Earlier this year Angelina Jolie seized the attention of women everywhere after undergoing a double mastectomy, but her decidedly difficult decision shouldn’t serve as a mass blueprint for women. As Melissa Etheridge -who, like Jolie, possesses hereditary breast cancer syndrome – recently pointed out, focusing heavily on hereditary risk factors is problematic. It steals the spotlight from the factors we can control, which play a greater role in breast cancer.
Examining the numbers illustrates just how rare Jolie’s case is. The Academy Award-winning actress inherited a genetic mutation shared by less than one in 20 women who develop breast cancer. Of the 232,340 women diagnosed with breast cancer this year, she is one of 16,668 – or as few as 2,323 – born with an inherited risk of the disease. So what we need to keep in mind is that most women who develop breast cancer begin life with healthy genes. Illness arises, however, as a result of things that women are exposed to through the course of their lifetimes.
BRCA is the test Jolie used, and that which many other women are now contemplating, to identify the presence of hereditary breast cancer syndrome. But many women may find it hard to pay the test’s hefty price tag – up to $3,500. If you are one of these women, educate yourself about environmental health risks that play a much greater role in developing most cases of cancer. Your family’s medical history also offers critical information. A mother, grandmother or father’s sister or first cousin who had breast cancer before age 40 indicates you may be at greater risk for developing breast cancer.
A September Annals of Internal Medicine study found that the procedure Jolie underwent, contralateral prophylactic mastectomy, does little to improve survival rates for most women. The study also reported that many who underwent the surgery overestimated their risk of dying from breast cancer. The researchers talked to 123 women, age 40 or younger, who were diagnosed with cancer in one breast but opted to get both breasts removed.
Almost all who participated in this study said they had both breasts removed in order to decrease the risk of cancer spreading to the other breast. Ninety-four percent of the women also said they believed removing the healthy breast would give them a better chance at overall survival, and 95 percent said the procedure would give them “peace of mind.” However, those who removed both of their healthy and diseased breasts greatly overestimated their actual risk of getting cancer in the other breast.
An accompanying editorial in the Annals of Internal Medicine states that doctors need to find a better way to share existing studies and statistics about cancer risks and the benefits and downsides of CPM to help patients decide whether they want the procedure.
Before considering CPM, women should examine the cadre of evidence that indicates many cases of breast cancer stem from environmental factors. History has taught us about some of these factors, at the cost of many women’s lives.
Indeed, among the causes of breast cancer confirmed by the Institute of Medicine were a number of unsurprising agents: hormone replacement therapy, once given to millions of women to hamper the “disease” of aging, the ineffective miscarriage-preventing drug Di-ethylstilbestrol, and the sterilant and workplace hazard, ethylene oxide. Because each of these materials stimulates cell growth, and had been shown to induce cancer in laboratory studies, there were good reasons for predicting they would lead to cancer in women.
When Barbara Seaman warned in the 1970s that our rash use of artificial hormones to promote youth would prove deadly, many dismissed her despite evidence pointing to the danger of synthetic hormones. But that proof arrived in a big and undeniable way, when the large-scale Women’s Health Initiative studying hormone replacement therapy was suddenly called off because so many women were dying of stroke, heart attack and breast cancer.
From the moment it was discovered just prior to WWII, the synthetic hormone DES was understood to be dangerous. Two decades later, after physicians had prescribed this compound to millions of pregnant women in the 1950s and 60s, its cancerous risks to their babies and to the mothers themselves were clear.
The cancer-causing impact of diagnostic and environmental radiation has also been known for several decades. Young survivors of the Chernobyl catastrophic release of nuclear radiation have high rates of thyroid and breast cancer. Yet today many emergency room doctors and pediatricians still are unaware of the need to curb radiation exposure to young women’s chests.
The challenge of these findings is immense. History has not been kind to scientists like Rachel Carson, Sam Epstein, Rosalie Bertell or Janette Sherman, who have long warned about the need to curb environmental exposures to agents that promote cancer. Specifically, they and others have warned that mammography prior to menopause is likely to cause breast cancer.. In a commentary to the Journal of the American Medical Association in 1994, I reported with breast surgeon Susan Love that within a decade for every 1,000 women given mammograms starting at age 40, 700 of them would be called back for repeat x-rays or biopsies and the consequent stresses and expenses of undergoing them. A recent analysis by physician researcher Laura Esserman of the University of California at San Francisco confirms these findings, adding that, as a result, millions of women may well undergo unnecessary or inappropriate surgery.
Some two decades ago, Leon Bradlow and I advanced the idea that there were xenoestrogens in the environment that could stimulate the body to alter its own production of this natural hormone, thereby promoting cancer in the breasts. Cases of exceptionally rare and very unusually located breast cancer have been reported in young women who’ve stored cell phones in their bras.
Solid evidence now indicates that women can reduce their risk of breast cancer by avoiding toxic hazards, including unnecessary medical radiation exposure.
Women can also reduce their risk by avoiding combination menopausal hormone therapy, tobacco and alcohol, exercising regularly, using cell phones safely, maintaining a healthy weight and reducing exposure to likely environmental and workplace carcinogens.
A substantial body of scientific evidence indicates that exposures to common chemicals and radiation, alone and in combination, are an important cause of breast cancer. The challenge in understanding breast cancer is considerable as the disease can arise decades after critical exposures take place. The disease may well arise from either hormonally active materials or those that directly damage DNA.
Pre-menopausal breast cancer and post-menopausal breast cancer are likely to have different causes. Several classes of environmental factors have been implicated as an increased risk for breast cancer, including hormones and endocrine-disrupting compounds, organic chemicals and by-products of industrial and vehicular combustion, and both ionizing and non-ionizing radiation.
In its review of “The State of the Evidence,” the Breast Cancer Fund recently concluded that there are major opportunities to reduce breast cancer risk through lowering chemical exposures in many different workplaces.
The fundamental challenge to researchers and policymakers remains this: we seldom can identify specific distinct causes of breast cancer through public health research. Yet every proven cause of cancer in humans has also been shown to cause cancer in animals when adequately studied. Policymakers have agreed that in order to prevent cancer in humans, we should rely on experimental findings.
We cannot wait for sufficient numbers of illnesses or deaths to amass when we already know that certain compounds and professions increase the risk of breast cancer in women. Acting to control or restrict such exposures is critical in order to control disease.