Three new studies published March 21, 2012 in the Lancet, add more evidence that long term daily low-dose aspirin (81mg) leads to significant cancer risk reduction, metastatic disease from those cancers and death from cancer http://www.thelancet.com/.
We are interested in breast cancer, although the greatest benefit was for prevention of colorectal cancer. Daily low-dose aspirin for at least 3 years decreased the risk of all cancers, including breast cancer, by 25%.
The trials were designed to find out what effect daily aspirin had on cardiovascular events, but collected cancer data also. Early on the risk of heart disease was lowered, and the risk of internal bleeding was increased, but by 3 years and onward statistically significant reductions in both bleeding and cancer were seen.
For many individuals the risk benefit ratio will be in favor of cancer risk reduction, particularly in long term use. The risk of bleeding was actually less in long term users--after 3 years of use; which is when cancer reduction begins to show up in the studies.
In the expert comment section, it was noted that two trials have not shown cancer reduction from aspirin, but in each of these, aspirin use was every other day. These two trials were not included because of likely biological differences in daily versus alternate day use.
The content is information and not personal medical advice. You and your doctor must discuss the issue and make the decision for you, since your situation is unique.
Together we can prevent 75,000 breast cancer cases each year!
Friday, March 30, 2012
Thursday, March 29, 2012
Your personal weight loss coach
Imagine, those of you who want to lose weight, that you could get help, right now, and almost all the time! A device you carry with you. Think that might work?
Research says it does! The SMART (Self-Monitoring and Recording with Technology) study just reported by Dr. Lora E Burke at the American Heart Association meeting March 15 in San Diego presented convincing evidence. This trial, started in 2005, included 210 overweight or obese adults (84% women) comparing paper diary to handheld electronic device without feedback or handheld electronic device with feedback. "Have you exercised yet today" won.
At 6 months those with daily feedback lost significantly more weight than the other groups. They logged in a 5% weight loss!
Wow! Remember back to 2005? That was the clunky PDA. They found that with longer followup, enrollees just got tired of the PDA and used it less and less.
Do you know anyone who uses his or her cell phone less and less?
There are now apps for the smart phone that do everything in this study and even more. What a perfect solution for those who want it. It is with you almost all the time: easy to record food eaten (the app has the calorie count) and exercises done (you select intensity to get proper calorie count), and keeps track, gives daily totals, goals, and most have notifications for you to set. You can invite friends, sync to your laptop or other computer, set up reminders. Imagine your personal weight loss coach setup by you, for you!
I have Lose It! and Fooducate and Tap & Track and Nutrition on my iPhone. There are many others. Here is link to what the Huffington post suggests http://www.huffingtonpost.com/2012/03/22/fitness-weight-loss-nutrition-apps_n_1371705.html#s803227&title=ThinCam.
Imagine, weight loss your way!
Together we can prevent 75,000 breast cancer cases each year!
Research says it does! The SMART (Self-Monitoring and Recording with Technology) study just reported by Dr. Lora E Burke at the American Heart Association meeting March 15 in San Diego presented convincing evidence. This trial, started in 2005, included 210 overweight or obese adults (84% women) comparing paper diary to handheld electronic device without feedback or handheld electronic device with feedback. "Have you exercised yet today" won.
At 6 months those with daily feedback lost significantly more weight than the other groups. They logged in a 5% weight loss!
Wow! Remember back to 2005? That was the clunky PDA. They found that with longer followup, enrollees just got tired of the PDA and used it less and less.
Do you know anyone who uses his or her cell phone less and less?
There are now apps for the smart phone that do everything in this study and even more. What a perfect solution for those who want it. It is with you almost all the time: easy to record food eaten (the app has the calorie count) and exercises done (you select intensity to get proper calorie count), and keeps track, gives daily totals, goals, and most have notifications for you to set. You can invite friends, sync to your laptop or other computer, set up reminders. Imagine your personal weight loss coach setup by you, for you!
I have Lose It! and Fooducate and Tap & Track and Nutrition on my iPhone. There are many others. Here is link to what the Huffington post suggests http://www.huffingtonpost.com/2012/03/22/fitness-weight-loss-nutrition-apps_n_1371705.html#s803227&title=ThinCam.
Imagine, weight loss your way!
Together we can prevent 75,000 breast cancer cases each year!
Wednesday, March 28, 2012
Chocolate lovers read on!
An interesting finding about chocolate was published 2 days ago, by Dr. Beatrice Golomb, from UC San Diego medical school, in the Archives of Internal Medicine: chocolate lovers tend to weight less!
From a study primarily of cholesterol-lowering drugs in 1018 women and men in San Diego, 20 to 85 years old with an average BMI of 28 (overweight but not obese) other data was included in the survey, including chocolate consumption.
They found that those who regularly ate chocolate weighed less. They controlled for age, gender and amount of exercise. Those who ate chocolate 5 days a week weighed 5-7 pounds less than those who didn't eat any chocolate. Interestingly those regular chocolate eaters did not eat fewer calories.
SO, what does this mean? Dark chocolate consumption has been associated with many benefits including, lowering blood pressure, lowering cholesterol, and stabilizing insulin sensitivity. The cocoa bean is a good source of antioxidants called flavonoids. For a review, check out http://www.webmd.com/diet/news/20030827/dark-chocolate-is-healthy-chocolate.
Should we all go out and buy a little chocolate? Well, maybe. A with so many foods, not all chocolates are the same. Most of us don't need the extra sugar and fat calories of milk chocolate and all the processing removes the beneficial flavonoids. The darker the better rendered on the label as higher percent cocoa. Most European dark chocolates, for instance, are at least 50% cocoa (bean) and the goodness comes from the cocoa bean.
This study is an association study not implying any cause or effect, so don't trade a fruit or veggie for a square of chocolate or eat too many squares. If you do eat dark chocolate, then take heart!
Not breast cancer prevention, but good news for chocolate lovers.
Remember this content is information and not personal medical advice.
From a study primarily of cholesterol-lowering drugs in 1018 women and men in San Diego, 20 to 85 years old with an average BMI of 28 (overweight but not obese) other data was included in the survey, including chocolate consumption.
They found that those who regularly ate chocolate weighed less. They controlled for age, gender and amount of exercise. Those who ate chocolate 5 days a week weighed 5-7 pounds less than those who didn't eat any chocolate. Interestingly those regular chocolate eaters did not eat fewer calories.
