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


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

  1. 1. Can I Prevent Breast Cancer?Patty Tenofsky, MD FACSVia Christi 50+ Lunch and LearnWednesday, Oct. 17
  2. 2. Topics Breast cancer risks Breast cancer prevention Breast cancer screening Improving breast cancer outcomes2
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. Risk Factors Breast density8
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. Risk Reduction Chemoprevention medications, given to help prevent cancer from occurring, can lower risk  SERMS — Selective estrogen receptor modulators  Tamoxifen and raloxifen (Evista)18
  19. 19. Risk Reduction Tamoxifene results  Dark circles — tamoxifene  Open circles — placebo  Left — invasive  Right — noninvasive  Risk decrease by 1/219
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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