Expert Analysis Highlights:

• Harvard Medical School study shows women who took an average of two-five aspirin a week were 60% less likely to develop metastatic breast cancer and 71% less likely to die of breast cancer
• This was a retrospective epidemiology type of study that does raise important questions but does not give definitive evidence that taking aspirin for breast cancer is a mandatory treatment.
• Since aspirin has such low toxicity in most individuals as well as a proven benefit across a range of diseases, it seems reasonable to recommend it as part of healthy lifestyle

What makes this drug so special?  Well, it’s inexpensive, widely available at any grocery store, non-toxic, and studies show that it increases breast cancer survival rates. It’s acetylsalicylic acid…also know simply as aspirin! A new study published in the February 16, 2010 issue of the Journal of Clinical Oncology suggests for the first time that pre-menopausal women who take two or more aspirin each week in the years after the diagnosis of early stage breast cancer could increase their probability of survival (or prognosis) compared to women who don’t take aspirin. So, those women who took aspirin were less likely to develop metastatic spread of their breast cancer, or to die of breast cancer or other causes of death.

It is important to point out that this was a retrospective epidemiology type of study that does raise important questions but does not give definitive evidence that taking aspirin for breast cancer is a mandatory treatment. The women self-reported the use of aspirin through an annual survey over the last 20 years, and the intent of aspirin use was not necessarily to treat breast cancer. It is likely that the women taking aspirin were following recommendations from the American Heart Association and other organizations to reduce the risk of heart attack and stroke.

Having said that, since aspirin has such low toxicity in most individuals as well as a proven benefit across a range of diseases, it seems reasonable to recommend that women (and men too!) take aspirin on a regular basis as part of healthy lifestyle.

Aspirin has been available for many years and is recommended as a preventative for heart and stroke disease. There’s also some evidence that it decreases the risk of colon cancer. The mechanism of action for such a simple compound is unknown. It may relate to its anticoagulation effects that prevent circulating tumor cells from lodging in blood vessels and then growing in a vital organ. It also decreases the invasive nature of cancer cells (i.e. the process of attaching to blood vessels, working its way into the blood stream, and spreading to other organs), lowers the level of the hormone estradiol, or may have an anti-inflammatory effect.

The results from the large population-based study mentioned above involving 4106 women nurses were impressive.  The investigators, Dr Michelle Holmes and others from Harvard Medical School, concluded that “aspirin use was associated with a decreased risk of breast cancer death.” Women who took an average of two-five aspirin a week were 60% less likely to develop metastatic breast cancer and 71% less likely to die of breast cancer. There was also a suggestion of a protective effect with other non-steroidal anti-inflammatory medicines besides aspirin, such as ibuprofen (Advil, Motrin, Nuprin) or naproxen (Aleve, Anaprox), but this could not be demonstrated with acetaminophen (Tylenol, Bayer).

It is important to note that women who took an average of one aspirin a week (or less) as opposed to two-five had the same risk of developing metastatic breast cancer or dying from breast cancer as women who didn’t take any aspirin at all. I also want to point out that taking aspirin regularly before the diagnosis of breast cancer did not affect prognosis. Only taking aspirin after the diagnosis improved the outcome.

I take aspirin myself as a preventive medicine. Whether you take the “low dose” aspirin, a regular dose, or one of the other nonsteroidal anti-inflammatory drugs (NSAID) is a personal decision that is also based upon your body’s tolerance to taking these medicines without any ill effects (such as stomach upset or bleeding tendencies). If you have any questions about this, you should ask your doctor.