SO, what does this mean? Dark chocolate consumption has been associated with many benefits including, lowering blood pressure, lowering cholesterol, and stabilizing insulin sensitivity. The cocoa bean is a good source of antioxidants called flavonoids. For a review, check out http://www.webmd.com/diet/news/20030827/dark-chocolate-is-healthy-chocolate.
Should we all go out and buy a little chocolate? Well, maybe. A with so many foods, not all chocolates are the same. Most of us don't need the extra sugar and fat calories of milk chocolate and all the processing removes the beneficial flavonoids. The darker the better rendered on the label as higher percent cocoa. Most European dark chocolates, for instance, are at least 50% cocoa (bean) and the goodness comes from the cocoa bean.
This study is an association study not implying any cause or effect, so don't trade a fruit or veggie for a square of chocolate or eat too many squares. If you do eat dark chocolate, then take heart!
Not breast cancer prevention, but good news for chocolate lovers.
Remember this content is information and not personal medical advice.
Tuesday, March 27, 2012
746 women, not 1904.
You have probably read about the controversy around the United States Preventive Services Task Force (USPSTF) recommendations about screening mammography. Yesterday I blogged about at least one of the studies they did not include in their determination for not routinely screening women 40-49 years old. Today, I will review a study from the March issue of American Journal of Roentgenology http://www.ajronline.org/content/198/3/723.abstract which critically evaluates the methods used by the USPSTF.
Drs. Hendrick and Helvie noted that the task force used "old" data, specifically they reviewed only 8 trials and all but one were performed between 1963 and 1982. The USPSTF also used the number of women invited to screen and not actually screened. They site that 25-30% invited are never screened.
These investigators used data on 7.2 million actual screening mammograms performed since 1996 and arrived at different numbers of women needed to be screened (NNS) to save one life. In their data only 746 women needed to be screened (NNS) in the years 40-49 to save one life and not 1904. That is a 39% difference! Reduced numbers were shown for every age group.
Mammograms do save lives! And do so at age 40 years!
Together we can prevent 75,000 breast cancers each year!
Drs. Hendrick and Helvie noted that the task force used "old" data, specifically they reviewed only 8 trials and all but one were performed between 1963 and 1982. The USPSTF also used the number of women invited to screen and not actually screened. They site that 25-30% invited are never screened.
These investigators used data on 7.2 million actual screening mammograms performed since 1996 and arrived at different numbers of women needed to be screened (NNS) to save one life. In their data only 746 women needed to be screened (NNS) in the years 40-49 to save one life and not 1904. That is a 39% difference! Reduced numbers were shown for every age group.
Mammograms do save lives! And do so at age 40 years!
Together we can prevent 75,000 breast cancers each year!
Monday, March 26, 2012
MORE benefit from mammograms at age 40 years!
Another particularly long term study was reported in March in the Journal Radiology and recounted at http://www.breastcancer.org/symptoms/testing/new_research/20120223.jsp.
In 18 years of followup, on 1977 women aged 40-49 years, Dr. Judith Malmgren and her colleagues from Swedish Cancer Institute in Seattle, Washington compared mammographically detected breast cancers to those detected by patient or physician. They found that the mammogram-detected cancers were smaller, required less aggressive treatment and had better survival.
The mean size of the patient or doctor detected cancers was 2.98 cm and the size of the mammographically detected tumors only 1.8 cm.
Mammographic cancers were more likely to have lumpectomy by 67% to 48%. Chemotherapy was also less likely in the mammographically detected cancers.
The survival was better for the mammographically detected cancers. In the 8.8 year followup, only 4% died in the mammogram group and 11% in the self or physician detected group.
Overall the estimated disease-specific 5 year survival for the mammographically detected cancers was 98%, compared to only 93% for the patient or doctor detected cancers.
Mammograms in women 40-49 years do save lives!
In 18 years of followup, on 1977 women aged 40-49 years, Dr. Judith Malmgren and her colleagues from Swedish Cancer Institute in Seattle, Washington compared mammographically detected breast cancers to those detected by patient or physician. They found that the mammogram-detected cancers were smaller, required less aggressive treatment and had better survival.
The mean size of the patient or doctor detected cancers was 2.98 cm and the size of the mammographically detected tumors only 1.8 cm.
Mammographic cancers were more likely to have lumpectomy by 67% to 48%. Chemotherapy was also less likely in the mammographically detected cancers.
The survival was better for the mammographically detected cancers. In the 8.8 year followup, only 4% died in the mammogram group and 11% in the self or physician detected group.
Overall the estimated disease-specific 5 year survival for the mammographically detected cancers was 98%, compared to only 93% for the patient or doctor detected cancers.
Mammograms in women 40-49 years do save lives!
Friday, March 23, 2012
What are they saying "down under" about breast cancer prevention?
As a reality check and to show that it is recognized as a problem elsewhere, I offer this piece from the Sidney Morning Herald reporting on an Australian cancer council's recommendation http://www.smh.com.au/lifestyle/diet-and-fitness/better-diet-exercise-can-cut-cancer-by-one-quarter-20120318-1vdt7.html.
To paraphrase one of the authors, Pip Youl, from the Cancer Council of Queensland, 25% of Australian cancers, including breast cancer, could be prevented through diet and exercise. Specifically recommended are whole-grain cereals, low salt intake and low fat diet. The Cancer Council of South Australia recommends daily exercise, limiting red meat and not smoking.
The word is out, not only "up" here but "down under". Call a buddy for a walk this weekend!
Together we can prevent 75,000 breast cancer cases each year (in the US)!
To paraphrase one of the authors, Pip Youl, from the Cancer Council of Queensland, 25% of Australian cancers, including breast cancer, could be prevented through diet and exercise. Specifically recommended are whole-grain cereals, low salt intake and low fat diet. The Cancer Council of South Australia recommends daily exercise, limiting red meat and not smoking.
The word is out, not only "up" here but "down under". Call a buddy for a walk this weekend!
Together we can prevent 75,000 breast cancer cases each year (in the US)!
Wednesday, March 21, 2012
Cool hands can make exercise easier! and more fun?
Yes, a recent study suggests that for some, cool hands may be the key to a regular exercise routine.
Some people get hot and don't like being sweaty and feel generally uncomfortable because of the heat generated during exercise. If that is what is limiting your exercise program or someone you know, try carrying a cold water bottle or two! Don't try this without checking with your doctor and especially if your have Raynaud's phenomenon.
