What do you do if you have dense breast tissue?

Dense breast tissue is important, because there are five times more breast cancers in dense tissue and dense breast tissue can hide abnormalities on the mammogram (http://www.nejm.org/doi/full/10.1056/nejmoa062790).


One proactive Texan, Henda Salmeron, had that experience.  Her cancer did not show up on her mammogram.  She persisted and, the cancer was revealed by a sonogram (or  breast ultrasound).  She had not been told that she had dense breast tissue and that another kind of study might be helpful for her.  She decided to try to make a difference for other women with dense breasts and ultimately "Henda's Law" was passed and takes effect January 1, 2012.  It requires that the mammography facility inform you if you have dense breast tissue and "that you might benefit from supplemental screening tests that might be suggested by your ordering physician" (http://txrad.org/index.cfm/trs-forum/texas-hb-2102).
  


If you have dense breast tissue, you will be told when you get your mammogram  and then you may pursue additional screening, such a breast sonogram, like Henda, or a breast MRI.  You are now empowered thanks to Henda Salmeron.  The law was not meant to cause concern, but to increase awareness and promote the discussion about a more complete screening for those with dense breast tissue.


If you need help don't hesitate to call or email.


Owen Winsett, MD
512-451-5788
http://www.owenwinsettmd.com

More on Personal Prevention of Breast Cancer

Last week at the San Antonio Breast Cancer Symposium a panel of researchers released a 364 page document on the science behind the risk of breast cancer development and the environment.  The exhaustive report from the Institute of Medicine was paid for by the Susan G. Komen Foundation.


Some saw it as a disappointment because they found little evidence to correlate certain pesticides, cosmetics or bishphenol A (or BPA in some plastic bottles) with breast cancer risk.


BUT, what they did say that does matter: 


          Don't gain weight (or loose weight)
          Regularly Exercise
          Limit or avoid Estrogen-Progestin use
          Limit Alcohol consumption
          Don't smoke
          Avoid unnecessary medical radiation


Sounds just like what we have been blogging.


The complete study may be found on the Institute of Medicine website and a quote is below: https://www.iom.edu/reports/2011/Breast-Cancer-and-the-Environment-A-Lifecousre-Approach.aspx


The IOM concludes that women may have some opportunities to reduce their risk of breast cancer through personal actions, such as avoiding unnecessary medical radiation throughout life, avoiding use of estrogen –progestin hormone therapy, avoiding smoking, limiting alcohol consumption, increasing physical activity, and, for postmenopausal breast cancer, minimizing weight gain.


The evidence is there and more and more data is accumulating and being recognized!  


So LET'S GET MOVING and BE LEAN.

Now is the time!

Holiday time is a perfect time to begin exercising.  You have time and can be encouraged by family to do so or encourage a family member to do so and find a lasting exercise buddy.


One of the added benefits of just going for a walk, say after a turkey dinner, is that you will feel better!  Not so stuffed!  More energetic! 


And, on a walk you can communicate with a friend or family member better than in front of the TV!


Moving around and exercise can be fun and rewarding!


Let this holiday season be the one that gets you started on a program to reduce your risk for breast cancer and begin with exercise.  Don't wait for inspiration.  Do it and you will feel better and get the inspiration to continue!

PREVENTION, PREVENTION, PREVENTION!!!

I am sure that you all noted a lack of attention to PREVENTION in this week's "pink page" breast cancer supplement to the Austin American Statesman.


We need to tell all our friends and families about the good news.  At least 75,000 breast cancer diagnoses per year can be prevented!


BE LEAN.  BE ACTIVE.  EXERCISE EVERY DAY.  


Those three are the main achievements for breast cancer reduction.


For some (after discussion with your doctor or me) aspirin, omega3, limit alcohol, limit red meat, add red apples, red grapes, strawberries, walnuts and coffee.


Help me get the news out:  75,000 cases of breast cancer prevented each year!

More is better when talking about activity.

Data is emerging that, although exercise is a good way to reduce the risk of breast cancer, one needs to be active all day.  According to Dr. Neville Owen at the recent American Institute for Cancer Research meeting (http://aicr.org) "sitting time is emerging as a strong candidate for being a cancer risk in its own right."


Many people sit as much as 10 hours a day: driving to work, work , eating, etc.  He cited studies that demonstrated that measures such as waist circumference, insulin resistance and inflammatory factors, all increased with sitting and decreased with activity.  These factors are related, not only to cardiovascular disease, but also cancers.  He noted a benefit to just 1 or 2 minutes ACTIVITY during each hour.


We need practical solutions NOW.  I offer mine and others from the meeting.  I am fortunate to have a job of walking up and down the hall and in and out of rooms, but I sit on a 65cm exercise ball at the computer and use a standing desk when writing.  Get up and walk down the hall or around your desk the last 5 minutes of each hour (set the alarm on your computer).  Use hand weights.  Stand to talk on the phone.  Walk down the hall to deliver a message instead of emailing.  You get the idea.


MORE MOVEMENT MEANS FEWER BREAST CANCERS!

From IDEA to ALPHA and MORE EXERCISE EQUALS FEWER BREAST CANCERS

A recent report of the continuing ALPHA trial (Alberta Physical Activity and Breast Cancer Prevention) by Christine Friedenreich, PhD not only gives more evidence that physical activity lowers the risk for breast cancer but gives insight into mechanisms at work (http://www.medscape.com/viewarticle/753114).


The study was designed to examine the effect of a year long supervised exercise intervention on biomarkers associated with breast cancer.  Previously these researchers have reported lower estrogen levels with exercise in postmenopausal women.  


The trial of 320 healthy but inactive women, 156 agreed to one year of supervised exercise 5 days a week for 45 minutes.  The ages of the women ranged from 50 to 74 years.  The control group did not change activity level and neither group changed diet.  


