Risk Reduction

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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 because only 25 percent of all women or men diagnosed have a positive family history. It means in the other 75 percent 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 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 up to a 90 percent chance of developing cancer. But this gene alteration accounts for only 5 percent to 9 percent 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.

Here are the most common risk factors:

Being a woman. Only 1 percent of breast cancers are diagnosed in men.
Age. The preponderance of breast cancers are diagnosed in women over 60, but cancer can occur at any age. (For example, 80 percent of all breast cancers occur in women over 50, with no family history).
Family history. How many of your first-degree family members (mother, sister or daughter) have been diagnosed with this disease?
Your history. A history of multiple breast biopsies, particularly those with atypical changes is a significant factor.
Estrogen exposure. Estrogen does not cause a cancer to form, but it can promote the growth and progression of the disease.
When your period started. The age of your first menstrual period is a factor that you can’t control, but the earlier your period begins; the higher the risk you have of developing breast cancer.
Children. If you’ve never given birth or had your first child after the age of thirty, this 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. Tobacco and excessive alcohol consumption can be eliminated because each is 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. Getting enough vitamins, antioxidants and maintaining a healthy lifestyle are ways to be proactive about breast cancer.

The incidence of breast cancer has increased over the past 25 years from 1 in 15 women to 1 in 8 women. 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 lifestyle and dietary modification, there are several options for women at high risk. If you are pre-menopausal 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 percent reduction in the development of breast cancer in women at high risk. Tamoxifen works by blocking estrogen receptors in the breast and preventing 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 because there are potential side effects, along with its benefits.
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Breast Cancer Risk Assessment

Am I at risk for developing breast cancer?
Women by virtue of being born female are at increased risk of developing breast cancer. One in eight women will be diagnosed in her lifetime. Only 25 percent of all breast cancers occur in women who have a family history of breast cancer. Of those women, only 6 percent of them are related to the BRCA I and BRCA II gene. Therefore, 75 percent of all breast cancers occur in women without any family history. For this reason, it is important for all women to understand what her risk is. For every 100 women diagnosed, one man will be diagnosed with breast cancer therefore, men should not ignore a breast mass either.
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Gail Risk Assessment

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 percent of breast cancers are diagnosed in men. The next factor that comes into consideration is age. The preponderance of breast cancers are diagnosed in women over 60, but cancer can occur at any age. (For example, 80 percent 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 nulliparous, never having given birth, and having your first child after the age of thirty, also increases your risk profile.

BRCA Testing

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 percent chance of developing cancer. But this gene alteration accounts for only 5 to 9 percent of all breast cancers diagnosed. Other internal and external factors are involved in the formation of a cancer. Testing for the gene is as simple as a blood test or a buccal (cheek) sample. Patients should be counseled on the implications of the test results for them and their families.

For more information regarding genetic risk, visit FORCE-Facing Our Risk of Cancer Empowered.

Who should be tested for the gene?

If you have the any of following:

Personal history of breast cancer diagnosed before age 50.
Ovarian cancer at any age.
Male breast cancer at any age.
Multiple primary cancers.
Bilateral breast cancers.
Ashkenazi Jewish ancestry.
Relative of a BRCA mutation carrier.
Family history of breast cancer before 50 and/ or multiple relatives on either you father or mothers side of the family.

If you have the gene, know your risk:

50 percent of carriers will get breast cancer by age 50: 2 percent in the general population
87 percent of carriers will get breast cancer by age 87: 5 percent in the general population
44 percent of carriers will develop ovarian cancer: 2 percent in the general population

BRCA I and II Prevention Strategies 
Surgery and Tamoxifen are both options for women who are found to be carriers of the BRCA I or II mutations. Surgery for removal of the ovaries is recommended for women when they have completed child bearing. The ovaries are very difficult to follow for the development of ovarian cancer. Trans vaginal ultrasound and blood testing for Ca 125 levels are options for surveillance, but surgical removal of the ovaries is recommended.

Bilateral removal of the breasts is the surgical option of women carrying the gene. Immediate reconstruction is recommended to help with the psychological and emotional issues that come with the surgery. Removal of the breasts does not discount all risk of breast cancer because you can’t remove each and every ductal cell of the breast. The risk of cancer forming after prophylactic surgical removal of the breasts is approximately 2 percent.

