My Big Squish: Cancer, Chemicals, Mammos, Oh My!

In my bed, I do what I instruct my patients to do--lay down, one arm over head, walking fingers in circles around the breast, into the armpit, feeling for lumps. I do several breast exams a week on women during their annual wellness exams, but that does not take away from the alarm I felt four months ago when I found a lump on my own breast. My fingers roll over and over the same spot, while my tiny daughter sleeps soundly beside me. I categorize it in my head, the way I would on a chart note. Non-tender. Mobile. No skin or nipple changes. No axillary lymphadenopathy. No new breast asymmetry. Position: 3 O'clock, approximately 6-7 mm. I know what to look for, but nonetheless I'm worried.

I lay awake, counting the number of friends, patients, and acquaintances I have with breast cancer right here in Bend, Oregon. Four years ago, it was five. Three years ago it was eight. Two years ago it was twelve. This year, the number of women I've know locally with breast cancer in the last four years is 13. I think of all my friends with young children like myself, fighting breast cancer right now, here, in my little town. I think of the moms I know who were misdiagnosed with mastitis and found out it was actually cancer after it had progressed to stage 3. This is a club I don't want to be a part of.

I've been meaning to schedule a mammogram for myself but keep putting it off--between caring for my patients and my family, I often don't prioritize my own health.

I think of our family member, a naturopath, who passed away recently from breast cancer. Having been trained to believe that thermograms were somehow safer than mammograms, she elected for the thermogram. Because thermograms only detect lumps at certain sizes and are not as reliable as mammos, the lump she had went undected until finally it grew to big to ignor. She went in reticently for a mammogram, finding out that though in ideal health (aside from her weight), she had stage four breast cancer. The providers offered chemo, but again, being trained to consider most conventional medicine as harmful and unncessary, she refused it, opting for herbs and alternative modalities instead. In less than one year, she went from new diagnosis to death. It was a tragic loss that felt preventable.

I finally got in for the Big Squish today. As always, I was impressed with the professionalism and kindness of the CORA staff. I laughed with the tech as she tried to squeeze my entire chest wall into the compressor. Embarrassed by my failure to shave my armpits and my general "just rolled out of bed" appearance, I sheepishly followed her direction--"move your breast this way, now turn your head to the right and your body to the left--good, a little more"-I apologized that I probably had coffee breath and B.O. I apologized that I hadn't shaved. I realized I was sounding like all my patients who keep apologizing to me that they didn't shaved before their PAP. I decided to shut up, because really, none of us in medicine care if you shave or don't shave. We've seen it all.

The tech left the room to go over the readings with the radiologist, leaving me time to contemplate. Contemplating led me to writing, jotting down some of the frequently asked questions I get from patients regarding their breasts, breast cancer, risks, preventions, etc-I scribbled some notes in the mammo room before being led to the follow-up ultrasound room where another tech ran the jelly-gooped probe over my two lumps for further eval.

The radiologist came in and chated with me--"It appears your lump is just be a lipoma (fatty cyst)", she assured me, followed by ".....but you have dense breasts, really dense, which means it is harder to tell, so you might benefit from a breast MRI.

Insurance won't cover the limited MRI, so your cost would be about 400.00 dollars. If you wanted the full MRI, insurance would cover it, but usually patients end up having to pay about 700.00 out of pocket for that one which goes to your deductible."

I left contemplating all this, thinking of course about politics and medicine and insurance companies and screwed up our healthcare system is, but mostly, I left contemplating the elephant in the room: why do so many women I know have breast cancer?

Let's be clear: I am NOT a breast cancer expert. I am NOT a radiologist. I am a family practice provider, nurse practitioner. I do a lot of breast exams and have made an effort to frequently get continuing medical education (CME) on breast cancer. I write this disclosure before I share some "commonly asked questions" I field regularly about the safety of mammograms vs thermograms, risks of breast cancer, ways to prevent it, and on and on.

In this blog, I draw from several reputable sources, including CORA's own website. My resources are at the end. I provide some quick pearls, incorporating my integrative medicine approach to mind-body health and holistic practice.

Who is at risk and what are my risk factors?

· Advancing age is the biggest risk factor for breast cancer (aside from being cis-female)

· Factors that increase exposure to estrogen, such as starting one’s period early and starting menopause late

· Use of combination estrogen-progesterone hormones after menopause (there are some routes and forms of hormones that are safer than others, such as patch vs pill, bioidentical vs not)

· Never having had a child (nulliparity)

· Alcohol consumption -increases a woman's risk of hormone-receptor-positive breast cancer. Alcohol can increase levels of estrogen and other hormones associated with hormone-receptor-positive breast cancer. (Compared to women who don't drink at all, women who have three alcoholic drinks per week have a 15% higher risk of breast cancer. Experts estimate that the risk of breast cancer goes up another 10% for each additional drink women regularly have each day!!)

· Women with a family history or personal history

· Increased breast density is associated with increased risk

· Exposure to radiation, especially during puberty or young adulthood

· Genetic inheritance of detrimental genetic mutations increase breast cancer risk.

