OB-GYN NORTH is the practice of

Christina Sebestyen, MD, FACOG, Tesa Miller, MD, FACOG, April Schiemenz, MD,
Siobhan Kubesh, CNM, Lisa Carlile, CNM, Kathy Harrison-Short, CNM and Katherine Davidson , FPNP

Thursday, May 29, 2014

Breast Cancer Awareness and Prevention

Breast cancer is the most common cancer in females in the United States and the second most common cause of cancer death in women. Approximately one-half of newly diagnosed breast cancers can be explained by known risk factors, such as age at menarche, first live birth, menopause, and proliferative breast disease. An additional 10% are associated with a positive family history. Risk factors for breast cancer may be modified by demographic, lifestyle, and environmental factors. 

So, what increases our risk? What can we change? What do have no control over? 

Age:  the risk of breast cancer increases with older age.  In recent surveillance risk stratifies as such: Birth to age 39 - 1 in 203 women;  Age 40 to 59 - 1 in 27 women;  Age 60 to 69 - 1 in 28 women; Age 70 and older - 1 in 15 women;  Birth to death - 1 in 8 women.

Female gender:  Breast cancer occurs 100 times more frequently in women than in men.  In the United States, over 200,000 women are diagnosed with invasive breast cancer each year, compared with approximately 2000 cases that occur annually in men. 

Caucasian race:  the highest rate of breast cancer occurs among white women, although breast cancer remains the most common cancer among women of every major ethnic group.  

Weight:  Obesity (defined body mass index ≥30 kg/m2) is associated with an overall increase in morbidity and mortality.  However, the risk of breast cancer associated with BMI appears to depend on the menopausal status of women. 

Postmenopausal women:  A higher body mass index (BMI) and/or perimenopausal weight gain have been consistently associated with a higher risk of breast cancer among postmenopausal women.  The association for risk can be explained by higher estrogen levels resulting from the adipose tissue to estrogen.  

Premenopausal women:  Unlike postmenopausal women, an increased BMI is associated with a lower risk of breast cancer in premenopausal women.  The explanation of this finding remains unclear.

Tall stature:  Increased height is associated with a higher risk of breast cancer in both premenopausal and postmenopausal women.  The mechanism underlying this association is unknown, but may reflect the influence of nutritional exposures during childhood and puberty. 

Estrogen levels:  High endogenous estrogen levels increase the risk of breast cancer (particularly hormone receptor-positive breast cancer) in both postmenopausal and premenopausal women. For postmenopausal women, the correlation between an increased risk for breast cancer and increasing hormone levels (eg, estradiol, estrone) has been consistent.  

Benign breast disease:  A wide spectrum of pathologic entities is included in the category of benign breast disease. Among these, proliferative lesions (especially those with histologic atypia) are associated with an increased risk of breast cancer. 

Dense breast tissue:  The density of breast tissue reflects the relative amount of glandular and connective tissue (parenchyma) to adipose tissue. Breast density is a measure of the extent of radiodense fibroglandular tissue. Women with mammographically dense breast tissue, generally defined as dense tissue comprising ≥75 percent of the breast, have a 4 to 5 times risk of breast cancer compared with women of similar age with less or no dense tissue.  It is unclear whether screening recommendations should differ for women with dense breasts in the absence of other risk factors. 

Bone mineral density:  Because bone contains estrogen receptors and is highly sensitive to circulating estrogen levels, bone mineral density (BMD) is considered a surrogate marker for long-term exposure to endogenous and exogenous estrogen. In multiple studies, women with higher bone density have a higher breast cancer risk.

Androgens:  Elevated androgen (ie, testosterone) levels have been associated with an increased risk of postmenopausal and premenopausal breast cancer. 

Insulin pathway and related hormones:  Although diabetes is not considered a breast cancer risk factor, a large pooled analysis drawing from 17 prospective studies suggested that insulin growth factor-1 was associated with breast cancer risk in both premenopausal and postmenopausal women.

In utero exposure to diethylstilbestrol:  Before 1971, several million women were exposed in utero to diethylstilbestrol (DES) that was given to their mothers to prevent pregnancy complications. Whether these women are also at an increased risk for breast cancer is unclear.  

Exogenous hormones:  Much of the available evidence supports a causal relationship between menopausal hormone replacement therapy and breast cancer. The duration of use and type of hormone formulation seem to be important factors in the risk for breast cancer.  While long-term use has been associated with the highest risk, short-term use of combined estrogen-progestin therapy (<3 administration="" an="" appear="" as="" associated="" breast="" cancer.="" clearly="" contraceptives="" does="" estrogen="" exogenous="" for="" hormones="" however="" in="" increase="" increased="" induction="" is="" nbsp="" not="" of="" or="" oral="" ovulation="" premenopausal="" previous="" purpose="" risk="" significantly="" span="" the="" to="" users="" with="" years="">

Earlier menarche or later menopause:  Early age at menarche is associated with a higher risk of breast cancer.  Women with menarche at or after age 15 years of age were less likely to develop estrogen receptor/progesterone receptor positive breast cancer compared with women who experienced menarche before the age of 13 years.  Women with menarche at or after age 15 years also had a 16 percent decreased risk of estrogen receptor/progesterone receptor negative breast cancer.

