The news media has lots to say about breast cancer, mammograms, and menopause. At times, I find myself a bit confused over all the conflicting opinions of doctors over the new data. We all want to keep our breast friends healthy, so let’s go over the information together.
As the number of candles on our birthday cakes increases, so does our risk of developing breast cancer. While a 30-year-old woman’s risk of developing breast cancer in the next 10 years is one in 227, that of a 60-year-old woman is one in 28, according to the National Cancer Institute. Hit 70 and the risk increases to one in 26.
Dr. Ricki Pollycove, M.D., a women’s health expert agrees, “Age, or getting older, is the single greatest risk for getting diagnosed with breast cancer. There are many likely reasons for this, and many are related to what are called epigenetic factors. In simple words, our lifestyles influence our genes. We can become educated and actively change our behaviors to lower individual risks as we get older.”
Many women are suffering from the various symptoms of perimenopause and menopause, and in spite of the data, remain afraid of hormone therapy (HT). They are convinced it will increase their risk of breast cancer. I asked Dr. Pollycove to tell us how hormone therapy can affect the risk of breast cancer.
“Estrogen use over the long term actually lowers a woman’s risk for breast cancer! It decreased rates of breast cancer by 23 percent in the largest clinical trial out of the U.S., which was re-analyzed after 11 years of conjugated estrogen (estrogen only) use and published in 2011. In fact, a 33 percent lowered rate of breast cancer was seen in women who took more than 80 percent of their study pills! 2015 updates show a continued decrease in breast cancer rates even 5 years after stopping estrogen therapy. However, headlines often read differently and scare women out of the HT they need.”
For example, Dr. Pollycove said that there is a 2013 large mammogram review study in the Journal of the National Cancer Institute that found HT’s effect on breast cancer risk varies somewhat by ethnicity, body mass index, and breast density. Dr. Pollycove further noted that the HT used in this study was MPA (Medroxyprogesterone Acetate), a synthetic progestin (not a bioidentical HT). This form of HT had a small but negative impact – an additional 8 cases of breast cancer in 10,000 women-years of use. It is frustrating that the press often does not mention the different types of HT (bioidentical/natural vs non-bioidentical/synthetic) in their news reports.
Pollycove added, “Most diseases we see on the rapid rise (heart disease, diabetes, osteoporosis, fracture, frailty, dementia and dependency) are all associated with not taking estrogen after menopause. These worse outcomes with aging have appeared in recent population data involving millions of women around the globe.”
Dr. Josh Trutt, MD, a healthy aging expert at Evolved Science in New York City, agrees. Although he prescribes bioidentical hormones, he points out that both bioidentical and non-bioidentical estrogen decrease breast cancer risk, however, when combined with non-bioidentical/synthetic progestins like Medroxyprogesterone acetate or norethisterone, there is a small increased breast cancer risk.”
Dr. Trutt said, “The pervasive fear of breast cancer is causing women to avoid estrogen therapy—which is a tragedy because avoiding estrogen therapy is killing women by the tens of thousands. That’s because each year, heart disease kills 20 times as many women as breast cancer– and taking estrogen cuts your risk of heart disease in half. Because of estrogen’s tremendous benefit in heart disease prevention, if a woman starts estrogen replacement within ten years of menopause, it lowers her risk of death by 40% for as long as she takes it (at least for up to 16 years, which is as long as the randomized prospective studies have followed women on hormones.”
Dr. Pollycove adds, “Observational studies of estrogen users have shown significantly reduced rates of heart disease and diabetes for over 30 years; the more years of use the better the health in menopause.”
“Which hormone regimen is right for you,” says Dr. Trutt, “Depends on how many years it has been since menopause, and what other risk factors you may have. But some form of hormone therapy is appropriate –and, in fact, should be standard of care for prevention of heart disease and osteoporosis– for all menopausal women.”
