years before

youngest affected family member Mammogram MRI screens for very high risk

25

ScreeningScreening

10 year survival for mammogram detected lesions: 95%

Women 50-69 have decreased mortality with screening (30% fewer deaths)

Women 40-49 with less benefit, but most (not all) studies show 17-24% decreased mortality

26

ScreeningScreening

MRI screening BRCA Lifetime risk of

20-25% (Gail or other models)

History of radiation to the chest between ages 10 and 30

Evaluates breast implants for rupture

27

Improving OutcomesImproving Outcomes

Screening is the key to detecting cancer early when it is most curable

Mammograms started in the 1980s — they aren’t perfect, but they are a good screening tool because they are inexpensive, have low risk and have been shown to work

Improvements: Digital CAD detection Addition of sonograms to test suspicious areas

Screening rate: 65-70%

28

Improving OutcomesImproving Outcomes

Mortality rates from breast cancer in women under age 70 have shown a sharp and sustained fall

Improving outcomes linked to: Good screening regimens Minimizing delay in treatment Multidisciplinary teams working together

• Surgeons, medical oncologist, radiation oncologist, plastic surgeons, radiologists, pathologists, research cooperatives

Follow up to identify and treat local recurrences and adverse effects of therapy

29

SummarySummary

Best advice to lower your risk: Regular, intentional physical activity Reduce your lifetime weight gain by limiting

calories Avoid or limit your alcohol intake If you require hormone replacement

medication for menopausal symptoms, try to take it for a short period of time at the lowest possible dose.

30

SummarySummary

Best advice to improve your outcome: GET YOUR MAMMOGRAMS — it is the BEST way to

detect cancer at it’s smallest, most curable stage, especially over age 50

Women at high risk (strong family history; BRCA gene; radiation to chest wall) should:

Consider additional screening (MRI) Consider risk reducing medications

Remember — 95% of women will be alive at 10 years post-treatment if their breast cancer is not able to be felt and is detected only by a mammogram.