Staying cool may enable you to remain comfortable and exercise longer and harder. Simply cooling the hands may pull enough heat from the body for a more pleasant exercise time.
A recent study, presented at the American Heart Association's Epidemiology and Prevention/Nutrition, Physical Activity and Metabolism by Dr. Stacy Sims is preliminary, but exciting!
24 women began a 3 times a week exercise regimen and continued for 12 weeks. Each session included 10 minutes warm up, 25-45 minutes walking on a treadmill and 10 minutes cool down. All had a BMI of 30-34.9 kg/m or 20-30% over the ideal. The experiment group held on to a cooling device called the AvaCore Rapid Thermal Exchange, circulating 60.8º F water. See one at http://www.avacore.com/applications/athletic. The water was 98.6º F for the control group.
The results were quite remarkable with multiple benefits for the cool hand group!
Almost 100% of the cool hand group finished the study and only 78% of controls.
The cool group noted more energy, less fatigue and less muscle soreness.
The control group made no improvements during the 12 weeks but the cool hands made several gains when comparing baseline to end of study:
Some people get hot and don't like being sweaty and feel generally uncomfortable because of the heat generated during exercise. If that is what is limiting your exercise program or someone you know, try carrying a cold water bottle or two! Don't try this without checking with your doctor and especially if your have Raynaud's phenomenon.
Staying cool may enable you to remain comfortable and exercise longer and harder. Simply cooling the hands may pull enough heat from the body for a more pleasant exercise time.
A recent study, presented at the American Heart Association's Epidemiology and Prevention/Nutrition, Physical Activity and Metabolism by Dr. Stacy Sims is preliminary, but exciting!
24 women began a 3 times a week exercise regimen and continued for 12 weeks. Each session included 10 minutes warm up, 25-45 minutes walking on a treadmill and 10 minutes cool down. All had a BMI of 30-34.9 kg/m or 20-30% over the ideal. The experiment group held on to a cooling device called the AvaCore Rapid Thermal Exchange, circulating 60.8º F water. See one at http://www.avacore.com/applications/athletic. The water was 98.6º F for the control group.
The results were quite remarkable with multiple benefits for the cool hand group!
Almost 100% of the cool hand group finished the study and only 78% of controls.
The cool group noted more energy, less fatigue and less muscle soreness.
The control group made no improvements during the 12 weeks but the cool hands made several gains when comparing baseline to end of study:
- walked 1.5 miles in 5 minutes faster time
- exercising heart rate increased from 136 bpm to 154 bpm
- waist-line decreased 3 inches from 41.8 to 39.1
- Bp improved from 139/84 to 124/70
The device used in the experiment is a $3000 piece of equipment used by high-priced sports teams, but how about a frozen water bottle? You can even drink a little along the way!
Longer, better exercise, feel better; ultimately fewer breast cancers.
This content is intended as information and not intended as personal medical advice.
Together we can prevent 75,000 breast cancer cases each year!
A link between progesterone and breast density
We have known of the increased risk of breast cancer associated with increased breast density since Wolfe's work published in 1976. Many other reports have shown a strong association, and even stepwise increase of breast density to breast cancer risk. An often quoted article from the New England Jr of Medicine in 2007, by Boyd, et al, compared women with density in <10% of the breast to those with density in 75% or more and found 4-5 times the number of breast cancers in the denser breasts.
Results from the WHI http://drwinsett.blogspot.com/2012/03/updated-menopausal-hormone-therapy.html#uds-search-results showed that women who took both estrogen and progesterone (EPT) had more breast cancers and further study of that group found that combined EPT users were also associated with increased mammographic density.
A recent study in Menopause (March 2102) looked into the link between progesterone and breast density. Dr. Lee and a research team at University of Southern California reported on 280 postmenopausal women randomized to receive estrogen and progesterone therapy (EPT). They observed that those taking the combined hormones (EPT group) had a post treatment increase in serum progesterone which was associated with increased mammographic density. Furthermore, they noted that the higher the serum progesterone level, the greater the breast density as measured by mammogram. Importantly, the higher progesterone levels (and higher mammographic density) was independent of increased estrogen levels.
Increases in mammographic density have been associated with more breast cancers, whether taking hormones or not. Conversely decreased density has been associated with fewer breast cancers. In review of the first International Breast Cancer Intervention Study using Tamoxifen to prevention breast cancers, the benefit of Tamoxifen was limited to the women who showed a significant decrease in breast density on mammography.
They looked at genetic variability in the progesterone receptor gene, but did not find evidence that genetic variation was involved in the density change, in this small study.
Still, it would seem that serial changes in breast density, judged mammographically, could be used to measure the risk or benefit of therapy, whether increasing risk with EPT or decreasing with Tamoxifen. Maybe the answer is in the progesterone receptor and its variability of response to therapy. Only further research may answer the question.
Nevertheless, I recommend that you know your breast density!
This content of this blog is intended as information and to provoke thoughtful discussion with your doctor. It is not intended as personal medical advice.
Together we can prevent 75,000 breast cancers each year!
Results from the WHI http://drwinsett.blogspot.com/2012/03/updated-menopausal-hormone-therapy.html#uds-search-results showed that women who took both estrogen and progesterone (EPT) had more breast cancers and further study of that group found that combined EPT users were also associated with increased mammographic density.
A recent study in Menopause (March 2102) looked into the link between progesterone and breast density. Dr. Lee and a research team at University of Southern California reported on 280 postmenopausal women randomized to receive estrogen and progesterone therapy (EPT). They observed that those taking the combined hormones (EPT group) had a post treatment increase in serum progesterone which was associated with increased mammographic density. Furthermore, they noted that the higher the serum progesterone level, the greater the breast density as measured by mammogram. Importantly, the higher progesterone levels (and higher mammographic density) was independent of increased estrogen levels.
Increases in mammographic density have been associated with more breast cancers, whether taking hormones or not. Conversely decreased density has been associated with fewer breast cancers. In review of the first International Breast Cancer Intervention Study using Tamoxifen to prevention breast cancers, the benefit of Tamoxifen was limited to the women who showed a significant decrease in breast density on mammography.
They looked at genetic variability in the progesterone receptor gene, but did not find evidence that genetic variation was involved in the density change, in this small study.
Still, it would seem that serial changes in breast density, judged mammographically, could be used to measure the risk or benefit of therapy, whether increasing risk with EPT or decreasing with Tamoxifen. Maybe the answer is in the progesterone receptor and its variability of response to therapy. Only further research may answer the question.
