Wednesday, October 2, 2013

The Business of Breast Cancer Awareness Month (And How To Prevent Breast Cancer In The First Place)



Every year October comes along. Every year during October pink ribbons are more plentiful than ever signifying National Breast Cancer Awareness Month. The intentions of many well-meaning non-profit organizations, medical establishments, individual healthcare providers, and even government agencies is to promote the awareness of breast cancer as well as raise funds for research in relation to its cause, prevention, diagnosis, treatment, and cure. These are all very noble intentions. I commend any individual or organization who truly desires to eradicate this horrible disease.

However, many of these efforts are designed to promote the business of breast cancer diagnosis and treatment through the use of expensive medical care instead of focusing on the eradication (and subsequent loss in business opportunities) of this terrible disease. Allow me to explain.

Breast Cancer Overview


Breast cancer is the most common cancer affecting women and the second most common cancer in the United States (excluding basal and squamous cell cancers of skin) [1].

Estimated number of new cases and deaths due due to breast cancer in 2013 according to the American Cancer Society [2]:
  • New cases: 234,580 (total); 232,340 (women); 2,240 (men)
  • Deaths: 40,030 (total); 39,620 (women); 410 (men)

What Is Breast Cancer?

The inside of the female breast is made up of fatty tissue, lobes, lobules, and ducts surrounded by a network of surrounding lymph nodes. The outside of the breast consists of the nipple and areola.

Breast cancer occurs when malignant cells develop in the tissues of the breast. Breast cancer occurring in the ducts (invasive ductal carcinoma or IDC) is the most common form of breast cancer and accounts for approximately 75% of all cases [3]. The second most frequent form of breast cancer (roughly 10% of all cases) occurs in the lobes and is classified as invasive lobular carcinoma (ILC). Other forms of breast cancer are divided up into several different types and occur more rarely.

Breast cancer can be localized or metastatic. Localized breast cancer involves a cancerous tumor contained within the breast. Metastatic breast cancer involves the spreading of cancer to other organs and systems in the body. Metastatic cancer happens when cancer cells are transported via the lymphatic system (lymph nodes and vessels) or the circulatory system (blood vessels). Metastatic breast cancer most often affects the brain, liver, lungs, and bone [3].

Is Breast Cancer Genetic?

This is a tricky question. As you will soon find out, the development and progression of breast cancer is largely influenced by a person's lifestyle choices, especially their dietary habits. However, there are two specific genetic markers which confer a greater risk in person's afflicted with them.

The presence of BRCA1 and BRCA2 gene mutations carry a higher risk of both breast and ovarian cancer [4]. BRCA1 carries the higher risk of the two. This is the gene mutation Angelina Jolie spoke publicly about earlier this year as she made the decision to undergo a preventative double mastectomy. The estimated lifetime risk of developing breast cancer with a BRCA1 mutation is 65% and a BRCA2 mutation confers a 45% lifetime risk.

Getting tested for genetic risk factors for breast cancer is a very personal decision that only you can make with the guidance of a qualified healthcare professional. It is not something to take lightly as the subsequent actions thereafter may involve serious and potentially high-risk medical treatments and/or procedures which may or may not enhance your overall survival chances. Like Angelina Jolie, you'll simply never know with 100% certainty whether or not surgical or medical intervention saved your life.


Breast Cancer "Awareness"


The main effort in October's Breast Cancer Awareness month encourages women to get screened for early detection of breast cancer. The intended reason for this is that if breast cancer is caught early enough then more lives could be saved. Hence, more mammogram screenings equal more lives saved. The official recommendations of the American Cancer Society urges women 40 and over to get yearly mammograms claiming these same benefits.

However, the reality of the situation is far different. Overall, women experience less benefits not more with increased mammogram screening. Worse yet, more women are actually harmed by getting mammograms due to false positive tests and unnecessary treatment with chemo, radiation, and surgery that do not improve overall survival rates. As with any medical procedure or test there are always exceptions to the rule, but in the case of routine mammogram screening to detect breast cancer more harm than good is the result.