The results reported at this time reveal a lower C-reactive protein (CRP) level in the exercisers.  This is a protein which is a biomarker for inflammation.  Although we don't know exactly how inflammation raises cancer risks, we know that chronic inflammation produces chemicals in the body that encourage cell proliferation and suppress normal cell death, which increases cancer risk.


We are getting closer to the answer for how exercise reduces cancer risk, in the meantime, we know exercise works.  


MORE EXERCISE LEADS TO FEWER BREAST CANCERS!!!

I have a new IDEA!

Impressive results were recently presented at the American College of Rheumatology 2001 meeting (http://www.reuhmatology.org) in the Intensive Diet and Exercise for Arthritis (get it?) trial.


454 overweight and obese people (72% women) with an average BMI of 33 (e.g. 5'5" and 200#) and an average age of 66 years were randomized into 3 groups: intensive diet  (maintaining >10% weight loss), moderate exercise (two 15 minute walks and 20 minutes of weight training 3 times a week) or both.


Each group lost weight, but the group both dieting and exercising lost the most.


All groups reported less pain in the knees, but at 18 months the exercise/diet group noted a 51% reduction in pain (twice the reduction of the other two).  Furthermore, 40% of those in the diet and exercise group rated their pain at only 0 or 1 out of 10.  


Functional status including walking speed improved in 50% of the combined exercise and diet group!


So, LESS PAIN, ABLE TO FUNCTION BETTER!  


And they didn't even study the incidence of breast cancer, but we now know those women who lose weight and regularly exercise also will have fewer breast cancers.

An update on breast cancer screening.

Screening mammograms have received too much bad press recently!  


In the NY Times Oct 24, by Tara Parker-Pope and in the Washington Post Oct 31, by Manoj Jain, each author chose to compare PSA screening for prostate cancer to mammographic screening for breast cancer, despite the fact that the benefits, risks and science behind each is quite different.  There is not nearly the evidence for the value of PSA screening as there is evidence for LIVES SAVED by screening mammography. 


I will rehash all of the studies showing that screening mammograms SAVE LIVES in a future blog, but more immediately offer an option for those women dissuaded from mammography by the recent "news" articles.


A new test would seem to be an excellent option to find out who would benefit the most from screening mammography by giving us information on personal risk.  Those at higher risk could benefit the most from the screening and intervention.  


One such test is the BREVAGen test, which has been validated by science (see my blog 09-12-2011).  We have used it to learn who is at higher risk for breast cancer and then offer appropriate screening and intervention.  The test is without radiation or false positive risk.  It is an inner cheek swab plus personal clinical data.  The results are easy to understand, quite convincing and can be compared to the meaning of the cholesterol level to heart attack risk.


Join my blog or call to come in to learn more or have the test done.

More evidence for the protective effect of exercise!

Presented this week at the 10th Annual American Association for Cancer Research Conference (www.aacr.org) was even more data linking physical activity with reduced risk for breast cancer.  


This European trial recruited 520,000 women from 10 European countries and reported on 12 years of follow-up.  The risk reduction was significant for both total physical activity and recreational activity.  When comparing the highest and lowest levels of physical activity, they found that the more activity the fewer tumors! 


The benefit was greatest for Estrogen positive tumors (the most common kind) and the benefit was more robust for postmenopausal women (who have most of the breast cancers).


This, the largest such trial, lead by Dr. Karen Steindorf, from the German Cancer Research Center in Heidelberg, confirms what many other smaller trials have shown: THE MORE ACTIVITY, THE FEWER BREAST CANCERS. 


So have you been on your walk or jog, today?  I enjoyed the 55º weather this morning on a long trek with my dog!  It is not as easy as taking some pill, but it is more fun, has more benefits and has fewer side effects.

A brief RANT!

You may have heard or seen a media review of a recent study published the Arch Intern Med 2011:171(18):1625-1633.  The authors concluded that multivitamins were not beneficial and might even be harmful.


This was a long-term study of women in Iowa and it was self reported.  If the questions are asked and answered correctly we can learn a lot from population studies like this, but in this case they asked "do you take a multivitamin?" NOT which multivitamin?  Each participant was queried three times during the 22 years, whether she was taking a multivitamin, not which.  


This reminds me of Mark Twain: the difference between the right word and the almost right word is like the difference between a lightning bolt and a lightning bug!  


Do you eat cereal?  Most of us know the difference between nothing added granola or shredded wheat AND sugar-added cereals, but if you ate either you would answer the question, "Yes."  But what a difference.


Like cereals, all vitamins are not the same: not just varying amounts of vitamins and minerals, but other additives, as well.


Enough of a rant; if you want to know more, email your questions to thedoctor@owenwinsettmd.com or call 512-451-5788.

More about walnuts: The Good, The Not So Bad and The Not So Ugly!

Ok, I will delve into walnuts further, before we go on to another food, tomorrow.  I was asked, "What about the fat in walnuts?" and "Should men eat them, too?"


14 whole unadulterated walnuts weigh about 2 ounces or about 56 grams.  So let's call it a handful.  According to http://nutritiondata.com that would be a whopping 370 calories or 18% of a referenced 2000 calorie diet.  Not so bad if your are substituting walnuts for french fries or potato chips or salty pretzels, etc. 


The majority of the calories are from fat (83%), but they are the good plant fats: mono- and poly-unsaturated (90% of the total).  Fiber (4grams) and protein (8.6 grams) come in as the good, too.  Some vitamins are part of the good: thiamin, B6 and folate.  More of the good: manganese, copper, magnesium and phosphorus.  


And NO salt!  And NO cholesterol!


And the good for cancer reduction: omega-3 fatty acids, , phytosterols, and antioxidants.  In fact, walnuts have a lot of alpha-linolenic acid (like canola oil), which may be one of the main cancer suppressors.