I was curious if having a hysterectomy affects a women’s risk of breast cancer. Here is the silver lining according to Dr. Pollycove, “Surgical menopause with the removal of ovaries actually slightly lowers a woman’s risk for breast cancer. The basis for this lowered risk is not well understood, but it is one of the good-news aspects of the upsetting situation many women feel when they have to give up their uterus due to pain, diseases like severe endometriosis, or abnormal precancerous or cancerous growths. A 2011 multi-center study from the University of Southern California, Los Angeles, shows that removal of one or both ovaries is associated with a decreased risk of breast cancer.”
On a related matter, mammograms are quite a hot topic! There was a large study published June 2015 which demonstrates, “that routine mammography screening frequently results in overdiagnosis because it identifies invasive breast cancers that would either have regressed on their own or never developed to clinical significance. Overdiagnosis may account for 30%-50% of cancers identified by mammography screening. The absolute number of overdiagnoses may exceed 70,000 women in the U.S. each year.”
Dr. Pollycove feels that the mammogram controversy mostly revolves around Ductal or Lobular Carcinoma in Situ, DCIS or LCIS. These are the presence of abnormal cells inside a potential milk-transporting duct or a milk-producing lobule in the breast.
In the September 2015 issue of the New York Times, there is an interview with Dr. Laura Esserman, a well-recognized breast surgeon and researcher at the University of California, San Francisco. Esserman is one of the most vocal proponents of the idea that breast cancer screening brings with it overdiagnosis and treatment. She is advocating for more “watchful waiting” rather than biopsy-diagnosing these “indolent precancerous lesions.” Her approach was given a boost in a long-term study published in JAMA Oncology. After 20 years of analysis, this study made the case for a less aggressive approach for DCIS.
Pollycove acknowledges that clinical trials are in progress, but she feels that at present, it takes a lot of courage for some women to wait and repeat imaging in a year or so. How completely a woman and her doctor need to explore such mammogram findings, undergo biopsy diagnosis, is a matter of personal opinion.
The study suggests that the more mammograms you do, the more non-dangerous tumors you find, which are then removed, and, therefore, the “mortality rate” is artificially lowered. The study reports that “Overdiagnosis also distorts mortality rate calculations; because the mortality rate is defined as the number of women who died divided by the number diagnosed with cancer. Increasing the number of “diagnosed” women by 30–50% in the screened group lowers the apparent mortality rate. This causes women to believe that mammograms lower mortality much more than they actually do.”
The study authors concluded that, given the impact to the patient of overdiagnosis, together with the lack of evidence that mammography actually lowers mortality rates; informed consent to asymptomatic women should include these results and consideration of the benefits of avoiding mammograms.
Dr. Trutt helped to clarify this for me. He said, “About 40% of “positive” mammograms are not actually dangerous cancers– yet women still go around thinking that they have/had cancer. They undergo more repeat studies, biopsies, often unnecessary surgery. Then they are “cured,” which makes people think “wow, look how many lives we are saving by screening with mammograms”– but these are not women who actually had dangerous cancers, so it is misleading. The mammograms didn’t help at all.”
Dr. Pollycove currently serves on the Board of Trustees of the NCoBC, which includes the society that was formerly known as the American Society of Breast Diseases. Her colleague, Dr. Daniel B. Kopans, Professor, Radiology, Harvard Medical School, Director, Breast Imaging at Massachusetts General Hospital takes great issue with simple statements about overdiagnosis and death rate declines. Dr. Kopans feels that the statement, “mammograms save lives” is not an empty phrase and that primary care clinicians see the enormous difference in the quality of life when breast cancers are detected early and treatments for a cure are much simpler. He and Dr. Pollycove both feel that MRI’s have their place in conjunction with mammography. Seeing “all of the elements in a haystack” makes MRI more difficult to interpret when not guided by mammograms.