Tamoxifen has been shown through the NSABP (National Surgical Adjuvant Breast and Bowel Project) breast cancer prevention trial to decrease the risk of breast cancer occurring by 48 percent in high-risk patients. Tamoxifen is taken once daily and is fairly well-tolerated. In women who carry the BRCA I mutation, Tamoxifen my not be as effective as 67 percent of the breast cancers in these women are called Basal cancers or Triple Negative cancers that are not receptive to estrogen blockade.

Side Effects of Tamoxifen

Endometrial cancer
Hot flashes
Weight gain
Thrombo-embolic disease

One downside to Tamoxifen for prevention in BRCA I and II carriers is that many cancers that form in these carriers are ER-, PR- Her 2 Neu negative; therefore, Tamoxifen would not prevent the formation of these tumors.

Evista is an alternative anti-estrogen agent that can be used in postmenopausal women to prevent breast cancer.

SURVEILLENCE

Increased Surveillance

Breast self exam monthly
Clinical exam semi annually (by a physician)
Digital mammogram annually alternating with
Breast MRI

Ovarian cancer prevention

CA-125
Pelvic exam annually
Transvaginal ultrasound

Chemoprevention

Breast: Tamoxifen
Ovary: Oral contraceptives

Prophylactic surgery

Breast: Bilateral breast removal
Ovary: Bilateral tubes and ovary removal
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Breast Cancer Risk Reduction

75 percent of all women diagnosed with breast cancer have no family history. Our genes have not changed, but the Western diet and lifestyle has deteriorated and our stress has increased. Although you can’t change the “genes” you were born with (i.e. family history), you can modify how your genes are expressed (i.e. epigenetics).

Obese women have a 60 percent higher chance of developing breast cancer and having a recurrence of their cancer. It is believed that 30 percent of breast cancers could have been prevented with lifestyle modification.
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Lifestyle Choices

Lifestyle Modification 
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. Tobacco and excessive alcohol consumption can be eliminated because each is associated with so many cancers and disease processes in our bodies.

Dietary modification 

Increase the amount of vegetables consumed
Decrease the saturated fat, including meat and dairy products, as well as trans fatty acids found in processed foods
Choose health fats found in cold-water fish (salmon, tuna, mackerel)
Add flaxseed to your diet
Fiber rich foods such as vegetables, legumes, whole grains and fruits
Several foods in particular have known anti-cancer properties and should be come a part of your regular diet. These include: cruciferous vegetables (broccoli and cauliflower);leafy green vegetables, yellow-orange vegetables, berries, citrus fruits, garlic and green tea.

Omega 6 Fatty Acids (negative)

Plant sources
Liquid at room temp
Can lower HDL
Seem to contribute to cancer risk
Sunflower oil, corn oil, safflower oil, cottonseed oil
Soybean oil, canola oil

Omega 3 Fatty Acids (positive)

Fish oil, flaxseed oil, olive oil
Green, leafy vegetables
Nuts
Meat of herbivores and wild game

Alcohol Modification 
Alcohol is officially listed as a carcinogen for the development of breast cancer. Your risk is directly related to your level of consumption.

6 percent increased risk ½ glass wine per day
21 percent increased risk 1-2 glasses per day
37 percent increased risk 3 or more glasses per day

Risk Reduction Medicines

Breast Cancer Risk Reduction with Medication 
The Breast Cancer Prevention Trial determined that taking Tamoxifen for at least five years can prevent breast cancer in women who have never been diagnosed with breast cancer, but who are at increased risk of developing the disease. Women who took Tamoxifen also had fewer diagnoses of noninvasive breast tumors, such as DCIS or LCIS. After seven years of follow-up, researchers found similar results. The study found that Tamoxifen reduced the occurrence of estrogen receptor-positive tumors by 69 percent, but no difference in the occurrence of estrogen receptor-negative tumors was seen.

Should you take Tamoxifen to reduce breast cancer risk?
The decision to take Tamoxifen is an individual one. You and your doctor must carefully consider the benefits and risks of taking this medicine. At this time, there is no evidence that Tamoxifen has a net benefit for women who do not have an increased risk of developing breast cancer.

How does raloxifene (Evista) compare to Tamoxifen?
Evista is a drug approved by the FDA for the prevention and treatment of osteoporosis in postmenopausal women. Raloxifene is also approved by the FDA for reducing the risk of invasive breast cancer in postmenopausal women with osteoporosis and in postmenopausal women at high risk for invasive breast cancer.

The NCI funded the Study of Tamoxifen and Raloxifene (STAR), a clinical trial comparing raloxifene (Evista) with Tamoxifen in preventing breast cancer in postmenopausal women who are at an increased risk of developing the disease. The study found that Raloxifene and Tamoxifen are equally effective in reducing invasive breast cancer risk in postmenopausal women who are at increased risk of the disease.

