Protecting the Breasts - The Hidden Truth about Mammography, Hormones, and Cancer
"Look Inside" Dr. Winnifred Cutler's essential book; an excerpt from Chapter 10 for readers.
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Copyright © 2009 John Wiley & Sons, Inc.
Hormones and Your Health: The Smart Woman's Guide to Hormonal and Alternative Therapies for Menopause
Excerpted pages 184 -191, 209-210
** Regarding "Breast Density" mentioned in recent Forum **
Twelve studies revealed that women with very dense breasts are at a significantly increased risk for developing breast cancer, compared to women who have the very lowest level of density.318 Although one study reported it, the others found there was no trend to show that medium-density breasts were at higher risk than low-density breasts.90 Likewise, an increase in density does not clearly increase the risk of breast cancer.318
Effect of Hormonal Therapies on Breast Density
Some hormonal therapies increase breast density; others do not. But whatever change the hormones generate tends to occur immediately, with no further changes after the first few weeks.319
What you should know: Different HRTs produce different effects:
- Increased mammographic density is most likely with oral continuous-combined estrogen and certain synthetic progestins. Up to 50 percent of women who start such combined regimens experience this phenomenon.153, 319, 474, 687
In comparison, several different sequential regimens that mimicked a fertile menstrual cycle produced no significant increase in the density of the breasts.687
- An increase of more than 25 percent in the breast-density score was experienced by 16 percent of those whose estrogens were oral but by only 4 percent of those whose estrogen was taken transdermally in HRT regimens that used continuous-combined synthetic progestin that was available in Europe (NETA).319
- An oral estrogen used in Finland (estradiol valerate) that was combined with a low dose of the progestin levonorgestrel, which an intrauterine device released slowly, produced minimal effects on breast density.474 This was considered a promising new regimen.
- Oral conjugated equine estrogen such as Premarin appears to substantially increase cell proliferation and breast density for most women.793
- Fibrocystic breasts have also been tested for their response to hormone therapies in postmenopause. Experiments in Turkey showed that some regimens (Prempro) increased the size of the cysts, whereas two regimens (transdermal estrogen alone or with oral medroxyprogesterone acetate) were neutral.865
Breast cancer is the subject of a perpetual barrage of fear-inducing headlines. And as of April 2006, the U.S. Department of Health and Human Services advises: “Women 40 years and older should get a mammogram every one to two years” (www.4women.gov/mammography.htm).
Symbolic pink ribbons are everywhere. Famous personalities urge us to have mammograms to detect our cancer early. And an emerging “breast-terror industry” alarms women with marketing methods that are ostensibly designed to generate money for research but that also coincidentally increase product sales and support an army of people who do not do any research. I find that these messages subtly misinterpret data. The excessive search for disease can stress and traumatize a woman. Stress is unhealthy. It damages our immune systems and reduces our natural capacity to fight cancer and other diseases. We should focus our energies on what to do to be healthy. First, let’s take the fangs out of the fear mongering.
Here’s what the current science has to say—and it’s not as frightening a picture as the breast-terror industry would have you believe:
- The actual incidence of breast cancer is much lower than that of cardiovascular or bone disease.
- Breast cancer is highly unlikely to kill you.
- You can cut your risk dramatically by making wise food choices, cultivating good exercise habits, getting exposure to fresh air and sunshine, and taking steps to promote mental health.
- Mammograms are not “treatment”; they are stressful detection techniques.
- Users of some types of HRT have less cancer than nonusers do. And 99 percent of women will not be at increased risk of developing breast cancer, regardless of which hormones they take.
What You Should Know
You do have choices. This chapter outlines your options by reviewing the real facts behind the scientific research. My goal is to expose how the misunderstanding of statistical jargon distorts results. I’ll show you the actual studies and the good news that a correct interpretation can offer.
Does mammography reduce mortality rates? Maybe not.
We hear that more breast cancers are occurring, but what this really means is that more breast cancer is being “discovered” when mammograms are used to search for it. Breast cancer screening seems to explain recent increases in breast cancer detection.219 If you’re looking for something (such as cancer) and you look regularly, chances are, you’re more likely to find it.
Does mammography reduce the devastating experiences of developing incurable metastatic breast cancer or having a mastectomy or does it lower mortality rates? The science behind such claims has not proved that it has.
In 2002, the U.S. Preventive Service Task Force commissioned a review of everything published up until that time, in order to update its recommendations .The task force findings were sobering to me:368
- There were no randomized, controlled treatment-outcome trials. In other words, no current breast cancer treatment had been proved effective.
- The efficacy of early treatment on reducing death rates has not been established.
- The quality of published data ranged from poor to fair, with numerous flaws limiting any conclusions about mammography’s usefulness.