· Exposure to chemicals in sunscreens- some of the chemicals in some sunscreen products may cause cancer in people, which is why I always advocate for my patients and friends to use mineral-only sunscreens (titanitum or zinc)

· Exposure to chemicals in plastic: plastics may leach chemicals if they're scratched or heated. Research also strongly suggests that at certain exposure levels, some of the chemicals in these products, such as bisphenol A (BPA), may cause cancer in people.

· BPA is a weak synthetic estrogen found in many rigid plastic products, food and formula can linings, dental sealants, and on the shiny side of paper cashier receipts (to stabilize the ink). Its estrogen-like activity makes it a hormone disruptor, like many other chemicals in plastics. These chemicals can act like estrogen.

· BPA can act like a weak form of the hormone estrogen and turn on breast cell growth and trigger other unhealthy activities in your body. Significant BPA exposure has been linked to many illnesses, including heart disease, diabetes, immune- and nervous-system disorders, and brain, prostate, and breast cancer.

· BPA also may affect fertility. Studies have shown that BPA may play a role in infertility in both men and women and may even affect the course and outcome of a pregnancy.

· BPA-Free: manufacturers have started using alternatives. You may have seen these products in stores — they’re labeled “BPA-free.” Unfortunately, these alternatives — bisphenol S (BPS), bisphenol F (BPF), bisphenol B (BPB), and others — are chemically similar to BPA, have limited safety profiles, and may share similar unhealthy effects on the body.

· Exposure to chemicals in lawns/gardens: you may be exposed to a number of man-made and naturally occurring lawn and garden chemicals every day. Chemicals are used to kill bugs, keep lawns green, and make flowers bloom. Research strongly suggests that at certain exposure levels, some of the chemicals in these products may cause cancer in people.

· Exposure to growth hormones, antibiotics, and chemicals/preservatives in foods—more and more data is emerging showing that these additions to our food/drink consumption are correlated with hormone disruption and increased risk for cancers. One of my favorite resources for checking food safety is https://www.ewg.org/foodnews/

· Exposure to chemicals in our cosmetics: cosmetics and personal care products are made up of a number of ingredients, there are two groups of chemicals that are being studied for links to breast cancer.

-*Parabens (the most common are methylparaben, propylparaben, ethylparaben, and butylparaben) are chemicals commonly used as preservatives in many cosmetic products, including makeup, moisturizers, hair care products, and shaving creams can penetrate the skin and act like a very weak estrogen in the body -- potentially turning on the growth of hormone-receptor-positive breast cancers.

· A great resource for finding the safest cosmetics can be found here: http://www.safecosmetics.org/ as well as here: https://www.ewg.org/skindeep/

-*Phthalates are commonly used to hold color and reduce brittleness in nail polish and hair spray. They're also a component of many personal care and cleaning product fragrances. Phthalates are a hormone disruptor. Phthalates don't act exactly like estrogen, but they can disrupt the balance of other hormones that interact with estrogen, including testosterone.

· Exposure to chemicals in our cleaning products, furniture, carpets, and fragrances—a great resource for finding safe cleaning products can be found here https://www.ewg.org/guides/cleaners/

· Low vitamin D levels: Research suggests that women with low levels of vitamin D have a higher risk of breast cancer. Vitamin D may play a role in controlling normal breast cell growth and may be able to stop breast cancer cells from growing. I like to check a baseline Vit D in most of my patients who come in for their annual wellness exams.

· Smoking: Smoking causes a number of diseases and is linked to a higher risk of breast cancer in younger, premenopausal women. Research also has shown that there may be link between very heavy second-hand smoke exposure and breast cancer risk in postmenopausal women.

· Lack of exercise and/or obesity: Research shows a link between exercising regularly at a moderate or intense level for 4 to 7 hours per week and a lower risk of breast cancer. Exercise consumes and controls blood sugar and limits blood levels of insulin growth factor, a hormone that can affect how breast cells grow and behave. Fat cells make estrogen and extra fat cells make extra estrogen. When breast cells are exposed to extra estrogen over time, the risk of developing breast cancer is higher.

Which ethnicities are at higher risk?

· White women are slightly more likely to develop breast cancer than Black, Hispanic, and Asian women.

· Black women are more likely to develop more aggressive, more advanced-stage breast cancer that is diagnosed at a young age.

· Black women are also more likely to die from breast cancer. Some of these differences in outcomes may be due to less access to mammography and lower quality medical care, as well as various lifestyle patterns (eating habits and weight issues for example) that are more common in some ethnic groups than in others. These factors can be changed and improved.

HOW EFFECTIVE IS MAMMOGRAPHY?

· Since annual screening mammography became available in the early 1990s, breast cancer deaths have been reduced by 39%.

· Depending on your breast density, the ability to detect a cancer or abnormality ranges from 75-89%.

· Therefore, because some breast cancers do not show up on mammograms, it is important to continue regular monthly breast self-examination and an annual clinical breast exam by your healthcare provider as part of your breast health routine.

HOW OFTEN SHOULD I GET A MAMMOGRAM?

· CORA advises women to get screening mammograms every year starting at age 40.