But walnuts do have a lot of omega-6 fatty acids; not so ugly, if you add a high quality omega-3 supplement.  Many researchers believe that our diet is over weighted in omega-6 fatty acids (primarily from processed foods), which are pro-inflammatory and contribute to every thing from joint aches to cancer.


I eat a handful of walnuts every day!


So what do I take to help my omega-3 to 6 ratio?  I searched until I found the highest purity omega-3 and the healthiest ratio of EPA to DHA (the two most important omega-3 fatty acids) to decrease inflammation.  If you want to learn more about what I take go to http://oewmd.com.  I take at least 3 grams a day of WINOmega-3 and have for more than 4 years. 

A nut for all reasons!

Adding walnuts to the diet helps keep breast cancer away, according to a recent report.  A group at Marshall University, headed by Dr. Elaine Hardman, have extensively studied the benefits of walnuts and their most recent paper is quite exciting.  You can find the actual article at http://dx.doi.org/10.1080/01635581.2011.589959.


They are some of an ever enlarging group of scientists that think that diet can alter the formation of cancers.  Previous research has shown that walnuts slow the growth of implanted breast tumors.  In this study they added whole walnuts to the diet of mice genetically programmed to all have breast cancer.  When the control group all had breast cancers, only 40% of the mice receiving a lifelong diet containing whole walnuts had breast cancers!  The tumors were also smaller and fewer in numbers than in those not eating walnuts.


What makes this study particularly interesting is its applicability to the human diet. These mice were given the human equivalent of 2oz or about 14 whole walnuts a day.  Previous studies have tried to identify individual components of certain foods that might reduce cancers with mixed results.  The beauty of this study is that whole walnuts were used, so they can figure out which ingredient or combination of ingredients is effective later, while we can benefit now!  


Further comparability to humans was suggested by looking at the DNA changes in the mice.  The signaling pathways leading to cancers in mice have been shown to be important in humans and these are the ones blocked by the whole walnuts.  So, the data may not define the active ingredient, but the data strongly support the idea that 14 walnuts a day could reduce the number of breast cancers.

Exercise to feel better!

A study presented last week at the North American Menopause Society (NAMS at www.menopausejournal.com) demonstrated one other feature of exercise for women.  THE RIGHT EXERCISE CAN MAKE YOU FEEL BETTER!  


Dr. Steriani Elavsky and her team reported on 134 women after vigorous vs. moderate exercise.  Vigorous was defined as on the treadmill increasing intensity until it could no longer be tolerated.  Moderate intensity was defined as an exercise that would allow "talking in short sentences but not singing," according to Dr. Elavsky.  Examples of the latter include: brisk walk, ball room dancing, biking with few hills, canoeing, baseball, tennis and water aerobics.  That means getting your heart rate up to near 65% maximum.  


The study found that moderately intense exercise promoted psychological wellbeing, and caused women to feel more energized!  The moderate exercisers  also reported decreased feelings of sadness and anxiety!  


You don't have to go all out, but do something you enjoy and feel better!  Do it often so you can get the long-term benefits, like reducing the risk for getting breast cancer!




I can recommend one book for further reading: Younger Next Year for Women, by Chris Crowley & Henry S. Lodge, MD.

Want to increase productivity?

I have the study for you!  Trade in some work time for exercise!


This study in dental offices in Sweden was published in the Journal of Occupational and Environments Medicine 10.1097/JOM.0b013e31822589c2 August 2011.


Researchers compared a group who exercised 2.5 hours of a 40 hour work week to a group maintaining usual work hours without exercise during work hours.


The group that exercised and actually worked fewer hours, maintained the same productivity level as those working more hours.  They not only got more done, they felt better.  Those who exercised showed a significant increase in self-rated productivity, perceiving that they got more work done, had greater work capacity and fewer sickness absences.




Other studies have shown MORE EXERCISE EQUALS LESS SICKNESS, like a study of 1000 adults followed for 12 weeks in fall and winter 2008, published in the British Journal of Sports Medicine in 2010 10.1136/bjsm.2010.077875.  These adults up to the age of 85 reported on how frequently they exercised and the number of days and severity of cold-like symptoms.


Yes, you figured it out!  Those reporting physical activity 5 or more days a week reported half the sick days of non-exercisers.  The severity of symptoms also fell, by 41% in the exercisers.


These are some of the short-term benefits of exercise.  Cancer reduction takes longer, but it is never too late to start exercising!


So may I recommend; walk in our beautiful weather, take your dog for a walk, get an exercise buddy, join a gym.  These are all proven motivators.  

Thinking about not getting breast cancer!

We are celebrating Breast Cancer Prevention Awareness!

We blogged about the breast cancer reduction among exercisers on March 28, 2011.  In fact, the more exercise, the greater the reduction in breast cancer!

We reviewed other benefits of exercise on April 18, 2011.

Since I suspect everyone is exercising now for fewer breast cancers, let's look at the benefits for the brain.  As long as you don't get breast cancer you might as well think as clearly as you can!

I will review one study of cognitive performance, two of imaging characteristics and one potential basic science reason for all the good news.

The first study of almost 3000 women with risk factors for coronary artery disease, published online 10.1001/archinternmed.2011.282, analyzed cognitive score changes over 5 years.  They found that as energy expenditures in the women increased, the rate of cognitive decline DECREASED.  The amount of exercise associated with the lower risk of cognitive impairment was was the equivalent of a brisk 30 minute walk every day!

A second study focussed on the hippocampus, a part of the brain associated with memory.  120 sedentary older people volunteered to be followed for one year with spatial memory tests and brain MRI's.  Half began a program of walking 40 minutes 3 days a week.  Those who exercised showed increase in the volume of the hippocampus and improved memory scores.  The same part of the brain in the sedentary individuals decreased. Published online 10.1073/pnas.1015950108.


