Breast health

Breast cancer awareness — our perspective

by Dixie Mills, MD, FACS

I remember a time before October became Breast Cancer Awareness Month. I spoke during the first Breast Cancer Awareness Month — and many times since and probably many times in the future — but I truly hope I live long enough to see the end of the need for a Breast Cancer Awareness Month. I remember talking to the grandmother in Oregon who made the first pink ribbon. I was laughed at for wearing one the first year and the next year I ran out of them. Now you can find pink ribbons in every shape and form and even pink bracelets. One would be hard-pressed to find a person who doesn’t know what the pink ribbon stands for. But do we really need more awareness? Unfortunately, almost every woman today knows someone who has had breast cancer, and most have had a good friend or family member affected. What I would really like to see is more progress on the prevention front.

Women in my mother’s generation didn’t talk much about their illnesses and rarely knew someone with breast cancer until they were in their 60’s. We Baby Boomers know many with the disease and some who have died. I understand that the numbers are increasing partly because of the population boom of women in their 40’s and 50’s. But it still seems like too many. Women may be surviving a few years longer but are still dying too young. The mortality rates have not changed significantly in over 50 years. And what I really do not like is that younger women, the Gen-X’ers, have friends in their 30’s contracting breast disease. Some of these young women have family histories of breast cancer but many don’t. I know I see it in my practice but am not sure if this is a national concern or not — I think it should be.

With many issues today it seems difficult to find the balance between realistic fear and obsessive anxiety. We have all noticed how the things that we are most afraid will occur often do seem to happen. Some call it the law of attraction. The solution is usually to face your fear, understand it and move on. Unfortunately, in breast cancer the answers are not always there and it is hard to find good places to go to understand the fear — who’s heard of support groups for women afraid of getting breast cancer?

At Women to Women we get asked every day: What can I do? What should I be doing so I don’t get breast cancer? How much broccoli should I eat, how much exercise should I get, is one drink a night okay, is nursing protective, is it my bra or my deodorant? Today there are many great resources available on breast cancer and we provide some of them at our clinic and on our website. But I would like to take this opportunity to tell you my personal assessment of the issues based on over 15 years of working in the trenches, what I see as new and exciting developments and my hopes for the future.

Breast health concerns and research

People have talked about the war on cancer for many years now. (Check out the article in the March 2004 issue of Fortune magazine, “Why We’re Losing the War on Cancer [and How to Win It]”). Today all we hear about is the war on terrorism. One can make many analogies. Many women have lived in a mini terror state — or constant heightened alert — around their breasts for years. Most women do not feel very secure about their breast health. We have no idea what we should be looking out for. Eating a lot of vegetables and exercising just doesn’t seem enough protection.

In the past 15 years of working with breast cancer I have seen some changes, a few new innovations and some better drugs but I’m still impatient for more progress. Mammograms can detect but don’t protect and we wonder, are they really that good? The false negatives abound and women are made to feel it is their fault if their breasts are dense and can’t be read. Ultrasounds are much kinder to the breasts but cannot be easily compared from year to year and cannot detect in situ disease. MRI’s are not cost-effective at this time and also turn up too many false positives.

Ironically, we have managed to send the Rover up to Mars to explore its surface but we still can’t get a good picture of a breast! I trust that researchers are still looking into better imaging of the breast — including digital — that will be more enhanced than just flat black and white.

I often joke with my patients that when I retire I have dibs on being the curator of a mammogram museum. Self-exams are not encouraged anymore because they seem to cause too much anxiety and don’t really detect small lesions. That being said, most women find their own lumps themselves and should feel comfortable touching themselves. There is also a urine test being evaluated in Boston and other places around the country. Hopefully, in the near future this test can be used to screen women who can then decide whether they should go on and have a mammogram, an ultrasound or an MRI.

These days, women are definitely more informed and go to their doctors armed with great questions. Women today know they have choices for treatment and should also know they have time to weight their options and get second opinions. Women today should not go into surgery wondering if they will wake up with or without a breast. Most women can now choose to have a mastectomy or lumpectomy. They can talk with other women who have had breast cancer. There is a computer program to analyze a woman’s benefit from chemotherapy. Actually, many women feel overwhelmed by the amount of information they are given and the people who come out of the woodwork to give them advice. But I’ve found that with time, the majority of women are grateful for this input and have no regrets about their decisions years later.

Today, I am actually seeing many women who are choosing to have mastectomies because they want to, not because their doctor told them it would be best. In the last year I have performed more preventative mastectomies than in any prior year because a greater number of pragmatic women are saying, “I don’t want to keep going through mammograms every six months waiting for a time bomb to go off. I’ve nursed my babies, I can get reconstruction, and I’ll feel much better with ‘them’ off my chest.” When they ask me if I think they are crazy for going this way, I say to them, “While I would never say you must, I won’t say you shouldn’t.” In fact, some days after seeing so much breast cancer in women younger than me, I think I should have bilateral surgery myself.

After 15 years, I realize as I write this that it has been a long war. I have seen some battles won, others lost, but most are still being fought. I admit that some days I get depressed and discouraged and truly could not keep going if it weren’t for my patients. I’ve had the great fortune to meet such wonderful women who have inspired me with their strength, courage, resilience and hope. What being a breast cancer doctor is all about for me is seeing and hearing the amazing, true and diverse stories of personal growth and connection — the discovery of some sort of purpose and meaning out of all the suffering. On the days when I think I’d rather be selling chocolates or flowers, I realize I am fortunate to have the opportunity to really see inside people’s bodies (besides actually cutting them open) and to help them find their core, if they want to. Although I don’t have a degree in psychology, I do find it very valuable for my patients to talk about their relationship with their breasts. The doctor-patient relationship is a sacred one and one of the important “dances” in our life. I want to express my personal gratitude (and I’m certain I speak for most other providers) in saying thank you to all our patients. I know we are all working toward the day that Breast Cancer Awareness Month will no longer be necessary because a true understanding of its causes and treatments will have been found.