Nevertheless, I recommend that you know your breast density!
This content of this blog is intended as information and to provoke thoughtful discussion with your doctor. It is not intended as personal medical advice.
Together we can prevent 75,000 breast cancers each year!
Tuesday, March 20, 2012
Walk away from those night sweats!
In a study published last month in the Journal Menopause, a group of Finnish women reported fewer menopausal symptoms after a 24 week trial of aerobic training.
We have seen that exercise:
We have seen that exercise:
- REDUCES THE NUMBER OF BREAST CANCERS
- promotes weight loss
- helps maintain weight
- decreases visceral fat
- reduces bone loss
- reduces depression and anxiety
- enhances cognitive function
- improves cardiac risk factors (lowers BP, triglycerides, LDL, etc)
Dr. Ritta Luoto, who has published other articles showing the benefit of exercise, recently reported a randomized controlled trial of the effect of exercise on menopausal symptoms.
She divided 176 sedentary postmenopausal Finnish women, ages 45-63 years, into two groups. One did aerobic exercise 50 minutes 4 times a week (walking at least 2 of those days) and the other (control) group went to lectures. Amazingly 88% completed the 24 week study. They all agreed to twice daily cell phone conversations about symptoms.
At baseline, 55% reported night sweats, 27.5% reported mood swings, 22.5% reported irritability and depression, and other symptoms to a lesser degree.
The effect on mood swings and irritability were the most impressive, dropping by half in the exercising group. Night sweats also decreased over time. Exercise is medicine for menopausal symptoms!
To learn more about what aerobic exercise might be right for you, consult with your physicians, particularly if you are just starting or find more information at http://www.greatist.com/fitness/new-acsm-exercise-guidelines/ from the American College of Sports Medicine.
Not only fewer breast cancers, but feel better, too!
Together we can prevent 75,000 breast cancer cases each year!
Monday, March 19, 2012
Emerging techniques in breast imaging
As a service to "promote state-of-the-art cancer care" Elsevier does expert commentary periodically. Recently, Dr. Maxine Jochelson, the Director of Radiology, Breast and Imaging Center, at Memorial SLoan-Kettering Cancer Center in NY discussed emerging breast imaging. See http://www.oncologystat.com/viewpoints/commentary/Update_on_Emerging_Techniques_in_Breast_Imaging.html.
Of note to me, are two nuclear studies because they are functional assessments of breast lesions at a cellular or molecular level, not just a "picture" of the tissues.
It should be noted, that she reminds us all that mammography does save lives and the reduction in mortality due to screening mammography, looking at all studies, is 30%.
Different from mammography, which is the standard breast screening are the two radionuclide studies. Each requires IV injection and radiation exposure to organs other that the breast. They are relatively new and she points out that each is promising and may have a roll in diagnosis, but probably not screening.
Breast-specific gamma imaging (BSGI) uses technetium-99m sestamibi. The gamma counter "sees" the sestamibi in the mitochondria of the cells. Cancer cells generally have more than normal cells and are "hot".
Positron emission mammography (PEM) is basically a PET scan of the breast. The fluorine-18 labelled deoxyglucose (FDG) that is injected then accumulates in tumor cells, actively metabolizing glucose.
In small studies each has shown a specificity of around 90%, but the key will be lowering the radiation dose and perhaps increasing the sensitivity of the receivers picking up the signal.
We are talking about finding a small number of additional cancers and we should remember that neither has replaced mammography as a screening tool.
There are additional ultrasound techniques which will be reviewed later.
Of note to me, are two nuclear studies because they are functional assessments of breast lesions at a cellular or molecular level, not just a "picture" of the tissues.
It should be noted, that she reminds us all that mammography does save lives and the reduction in mortality due to screening mammography, looking at all studies, is 30%.
Different from mammography, which is the standard breast screening are the two radionuclide studies. Each requires IV injection and radiation exposure to organs other that the breast. They are relatively new and she points out that each is promising and may have a roll in diagnosis, but probably not screening.
Breast-specific gamma imaging (BSGI) uses technetium-99m sestamibi. The gamma counter "sees" the sestamibi in the mitochondria of the cells. Cancer cells generally have more than normal cells and are "hot".
Positron emission mammography (PEM) is basically a PET scan of the breast. The fluorine-18 labelled deoxyglucose (FDG) that is injected then accumulates in tumor cells, actively metabolizing glucose.
In small studies each has shown a specificity of around 90%, but the key will be lowering the radiation dose and perhaps increasing the sensitivity of the receivers picking up the signal.
We are talking about finding a small number of additional cancers and we should remember that neither has replaced mammography as a screening tool.
There are additional ultrasound techniques which will be reviewed later.
Friday, March 16, 2012
Chalk up another benefit for broccoli
Broccoli and the other cruciforms that make "heads" like Brussels sprouts, cabbage, rapini, cauliflower and turnips, help prevent cancer.
They contain compounds that help eliminate carcinogens from the body.
They contain glucosinolates that are converted to isothiocyanates (ICTs) that enhance the function of normal tumor suppressor genes. See http://drwinsett.blogspot.com/2012/02/have-some-broccoli.html.
Now another mechanism has been found. We saw earlier this week that DNA methylation changed with exercise and researchers at the Linus Pauling Institute at Oregon State University have found that sulforaphane (a form of ICT) helps maintain the normal DNA methylation required for normal cell growth. In cancer cells this methylation has been altered. A nice review of this research can be seen at http://lpi.oregonstate.edu/infocenter/phytochemicals/isothio/#summary.
These compounds can be inactivated by cooking. Boiling and even steaming in water can decrease the effective amounts by 50%. If, you don't like it raw, then cook minimally for the maximum benefit. Microwaves also diminish the effective concentrations. The highest concentrations are in the youngest and freshest (concentrations begin to drop 3 days after picking) plants. For a review of preparing go to http://www.aicr.org/foods-that-fight-cancer/broccoli-cruciferous.html.
I need to go plant some broccoli to pick for dinner this summer!
Together we can prevent 75,000 breast cancer cases each year!
They contain compounds that help eliminate carcinogens from the body.
They contain glucosinolates that are converted to isothiocyanates (ICTs) that enhance the function of normal tumor suppressor genes. See http://drwinsett.blogspot.com/2012/02/have-some-broccoli.html.