A third study, again an imaging study, but with 10 year followup, presented by Dr. Cyrus Raji at the Nov 2011 Radiological Society of North America meeting, reported on 426 people.  How far each person walked per week  was recorded and serial brain MRI's and mini-mental state exams (MMSE) were compared.  At ten years, the greater the amount of physical activity, the greater the brain volume.  The group that walked 6 miles per week also had significantly less cognitive decline.


The last article, published online last month 10.1152/japplphysiol.00343.2011 suggests that what is happening in the brain cells may help explain how exercise makes the brain more fit.  When comparing the brains of exercised mice versus those sedentary, they found markers of mitochondrial proliferation, the powerhouse of all cells, only in the exercising animals.  We know that some neurodegenerative diseases are characterized by depletion of mitochondria.  Imagine what physical exercise can give back to the brain!


So what am I doing when I exercise every day?  Building energy and strength in my brain!

Breast cancer prevention with a political twist!

We have discussed in previous blogs the adverse effect of weight gain on breast cancer occurrence, but today I want to commend to all a New York Times article in the Personal Health section online now (www.nytimes.com).  This article: Attacking the Obesity Epidemic by First Figuring Out Its Cause, by Jane E Brody reports on a series of studies published in the scholarly peer-reviewed journal, Lancet (www.thelancet.com) in August.  Experts from Harvard's School of Public Health, the World Health Organization and the National Institutes of Health and others,  report, in a series of four papers, the results of their two year study.

They list three cost-saving and health-savings measures, but I will leave you with just one.  This one measure is a tax on unhealthy foods and drinks.  It is a tough measure to sell, but cigarettes are taxed.  Such an attempt to tax sugar-sweetened beverages was recently defeated in New York State by industry pressure.  However according to their research, a 1 penny-per-ounce tax on sugar-sweetened beverages in California, alone, would bring in 1.5 billion dollars a year! Dr. Gortmaker, one of the authors, calls a tax on such beverages a "no-brainer" in the interview.  Can you imagine 2 cents or 10 cents? 

An easier way to learn your risk!

In the june 15, 2011 blog, I created a complicated model to answer the question, "What is the chance that YOU will get breast cancer?''  Now there is an easier way: BREVAGen.   A noninvasive swab of the inner cheek combined with the Gail Score identifies your personal breast cancer risk.  This new test provides a 5-year and lifetime risk by combining genetic markers and clinical factors.  The validation study was published in The Journal of the National Cancer Institute (online at www.jnci.oxfordjournals.org).

Genetic markers, called SNPs, associated with breast cancer were identified in genome-wide association  studies (GWAS) involving more than 50,000 women.  These common SNPs, obtained from DNA in saliva, are different from and unrelated to the BRCA 1 and 2 familial breast cancer genes that only 7% of women have.  These seven SNPs apply to many more women, particularly to those 70% of women without a family history of breast cancer.

Seven known risk factors, such as age, age at first menstrual cycle, age at first live birth, family history and biopsy history are used to generate a clinical risk in the National Cancer Institute's Breast Cancer Risk Assessment Tool (BCRAT) called the Gail Score.

Combining this genetic information from a noninvasive buccal swab with the clinical factors in the Gail Score gives the 5-Year risk and the Lifetime risk.  The results of the test allow us to make recommendations that align with American Cancer Society (ACS) and The American Society of Clinical Oncologists (ASCO) recommendations for screening and treatment in low, intermediate and high risk individuals.  Furthermore, the BREVAGen test reclassifies 64% of intermediate Gail Scores (about 30%) to either low or high risk.


SO WE HAVE THE INFORMATION AND KNOW WHAT TO DO WITH IT!

Who should take the test:

• anyone who wants to know her personal risk
• anyone concerned about an elevated breast cancer risk
• high risk not qualifying for BRCA 1 & 2 testing
• negative BRCA 1 & 2 test
• intermediate Gail Risk
• anyone who has had a breast biopsy or aspiration.

Call 512-451-5788 to get yours today.

The earliest (and definitely the best) diagnosis is prevention!

Imagine not having breast cancer!

Those who don't gain weight or lose after 50 have fewer breast cancers.

Those who move more have fewer breast cancers and those that exercise have even fewer, and those that exercise more vigorously have even fewer breast cancers.

Those who eat foods high in polyphenols have fewer breast cancers: apples, strawberries, even coffee!

Those who regularly take Omega3 (fish oil) have fewer breast cancers.

Are you doing all of these?


In the coming blogs we will discuss even more ways to prevent breast cancer.

What is the chance that YOU will get breast cancer?

  

Do you want the answer to that question and what can be done about it?

We now have the data to give each person an answer.

Using a 12 point risk assessment, we can give an individualized life-time risk for breast cancer.

More importantly, we can give a personalized plan for reducing the risk of ever getting breast cancer.

Imagine, just one short office visit with me and I will give you a written plan of action!

Call today 512-451-5788

Aromatase Inhibitors now for breast cancer prevention.

A new option for breast cancer prevention has just been presented at the American Society of Clinical Oncology in Chicago and printed online in the New England Journal of Medicine.

Results of the MAP.3 (Mammary Prevention.3 trial) demonstrated a 65% reduction in breast cancers in women who were high risk and took the aromatase inhibitor exemestane (Aromasin) each day.

The planned 5 year study enrolled 4500 women in the US, Canada, Spain and France.  They reported at an average follow-up of 3 years at the meeting.  The women were all postmenopausal with one or more of the following risk factors: 60 years of age or older, Gail risk of >1.66, prior biopsy revealing atypical ductal or lobular hyperplasia, lobular carcinoma in-situ (LCIS), or prior treatment of contralateral DCIS by mastectomy.

After only 3 years of follow-up, the treated group demonstrated a 65% reduction in invasive breast cancers: the exemestane group of 2285 women had only 11 cancers but 32 cancers were reported in the placebo group of 2275 women.