In contrast, Dr. Eric Topol, Director of the Scripps Translational Science Institute in La Jolla, California- Chief Academic Officer for Scripps Health, professor of Genomics at The Scripps Research Institute, and Editor and Chief of Medscape states in his commentary on Medscape, “It is time to reboot how we screen for breast cancer. Until now, the use of mass screening suggests that we are unable to differentiate the risk in any given individual. So instead of a smart approach that uses family history and genetics, we have dumbed it down and treated all women the same. As a result, we have come to rely on a test that is notoriously inaccurate but has become a fixed part of American medical practice since it was introduced almost 50 years ago. With the tens of millions of low-risk women unnecessarily undergoing screening each year, any test would be vulnerable to a high rate of false positives. That applies to higher-resolution scans, too, such as magnetic resonance, digital mammography, and ultrasound. Indeed, there is a better path forward.”
I asked Dr. Trutt to tell us about the breast screening protocol he recommends for his patients. He replied, “Not surprisingly, this recent paper demonstrates that for the vast majority of women, irradiating their breasts while applying 50 lbs. per square inch of pressure is more likely to be harmful than beneficial. For higher risk women or women who insist on imaging, I now refer them to Alpha 3T MRI in NYC. Drs. Newatia and Hussman are able to offer what is essentially the Ferrari of breast MRIs because they have optimized their equipment and the technique used. Specifically, they have 16-channel breast coils and a 3 Tesla magnet, and they use “multiparametric” imaging with dynamic (rather than static) contrast enhancement (DCE), diffusion imaging, and spectroscopy. Multiparametric MRI optimizes the accuracy of breast MRI screening for all patients of any age, even the 40% of women with dense breasts. No test is perfect, but they are able to distinguish dangerous from benign lesions better than a mammogram can, which cuts down the stress and expense of having to repeat the study, and reduces unnecessary biopsies.”
Trutt explained, “If insurance doesn’t approve the screening, they charge about $600 cash. Not everyone can afford that, but hopefully insurance will start paying for it when they realize how much cheaper and more accurate a quality MRI is than a mammogram, the results of which are more often “indeterminate” (which leads to more mammograms and then biopsies that could be avoided).”
In contrast, Dr. Pollycove expressed that, “The logic of this is not obvious, but imaging experts disagree with Dr.Topol and Dr.Trutt. The most important thing women can do to lower their chance of having their quality of life or lifespan affected by breast cancer is to get regular mammograms and at least an annual clinical breast exam by a provider. The reassuring news is that the older a woman is when diagnosed, the less likely she is to have a life-threatening cell type of breast cancer. Women with non-invasive cancers of the breast (which are the most common in women who undergo regular screenings) have a disease-free survival rate of 93 percent. Women with non-invasive breast cancer or invasive tumors that are less than a centimeter in diameter often have a lumpectomy in which the cancerous tumor is removed while leaving the rest of the healthy breast tissue intact; called breast conservation. The key here, however, is early detection. Virtually no one dies of in-situ abnormalities. The problem is that without proper removal of some aggressive types of in-situ abnormalities, tumor progression does in fact occur. Using the simple label, ‘Overdiagnosis,’ is vague and can be falsely reassuring.”
Pollycove went on to explain, “The National Consortium of Breast Centers (NCoBC) and internationally respected as the premier multidisciplinary breast care society, recommend annual screening for women 40 and older. To confuse things, however, in 2009, the U.S. Preventive Services Task Force issued new guidelines stating that women younger than 50 didn’t need routine annual mammograms and those ages 50 to 74 should only get screened every two years. Before that, the recommendation was that all women aged 40 and older get mammograms every one to two years—a recommendation the American Cancer Society, NCoBC, ASBD, ASPRS, many physicians, and, according to a study from Brigham and Women’s Hospital, about half of women, still follow.”
In their latest statement, the U.S. Preventative Services Task Force states the following: “The Task Force recognizes that a mammography is an important tool in reducing breast cancer deaths. The science shows that screening is most beneficial for women ages 50 -74. The decision to start screening before age 50 should be an individual one and should be made by a woman in partnership with her doctor. The draft recommendation on breast cancer screening will not affect insurance coverage. Mammography is a screening service generally covered by all public and private insurance plans without co-pays or cost sharing for the patient.”