Breast cancer treatment

In the meantime, one of the brightest surgical innovations in the last five years is the sentinel node biopsy, which spares women a complete axillary dissection which often leads to the dreaded arm swelling, or lymphedema. Sentinel node biopsy is the standard of care almost everywhere now and should be offered to all women. There are still some unanswered questions about its use — like if it should be done with DCIS (ductal carcinoma in situ), what a surgeon should do with a positive sentinel node, or what to do with internal (under the sternum) nodes — but there are clinical trials going on to answer these questions. Ask your doctor about them.

Just as every person is an individual, I’ve learned that breast cancer is certainly not just one disease. Each tumor is different and each woman is unique. Treatment plans are just now becoming customized as tumors are being analyzed with genetic profiling — check out www.genomichealth.org.

Hopefully, in the future more individually-targeted therapies can be used rather than giving all women the same harsh drugs. Today all the anti-estrogen drugs, tamoxifen, and the newer aromatase-inhibitor pills are often prescribed in the same dose to every woman, regardless of her body weight, age or hormone levels. We regularly monitor doses of most other drugs to see if they are working, but for breast cancer patients the rule is five years for everyone. When women ask why, they are told that “studies” support this. Well, I think women are going to — and should — be demanding more individualized studies in the future.

I also hope that women’s immune systems will be better understood to maximize the efficacy of their treatments. And some day we will unlock the mysteries of women’s hormones. Why if women’s estrogens naturally decline with age does breast cancer linked to estrogen increase with age? I’ve never heard a good answer to that question. Would it be heresy to ask — maybe some breast cancers are related to an estrogen deficiency? Is there a good estrogen and a bad estrogen for cancer like there is a good and bad cholesterol? Some people think so and are beginning to measure them.

Breast cancer prevention and causes

As much as all breast cancers are different and treatments need to be individualized, I’m afraid that prevention will have to be individualized also. The causes of breast cancer have obviously eluded us; estrogen is guilty by association — women get breast cancer 100 times more often than men. But placing the onus on a ubiquitous, naturally-produced hormone is fraught with problems — as we’ve seen in so many women’s health studies. For years the dogma was that girls who got their periods early in life were at greater risk; now a recent study says that this may not be true. What may prove more important are influences on a fetus in her mother’s womb and birth weight. Now how can a public health policy intervene there? We do know that our environment is polluted with xenoestrogens from pesticides and hormones in the food chain, and that xenoestrogens have many negative health effects, but any direct link to breast cancer has not yet been established.

I hope we can find an “easy” method to prevent breast cancer — like brushing teeth with fluoride prevents cavities. Wouldn’t it be great if something could be “sucked” into the nipple ducts that would clean out any pre-cancerous cells? I now truly wish that the cause of breast cancer could be proven to be from exposure to a virus — as is being discovered with other cancers like those of the cervix and stomach. But is anyone looking?

Does stress cause breast cancer? The majority of my patients have had stressful lives at some point, but haven’t we all? We do know that inflammation is harmful for cells (click here to read about chronic inflammation) and we know that aspirin use and other anti-inflammatory drugs seem to reduce the risk of developing breast cancer.

There are obviously multiple triggers for a cancer cell to start dividing and not stop. One fantastic study looking at the different genetic and environmental factors is the Sister Study, now expanded to a national database derived from siblings, some of whom developed breast cancer and some didn’t. I am very exited about the possibilities to be learned from this study and encourage women to enroll.

As for other preventative measures: I do tell my patients that working at maintaining a healthy lifestyle, physically, emotionally and spiritually, is essential for all wellness and disease prevention. A study released in spring 2004 at the American Society of Clinical Oncology found that breast cancer patients who ate a low-fat diet lowered their risk of recurring estrogen negative tumors by 42%. No one has fully explained the science behind this, but it supports the idea that a healthy diet is an important step. While I don’t claim that our Personal Program is a wonder treatment or the “answer” — and I tell women to be suspect of anything that claims to be — I do know that our nutritional supplements are of the best quality and contain the most effective dosages for supporting good health. There is a lot of research underway into the relationship between multivitamins and the prevention of cancer. It appears that the addition of daily supplements helps boost the immune system, which may help the body ward off cancer. In addition, the nutrition plan in the Program is geared toward eating healthy foods and achieving and maintaining appropriate weight.

Going even further, we ask women to look at their life goals, their priorities, and where they want to be in the second half of their lives. We ask you to look at how you can best get there. Our philosophy is that your biography is your biology and you can create a new story at any point. All of this may take time and work, but our help and support is always there. I hope that someday a grocery aisle will have packages of a breast health product next to the toothpaste, deodorants, and Tampax. I look forward to a future where women can touch their breasts without fear, perhaps even in fun, hug them and truly say — girls, you are safe with me.

Related to this article:

References & further reading on breast cancer awareness

 

Original Publication Date: 10/26/2004
Last Modified: 02/16/2010
Principal Author: Dixie Mills, MD