Adverse symptoms such as hot flashes, fatigue, sweats, and joint aches were reported in 88% of the treated group and 85% of the placebo group.  So far no adverse cardiovascular events, clots, or nonbreast cancers have been reported.  Long-term use of any aromatase inhibitor leads to bone loss, which shows up later.

This adds a third prescription drug to our breast cancer prevention armamentarium, each with a slightly different rate of prevention and side effect profile.  Tamoxifen is the only drug approved for the premenopausal woman and raloxifene (Evista) is approved to both preserve bone density and reduce breast cancer.  The decision to pursue drug prevention is obviously a complicated one for anyone to make in thoughtful consultation with a breast specialist.

Other measures, such as weight control and exercise, apples, aspirin, omegas, that we have discussed and others that we will discuss, are appealing because they apply to almost everyone, don't require consultation and have a lower side effect profile.


As a disclaimer, I report that I am a faculty resource for Eli Lilly who makes Evista.

Fish oil (Omega3) reduces breast cancer risk!

An important study published last year in Cancer Epidemiol Biomarkers Prev 2010:19(7);1696-1708 has the important name The VITAL Cohort.  This sturdy compared VITamins And Lifestyle (VITAL) to breast cancer incidence.  35,000 women from Washington state were followed for an average of 6 years by researchers at Fred Hutchinson Cancer Center in this first ever prospective study specifically designed to investigate supplements and breast cancer.  The women enrolled were between 50 and 76 years old.

The supplements examined included: fish oil, glucosamine, chondroitin, MSM (mthylsulfonylmethane), grapeseed, black cohosh, soy, dong quai, St. John's wort, acidophilus, CoQ10, garlic, ginko biloba, gensing and melatonin.

The report was based on current and past use at 6 years.

Current users of fish oil had 32% fewer breast cancers!  Fish oil was the only one of the supplements to exhibit statistically significant risk reduction of breast cancer.  This is not the only study demonstrating a breast cancer reduction for the omega3 polyunsaturated fatty acids.  A study from Singapore sites a 28% reduction in breast cancers among those with high dietary intake of omega3 fatty acids.

So, here is another good reason to take fish oil.  I take 3gm daily, to relieve hand joint aches.  For all of the many other benefits review omega3 at www.umm.edu.  I have heard from some a worry about bleeding with omega3 use, but this theoretic risk has not proven so in reality.  In a review of 19 trials of heart and other vascular procedures, Dr. Harris found that bleeding among omega3 users, even up to 3 grams per day, was "virtually nonexistent" (Am J Cardiol 2007:99[suppl];44c-46c).

The only problem with fish oil supplements is that they are not regulated and may not be pure and may have other fillers.  In my research, I found some pills with only 30% omega3.  Mercury and PCB's are also found in some.  The one omega3 with the highest purity I could find you can read about at www.oewmd.com.

Good news for coffee drinkers!

I got the news last week, I even heard it on NPR, that coffee drinkers, men at least, had fewer prostate cancers.  BUT, what about women and breast cancer.  Let's look at the data.

A paper, published online 11 May 2011 in Breast Cancer Research, a peer-reviewed publication, can be found at http://www.breast-cancer-research.com/content/13/3/R49 does give us some data and good news for coffee drinkers.  Despite the fact that coffee has been the subject of many studies, we are just now beginning to understand the relationship between coffee intake and breast cancer.  A large meta-analysis of over 500 reports (Nutr Cancer2010,62:271-283) suggested no clear cut association of coffee consumption and breast cancer risk, in general.  Nevertheless, several other reviews, including Nurses Health Study data suggest a weak to modest reduction in breast cancer risk among coffee drinkers.

Coffee is a complex mixture of caffeine and polyphenols (remember the apples).  The preparation of coffee also adds to the complexity.  For instance, in Sweden, coffee is boiled and not filtered.  Breast cancer is a complex mixture of diseases.  One way that breast cancers may be subdivided is into those that are estrogen sensitive, so called estrogen receptor (ER) positive and those not influenced by estrogen called estrogen receptor negative.  Only 25% of breast cancers are ER negative, so a reduction of these less common tumors might not show up in some reviews.  Women are complex, too, and to define the relationship of coffee consumption to breast cancer many confounding dietary and lifestyle variables must be controlled.

A good example of such a study shedding light on the issue is the above mentioned study, comparing coffee consumption and breast cancer risk in Sweden.  In Sweden, the coffee consumption is high with a median consumption of 3 cups per person per day.  Researchers at the Karolinska Institute were able to control for confounding variables and detected a protective effect for coffee consumption and ER negative breast cancer in postmenopausal women.  Women who drank more than 5 cups of coffee per day were 57% less likely to get ER negative breast cancer.  They compared this data to a group of postmenopausal German women demonstrating only a more modest protection against ER negative breast cancer.

Although the mechanisms and even which compounds are active here is not yet clear, data suggests that coffee does have a protective effect on some forms of breast cancer.

Physical activity on the airplane?

How do the previous blogs fit into everyday situations? I am on a 4 hour plane ride to San Jose to talk about breast cancer pvention with Evista. I am reading Instant Recess by Toni Yancey and learning alot.

One of h stated objects in the book is to make physical activity enjoyable: to make physical activity part of our social, work, office, home life. Exercise is enjoyable for some, but not for all. Anything is better than being sedentary. We've seen the data in previous blogs, on the news, in her book, etc. Well, how 'bout on a long plane ride: a practical application?

The pilot made me say that I keep my seat belt loosely fastened when in my seat, but 4 hours? We are just beginning our fourth. I get up at least every hour and walk the aisle, stretch, do heel-to-toes 'till they tell me to sit. I flex in the seat, lift my legs, straighten then bend, do leg lifts, hold what I'm reading in different positions. Boy I'm fun to sit next to! I practice what I preach, not just go the gym, but move! You've heard of the nonsmoking flight? How about the non sedentary lifestyle?