Now another mechanism has been found. We saw earlier this week that DNA methylation changed with exercise and researchers at the Linus Pauling Institute at Oregon State University have found that sulforaphane (a form of ICT) helps maintain the normal DNA methylation required for normal cell growth. In cancer cells this methylation has been altered. A nice review of this research can be seen at http://lpi.oregonstate.edu/infocenter/phytochemicals/isothio/#summary.
These compounds can be inactivated by cooking. Boiling and even steaming in water can decrease the effective amounts by 50%. If, you don't like it raw, then cook minimally for the maximum benefit. Microwaves also diminish the effective concentrations. The highest concentrations are in the youngest and freshest (concentrations begin to drop 3 days after picking) plants. For a review of preparing go to http://www.aicr.org/foods-that-fight-cancer/broccoli-cruciferous.html.
I need to go plant some broccoli to pick for dinner this summer!
Together we can prevent 75,000 breast cancer cases each year!
Thursday, March 15, 2012
In response to questions about yesterday's blog
I found the news quite exciting that we could change our genome, but have received several questions about the findings. I will attempt to answer them.
The changes in the DNA with exercise are over and above the genes, called epigenetic. The methyl groups which go away with exercise prevent transcription factors from turning on the gene expression. The methyl groups clog up the mechanism and exercise "opens up" the gene to normal expression by removing the -CH3 group attached to the outside of the DNA, so the gene function may return to normal. In our case one of the benefits is more normal glucose metabolism in and out of the cell.
BUT, how can this be a lifetime effect? With as little as 20 minutes of exercise, the effect was seen for several hours. Imagine what can happen with longer and regular exercise! When you exercise and make these epigenetic changes happen, you won't just change the short term but may change your genome for a lifetime (as long as you exercise).
"This shows that there is some molecular evidence to support the notion that exercise is a medicine," Dr. Zierath told Science Daily March 6, 2012.
Imagine that genes involved in breast cancer prevention are covered up by the methyl groups and that exercise removes the group so that the normal gene expression can prevent breast cancer. We know that those who exercise have fewer breast cancers, maybe this is how it works or at least part of the process.
Together we can prevent 75,000 breast cancers each year!
The changes in the DNA with exercise are over and above the genes, called epigenetic. The methyl groups which go away with exercise prevent transcription factors from turning on the gene expression. The methyl groups clog up the mechanism and exercise "opens up" the gene to normal expression by removing the -CH3 group attached to the outside of the DNA, so the gene function may return to normal. In our case one of the benefits is more normal glucose metabolism in and out of the cell.
BUT, how can this be a lifetime effect? With as little as 20 minutes of exercise, the effect was seen for several hours. Imagine what can happen with longer and regular exercise! When you exercise and make these epigenetic changes happen, you won't just change the short term but may change your genome for a lifetime (as long as you exercise).
"This shows that there is some molecular evidence to support the notion that exercise is a medicine," Dr. Zierath told Science Daily March 6, 2012.
Imagine that genes involved in breast cancer prevention are covered up by the methyl groups and that exercise removes the group so that the normal gene expression can prevent breast cancer. We know that those who exercise have fewer breast cancers, maybe this is how it works or at least part of the process.
Together we can prevent 75,000 breast cancers each year!
Wednesday, March 14, 2012
And you thought you couldn't change your genes!
Interesting data, recently published in Cell Metabolism, suggests that what we do can influence our genes. Researchers from Lund University, Karolinska Institute and Copenhagen University have demonstrated that exercise can change gene expression.
They studied muscle fiber DNA from healthy but inactive humans, before and after exercise. They then confirmed these changes in the lab with muscle fibers they made to contract in vitro.
After a short bout of exercise they noted that methyl groups (-CH3) had been removed from certain places on the DNA. This change turned on certain genes that were either not working or only at a low level. As an example the removal of these markers from the outside of the DNA strand caused an increase of transport of glucose into the cell. Dr. Zierath, on of the authors commented on the results, "Exercise is medicine", with obvious implications for diabetes Type 2.
This is the study of epi- (from the Greek, outside or above) genetics. What we do can change the way our genes are expressed and initial research shows that the change persists for a few hours after just a short burst of exercise. Imagine what you could do with a lifetime!
What if you have a gene that is not expressed but exercise makes that gene up-regulate to become expressed and that gene, when expressed properly, prevents breast cancer, wouldn't you want to do that for yourself?
What if exercise then became a lifestyle and the epigenetic change caused by exercise became a permanent part of the genetic code you passed on to your children?
Together we can prevent 75,000 breast cancer cases each year!
They studied muscle fiber DNA from healthy but inactive humans, before and after exercise. They then confirmed these changes in the lab with muscle fibers they made to contract in vitro.
After a short bout of exercise they noted that methyl groups (-CH3) had been removed from certain places on the DNA. This change turned on certain genes that were either not working or only at a low level. As an example the removal of these markers from the outside of the DNA strand caused an increase of transport of glucose into the cell. Dr. Zierath, on of the authors commented on the results, "Exercise is medicine", with obvious implications for diabetes Type 2.
This is the study of epi- (from the Greek, outside or above) genetics. What we do can change the way our genes are expressed and initial research shows that the change persists for a few hours after just a short burst of exercise. Imagine what you could do with a lifetime!
What if you have a gene that is not expressed but exercise makes that gene up-regulate to become expressed and that gene, when expressed properly, prevents breast cancer, wouldn't you want to do that for yourself?
What if exercise then became a lifestyle and the epigenetic change caused by exercise became a permanent part of the genetic code you passed on to your children?
Together we can prevent 75,000 breast cancer cases each year!
Tuesday, March 13, 2012
Good news for estrogen-only users
You will remember The Women's Health Initiative (WHI) which enrolled women in 1993 to clarify the risks and benefits of hormone replacement use. In 2002 part of the study was terminated because in the estrogen and progesterone group (Prempro in this study) there were excessive breast cancers. See
Now, we will look at the estrogen-only group. These are women who have had a hysterectomy and don't need the additional progesterone. In the WHI study, the estrogen group took conjugated equine estrogens (Premarin 0.625mg). This part of the study was terminated in 2004 because of increased stroke and leg clots. BUT, modst of the 11,000 women agreed to continued follow-up. Recently the results at 11.8 years were published for the groups taking conjugated equine estrogens for a median of 5.9 years versus the placebo group in JAMA 2011 and Lancet Oncology 2012.
