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FOX 11 Los Angeles News Interview January 2013

There has been much in the news lately regarding dense breast tissue and the concerns regarding risk of breast cancer as well as the inability of routine mammography to detect breast cancers in women with dense breast tissue.

First of all, it is important to understand what is being discussed when you hear the term “dense breast tissue”. The breast is normally composed of fat and glandular tissue – the higher proportion of glandular tissue, the denser the breast. It is important to note that “lumpy” breast tissue is not the same as dense – density is determined by the appearance on a mammogram, not by feel. The denser your breast tissue, the more “white” will be seen on a mammogram; women with primarily fatty breasts will have a mammogram that appears darker. Digital mammograms (compared to older film screen mammograms) have an easier time seeing through dense breast tissue, but all mammograms are limited in their ability to see through dense tissue and identify cancers, as cancers usually appear as dense white lumps on a mammogram. In general approximately 10-20% of breast cancers are missed by standard mammography – that percentage can approach 40-50% in women with dense breast tissue.

It was previously thought that mammograms simply had a harder time detecting breast cancer in women with dense breast tissue. However, we now know that a woman with dense breast tissue does have an increased risk for developing breast cancer and this is the subject of intense research. There are many factors that influence breast density including age, hormone levels, genetics, age at first pregnancy and number of pregnancies, use of hormone replacement therapy, overall body weight – just to name a few. And as younger women naturally have denser breast tissue, that does not mean that women in their 20’s and 30’s have an increased risk of breast cancer – in fact the risk of breast cancer increases with increasing age; it is hard to sort out when the increased risk as it relates to breast density develops.

Unfortunately, it is sometimes difficult for a woman to know if she has dense breast tissue – remember it is not the same as “lumpy” breasts. When you undergo a mammogram, the radiologist is required to make a comment regarding breast density in his or her report. However, patients often do not receive the radiologist’s report. Mammography performance and reporting in this country is regulated by the FDA, through the Mammography Quality Standards Act, and currently it is required that patients receive a “lay letter” – a report written in layperson terms that gives a basic summary of the findings and recommendations. Your physician who ordered the mammogram will receive the official report with a notation of density.

Several states (including California) have now passed legislation requiring that patients be informed of their breast density. While I agree that patients certainly have a right to their full and un-edited test results, it is unfortunate that legislation was required to ensure that women receive their complete test results. Federal legislation is pending regarding this matter.

If you have dense breasts, what should you do? We know that MRI, and certain forms of ultrasound, especially automated whole-breast ultrasound, can be very helpful in evaluating women with very dense breast tissue. While I do recommend these studies for some patients, realize that there are no formal guidelines by either the American College of Radiology or the American Cancer Society regarding breast imaging for women with dense breast tissue, unless the woman is also considered to be in a high-risk category (for example those with a strong family history of breast cancer). Some of these tests are not covered by insurance. Also realize that MRI and ultrasound also have some limitations when imaging dense breast tissue – there is no perfect method of evaluation.

Newer methods of mammography such as tomosynthesis and contrast-enhanced mammography are showing promise, but studies are still being performed; these exams may also expose a woman to higher doses of radiation and/or a contrast material injection.

My recommendation is that women speak to their doctors. Ask if your breast tissue is considered dense, and if so, would you benefit from additional testing. Stay tuned for more information as newer imaging techniques which improve the rate of cancer detection in women with dense breast tissue are being developed.

Dr. Attai was one of the physicians invited to testify before the California Legislature in support of SB 1538, which was eventually signed by Governor Brown, requiring that mammography facilities in California inform patients if they have dense breast tissue on mammogram.

For more information on dense breast tissue read Dr. Attai’s editorial published in the Ventura County Star.

Breast Cancer is a common disease, affecting approximately 1 in 8 women over a lifetime. Men are also affected, at a rate of approximately 1 in 100. All women should have an awareness of the changes that occur in their breasts, and should undergo routine evaluation and imaging (such as mammogram, ultrasound, or MRI if appropriate) at recommended intervals.

As a breast surgeon, I focus not only on the treatment of disease, but on risk reduction and prevention as well. While having a family history of breast cancer increases your risk, all women are at risk. Unfortunately in any one individual, it is not currently possible to say exactly why breast cancer developed, but we are becoming more aware of the effects of lifestyle and environmental influences on the development of cancer as well as other diseases. A healthy lifestyle does not equal prevention, but here are some facts regarding breast cancer:

• Postmenopausal women who are overweight have a higher risk of developing breast cancer, and if they’ve been treated for breast cancer, their risk of recurrence is increased if they are overweight
• Moderate exercise has been shown to reduce the risk of breast cancer development as well as the risk of recurrent disease
• A high fat diet has been linked to an increased risk of breast cancer
• More than 3-6 alcoholic drinks per week in women is associated with an increased risk of breast cancer
• Exposure to some environmental toxins, such as BPA, has been linked to breast cancer development in laboratory animals. The link between breast cancer and various chemicals is the subject of intense research and there are many conflicting studies. Until we have firm data however, it does seem prudent to limit your exposure to toxic chemicals whenever possible.