One of the ways to prevent chronic disease and cancer is physical activity. So let's all get
moving!

What do "successful losers" (weight that is) have in common?

The National Weight Control Registry gives us more data.  The registry was begun in 1994 by Dr. Rena Wing and Dr. James O. Hill and is the largest prospective investigation of "successful (weight) losers"!  As of the most recent publication, American College ofSports Medicine's Health and Fitness Journal 2011 found at www.acsm-healthfitness.org, the registry now consists of 6000 individuals.  Each has maintained a weight loss of 30 lbs for an average of 5 years.

These "successful losers" have several highly commendable behaviors in common:  including high levels of physical activity, consistent low fat and low calorie diet, and self-monitoring of weight and calorie intake.

Some facts about the program are found at www.nwcr.ws/ and are revealing:

          80% are women

          the average age is 45 years

          members have lost an average of 66 lbs

          they have kept the weight off 5.5 years.

How was the weight loss achieved?  

          45% lost by changing what they ate on their own

          55% used the help of some program.

98% modified food intake in some way, mostly lower calorie and lower fat.

94% increased physical activity!

In the variety of ways that NWCR members kept the weight off there are 4 stand outs:

          78% eat breakfast (they didn't lose weight by skipping breakfast)

          75% weigh at least once a week and some daily

          62% watch less than 10 hours of TV a week

          90% exercise an average of 1 hour per day!

Dr. Hill comments that "these people, almost to a person, tell us it's all worth it, they feel better and life is better than when they were obese or overweight".  

These are the ones that may have tried many times and failed, but didn't give up.  The message is clear.  It is worth it!  I hear the same in my office.  If you need help from encouragement, to an accurate scale to a weight loss program, call me.  I want to see more women who don't get breast cancer.

          

More benefits of regular exercise!

Benefits of Regular Exercise

• Fewer Breast Cancers
• Fewer Breast Cancer Recurrences

• Decreased all-cause mortality
• Decreased cancer mortality including breast cancer
• Decreased cancer mortality including prostate cancer

• Fewer heart attacks
• Fewer cardiac events
• Fewer heart disease deaths
• Better blood pressure control
• Lower VLDL
• Higher HDL
• Fewer blood clots
• Fewer strokes

• Fewer colds and flu-like illnesses

• Better glycemic control and insulin sensitivity
• Fewer patients with Type II Diabetes

• Helps maintain healthy weight

• Helps quit smoking

• Fewer symptomatic gallstones

• Improves functional ability

• Prevents or delay of cognitive decline

• Reduce stress, anxiety and depression

• Saves money; Lower annual direct medical costs

• Live better longer

Find out more at http://www.owenwinsettmd.com/

Other benefits of weight loss: from top to bottom!

We have shown the numbers for breast cancer: risk goes up with weight going up and risk goes down with weight going down.  In the Nurses Health Study the benefit of weight loss was twice as powerful with 2% fewer cancers with a single pound lost and kept off.  There are many other benefits of weight loss, but we will review two, today.

The top is the brain.  In an article to be published in the Journal of the American Society for Metabolic and Bariatric Surgery, Gunstad (a neuropsychologist) et al studied 150 people, comparing 109 bariatric surgery patients to 41 obese controls.  Weight loss is dramatic after the surgery and only 12 weeks after the surgery they noted improved memory and concentration, measured by performance on cognitive testing.  Imagine the application to voluntary weight loss!

Now near the bottom: the knees.  The knees are among the most frequent joints involved by osteoarthritis.  Felson, DT et al, published in Ann Intern Med 1992;116:535 the findings in a subgroup of patients with knee pain.  Reports from the ongoing Framingham Study (www.framinghamstudy.org) have shown among other findings that cigarette smoking increases the risk of heart disease (in 1960) and  physical activity was found to reduce the risk of heart disease and that obesity increases the risk of heart disease (in 1967).  In 1992, they reported that weight loss reduces the risk of knee pain in 800 women.  In this long term study, weight loss of 12 pounds or about 2 units on the BMI table, decreased symptomatic knee osteoarthritis by 50%.  Imagine reducing pain without a pill!

So, there are two more reasons for pursuing that ideal body weight: from top to bottom; and in the middle fewer breast cancers.

Should I get a breast MRI?

I am ask that question often, so lets look into the issue.  The American College of Radiology lists screening criteria at www.acr.org, but begins the list with "current indications for breast MRI include, but are not limited to:"  There is some controversy and a new program of breast MRI accreditation is enrolling now to help sort it out.  I think a breast specialist is needed.  In the meantime lets look at a group, for whom, routine MRI is not in much dispute.

A carrier of a deleterious mutation for breast cancer, BRCA 1 or BRCA 2, has at least an 85% chance of developing breast cancer in her life, much higher than the population risk of 12%.  Fortunately, only about 7% of women are carriers, usually with young primary relatives (mother, daughter, sister) with breast and/or ovarian cancer.  One option for these women is risk reduction TOTAL mastectomy, but the procedure is not chosen by all women who carry one of the gene mutations.  Several reports have been published about MRI in these women with a very high known lifetime risk who have declining surgery.  Let's look at two recent reports, interestingly enough with the same lead author.

Published this week in J Clin Oncol online by Dr. Ellen Warner from Toronto, is a prospective study of 1275 women carriers of the BRCA1 or BRCA2 mutation, comparing routine breast cancer surveillance (Clinical Breast Examination and mammography) without MRI to routine surveillance (CBE and mammography) with added yearly MRI.  The hope is that routine breast MRI would reduce mortality from breast cancer, like routine mammography has done.  When the two groups were compared over time, the number of cancers that developed was the same in each group.  In each group 9.2% of the women were diagnosed with breast cancer in only a mean of 3.2 years of follow-up.  But the tumors in the MRI group were significantly smaller (9mm vs 18mm), more were noninvasive and fewer were later stages.