Expert Analysis Highlights:

• Certain types of cancer like colon cancer have a slight association with a high-fat diet
• Avoid hydrogenated and trans fats, and seek out Omega 3 or Free Range products in your diet
• Big industries introduce products to market faster than the public health community can study them
• Until the research community catches up with the processed food industry, eat local food, organic food, and clean water seafood

Here are eight important diet tips, and read more below for an explanation of these points:

1) Look for free range milk, eggs and meats
2) Take Omega 3 supplementation
3) Seek wild-caught fish
4) Ask for clean water seafood
5) Buy organic foods (chemical-free)
6) Avoid hydrogenated fats
7) Avoid processed food
8) Eat local

50 years ago our food largely came from local farms with green pastures.  Today, most food we eat comes from factories and it travels 1,500 miles before it’s consumed.  At the same time we are seeing an increase in certain types of cancer, despite many medical advances.  Is there a connection?  Its simply too hard to study something that broad to say definitively.  But consider the following points when choosing your food.

Studying the cause of cancer is extremely complex.  Assessing the 20 or 30  year effects of environmental or nutritional changes on cancer is difficult to measure and costly to do right.  Also, the absence of research supporting a connection does not mean there isn’t one.

Historically, public health research has lagged behind the introduction of cancer-causing agents in the environment.  Big industries introduce products to market faster than the public health community can study them.  Take for example, cigarettes.  It took decades for public health researchers to confirm what they had long suspected–that they are bad for your health and cause cancer.  Cancer is believed to be multi-factorial, which means it could be caused by a combination of internal, genetic, and/or environmental factors.  What we do know is that certain types of cancer like colon cancer have a slight association with a high-fat diet.

Food increasingly is processed and not natural.  It has more fat, sugar and artificial ingredients.  Some in the public health community have warned that such processed food could be associated with certain types of cancer.   When animals are fed corn products and denied green pastures as they are when raised in factory farms, they concentrate the wrong types of molecules in their system.  This is so common that many doctors now recommend that patients take Omega-3 pills to balance out the high Omega-6 fats found in most processed food.  The use of Omega-3 has been studied and found to be beneficial in preventing repeat heart attacks, and that’s probably just the beginning of what we are learning about the Omega fat imbalance.  So avoid hydrogenated and trans fats, and seek out Omega 3 or Free Range products in your diet.

One great source of Omega 3′s are fish.  Specifically its high in fish livers which are purest in clean waters like Norway or Alaska.  Unfortunately, seafood increasingly come from areas where toxic metals are found, such as the Atlantic coast and the Gulf of Mexico.  Omega 3 pills extracted from small fish in Virginia, for example, are loaded with pollutants.  Alaskan fish on the other hand come from clean waters and are an excellent source of Omega 3′s.

Free Range food is important for good health because Free Range animals get more appropriate nutrition for their muscles.  Those muscles are what we eat as meat.  Most any fast food has factory-farm style animals raised under inhumane conditions, fed processed corn products.  The movie “Food Inc.” exposes this industry showing how the artificial food is even spray-painted green at times to trick the chickens into eating it.  Those chemicals can’t be good for your body.  Free Range foods are safer and more likely to be chemical free.  Free Range products taste better too.

Every nutritionist agrees that our consumer culture has minimized fruits and vegetables.  These are important for many reasons, including the magical potential of anti-oxidants.  Its believed that these compounds may have a slight benefit in preventing cancer, although further research is needed to know if they are really helping.  At minimum fruits and vegetables are important for balancing one’s diet.  A good variety of fruits and vegetables may eliminate the need to buy expensive vitamins, although Vitamin D and iron supplementation may still be recommended by your doctor if your levels are low.

Finally, the organic movement is good for public health.  There are many theories that genetically modifiable food and food grown with pesticides are not good for your health.  Trace amounts of pesticides have been detectable in people’s blood, and over years, such an accumulation of chemicals could be shown in the future to have an impact on cancer.  I highly recommend organic foods to young patients interested in taking care of their health and reducing their risk of cancer.  Until the research community catches up with the processed food industry, eat local food, organic food, and clean water seafood.

For related information, here’s another blog you might find helpful:

“Important Diet Tips for Cancer Prevention“

Cancer does not discriminate in any way! It affects rich and poor, famous and infamous, powerful and weak, all with an equal vengeance. It can affect whole families. I know….both of my parents died of cancer.

