Via Christi 50+ Lunch and Learn: Can I prevent breast cancer?

Can I Prevent Breast Cancer?Patty Tenofsky, MD FACSVia Christi 50+ Lunch and LearnWednesday, Oct. 17

Topics Breast cancer risks Breast cancer prevention Breast cancer screening Improving breast cancer outcomes2

Risk 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 biopsies3

Risk 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)4

Risk 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%5

Risk 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 met6

Risk 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 finding7

Risk Factors Breast density8

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.9

Risk 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 reduced10

Risk 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 factors11

Risk 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)12

Risk 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 diagnosed13

Risk 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 risk14

Risk 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 cancer15

Risk 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 link16

Risk 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 cancer17

Risk Reduction Chemoprevention medications, given to help prevent cancer from occurring, can lower risk  SERMS — Selective estrogen receptor modulators  Tamoxifen and raloxifen (Evista)18

Risk Reduction Tamoxifene results  Dark circles — tamoxifene  Open circles — placebo  Left — invasive  Right — noninvasive  Risk decrease by 1/219

Risk 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 cataracts20

Risk 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 tamoxifen21

Risk 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 higher22

Screening 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 better23

Screening 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 risk24

Screening 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 mortality25

Screening 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 rupture26

Improving 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%27

Improving 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 therapy28

Summary 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.29

Summary 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.30

Via Christi 50+ Lunch and Learn: Can I prevent breast cancer?

by Via Christi Health on Oct 18, 2012

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Via Christi 50+ Lunch and Learn: Can I prevent breast cancer? Presentation Transcript