Breast MRI is more sensitive in finding cancer in these women with a very high lifetime risk of developing cancer, but long term follow-up will be needed to see whether breast cancer mortality is reduced.

The second study in The Breast Journal 2011;17:9-17, by the same author offers more insight into why not offer MRI breast screening to all (lower risk) women.  Even at very experienced breast MRI centers, the false positive rate is too high.  A false positive breast MRI is one that looks like cancer, but isn't, but we don't know until further studies or even breast biopsy have ruled-out cancer.  MRI may be very sensitive at finding cancer, but finds too many benign tumors.  Breast MRI is also much more expensive than other breast screening, even without considering the other procedures, necessary to prove that the positive finding is not breast cancer.

So the answer is, for now, talk to your breast doctor about it.  Breast MRI might be right for you, but in general screening use may cause too much mental and fiscal pain.

An apple a day keeps breast cancer away

I know that's not what your grandmother told you, but the evidence is mounting.  There have been numerous reports (over 100 epidemiological studies) linking regular fruit and vegetable consumption to fewer cancers.  In 1992, a review published in Nutr Cancer 18:1-29 found that in 128 of 156 dietary studies, fruits and vegetables had a significant protective effect against many cancers.

Apples are unique because they are enjoyed by many cultures, they are a source of many antioxidants and several studies have looked specifically at apple consumption and its effects in humans and laboratory animals. These positive effects include protection from cancer, reduced cardiovascular disease and general good lung health (less asthma), just to mention a few.

We are interested in breast cancer reduction.  Dr. Liu at Cornell has published repeatedly on the subject (www.news.cornell.edu/ for a listing), but we will look at one study as an example and discuss the possible mechanisms at work.  Data published in J Agric Food Chem 2005: 53:2341-3 shows that whole apple extracts prevent breast cancer in a rat model in a dose-dependent manner.  A dose comparable to one apple a day prevented 43% of breast cancers and 3 and 6 apples, inhibited 50% and 75% respectively.  Almost half of the breast cancers prevented with just one apple a day!

This and other studies highlight the role of phytochemicals in apples, particularly phenolics, a large group of aromatic hydrocarbon compounds.  Remember the benzene ring?  It is these compounds that have anticancer properties.  These properties can be classified as antiproliferative (inhibiting cell growth), antiinflammatory (we are just now understanding how inflammation is related to cancer development) and antioxidant.  We will discuss all of these in later editions.

For now, which apple should I eat?  To get the greatest benefit: eat the skin, eat red apples (Fuji, Red Delicious and Gala have the highest concentrations) and only fresh and unprocessed (apple juice in the store  has only 10% of the good compounds).

Apples are a good source of dietary fiber and vitamin C.  They are very low in saturated fat, cholesterol and sodium.  The calories, about 100 in the average-sized apple, are mostly from the sugars: 50% from fructose and 25% each from sucrose and glucose.  The Environmental Working Group put apples on the list of those contaminated by pesticides in 2003 and suggests organic apples.

Best of all, an apple is better than any processed snack like candy or cookies.

BREAST CANCER AND WEIGHT

I appreciate all the comments about the blogs last week and I invite you to invite your friends to participate.

We begin this week with a topic some don't like to consider, but we should because of its impact.  The numbers are so profound that we will make this blog short.

We have all been reading about the "obesity epidemic" and the negative effects of being overweight, but let's take a look and the science in two of the many article relating weight increase to breast cancer risk increase.

The first study, published in 2000 in Am J Epidemiol 152:514, is a pooled analysis of almost 350,000 US women using data from 7 prospective cohort studies.  Women who weighed at least 176 pounds (80kg) had a 25% higher risk of breast cancer than those women weighing less than 132 pounds (60kg).  The analysis was controlled for other factors.  Expressed as Body Mass Index (calculate yours at www.nhlbisupport.com/bmi/), women with a BMI >33kg/m2 had almost 30% excess cancer risk when compared to BMI <21kg/m2.

The next study is another report from the Nurses Health Study published in 2006 in JAMA 296:193.  Weight changes since menopause were followed in 50,000 US women for up to 24 years.  Among those not taking hormone replacement the results were very dramatic.  Those women who gained and kept on 22 pounds had an 18% higher risk of breast cancer than those who maintained their weight.  But even more exciting, those women who lost and kept off 22 pounds or more had a 57% lower risk of breast cancer than those maintaining their weight.  So, after menopause, each pound put on and kept on equals one percent more breast cancer risk, BUT for each pound taken off and kept off there is a two percent decrease in the breast cancer risk.  Twice the benefit for losing weight!

In future blogs we will look at potential reasons.  We are learning that some kinds of fat cells, particularly those gained after menopause are tiny "endocrine" factories secreting all kinds of substances, most of them harmful.

Let's get moving? Where? How?

So the data seems clear, doesn't it?  Women who exercise can expect a 20-30% reduction in the number of breast cancers.  There is evidence for other beneficial effects on: blood pressure, cholesterol, diabetes, stroke, depression, colon cancer, bone density, balance and cognitive decline, to name a few.  But one of the more positive impacts of physical activity was found in a report from www.nurseshealthstudy.org published in the Archives of Internal Medicine Jan 2010 among the five articles in that issue regarding the benefits of exercise.  Women with higher levels of activity were more likely to be "successful" survivors past 70 years.  They define "successful" survival as no chronic diseases, and no major physical, mental or cognitive dysfunction.  Wow!  If you haven't exercised yet today, kinda makes you want to right now!