Cochrane Review - Screening For Breast Cancer With Mammography
A 2013 review of the evidence-based literature shows just that. The Cochrane Collaboration (which strictly prohibits funding from pharmaceutical or medical device companies in their research analysis efforts) performed a review of 7 randomized clinical trials looking at the rates of mammogram screenings and reduction in mortality (ie. death rate) [5]. This review included 600,000 women ages 39-74 who were randomly assigned to receive a mammogram or not. Researchers followed the women for 10-13 years during follow-up. Here's what the research authors found:

"The studies which provided the most reliable information showed that screening did not reduce breast cancer mortality. Studies that were potentially more biased (less carefully done) found that screening reduced breast cancer mortality. However, screening will result in some women getting a cancer diagnosis even though their cancer would not have led to death or sickness. Currently, it is not possible to tell which women these are, and they are therefore likely to have breasts or lumps removed and to receive radiotherapy unnecessarily. If we assume that screening reduces breast cancer mortality by 15% after 13 years of follow-up and that overdiagnosis and overtreatment is at 30%, it means that for every 2000 women invited for screening throughout 10 years, one will avoid dying of breast cancer and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress including anxiety and uncertainty for years because of false positive findings."

A group of independent physicians, known as theNNT, also reviewed mammography screenings in reducing deaths due to breast cancer. [Note that theNNT exists to evaluate medical therapies based on their patient-important benefits and harms in the course of clinical treatment decision making. In other words, this group of physicians goes to great lengths to find only the facts to share with the medical community and general public to benefit the health and wellbeing of people and not the bottom line of industries (pharmaceutical companies, medical device companies, etc.) making up our healthcare system.]

theNNT reviewed the above Cochrane Review as well as other studies in their investigation. Here's what they found in regards to mammogram screening:

- 100% of individuals saw no benefit
- 50% were harmed by false positives (1 in 2 individuals were harmed by a false positive, over 10 years of mammograms)
- 20% were harmed by an unnecessary surgical procedure (1 in 5 were harmed by an unnecessary surgical procedure over 10 years)

"Screening mammography (mammography in women without any signs or symptoms of possible breast cancer) has been studied in large randomized trials of nearly a half million women. The theoretic basis for the intervention is sound. It is presumed that therapeutic intervention at a point when cancer is visible on a mammogram but not yet palpable in the breast will, for a small number, result in earlier, ultimately life-saving, therapy. Overall mortality rate, however, was not improved in the groups in these studies assigned to receive regular mammograms. When aggregating data from those trials in which randomization was appropriate (resulting in balanced groups), there was also no identifiable reduction in deaths due to breast cancer...

In addition, despite the lack of identifiable benefit to screening mammography, women in groups assigned to receive mammograms were 20% more likely to undergo mastectomy and 30% more likely to undergo surgery. Finally, if it is true that breast cancer deaths are reduced it has been estimated that for every one patient who avoids death from breast cancer approximately 10 to 20 women are treated unnecessarily as cancer patients, typically receiving surgery, radiation, and chemotherapy...

Most recently, an observational study of the effects of screening in the United States over the past thirty years suggests that 50% of screen-detected cancers represent overdiagnosis, and that while early stage cancer diagnoses have doubled, advanced stage breast cancer is about as common today as it was before mammography was in widespread use."


Cochrane Review - Regular Self-Examination or Clinical Examination For Early Detection of Breast Cancer
If mammograms have little to no benefit then what about the old-fashioned method of self breast exams or going to your doctor for a breast exam? The Cochrane Collaboration reviewed this topic.

The review consisted of two large population-based studies [6]. Women were randomly assigned to self-examination or no intervention. The results and conclusions of the review are below:

"Two large population-based studies (388,535 women) from Russia and Shanghai that compared breast self-examination with no intervention were included. There was no statistically significant difference in breast cancer mortality between the groups... Almost twice as many biopsies (3406) with benign results were performed in the screening groups compared to the control groups (1856).