Dr. Pollycove feels that the task force is based on cost-effective benefit (dollars spent per cancer detected) not on what is always best for the patient. Sadly, the more lethal cancers are more often found in the women aged 40-50. Her hope is that the USPSTF draft recommendation on breast cancer screening will not be endorsed by the US Congress and adversely affect insurance coverage. The PALS Act (Patient Access to Lifesaving Screening Act) has been introduced in both the House (H.R. 3339) and the Senate (S. 1926). The sponsors are Senators Barbara Mikulski (D-MD) and Kelly Ayotte (R-NH) and Representatives Renee Ellmers (R-NC), Debbie Wasserman Schultz (D-FL), and Marsha Blackburn (R-TN). If passed, this would ensure that women who want to get regular mammograms retain insurance coverage with no copay and avert thousands of unnecessary deaths resulting from implementation of draft United States Preventive Services Task Force (USPSTF) breast cancer screening recommendations.
To further expand the conversation of breast cancer, many of us want to understand the risk factors. Dr. Pollycove explained, “Divide the risk factors for breast cancer into two buckets: the risks about which you can do something and those that are out of your control as you enter menopause. While it’s frustrating and often upsetting if you have a family history of breast cancer or mutated BRCA1 and BRCA2 genes, knowing—and communicating to your doctor—your inherited, “not-going-to-change,” risk factors is important in determining the right prevention plan for you. After childbearing is completed, some oncologists recommend considering oophorectomy in BRCA 1 and 2 gene carriers. Some other risk factors include dense breast tissues and previous benign breast conditions such as hyperplasia with atypia of ductal or lobular tissue, cysts, and papillomas. What’s more, if you’ve never been pregnant or had your first pregnancy after age 30, your risk for breast cancer increases slightly, according to the American Cancer Society. Pregnancy and breastfeeding reduce breast cancer risk likely because they help mature breast tissue and reduce the total number of menstrual cycles that a woman has throughout the course of her life; this may influence cancer risk by altering hormone exposure to the breast tissues.”
Whether to get the BRCA testing done is a decision that you and your physician should make together. Information is power. My cousin, Karen, had breast cancer and being that I am of Ashkenazi Jewish descent, I decided I wanted the BRCA test. The more baseline information available for my doctors and me to consider, the better. I wanted to have this information for me, my children, grandchildren and the many generations to follow so that it can be incorporated into our ongoing heath care decisions.
Pollycove went on to expand on the risk factors that we can control. She put it quite simply, “Basically, anything that’s bad for your overall health is bad for your breasts. Some examples: smoking, being overweight or gaining weight at mid-life, living a sedentary or stressful lifestyle, eating a diet high in saturated fat, drinking more than seven to 10 alcoholic drinks per week, and eating few fruits and vegetables.”
Dr. Pollycove, “beats the lifestyle drums” every day in caring for her patients. Her prevention prescription: Perform aerobic exercise for at least 20 minutes a day. She maintains that this alone can cut your risk of breast cancer in half. I shall remember that when I am having a hard time peeling myself out of my desk chair to go exercise!
Women have critical decisions to make regarding their breast health. As confusing as it may be, it is important to be aware of the latest information and science so that you can be a full partner at the table and discuss the pros and cons of these important health care decisions which affect your quality of life and lifespan.
This is a lot to digest for me, too! But, I wanted to give you a well-rounded and uplifting (pun intended) version of both sides of the story. Now, I think I need to take my breast friends out for a drink!
My Motto: Suffering in silence is OUT! Reaching out is IN!
Click here to download my free eBook, MENOPAUSE MONDAYS The Girlfriend’s Guide To Surviving and Thriving During Perimenopause and Menopause.