Where?  How?  Those who have exercise buddies or trainers or a regular plan, know.  But for those who are convinced now to start there are guidelines.  There are websites, such as www.health.gov/paguidelines.com or www.smallstep.com for help or you can ask your doctor or come to see me.  Begin by increasing your level of activity.  If you get no activity or have a balance problem, then walk in place holding on to a chair.  If you get little activity then begin by walking 5 minutes once a day (every day), then twice a day after a few days, then more often or longer.  Even if it takes a month or two, work up to 15 minutes, then increase the pace to where you notice it is not quite as easy to talk while you walk.  After a while you can add another activity or be more vigorous.  You will feel so much better!  Try it!

For those weekend warriors who exercise only once or twice a week: regular is better with fewer orthopedic injuries and cardiac events (JAMA.2006;295:1399-1403).  If you play tennis Saturday, then walk Tuesday and Thursday.

For those who run regularly and worry about your knees "wearing out", they won't.  A recent systematic review in Medicine and Science in Sports & Exercise 2011; 43:432-442 was reassuring.  There was no increase in joint space narrowing, but rather healthier cartilage, with more volume and decrease in knee cartilage defects seen by MRI.  

So enjoy the weekend with physical activity a part of each day.   

The Plan for Prevention

So, did I convince you to get out and walk or go the gym today?  I did!  And I feel great! 

Let the numbers sink in and think of the opportunity.  

75,000 women prevented from developing breast cancer each year in the US!

In this blog we will consider many steps, and they are not all easy, that one can take to reduce the risk of breast cancer development.  We will consider exercise further, giving a plan to those who want to start, encouragement to those just beginning and reassurance of long-term benefits to those already working-out regularly.  We will consider other major topics that can be modified in the favor of preventing breast cancer from what to and what not to eat, how much to eat, to supplements and prescription drugs.  We will consider, for example: apples, other fruits, soy, aspirin, omega3, vegetables, red meat, alcohol, and other factors that one can change.  

This will be, as you have seen evidence-based.  Sometimes both pros and cons will be presented.  Sometimes controversies will be examined and even a contrarian opinion may be given, or a reaction to a news item. 

My goal is to help women avoid breast cancer.  I hope to show you how.  Please join me and ask your friends to follow along, too.

Now let's look at the breast cancer numbers.

Unfortunately, breast cancer is all too common.  Let's review the numbers.  Of all non-skin invasive cancers, 26% are breast cancers.  To personalize the numbers, we can look at the statistics another way.  1 in 8 women will get breast cancer in a lifetime.  That means 12.5% of women will ever be diagnosed with breast cancer.  Again, that is lifetime risk.  To personalize even more, we can look at risk by decade.  The chance of a 50 year old women developing breast cancer in the next ten years is 1 in 40 or a 2.5% risk in her 50's.  The risk increases with age to achieve the lifetime risk quoted so often of 1 in 8.  This data available online www.seer.cancer.gov.

Those risks given above translate into almost 210,000 women newly diagnosed with breast cancer in 2010 in the US.  70% are over 50 years old and 70% have no family history of breast cancer.  The median age at diagnosis is 61 years.  

If we look at the incidence in the last 25 years something interesting is uncovered.  The number of new cases in the US rose to a peak in 1999 and then began to slowly drop until 2006-2007.  Latest data (Cancer Epidemiol Biomarkers Prev published online Feb 28, 2011) show that the decline in incidence rates have leveled off.  The reasons that the breast cancer rates fell for a few years and now are no longer falling are not clear and will be the subject of many other blogs, but you get the idea of the magnitude of the problem.

Fortunately, we have made some advances in early diagnosis and treatment of breast cancer so that the number of women dying from the disease has been slowly and steadily decreasing since the early 1990's.  Treatments are more effective.  Although some think early detection is another key to this decline, we now have the opportunity to reduce the numbers of women who ever get breast cancer.  Exercise is one way to reduce the risk (yesterday's blog and many more to come) and we will see that there are others.  The American Institute of Cancer Research (www.aicr.org) estimates that 75,000 breast cancers a year can be prevented!

Let's get moving!

Good afternoon to all.   As promised, I am now blogging about breast cancer prevention.  We have made great strides against breast cancer, from treatment to early detection; but another opportunity avails us, that of prevention.  We will discuss the many steps that can be taken to reduce the numbers of breast cancers by beginning with physical activity and exercise.

There have been numerous studies reported that show a negative correlation between exercise and breast cancer development, which means: more movement equals fewer breast cancers.  Let's examine just three.  An extensive review of the literature in 2008 (Br J Sports Med 2008;42:636-647) found evidence for risk of breast cancer reduction with increased physical activity in the majority of studies, with an average reduction of 25-30%.  Stronger reductions were noted for lifetime or later in life activity.  Never too late to start moving!  The second review comes form the Nurses' Health Study (Arch Intern Med 2010:170:1758-1764 or online www.channing.harvard.edu/nhs/) which reports on 95,396 women in 20 years of follow-up.  During this period, there were 4782 breast cancers.  Women who were the most active (>1 hour per day walking) or those who increased activity at menopause were at the lowest risk.  Likewise, the Women's Health Initiative Cohort (JAMA 2003;290:1331-1336) demonstrated fewer breast cancers with increasing exercise among 74,171 postmenopausal women followed 5 years.  10 hours or more per week of "brisk walking" led to the lowest breast cancer rate.

We know that 75% of breast cancers occur in postmenopausal women, so how does exercise reduce the number of breast cancers in these women.  The answer is not entirely clear, but research suggests an effect on decreasing endogenous estrogen, decreasing inflammatory factors that may lead to breast cancer, increasing immunity (two other studies show fewer colds and flu-like illnesses in exercisers) or all of the above.

So the best you can do: get moving!  The worst thing: don't move!  An American Cancer Society study (Am J Epidemiol July 2010 online) compared people who spent at least 6 hours a day of their leisure time sitting to those who sat less than 3 hours a day.  The data from 69,776 US women 50-74 years old was astounding!  The increase in the death rate for the least active women was 94% or almost double!  So, LET'S GET MOVING!!