Data from two large trials do not suggest a beneficial effect of screening by breast self-examination but do suggest increased harm in terms of increased numbers of benign lesions identified and an increased number of biopsies performed. At present, screening by breast self-examination or physical examination cannot be recommended.

Some women will continue with breast self-examination or will wish to be taught the technique. We suggest that the lack of supporting evidence from the two major studies should be discussed with these women to enable them to make an informed decision. Women should, however, be aware of any breast changes. It is possible that increased breast awareness may have contributed to the decrease in mortality from breast cancer that has been noted in some countries. Women should, therefore, be encouraged to seek medical advice if they detect any change in their breasts that may be breast cancer."

Costs of Breast Cancer Screening and Treatment

Breast cancer screening, workup, and treatment costs money like anything else in the practice of medicine. You've seen the evidence of the effectiveness (or lack there of) of mammography screening, now the next question is - How much does all this cost?

Dr. Cary Gross, MD reported costs associated with breast cancer screening in a Yale University School of Medicine study earlier this year, in January of 2013. In this study, costs associated with breast cancer screening and initial workup for Medicare beneficiaries were evaluated between 2006 and 2007. Dr. Gross and colleagues reported the following:

"We found that the Medicare fee-for-service program is spending over $1 billion per year on breast cancer screening and workup of suspicious lesions. This accounted for over 45 percent of the $2.42 billion total spent by Medicare on screening and the initial treatment phase of breast cancer...

Additionally, study results indicate that for women 75 years or older, annual screening-related expenditures topped $410 million. Age-standardized screening-related cost per beneficiary varied more than two-fold across regions (from $42 to $107 per beneficiary)...

'In summary, the costs of breast cancer care in the Medicare population, when incorporating screening costs, are substantially higher than previously documented and the adoption of newer screening modalities will likely contribute to further growth,' the authors conclude. 'The growth trajectory may be steeper than projected owing to Medicare’s reimbursement strategy, which supports rapid adoption of newer modalities, frequently without adequate data to support their use.'"

Another review published in the journal Pharmacoeconomics in 2009 evaluated the overall costs of treating breast cancer in the United States [7]. A total of 29 cost-of-illness studies for breast cancer in the U.S. were included in the analysis. Estimated lifetime per-patient costs of breast cancer ranged from $20,000 to $100,000. Patients receiving chemotherapy vs. patients not receiving chemotherapy during their lifetime course of treatment incurred, on average, an extra $23,000 to $31,000 in expenses.

Much of these costs remain hidden due to public and private insurers picking up the bill. Patients see (and pay for) only a fraction of the total costs of breast cancer screening, workup, and treatment while huge profits are realized by pharmaceutical companies, medical device companies, and all those in the healthcare system providing their services to combat this disease. This is not to say that all is wasted. Some patients will absolutely require the best medical care available to beat this disease. However, most of these scenarios will involve cases of more advanced, serious, and invasive forms of breast cancer. Much of the screening done today detects early stage breast cancer, which as you saw in the evidence from the Cochrane Collaboration and NNT reviews does more harm than good. Efforts should instead be focused on preventing breast cancer in the first place instead of making people "aware" of the disease.


Breast Cancer Prevention (And Treatment)


Very little emphasis is put on breast cancer prevention during Breast Cancer Awareness month. Awareness equals further workup and treatment resulting in more money to be made by those providing the workup and treatment of breast cancer. October should instead be renamed Breast Cancer Prevention month. Prevention equals less cases of breast cancer overall and less deaths due to breast cancer in the long term. Those who benefit from this approach are the actual women (and men) who would otherwise experience unnecessary pain, suffering, and premature death due to this horrible disease.

Prevention is best accomplished by making positive lifestyle choices on a daily basis such as eating healthy and exercising. The single most important factor is eating a health-promoting diet. Adopting a whole foods, plant-based lifestyle is key to accomplishing this.