Unfortunately is is possible to do everything “right” and still develop breast cancer. The reality is that breast cancer and many other diseases are caused and exacerbated by multiple factors - this is why studies evaluating methods of prevention are so difficult. And it’s also why the studies that pop up every so often regarding the benefits of a particular nutrient or extract need to be placed in proper perspective - it’s usually not as simple as one nutrient or extract.

My recommendation for all of my patients, not just those with breast cancer, is to simply take good care of yourself. As we age (and we’re all getting older!), our bodies become less tolerant of the effects of lack of sleep, heavy alcohol intake, and the dietary habits that we had when we were in our 20′s. Our bodies have changed, and we have to change our habits if we want to try to stay healthy. Here are some guidelines:

• A low fat (not no fat!!) diet - focus on the healthy fats such as olive oil, salmon, walnuts, avocados
• A plant-based diet - focus on lots of greens and veggies of all colors, as well as fruits. You may feel it’s easier to take your fruits and veggies in pill form, but while you may be getting some of the vitamins and extracts, the way the real foods interact is very complex (cancer development is a similarly complex process) and cannot be replicated in a pill. Trace nutrients that we may not even know about will also be missing, as well as fiber, not to mention the wonderful taste of properly prepared, fresh, real food! A periodic splurge is also fine - life is too short to go without chocolate -just make it is good quality, dark if possible. There is no one particular food known to reduce the risk of cancer development.
• Animal protein is ok, just consider the source and eat in moderation
• Don’t forget non-animal sources of protein such as legumes and quinoa
• Moderation in alcohol intake - 3-6 drinks per week (and no, you can’t save up your week’s “allowance” for Friday night…)
• Moderate exercise - it’s ok if you can’t do you spinning class like you did 10 years ago - a good 30 minute walk once a day is fine. If you need that endorphin rush of strenuous activity, make sure to balance it with some more meditative exercise such as yoga or pilates
• Proper sleep - we all need 7-9 hours a night, period. Our bodies repair themselves during sleep, and you can’t just “catch up” on the weekends. Those that catch me on-line after 10pm pacific time - feel free to call me out on this one!
• Meditation / Reflection – it is so very important to take some time each day to reflect on what is good in your life - having a sense of appreciation and gratitude for the good things will help make it easier to get through the tough times. This can be as formal or informal as you want, it’s just important to fit this in somewhere.

Hopefully this gives you something to think about and some motivation. Just remember that you’re not making diet and lifestyle changes only for breast cancer risk reduction - these are steps that can also make you a healthier and happier person.

Much has been written regarding the role of soy and breast cancer, but much confusion remains. While research in this area is active, here is what we know:

Soy is an isoflavone, a class of chemical that has weak estrogen-like activity. We know that women in Asian countries, following a traditional diet, have a lower incidence of breast cancer than women in the US. Their diet consists of large quantities of soy foods starting at a young age. However they eat soy in a natural form – they do not eat “foods” such as soy hot dogs or take soy in supplement form. Research has shown that consuming large quantities of natural soy products starting at a young age seems to confer some estrogen resistance to the breast tissue, which may account for the lower incidence of breast cancer in the Asian population.

So in this country, due to concerns about estrogen and hormone replacement therapy in terms of breast cancer risk, soy supplements are often marketed as a “natural” remedy for menopausal symptoms that may also reduce a risk of breast cancer, and women consume soy “foods” (such as hot dogs, meat substitutes, cheese substitutes) thinking that they are helping lower their risk of breast cancer. Remember that while the traditional Asian diet is high in natural soy products, it is also high in vegetables and low in animal protein and saturated fat. And there is probably more to their lower risk of breast cancer than just diet – a traditional Asian lifestyle is much different from ours in many ways. The development of breast cancer is not a simple cause-and-effect relationship in most cases – it is very complex and the importance of any one specific dietary intervention is difficult to determine.

So regarding menopausal symptoms, my advice is to go as natural as possible, which means soy in organic, whole form (edamame, miso, or tofu), regular exercise, and maintaining a healthy weight. Also do not underestimate the role of yoga, meditation and acupuncture. Anecdotal evidence exists suggesting that in some cases, omega 3’s, evening primrose oil, and black cohash may help.

In terms of breast cancer risk reduction, a moderate intake of soy in a whole-food, organic form may actually reduce risk, and research in this area is ongoing. As soy is one of most genetically modified and processed crops grown in this country, avoidance of soy in food-like forms (including highly processed “foods” and supplements) should probably be avoided. However a growing number of commercially available soy products are GMO-free, so do your research and read the labels – be aware of what you are putting in your body!

References:

American Institute of Cancer Research: http://www.aicr.org/foods-that-fight-cancer/foodsthatfightcancer_soy.html

Dr. Susan Love Research Foundation: http://dslrf.org/breastcancer/content.asp?L2=1&L3=4&SID=130&CID=2129&PID=4&CATID=0

BreastCancer.Org : http://www.breastcancer.org/tips/nutrition/reduce_risk/foods/soy.jsp