Breast Cancer: Complacency the Enemy of Cure

by Food and Drug Administration (FDA)

This is the first in a two-part series on breast cancer in FDA Consumer. Part I covers risk factors, the anatomy of the disease, and mammography. Part II will cover treatment and breast reconstruction after surgery.

Nineteen years ago at the age of 43, Joyce Fine of Bethesda, Md., had a radical mastectomy to treat breast cancer. She didn't discuss her disease much with anyone then, except her husband.

Twenty years ago and more, Fine remembers, cancer was not talked about. "Everything was secretive then. Obituaries of people with cancer read that they died of 'a lingering illness.' " Fine thinks that her father's mother may have had breast cancer, but she's not sure. The impression came from a single conversation she happened to overhear.

A New Attitude

There is today an unprecedented openness about breast cancer. Along with strides in diagnosis and treatment have come long overdue changes in attitudes and awareness about the disease. Happy Rockefeller, Betty Ford, Nancy Reagan, Jill Eikenberry, Shirley Temple Black, Gloria Steinem, and many other public figures have come forward in recent years to tell about their experiences, bringing breast cancer out of the closet and offering women hope and encouragement. But it's certainly not just because of the celebrities that breast cancer has captured the public's attention. For a disease that strikes 1 in about 10 American women (the American Cancer Society puts the figure at 1 in 9) it's almost become a rarity not to know someone who has had breast cancer.

Since the early 1970s, according to the National Cancer Institute, the incidence of breast cancer has increased about 1 percent a year. In 1970, there were about 69,000 newly diagnosed cases, compared with 150,000 in 1990. The number of deaths rose from 30,000 in 1970 to 44,000 in 1990.

Although researchers have identified several risk factors for breast cancer and are gathering data on possible others, one thing that's clear is that no woman can afford to be complacent. That fact came home to Ellen Weinberg of Chevy Chase, Md., when she was diagnosed last December.

"I had no risk factors at all," she says. "There was no family history. My son was born when I was 27. I did not start menstruating especially early. I grew up in a house where my dad was diabetic and a little overweight, so I've always had a low-fat diet. There was just nothing. The one mistake I made was that I didn't have a mammogram. I knew I should start having them at 40, but I was only 42, I was very healthy, I had no risk factors, and I felt no urgency. I just hadn't gotten around to it."

Risks: The Known

Some risk factors for breast cancer are clearly established, as are some factors known to reduce the chance of developing the disease. Although the average lifetime risk of breast cancer for a woman is 1 in 10, the actual risk of getting it in any given year is less than 1 in 100. A woman's risk rises continuously with age, but never exceeds 1 percent a year.

Breast cancer is more common in women from North America and Northern Europe and in women of high socioeconomic status. In the United States, women of European Jewish descent also have an increased risk. Certain types of benign (noncancerous) breast disease, radiation exposure, and family history of the disease are also established risk factors. Also, among post-menopausal women, obesity is associated with an increase in risk.

Women whose mothers or sisters have had breast cancer have two to three times the usual risk of developing the disease. The risk is greatest if the relative developed breast cancer before menopause or if both breasts were involved. Nevertheless, only 10 to 15 percent of women with breast cancer have a family history of the disease. As NCI researcher Susan Bates, M.D., says, the statement that "There's no breast cancer in my family" should provide a woman no security whatsoever.

In the Nov. 30, 1990, issue of Science, Stephen H. Friend, M.D., Ph.D., of the Massachusetts General Hospital Cancer Center reported that certain alterations in a gene called p53 lead to increased susceptibility to breast and certain other cancers, all occurring at unusually young ages. About 100 families around the world have been identified with this rare syndrome, named Li-Fraumeni for the two scientists who first described it in 1969. Followup of the four families originally identified revealed 16 new cancer cases when only one would have been expected.

The p53 gene is one of a few tumor suppressor genes researchers have identified. These genes act to control normal cell processes, and cancer results when the gene is missing or damaged and other genetic changes occur. The p53 gene is transmitted through the father's side of the family as well as the mother's.

Another genetic trait associated with breast cancer is wet ear wax. The breasts and the glands that produce ear wax are both apocrine glands. According to NCI's Breast Cancer Digest, women with wet ear wax are twice as likely to develop breast cancer as those with dry wax. Wet ear wax is a dominant genetic trait in the United States — 85 percent of whites and virtually all blacks in this country have wet ear wax. In Asia, where wet ear wax is rare, breast cancer is also much less prevalent.

A link between radiation and breast cancer has been established from studies of survivors of Hiroshima and Nagasaki and from women who have undergone radiation therapy or had repeated fluoroscopy, used many years ago to treat tuberculosis. The interval between exposure and disease development varies, but, according to Bates, the average is 20 years.

Women who begin menstruating before age 12, become menopausal after age 50, delay childbearing until after age 30, or bear no children are also at higher risk. On the other hand, the risk is lower in women who have their first child before age 18 and in women who, because of surgical removal of the ovaries, become menopausal before age 35.

Risks: The Unknown

Reserpine (a drug for high blood pressure), chemicals in hair dyes, alcohol consumption, dietary fat, use of birth control pills, and estrogen therapy have all been suggested as risk factors, but results from various studies have been contradictory, and their role in disease development remains controversial.

Some research has indicated that birth control pills might increase the risk of breast cancer, particularly in pre-menopausal women between the ages of 45 and 55, in women with a family history of breast cancer, or among young women who use them before the first pregnancy. One long-term study, however, reported that neither short-term nor long-term (more than 11 years) use appeared to increase risk, even in these groups of women. For now, the Food and Drug Administration requires that birth control pills carry a label indicating that the association between oral contraceptives and breast cancer is not clear.

Women who receive estrogen replacement therapy (ERT) may also be at increased risk. ERT is recommended for some menopausal women to counteract hot flashes and sweating and to slow bone thinning (osteoporosis). ERT may also confer protection from cardiovascular disease. A recently published study of 118,000 female nurses followed for 10 years found a "modest" increase in risk in current users — more so with increasing age, but not in past users, even if therapy had lasted more than 10 years. The researchers, led by Graham Colditz, M.B., B.S. (British equivalent of M.D.), of Brigham and Women's Hospital in Boston, concluded that "Though this increase in risk will be counterbalanced by the cardiovascular benefits, [there is a] need for caution in the use of estrogens."

About the Author

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