Nulliparity:  Nulliparous women are at increased risk for breast cancer compared with parous women, however, the protective effect of pregnancy is not seen until after 10 years following delivery.  

Increasing age at first pregnancy:  Women who become pregnant later in life have an increased risk of breast cancer.  One study showed when compared with nulliparous women at or near menopause, the cumulative incidence of breast cancer (up to age 70) was 20 percent lower, 10 percent lower, and 5 percent higher among women who delivered their first child at age 20, 25, or 35 years, respectively.  A later age at first birth may confer a greater risk than nulliparity because of the additional proliferative stimulation placed on breast cells that are more likely to be fully developed and perhaps more prone to cell damage.

Personal history of breast cancer:  A personal history of ductal carcinoma in situ (DCIS) or invasive breast cancer increases the risk of developing an invasive breast cancer in the contralateral breast. A 2010 study using Surveillance, Epidemiology, and End-Results (SEER) data that included almost 340,000 women with a primary breast cancer found the incidence of invasive contralateral breast cancer was 4% during an average follow-up of 7.5 years.

Family history of breast cancer:  The risk associated with a positive family history of breast cancer is strongly affected by the number of female first-degree relatives with and without cancer. In addition to a family history of breast cancer, the age at diagnosis of the affected first-degree relative also influences the risk for breast cancer.  Women have a threefold higher risk if the first-degree relative was diagnosed before age 30, but only 1.5-fold increased if the affected relative was diagnosed after age 60. 

Inherited genetic mutations:  Specific genetic mutations that predispose to breast cancer are rare; only 5 to 6 % of all breast cancers are directly attributable to inheritance of a breast cancer susceptibility gene such as BRCA1, BRCA2, p53, ATM, and PTEN. 

Alcohol:  Alcohol consumption in early life as well as later adult life is associated with an increased risk of breast cancer development. There appears to be a significant dose-response relationship between alcohol consumption (eg, beer, wine, liquor) and an increased risk of breast cancer, which begins with alcohol intake as low as three drinks per week compared with abstainers. The risk appears to increase with greater alcohol consumption and additive with the use of menopausal hormone therapy. There does not appear to be a difference by type of alcohol (wine versus beer versus liquor). 

Smoking:  The relationship between cigarette smoking and breast cancer is complicated by the interaction of smoking with alcohol and endogenous hormonal influences.  Although results have varied widely, multiple studies suggest there is a modestly increased risk of breast cancer in smokers. 

Night shift work:  Night shift work is recognized by International Agency for Research on Cancer and the World Health Organization (IARC/WHO) as a probable carcinogen.  This association may be related to nocturnal light exposure, which results in the suppression of nocturnal melatonin production by the pineal gland. Evidence to support this comes from the finding that low levels of 6-sulfatoxymelatonin (the major melatonin metabolite) are associated with an increased risk of breast cancer.

Exposure to therapeutic ionizing radiation:  Exposure to ionizing radiation of the chest at a young age, as occurs with treatment of Hodgkin lymphoma or in survivors of atomic bomb or nuclear plant accidents, is associated with an increased risk of breast cancer. The most vulnerable ages appear to be between 10 to 14 years (prepuberty), although excess risk is seen in women exposed as late as 45 years of age. After age 45, there does not appear to be any increased risk. 

So what can we do to help ourselves?
In addition to modifying some of the risk factors above and spreading awareness, some protective factors that may also reduce breast cancer risk are breastfeeding, soy/phytoestrogens (such as soybeans, legumes and lignans) and increased physical activity. 

Let us be your resource for concerns or questions about your breast health--that is what we are here for! 

Here are some other reliable resources too:
National Cancer Institute (www.nci.nih.gov)
People Living With Cancer: The official patient information website of the American Society of Clinical Oncology (www.cancer.net/portal/site/patient)
National Comprehensive Cancer Network (www.nccn.com)
American Cancer Society (www.cancer.org)
National Library of Medicine (www.nlm.nih.gov/medlineplus/healthtopics.html)

Susan G. Komen Breast Cancer Foundation (www.komen.org)

-Maansi Piparia, MD

Tuesday, May 13, 2014

It's National Women's Health Week!