Breast Cancer Incidence (And Differing Dietary Habits) Around The World

It has been found that the incidence of breast cancer is much lower in areas of the world where traditional plant-based diets are the norm compared to high-fat, animal-based diets of westernized countries (see map below). For example, the traditional Japanese diet of 1960 consisted mainly of plant-based foods (rice and vegetables) with only a very small amount of seafood included. Total fat intake was equal to 11% of total calories. In contrast, the typical American diet in the 1980's (similar to today) is a very high-fat (approximately 37% of total calories) animal-based diet consisting mainly of meat, dairy, eggs, and processed junk food. Breast cancer death rates differ by more than 5-fold between these two groups, with Americans experiencing far more tragedy than their Japanese counterparts [8].

Recent meta-analysis of studies on dietary fat, fat-containing foods, and breast cancer risk have shown this same correlation. Higher meat and saturated fat intake have been shown to increase the risk of breast cancer by 17% and 19% respectively [9]. The rich-western diet is literally serving as a cash-money machine for our current breast cancer "awareness" initiatives. The dark red regions below may as well be painted in $100 bills to more accurately reflect the link between breast cancer and our profit-based medicine system.


Breast Cancer, Diet, and Hormones

One reason why animal foods and other high-fat foods tend to increase the risk of breast cancer is due to their ability to boost female hormones (estrogen and progesterone) in the body, specifically estrogen levels [10]. Higher levels of estrogen have been associated with higher incidences of breast cancer in postmenopausal women [11]. Hormone replacement therapy (Premarin, Prempro, Activella, etc.) have also been associated with this same increased risk of breast cancer in women—specifically up to 20% greater risk in women of white, Asian, and Hispanic descent [12].

The best ways to reduce your levels of circulating estrogen are to avoid hormone replacement therapy and eat a plant-based diet. The video below gives a great overview of the dietary correlation between estrogen levels and cancer risk.



Best Foods to Include (and Avoid) in a Breast Cancer Prevention Strategy

Your best chance at warding off breast cancer is simple. Avoid processed and animal-based foods. These are typically higher in fat and contain animal protein, both of which have been linked to higher rates of several types of cancer including cancer of the breast [13]. Fried foods, packaged products, pastries, beef, chicken, fish, milk, etc. all fit this bill and should be avoided if you wish to give yourself the best chance at remaining cancer free. Alcohol consumption also significantly increases risk of breast cancer in women [14]. As little as one alcoholic drink per day increases women's risk of breast cancer by 4%. Three or more alcoholic drinks per day increase breast cancer risk by 40%-50% in women.

Instead, women should focus on developing a diet incorporating fruits, vegetables, legumes, whole grains, and nuts/seeds. These are the foods with an abundance of cancer-destroying phytochemicals and antioxidants to them. In particular, the food items below have been shown to have even more cancer-fighting properties amongst those in the plant kingdom in regards to breast cancer:

- Cruciferous vegetables (broccoli, cauliflower, cabbage, etc.) are associated with a lower risk of breast cancer [15]
- Mushrooms have a protective effect against estrogen receptor positive and progesterone receptor positive breast cancer cases [16]
- Flaxseeds are a great source of dietary lignans which have been shown to reduce breast cancer risk with regular consumption [17]. For more information on the benefits of flaxseeds in breast cancer prevention watch this video.

Can Breast Cancer Be Treated With Diet?

It appears that diet can play a significant role in the treatment of breast cancer after diagnosis. An article in the journal Nutrition and Cancer in 2006 reported markedly improved survival rates in postmenopausal women diagnosed with breast cancer who consumed a more plant-rich diet [18]. Their diet was low in fat, high in fiber (*note* fiber is only found in plant foods), high in fruits and vegetables, and contained more micronutrient-rich plant foods with folate, carotenoids, and vitamin C.