The study also found that women who took Raloxifene had fewer uterine cancers and fewer blood clots than the women who took Tamoxifen. However, Raloxifene did not reduce the risk of noninvasive breast tumors such as DCIS and LCIS. Other side effects associated with Raloxifene were similar to Tamoxifen and included hot flashes, vaginal dryness, joint pain and leg cramps. Studies of Raloxifene to date have only examined its role in breast cancer prevention, not treatment.

Aromatase inhibition, blocking the pathway of estrogen production, has been shown in a clinical trial to decrease the risk of developing breast cancer in high risk patients. The medication Exemestane, was found to significantly reduce the risk of estrogen receptor positive breast cancers in high risk patients as documented in the New England Journal of Medicine.

All risk reduction strategies should be discussed with your physician.
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Exercise and Breast Cancer

Exercise does not have to occur in the gym!

Exercise has been shown to decrease a woman’s risk of developing breast cancer.

Increased physical activity over a long period of time is associated with a reduced risk for breast cancer in postmenopausal women. Three hours of exercise per week can decrease your risk of developing breast cancer by 18 percent, even if the activity is not strenuous.

The benefits of physical activity are greatest for women with a low BMI; however, moderately overweight women also showed benefits from increased total activity. Benefits of exercise were even seen in women using hormonal therapy, a group known to have an increased risk of cancer.

The more lean muscle mass you have; the more fat you burn. This will lead to less fat remaining for estrogen production. Fat cells in our body are little estrogen factories. The more factories you have, the more estrogen you can produce.

Cardiovascular exercise should be combined with strength and resistance training to increase your lean muscle mass and to help to prevent osteoporosis.

Contrary to common misconceptions, exercise is safe after having lymph nodes removed. However, it is recommended that women with existing lymphedema only exercise with appropriate guidance. Consult your personal physician regarding your limitations and restrictions.
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Vitamins and Antioxidents

The following supplements are recommended for cancer prevention:

Vitamin A acts as a potent antioxidant by destroying free radicals in the body. It works to fortify mucous membranes and acts as a barrier for bacteria and carcinogens. It is essential for protein synthesis and normal cellular growth. A deficiency of this vitamin has been linked to the development of cancer. Sources of this vitamin are dairy products.

Recommended daily dosage: 5000 IU

Vitamin C acts as a potent antioxidant as free radical destroyer thought to inhibit the formation and growth of cancers. Vitamin C inhibits the production of the enzyme thought to be responsible for cancer cells ability to break up normal cells and therefore infiltrate normal tissues. It is also required for tissue growth and repair. Excellent sources of Vitamin C are lemons, oranges and green peppers.

Recommended daily dosage: 500mg-1000mg

Vitamin D has recently been associated with a decreased risk of several cancers. Vitamin D may also help to prevent diabetes and other cancers. Our bodies manufacture Vitamin D in response to sun exposure.

Recommended daily dosage: 1000 IU

Vitamin E acts as a potent antioxidant and is thought to be responsible for correcting abnormal levels of progesterone to estradiol, which improvement in this ratio can decrease the risk of mammary (breast tissue) dysplasia. Excellent sources of this vitamin are wheat germ, whole grains, lettuce and liver.

Recommended daily dosage: 800 IU

Selenium inhibits the action of chemical substances and viruses that cause cancer. It facilitates the quick repair of free radical damage to DNA. In addition to it’s own antioxidant properties, it is essential for the production of glutathione another important antioxidant. It requires adequate levels Vitamin E to be effective and can be toxic if over administered.

Recommended daily dosage: 150mcg-200mcg

CoQ10: plays a crucial role in cellular energy metabolism. It is a powerful anti-oxidant and cancer fighter. It ignites ATP, the body’s basic unit of energy that runs our entire body.

Recommended daily dosage: 100mg-200mg (should be taken with meals for best absorption)

Flaxseed is an Omega 3 essential fatty acid and has proven anti-cancer properties. It is also an excellent source of fiber. Flaxseed in the ground husk form has the greatest benefit.

Recommended daily dosage: 1Tbsp-2Tbsp of flaxseed husks

These are recommendations for prevention of the formation of cancer. If you are currently undergoing treatment with chemotherapy or radiation therapy, please do not take these supplements unless cleared specifically with your treating physician because they may interfere with chemotherapy and radiation therapy.
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