The estrogen group had fewer breast cancers in the added 5 year follow-up. The estrogen group also had a reduced risk of dying from the disease.
With subgroup analysis the lower risk was only seen in the women of low or usual risk for breast cancer. The estrogen did not lower the risk in those women with a family history of breast cancer or personal history of benign breast disease. The estrogen was not protective in anyone at increased risk for getting breast cancer. The possible mechanisms at work here will be discussed in later blogs, such as timing, which estrogen or which dose.
In review then, the results allow us to further personalize our recommendations for hormone replacement. This study showed us that estrogen did increase the risk of strokes and clots, but did decrease the risk of breast cancer in certain women. These findings should reassure women who have had a hysterectomy, are at usual risk for breast cancer and seek estrogen for symptomatic menopause relief and/or bone density maintenance.
This medical content is intended for information and not personal treatment advice. These are findings to discuss with your doctor.
Together we can prevent 75,000 breast cancers each year!
Now, we will look at the estrogen-only group. These are women who have had a hysterectomy and don't need the additional progesterone. In the WHI study, the estrogen group took conjugated equine estrogens (Premarin 0.625mg). This part of the study was terminated in 2004 because of increased stroke and leg clots. BUT, modst of the 11,000 women agreed to continued follow-up. Recently the results at 11.8 years were published for the groups taking conjugated equine estrogens for a median of 5.9 years versus the placebo group in JAMA 2011 and Lancet Oncology 2012.
The estrogen group had fewer breast cancers in the added 5 year follow-up. The estrogen group also had a reduced risk of dying from the disease.
With subgroup analysis the lower risk was only seen in the women of low or usual risk for breast cancer. The estrogen did not lower the risk in those women with a family history of breast cancer or personal history of benign breast disease. The estrogen was not protective in anyone at increased risk for getting breast cancer. The possible mechanisms at work here will be discussed in later blogs, such as timing, which estrogen or which dose.
In review then, the results allow us to further personalize our recommendations for hormone replacement. This study showed us that estrogen did increase the risk of strokes and clots, but did decrease the risk of breast cancer in certain women. These findings should reassure women who have had a hysterectomy, are at usual risk for breast cancer and seek estrogen for symptomatic menopause relief and/or bone density maintenance.
This medical content is intended for information and not personal treatment advice. These are findings to discuss with your doctor.
Together we can prevent 75,000 breast cancers each year!
Monday, March 12, 2012
More on individualized risk.
Last week we noted, in the consideration of who might benefit from hormone replacement, that we now have available screening tests to help us further personalize a recommendation derived from population based studies.
One of these tests is the BREVAGen test, which we have discussed in regard to finding out who is at increased risk. See http://drwinsett.blogspot.com/2012/01/do-you-want-to-know-your-personal-risk.html. We may also use this test to find who is at low risk and perhaps learn who might have the scale of risk and benefits tilted towards using combined hormone replacement (EPT), for prevention of bone loss, for instance. As you know, the test is a combination of clinical features and genetic information obtained form a cheek swab.
The American Society of Clinical Oncology and The American Cancer Society recognize the higher risk category and recommend consideration of other screening besides yearly mammography and even consideration of a chemopreventive medicine.
Another test of risk is the HALO breast pap, which is a 5 minute office procedure to obtain nipple aspirate fluid to test. The finding of atypia in the ductal fluid cells has been shown to precede cancer development and put that person in the category of consideration for other screening and even chemoprevention as noted above.
An ideal time for these tests would be at menopause when considering hormone replacement and the risks and benefits of the treatment. The results of these tests would help individualize the treatment decision.
Again, this content is intended to inform and is not specific medical advice. You may discuss these tests and hormone replacement with your physicians.
Together we can prevent 75,000 breast cancers each year!
One of these tests is the BREVAGen test, which we have discussed in regard to finding out who is at increased risk. See http://drwinsett.blogspot.com/2012/01/do-you-want-to-know-your-personal-risk.html. We may also use this test to find who is at low risk and perhaps learn who might have the scale of risk and benefits tilted towards using combined hormone replacement (EPT), for prevention of bone loss, for instance. As you know, the test is a combination of clinical features and genetic information obtained form a cheek swab.
The American Society of Clinical Oncology and The American Cancer Society recognize the higher risk category and recommend consideration of other screening besides yearly mammography and even consideration of a chemopreventive medicine.
Another test of risk is the HALO breast pap, which is a 5 minute office procedure to obtain nipple aspirate fluid to test. The finding of atypia in the ductal fluid cells has been shown to precede cancer development and put that person in the category of consideration for other screening and even chemoprevention as noted above.
An ideal time for these tests would be at menopause when considering hormone replacement and the risks and benefits of the treatment. The results of these tests would help individualize the treatment decision.
Again, this content is intended to inform and is not specific medical advice. You may discuss these tests and hormone replacement with your physicians.
Together we can prevent 75,000 breast cancers each year!
Friday, March 9, 2012
Updated menopausal hormone therapy guidelines
The North American Menopause Society has recently (www.menopause.org 03-01-2012) updated its 2010 position statement on menopausal hormone replacement therapy. I will summarize the major changes with reference to breast cancer. In today's blog we will discuss only combined estrogen and progesterone therapy (EPT). As you know the menopausal indication for the progestin (progesterone or progestogen) use is to prevent the increase of endometrial cancers seen with estrogen-only treatment. Therefore in this blog we are talking about women who have not had a hysterectomy and do have an intact uterus.
They state that individualized treatment is the key, but still the evidence that they site is mostly from population-based studies. Nevertheless we can and do learn from theses studies. Specifically, EPT does increase the risk of cardiovascular disease, stroke and leg clots. Individualizing care here means taking a history and then not compounding a problem with EPT. Studies point to routes other than oral administration for lowering these risks. Length of treatment recommendations are primarily dictated by breast cancer risk. Timing of treatment is emerging as a variable as well. The effects may not be present for the entire class of estrogen drugs, but just the combined equine estrogens used in most studies.
There is greater safety overall in younger women who use EPT, specifically beginning treatment in the perimenopause or early premenopause period. Interestingly, all adverse effects except breast cancer risk are less with early use and even risk of events for all outcomes is lower in younger women.
Why the beast cancer risk would be different is not yet known, but at least one idea will be discussed next week when we blog about estrogen-alone hormone replacement (ET) for those who have had a hysterectomy.