- Early treatment following either a clinical exam or a mammography was equally effective in reducing the risk ratio of death (by 3 percent) when 50- to 59-year-olds were randomly assigned to either group.
- Breast self-exams increased visits to doctors, but the resulting interventions did not affect the death rates.368
Nevertheless, the task force ended up recommending yearly mammograms. But looking at the same data, I come to somewhat different conclusions. In my opinion, the public information is unbalanced and falsely marketed when it suggests that mammographic screening is always good, leads to early detection, and implies that early intervention thereby improves lifespan. This message contradicts the data.869, 870
Mammograms are stressful. The WHI analysis reported that 36 percent of Premarin and 28 percent of placebo users had been called back to evaluate “abnormal” mammograms in the first 7 years.741 That is surely stressful. And worse yet is scheduling and then undergoing a biopsy has been recently shown to hurt the immune system for several months afterward.846 This means that a biopsy itself inhibits a part of the cancer-fighting machinery of an intact, healthy woman.
Is There Benefit to Finding Smaller Tumors Earlier?
- In Norway, investigators concluded that the increased detection from screening led to a dramatic overdiagnosis, not to an improvement in life circumstance.869, 870 There was some good news about HRT regarding mammograms that show calcifications. Taking hormones did not affect the malignancy rate for women who showed calcifications that were “indeterminate” when diagnosed at a routine screening.466
- By 2004, in the Journal of the American Medical Association, Dr. Lisa M. Schwartz commented that finally, there is a growing awareness among physicians that cancer screening is a double-edged sword. If early detection of breast cancer and the resulting treatment fail to lengthen life and harm its quality, is it useful to detect it?684
- In California, among the 13-million-member HealthNet HMO, mammograms were reported to detect small tumors at earlier stages than would otherwise be found without frequent mammographic screening. The discovery of smaller tumors, however, did not increase the number of surgeries that conserve breasts, as had been expected from “early detection.”441
- In a Swedish study, a slight reduction in the death rate was attributed to earlier treatment.569 The study did not test whether teaching women self-examination would have been just as good. Yet exactly this finding was reported when the Canadian National Breast Cancer screening study compared mammography to self-examination.519
What you should know: The data suggest to me that for reducing the future death rate from breast cancer, having one clinical exam by a competent clinician, followed by regular self-examination, is just as protective as four or five annual mammograms without any self-examination. Some women will prefer a mammogram; others, a self-exam. And there is no radiation in a self-exam.But women should not believe it is unanimously accepted that annual mammograms are required. Discuss this with your physician. Remember, it is effective treatment, not detection, of breast cancer that decreases the death rate.
From The Conclusion: There is little doubt that the general practice of hormonal therapy, by prescribing it with concomitant mammography, has caused a slight overall increased incidence in breast cancer detection. Likewise, among women with breast cancer, there is a slightly increased odds ratio for women who were using hormones compared to those who have not been disclosed to have breast cancer. But you have to put that risk in perspective. We increase our chances of having an automobile accident by getting into cars, but we also know that we can choose safer vehicles, safer routes, and safer times for road travel. Similarly, hormonal therapy can take you to good, healthy places—provided that you choose hormone products wisely.
The route of estrogen should also be carefully selected, based on weighing the overall benefits of each. (See the chapters on your cardiovascular health, bones, and cognition.) ***
Women should recognize that all hormone-replacement therapies are not alike. Their fear about the risks of developing cancer should not necessarily mandate against the marvelous health benefits that a well-managed hormone-replacement regimen can provide. Breast self-exams, assisted by a competent clinician, may be as effective as a mammogram and without the adverse effects. Women should not believe that annual mammograms are “required.”
The healthy body's natural anti-cancer defense mechanisms have recently been in the news. Prostate cancer is no longer immediately treated aggressively in its earliest states because of the recognition that an otherwise generally healthy body's internal defenses can produce "spontaneous remissions". It may be the same for the natural history of early stage breast cancer, according to a large November 2008 study by the Norwegian researchers discussed earlier. They concluded: "It appears that some breast cancers detected by repeated mammogramic screening would not persist to be detectable by a single mammogram at the end of 6 years." 871b
Finally, when alarming media headlines trumpet “risks doubled” or “27 percent increases shown,” you should ask, “Double what? Or 27 percent of what?” Is this from 1 in 10,000 to 2 in 10,000? Is this 27 percent of 2.2 percent? Remember, breast cancer deaths in 1950 were 32 per 100,000 women; in 2003, they were 25 per 100,000 women; this is one-eighth the cardiovascular disease death rate. We sorely need to keep this perspective when bombarded by seemingly terrifying advertisements and headlines.
Also in this chapter:
- Hormone Therapy and Breast Cancer Risks
- A revealing overview of the international studies
- Different HRT Regimens have different risks
- Effect of Hormonal Therapies on Breast Density, Cell Proliferation
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