· One in every six new breast cancers occurs in women in their 40s.

· Women whose breast cancer is detected at an early stage have a 98% percent or higher survival rate in the first five years. Our goal is to detect cancer before you can feel it.

WHAT IF I DON’T HAVE ANY RISK FACTORS FOR BREAST CANCER?

· 85% of all new breast cancers are diagnosed in women without any known risk factors or family history of breast cancer.

·

· Only 5-10% of cancers have a genetic or hereditary component. If you are an average risk woman, you have a 1 in 8 lifetime chance of developing breast cancer.

·

· Women whose breast cancer is detected at an early stage have a 98% percent survival rate in the first five years.

WHAT IF I AM AT HIGHER RISK FOR BREAST CANCER?

· CORA and the American College of Radiology recommends all women be evaluated for their risk level by age 30.

· If you have a family history of breast, ovarian, or pancreatic cancer, or you have had a prior breast biopsy with atypia, chest wall radiation at a young age, or are Ashkenazi Jewish, you may be at increased risk.

· You can review this information with your provider or try an online risk assessment tool here: https://bcrisktool.cancer.gov/

· The risk that a woman will be diagnosed with breast cancer during the next 10 years, starting at the following ages, is as follows:

· Age 30 . . . . . . 0.48% (or 1 in 208)

· Age 40 . . . . . . 1.53% (or 1 in 65)

· Age 50 . . . . . . 2.38% (or 1 in 42)

· Age 60 . . . . . . 3.54% (or 1 in 28)

· Age 70 . . . . . . 4.07% (or 1 in 25)

· These risks are averages for the whole population. An individual woman’s breast cancer risk may be higher or lower depending on known factors,

· I often refer my high risk patients to the High Risk Breast Cancer Clinic where they can get specialized guidance and evaluation. Breast MRIs are also available for a more in depth evaluation.

WHAT IF I’M PREGNANT or Breastfeeding?

CORA site states they delay *screening* mammos (different than the diagnostic mammos used if a lump is found on exam) until after pregnancy and optimally begin 4 to 6 months after cessation of breastfeeding. If you feel a lump, do not hesitate to contact your provider for an exam! Do not delay getting that lump imaged because you are pregnant or breastfeeding.

IS MAMMOGRAPHY SAFE FOR WOMEN WITH BREAST IMPLANTS?

· Yes. Most breast implants are designed to withstand hundreds of pounds of pressure. A mammogram generates an average of 20 pounds of pressure.

· Visualization of breast tissue around implants can be more difficult. This makes regular breast self-exams and clinical breast exams by your health care provider an important part of your breast health routine.

WILL I BE EXPOSED TO UNNECESSARY RADIATION BY GETTING A MAMMOGRAM EVERY YEAR STARTING AT AGE 40?

· Radiation exposure to the breast is extremely low. One screening mammogram =5 to 7 weeks of radiation we are all exposed to on earth, called background radiation. If you have a yearly mammogram from age 40 to 75, the radiation is equivalent to two CT scans.

· For women who receive annual mammograms from age 40 to 80, the total lifetime risk of developing cancer from the tiny amount of radiation scattered to the thyroid is less than 1 in 17.1 million.

· The harmful risk of breast cancer going undetected and untreated due to skipped mammograms are infinitely higher than the nearly non-existent risk that a mammogram could cause thyroid or other cancers.

How does a Thermogram compare to a MAMMOGRAM and is it safer?

· Thermography is not a substitute for mammography screening. Mammography remains the gold standard for breast cancer screening.

· The detection rate for thermography is only 42% to 80% of cancers, as against 82% to 93% with mammography. Its false positive rate is 25%, more than double that of mammography. No evidence exists that it can reliably detect breast cancer as sensitively as mammography

WHEN SHOULD I STOP GETTING MY SCREENING MAMMOGRAM?

Until age 84 as long as your remain in good health.

WHAT IF I HAVE DENSE BREAST TISSUE?

· Dense tissue refers to the amount of glandular tissue we see on your mammogram

· Dense tissue does slightly increase the risk of developing breast cancer and it does make your mammogram slightly more difficult to evaluate. Breast MRI may be an option.

· This means it is even more important to continue regular yearly screening mammograms, monthly self-exams, and annual physical exams by your provider.

Havilah Brodhead, FNP, Owner

Hearthside Medicine Family Care

Havilah is a mountain biking mama who loves raising her daughters to be compassionate and fierce; she loves camping, writing, learning, and integrating holistic medicine with conventional medicine whenever possible. Learn more about our practice at www.hearthsidemedicine.com We are always accepting new patients and accept most insurances, caring for the whole family, all ages.

References:

https://www.bcpp.org/

https://www.breastcancer.org/risk/factors

https://bcrisktool.cancer.gov/about.html#OtherRiskAssessmentTools

https://knowyourchances.cancer.gov/special_cancer_tables.php

https://bcrisktool.cancer.gov/

https://centraloregonradiology.com/mammography-qas/

https://www.news-medical.net/health/Thermography-versus-Mammography-Which-is-Best.