All three of the large studies used in the analysis showed a greater risk of breast cancer in women beginning EPT shortly after menopause. The Womens' Health Initiative (WHI) initially reported that those who began EPT early in menopause had more breast cancers, but those waiting 5 years did not. Later detailed analysis revealed a delayed increase in those later users. This increase in breast cancers was confirmed in the Million Women Study (MWS) and the French E3N.
BUT, what is the increased risk and when does it present? The absolute risk reported in the WHI was 8 additional cancers per 10,000 women using EPT for 5 years or more. Long term follow up suggests that the increased risk goes away 3 years after hormones are stopped. However, long term follow up also showed an increase in death from breast cancer with 2 additional deaths per 10,000 women followed for 11 years. Specifically, NAMS recommend for EPT use 3 to 5 years of safety from breast cancer.
We will see in blogs next week, that we can further individualize recommendations for EPT with two simple tests. Genetic and histologic information, as well as clinical information is part of the key to an individual treatment recommendation.
This is general medical content and intended, not as treatment for any one person, but to inform and prompt a thorough discussion between a woman and the prescribing physician.
Together we can prevent 75,000 breast cancer cases each year!
They state that individualized treatment is the key, but still the evidence that they site is mostly from population-based studies. Nevertheless we can and do learn from theses studies. Specifically, EPT does increase the risk of cardiovascular disease, stroke and leg clots. Individualizing care here means taking a history and then not compounding a problem with EPT. Studies point to routes other than oral administration for lowering these risks. Length of treatment recommendations are primarily dictated by breast cancer risk. Timing of treatment is emerging as a variable as well. The effects may not be present for the entire class of estrogen drugs, but just the combined equine estrogens used in most studies.
There is greater safety overall in younger women who use EPT, specifically beginning treatment in the perimenopause or early premenopause period. Interestingly, all adverse effects except breast cancer risk are less with early use and even risk of events for all outcomes is lower in younger women.
Why the beast cancer risk would be different is not yet known, but at least one idea will be discussed next week when we blog about estrogen-alone hormone replacement (ET) for those who have had a hysterectomy.
All three of the large studies used in the analysis showed a greater risk of breast cancer in women beginning EPT shortly after menopause. The Womens' Health Initiative (WHI) initially reported that those who began EPT early in menopause had more breast cancers, but those waiting 5 years did not. Later detailed analysis revealed a delayed increase in those later users. This increase in breast cancers was confirmed in the Million Women Study (MWS) and the French E3N.
BUT, what is the increased risk and when does it present? The absolute risk reported in the WHI was 8 additional cancers per 10,000 women using EPT for 5 years or more. Long term follow up suggests that the increased risk goes away 3 years after hormones are stopped. However, long term follow up also showed an increase in death from breast cancer with 2 additional deaths per 10,000 women followed for 11 years. Specifically, NAMS recommend for EPT use 3 to 5 years of safety from breast cancer.
We will see in blogs next week, that we can further individualize recommendations for EPT with two simple tests. Genetic and histologic information, as well as clinical information is part of the key to an individual treatment recommendation.
This is general medical content and intended, not as treatment for any one person, but to inform and prompt a thorough discussion between a woman and the prescribing physician.
Together we can prevent 75,000 breast cancer cases each year!
Wednesday, March 7, 2012
The trouble with vitamin D
We all know that vitamin D is a necessary fat soluble vitamin that is synthesized in the skin in response to sunlight and is in a few foods. The best natural food sources are fatty fish such as salmon, tuna and mackerel with only small amounts in egg yolks, cheese and beef liver. Many foods are fortified with vitamin D. Milk is usually fortified, but products made form milk may not be, so we have to read the label. Mushrooms may have the vitamin D content enhanced by exposure to ultraviolet light. Most people get vitamin D from supplements. In fact, the Nutrition Business Journal reported that sales are significantly up: from $50 million in 2005 to $550 million in 2010.
The essential role of vitamin D in skeletal health is likewise well known, but what about the non-bone and particularly breast cancer benefits.
Much of our information about the health effects of vitamin D comes from population-based observation trials. Vitamin D3 form the skin and most supplements as well as D2 from a nutrients is changed into 25OHD by the liver and finally the active 1,25OHD by the kidney. We use the serum concentration of 25OHD, an expensive test, as indicator of vitamin D status.
We have learned from these studies that levels are lower in the higher latitudes and in winter, because of less sun exposure. It has been noted that low levels of vitamin D have been linked with many chronic disease states:
The essential role of vitamin D in skeletal health is likewise well known, but what about the non-bone and particularly breast cancer benefits.
Much of our information about the health effects of vitamin D comes from population-based observation trials. Vitamin D3 form the skin and most supplements as well as D2 from a nutrients is changed into 25OHD by the liver and finally the active 1,25OHD by the kidney. We use the serum concentration of 25OHD, an expensive test, as indicator of vitamin D status.
We have learned from these studies that levels are lower in the higher latitudes and in winter, because of less sun exposure. It has been noted that low levels of vitamin D have been linked with many chronic disease states:
- Hypertension
- Stroke
- Congestive heart failure
- Peripheral arterial disease
- Colon cancer
- Prostate cancer
- Breast cancer
- Diabetes mellitus
- Muscle weakness and falls
- Overall mortality
Studies reveal that women living in areas of little sunlight exposure have more breast cancers and higher mortality rates from the disease. Several studies, dividing women into groups by 25OHD levels, have shown a decrease in breast cancer risk with higher concentrations of D. Studies of supplementation have not been consistent. A Canadian study and a US study have both demonstrated a decrease in breast cancers with supplements of 1000IU and 400IU, but in the Nurses' Health Study, the benefit of supplementation was seen only in premenopausal women. In the early reports from the Women's Health Initiative there was no benefit seen to supplementation with D3, but in later reports a decreased breast cancer risk is reported.
Overall, the literature suggests a benefit for reducing breast cancer risk by supplementing Vitamin D, but the trouble with vitamin D is how much. In these studies, the supplemented amount ranges from 400IU to 4000IU. Obviously, the total 25OHD is also influenced by diet and sun exposure. There have also been genetic studies that have shown hereditary variation in D levels in twins living in the same environment. Four gene polymorphs have been implicated, as well.
Even experts can't decide what amount to recommend for daily intake. The Institute of Medicine: 600IU, various Endocrine and Osteoporosis groups: 1000-2000IU and one of the authors in a paper sited above: 4000IU per day.