There are also many case reports of women defeating breast cancer by adopting a whole foods, plant-based diet. Ruth Heidrich, Anneliese Moore, and Kelly Binkoski are three women who did just that. You can read Ruth's story here, Anneliese's story here, and Kelly's story here. One of the most inspiring stories comes from Jessica Bowen. She overcame stage 3 breast cancer as she talks about in the video below.


Conclusion


Breast cancer is a horrible disease that affects millions of women worldwide. Much of it is preventable and some have even treated it with a health-promoting, plant-based diet. While many well-meaning efforts during the month of October work to "raise awareness" for breast cancer we as a society will never win the battle against this disease by performing more mammographies, conducting more breast exams, or doing more preventative surgeries (mastectomies).

Early detection has been proven to do more harm than good. It boosts profits of major corporations, businesses, and individuals alike involved in providing these services while breast cancer rates remain largely unchanged. If we want to win the war on breast cancer we need less medical care not more. By taking personal responsibility for your health and adopting healthy dietary habits in the form of a whole foods, plant-based diet you'll give yourself the best opportunity possible to never have to face this disease in the first place. You owe it to yourself to do so.

For more information on breast cancer prevention and treatment please visit the following sites:










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by Dustin Rudolph, PharmD
Clinical Pharmacist

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Photo credits
Pink Ribbon: MesserWoland - Wikimedia Commons
Breast Anatomy: NCI Don Bliss (Illustrator) - Wikimedia Commons

References:
1 U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2009 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2013. Available at: www.cdc.gov/uscs.
2 American Cancer Society.: Cancer Facts and Figures 2013. Atlanta, Ga: American Cancer Society, 2013. Available: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-036845.pdf. Accessed September 16, 2013.
3 Bertos NR, Park M. Breast cancer — one term, many entities? J Clin Invest. 2011;121(10):3789–3796.
4 Pasche B. Recent advances in breast cancer genetics. Cancer Treat Res. 2008;141:1-10. Review.
5 Gøtzsche PC, Jørgensen K. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD001877. DOI: 10.1002/14651858.CD001877.pub5.
6 Kösters JP, Gøtzsche PC. Regular self-examination or clinical examination for early detection of breast cancer. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD003373. DOI: 10.1002/14651858.CD003373.
7 Campbell JD, et al. The costs of treating breast cancer in the US: a synthesis of published evidence. Pharmacoeconomics. 2009;27(3)199-209. Review.
8 Lands WEM, Hamazaki T, Yamazaki K, et al. Changing dietary patterns. Am J Clin Nutr. 1990;51:991-993.
9 Boyd NF, Stone J, Vogt KN, et al. Dietary fat and breast cancer risk revisited: a meta-analysis of the published literature. Br J Cancer. 2003 Nov 3;89(9):1672-85.
10 Dorgan JF, Hunsberger SA, McMahon RP, et al. Diet and sex hormones in girls: findings from a randomized controlled clinical trial. J Natl Cancer Inst. 2003;95:132-141.
11 Dorgan JF, Longcope C, Stephenson HE Jr, et al. Relation of prediagnostic serum estrogen and androgen levels to breast cancer risk. Cancer Epidemiol Biomarkers Prev. 1996 Jul;5(7):533-9.
12 Hou N, Hong S, Wang W, et al. Hormone replacement therapy and breast cancer: heterogeneous risks by race, weight, and breast density. J Natl Cancer Inst. 2013 Sep 18;105(18):1365-72.
13 La Vecchia C. Cancers associated with high-fat diets. J Natl Cancer Inst Monogr. 1992;79-85.
14 Seitz HK, et al. Epidemiology and pathophysiology of alcohol and breast cancer: Update 2012. Alcohol-Alcohol. 2012 May-Jun;47(3):204-212.
15 Terry P, et al. Brassica vegetables and breast cancer risk. JAMA. 2001;285(23):769-776.
16 Shin A, et al. Dietary mushroom intake and the risk of breast cancer based on hormone receptor status. Nutr Cancer. 2010;62(4):476-83.
17 Lowcock EC, et al. Consumption of flaxseed, a rich source of lignans, is associated with reduced breast cancer risk. Cancer Causes Control. 2013 Apr;24(4):813-6.
18 McEligot AJ, et al. Dietary fat, fiber, vegetable, and micronutrients are associated with overall survival in postmenopausal women diagnosed with breast cancer. Nutr Cancer. 2006;55(2):132-40.