National Women’s Health Week kicked off on Mother’s Day and yesterday was National Women’s Checkup Day. These nationwide awareness campaigns happen every year in the month of May to encourage women to schedule their annual well-women visits. 

The U.S. Department of Health and Human Services suggests women set aside time to discuss their health habits, family history and goals for optimal health at their annual well-women visit. During these visits, women receive preventative care and necessary screenings for blood pressure, cholesterol, cervical cancer and many other conditions. 

People often confuse the well-woman exam as just a pap smear—but it is truly our opportunity as women to assess our whole health status. Well-women visits help identify diseases such as cervical precancers early, when they are easier to treat. They allow providers to teach preventative strategies that empower women to reduce their risk for illness. And now, under the Affordable Care Act, most health plans allow women to receive these services without cost.

The goal of National Women’s Health Week is to encourage women, in their busyness, to find time to schedule screenings for potentially life threatening, but mostly preventable diseases. 

To participate in National Women’s Health Week, women are asked to make a well-women appointment with their provider, learn which screenings they need during each phase of life, urge others to participate and share information on women’s health through social media. 

Proper Technique and the Importance of Breast Self Exam

Breast self exam has long been included with the standard instructions during the annual well woman exam. However, there are very few randomized trials examining the effectiveness of this routine.  One large study in China compared breast self exam (BSE) to a control group who did not do them. The BSE group was instructed in proper technique and received a review of those instructions at one and 5 years. They also had supervised exams every 6 months for 5 years.  The women were followed for 10 years and they found no difference between the two groups in breast cancer deaths but more benign breast lesions were diagnosed in the self-examination group.  Other studies also failed to find a benefit of regular BSE in the rate of breast cancer diagnosis, death, or tumor size. These studies also found an increased rate of biopsy for benign breast disease in the BSE groups. The findings of two other case controlled studies suggest that proper BSE technique is important. Despite these studies and the findings that BSE might not change diagnosis we still recommend that women get to know their breasts so they will recognize any changes. This new approach is breast awareness...being comfortable and knowledgeable about your own body.  

Breast awareness and self-exam

At the wellness exam, all women should be told about the benefits and limitations of breast self-exam (BSE). Starting in their 20's, women should become comfortable with how their breasts normally look and feel.  They should report any breast changes to their provider as soon as they are found. Not all changes indicate cancer. Most changes are benign but should be evaluated and documented. 

A woman can choose to be aware of how her breasts normally look and feel and feeling her breasts for changes (breast awareness), or to use a systematic scheduled approach to examine her breasts with monthly breast self exam. 

If BSE is the chosen method, a step by step approach is important to follow. The best time for a woman to examine her breasts is when they are not tender or swollen, usually after their menstrual cycle.  Women can choose not to do BSE or to do BSE occasionally. Women who are pregnant or breastfeeding, or who have implants can also choose to examine their breasts regularly. There is some thought that the implants push out the breast tissue and may make it easier to examine. 

How to examine your breasts (taken from cancer.org)

Lie down on your back and place your right arm behind your head. The exam is done while lying down, not standing up. This is because when lying down the breast tissue spreads evenly over the chest wall and is as thin as possible, making it much easier to feel all the breast tissue.

Use the finger pads of the 3 middle fingers on your left hand to feel for lumps in the right breast. Use overlapping dime-sized circular motions of the finger pads to feel the breast tissue.

Use 3 different levels of pressure to feel all the breast tissue. Light pressure is needed to feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel the tissue closest to the chest and ribs. It is normal to feel a firm ridge in the lower curve of each breast, but you should tell your doctor if you feel anything else out of the ordinary. If you're not sure how hard to press, talk with your doctor or nurse. Use each pressure level to feel the breast tissue before moving on to the next spot.

Move around the breast in an up and down pattern starting at an imaginary line drawn straight down your side from the underarm and moving across the breast to the middle of the chest bone (sternum or breastbone). Be sure to check the entire breast area going down until you feel only ribs and up to the neck or collar bone (clavicle).

There is some evidence to suggest that the up-and-down pattern (sometimes called the vertical pattern) is the most effective pattern for covering the entire breast without missing any breast tissue.

Repeat the exam on your left breast, putting your left arm behind your head and using the finger pads of your right hand to do the exam.

While standing in front of a mirror with your hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin. (The pressing down on the hips position contracts the chest wall muscles and enhances any breast changes.)

Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and makes it harder to examine.

This procedure for doing breast self-exam is different from previous recommendations. These changes represent an extensive review of the medical literature and input from an expert advisory group. There is evidence that this position (lying down), the area felt, pattern of coverage of the breast, and use of different amounts of pressure increase a woman's ability to find abnormal areas.

uptodate.com. Screening for breast cancer: Evidence for effectiveness

cancer.org. Breast awareness and self exam