Excess vitamin D can cause nausea, vomiting, poor appetite, constipation, weight loss, confusion, disorientation, heart dysrhythmias and kidney damage.
The 25OHD concentration is related to intake and there is a toxicity level. The Food and Nutrition Board (FNB) at the Institute of Medicine studied the problem of daily intake (not the amounts needed to replace a very low level quickly). Studies have shown that taking 5000IU per day long term leads to a 25OHD concentration of no more than 40-60ng/ml, the toxicity threshold concluded by the FNB review http://www.iom.edu/Activities/Nutrition/SummaryDRIs/DRI-Tables.aspx. They applied an "uncertainty factor" of 20% and came up with the "tolerable upper intake level" of 4000IU per day. Again, this is chronic daily long term dose. More may be required in the short term to increase a severely low level.
You can see that this is difficult issue to study because of all the confounding variables such as inter-individual variation, age, where you live, sun exposure, genetics, ethnicity and even what dose of supplementation.
Clearly, this is a complicated issue and requires personalization for each patient. On their website The National Cancer Institute concludes that they cannot recommend "for or against" vitamin D supplements for cancer prevention http://www.cancer.gov/cancertopics/factsheet/prevention/vitamin-D.
The content of this blog is general health information, intended to inform and prompt a conversation with your doctor. This information is not medical advice.
Together we can prevent 75,000 breast cancer cases each year!
Excess vitamin D can cause nausea, vomiting, poor appetite, constipation, weight loss, confusion, disorientation, heart dysrhythmias and kidney damage.
The 25OHD concentration is related to intake and there is a toxicity level. The Food and Nutrition Board (FNB) at the Institute of Medicine studied the problem of daily intake (not the amounts needed to replace a very low level quickly). Studies have shown that taking 5000IU per day long term leads to a 25OHD concentration of no more than 40-60ng/ml, the toxicity threshold concluded by the FNB review http://www.iom.edu/Activities/Nutrition/SummaryDRIs/DRI-Tables.aspx. They applied an "uncertainty factor" of 20% and came up with the "tolerable upper intake level" of 4000IU per day. Again, this is chronic daily long term dose. More may be required in the short term to increase a severely low level.
You can see that this is difficult issue to study because of all the confounding variables such as inter-individual variation, age, where you live, sun exposure, genetics, ethnicity and even what dose of supplementation.
Clearly, this is a complicated issue and requires personalization for each patient. On their website The National Cancer Institute concludes that they cannot recommend "for or against" vitamin D supplements for cancer prevention http://www.cancer.gov/cancertopics/factsheet/prevention/vitamin-D.
The content of this blog is general health information, intended to inform and prompt a conversation with your doctor. This information is not medical advice.
Together we can prevent 75,000 breast cancer cases each year!
Monday, March 5, 2012
Another look at successful losers...weight losers!
A recent review reminds us of what those who lose weight and keep it off have in common. The information is from the National Weight Control Registry, now with over 10,000 enrolled. I first blogged about this April 25, 2011 and you can find out the latest at http://www.nwcr.ws/default.htm.
This is "the largest prospective investigation of long-term successful weight loss maintenance" according to the website. It is not a weight loss program, but examines the behavior, characteristics and strategies of those who have successfully lost and kept the weight off.
What can we learn?
Those who have successfully lost weight and are maintaining:
This is "the largest prospective investigation of long-term successful weight loss maintenance" according to the website. It is not a weight loss program, but examines the behavior, characteristics and strategies of those who have successfully lost and kept the weight off.
What can we learn?
Those who have successfully lost weight and are maintaining:
- decreased caloric intake (98% report a dietary change)
- maintain a daily routine (78% report eating breakfast)
- self monitor food intake and weight (75% weigh at least weekly)
- decreased TV watching (62% report <10 hours per week)
- regularly exercise (90% report about 1 hour each day)
Not easy, but this is how many of those who are successful at losing and maintaining the weight loss do it.
We have seen how important maintaining or getting to the lean weight is in breast cancer. For every pound gained after the age of 50, a woman gains 1% increased risk, BUT, even more important, for every one pound lost and kept off after 50, a woman gets twice the benefit or 2% fewer breast cancers. 10 pounds lost equals 20% less breast cancer risk! See
Together we can prevent 75,000 breast cancer cases each year!
Friday, March 2, 2012
Another benefit of exercise...and someone else talking about it
Maybe some of you are tired of me talking about the benefits of exercise so I am sending you a link to someone else promoting exercise. Check out the link http://www.medscape.com/viewarticle/758595?src=nl_topic.
Together we can prevent 75,000 breast cancer cases each year!
Together we can prevent 75,000 breast cancer cases each year!
Thursday, March 1, 2012
How do you make the numbers work for you?
We have reviewed the science behind the chemoprevention drugs in the last two blogs, but how do you make the numbers work for you?
The studies provide us guidelines and the science tells us that the higher the risk, the more likely the benefit.
BUT, we can personalize the risk even more. With a combination of your clinical data and your genes, the BREVAGen test can give you a more precise risk assessment. See
. If your lifetime risk is 20% or higher or your 5 year risk is 1.67% or higher then you might benefit from specific chemoprevention and should discuss this with your physician.
For those younger than 35 years, the HALO is the test for you. This 5 minute breast pap test allows us to identify those at higher risk because of cellular abnormalities much like the cervical pap test. See http://www.neomatrix.com/halonaf/NAF-Collection.aspx.
These advances in medicine are allowing us to more precisely predict and personalize our recommendations. This is how the numbers work for you.
Discuss these tests with your doctor and find out which is right for you.
Together we can prevent 75,000 breast cancer cases each year!
The studies provide us guidelines and the science tells us that the higher the risk, the more likely the benefit.
BUT, we can personalize the risk even more. With a combination of your clinical data and your genes, the BREVAGen test can give you a more precise risk assessment. See
. If your lifetime risk is 20% or higher or your 5 year risk is 1.67% or higher then you might benefit from specific chemoprevention and should discuss this with your physician.
For those younger than 35 years, the HALO is the test for you. This 5 minute breast pap test allows us to identify those at higher risk because of cellular abnormalities much like the cervical pap test. See http://www.neomatrix.com/halonaf/NAF-Collection.aspx.
These advances in medicine are allowing us to more precisely predict and personalize our recommendations. This is how the numbers work for you.
Discuss these tests with your doctor and find out which is right for you.
Together we can prevent 75,000 breast cancer cases each year!
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