5 comments:

  1. This article was hugely informative but left me very scared and very confused about diet and its correlation to the disease. Goodness!

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    1. I'm glad it opened your eyes Angeline. The best thing you can do is educate yourself based on the facts. The links at the end of my articles are from physicians and experts who have been practicing patient-centered, evidenced-based medicine for many years or decades if you are interested in checking them out.

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  2. your research and blog are commendable and worthy of sharing. another intervention in the prevention of breast cancer is breastfeeding. there are many studies supporting this, whether extended nursing of one child or shorter nursing of several children, the cumulative effect has been documented as cutting breast cancer risk by 1/3!!

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  3. What you said in this article is so true. Thank you so much for writing it.

    I have first hand experience. I had 2 breast biopsies, both due to calcium deposits found by mammogram. The first time I did it without question. Because my breasts are small and dense, it took almost two hours of constant scanning (I assume put out radiation) and agony before the biopsy was done. Result was negative.

    Second time around which was a few years back, I researched literature and found some studies done overseas showing that more mammograms and biopsies found no increase in mortality rate, but only the rate of unnecessary procedures. And so I spoke with the doctor at the hospital responsible for my biopsy, and she was adamant that I was wrong, and frankly somewhat patronizing. Regardless, I was about to wait and see, not to do the biopsy but keep doing periodic mammograms to monitor if there is growth and that it is a real concern. However, some of my family got very alarmed, and without understanding the studies, said that I should listen to the doctor. And so in order to avoid the family member being so upset, I reluctantly gone for another biopsy. It was negative again.

    But the second biopsy was outright barbaric. The area to be biopsied was at the edge of my breast, difficult to get to. And it took over 3 hours of pain (yes, pain despite anesthesia) to complete the procedure. I also got a vagal reaction right after, and fainted. Moreover, with the constant scanning during the biopsy, I imagine I got quite a high dose of radiation, which would increase future chance of breast cancer.

    In short, I think good info such as what you wrote here is very important in educating the public. The truth needs a hand especially when the opposite is backed by so much money. So I commend you for writing this. If you had written this a few years ago, I could have pointed this article out to my family and most likely avoided painful, stressful and unnecessary procedures.

    I have seen first hand how doctors' opinions have been knowingly or unknowingly biased by personal gain. There is just is a lot of money in the cancer business. I urge everybody to find out more info themselves, get second opinion, etc, and not take doctors' words without question.

    By the way, I am a vegan now, and never felt better in my life. My reason of changing to a vegan diet was due to the horrific sufferings I saw factory farm animals go through these days. Most people don't know how factory farming these days have done to animals. Just standard farming practice is daily animal abuse already if we would apply the same standard for our pets. And so there was no way for me to continue contributing to animal abuse after I knew about it.

    Anyways, what I wanted to say is that I was pleasantly surprised (shocked) when my rheumatoid arthritis was completely gone after I became a vegan. Not only the swelling and pain was gone, but the range of the movement of my entire body was back to when I was in my teens and twenties. My acid reflux and IBS were also gone. My checkup with my primary physician also showed that my cholesterol levels, blood pressure, etc, have all become perfect. I have perfect health now and full of energy. I didn't expect that when I started my vegan diet. But now I know vegan diet is what we humans are meant to eat!

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    1. Helen, your story is incredibly inspiring for myself and others to hear. Individuals like yourself are why it is so rewarding to put in all the work to comb through the literature to tell the truth about science and medicine. Thank you for sharing your story and being a beacon of light for others to look up to.

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