Senator John Kerry had prostate cancer, and his wife Teresa Heinz was recently diagnosed with breast cancer. These are two of the most common cancers that affect Americans. Both of them had an early diagnosis because of screening tests. Senator Kerry’s prostate cancer was discovered by a PSA test (a test that is becoming more common) and his wife by a screening mammogram. In this video, Teresa speaks out against the recommendations for mammography screening by the US Preventative Health Task Force, as I have done in a recent blog (see “Raging Debate on Mammography Guidelines“).

Hopefully both Mr. and Mrs. Kerry have a very successful outcome. We are grateful that they have come forward with their cancer story. It raises hope among us….we are all in this battle together!

This is an Oncology Podcast that covers three news highlights in breast cancer. The first one, and the most significant, concerns a report from Europe in women with inflammatory breast cancer (expressing the HER2 receptor) that is associated with a very high risk of dying. In a randomized study, researchers found that the complete response rate (that’s right: COMPLETE RESPONSE) in patients who received Herceptin (trastuzumab, Genentech Oncology) plus chemotherapy had a 55% complete response in these HER2+ breast cancers compared to only 19% for those women who had chemotherapy alone. Similar impressive results with Herceptin plus chemotherapy have been reported from UT MD Anderson cancer center in Houston.

The second report here describes FDA approval for a new drug Ixabepilone (Ixempra, Bristol Meyers Squibb) for advanced breast cancer refractory to other forms of chemotherapy.

The third news highlight describes a large study in Germany of 7000 women undergoing breast screening with mammography and breast MRI. The MRI scans were more accurate in detecting breast cancer, but it is a more expensive study and requires skill in interpretation. Breast MRI is used selectively in the United States, especially for women who have an inheritable form of breast cancer (BRAC! and BRAC2)

In November last year, a series of “bombshell” recommendations about screening mammography was made by the U.S. Preventative Services Task Force , an independent panel that makes health care recommendations. Their recommendations were published in the Annals of Internal Medicine..(2009;151:716-726). (www.annals.org) and are summarized below:

Recommendations: The U.S. Preventative Services Task Force (USPSTF) recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms. (Grade C recommendation)
The USPSTF recommends biennial screening mammography for women between the ages of 50 and 74 years. (Grade B recommendation)
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (I statement)
The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women 40 years or older. (I statement)
The USPSTF recommends against clinicians teaching women how to perform breast self-examination. (Grade D recommendation)
The USPSTF concludes that the current evidence is insufficient to assess additional benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities for breast cancer.

While their recommendations are indeed provocative, I strongly believe they are not valid and they should NOT be adopted. For example, when mammography screening was introduced in Sweden, the death rate from breast cancer was reduced by about 40%. In the U.S., the breast cancer death rate has decreased by 30% since 1990, when screening mammography began to be widely used. Before that, the breast cancer death rate had been unchanged for the preceding 50 years. Of course, my worry is the insurance carriers will use these USPTF recommendations as a “cover” for denying coverage for the costs of breast screening and further, that the public will be unnecessarily confused by the conflicting opinions and not seek regular screening. That would be a major setback, for breast cancer will get a longer headstart prior to detection (if these guidelines would be followed) and more women with breast cancer will require more radical (and expensive) treatments, more debilitating symptoms, and a lower probability of living a normal life span.

The USPSTF recommendations have been endorsed by the following organizations: American Academy of Family Physicians, American College of Medicine, American College of Preventative Medicine, National Association of County and City Health Officials, and the American Public Health Association.

On the other hand, virtually all the national organizations whose physician members are directly responsible for the screening and management of breast cancer are strongly opposed to these recommendations, including the American Cancer Society, the American College of Radiology, the American College of Surgeons, American Society of Breast Surgeons, the Society of Breast imaging, and the National Comprehensive Cancer Network. Indeed, many of their leaders have made very strong statements lamblasting the conclusions of the USPSTF.

“The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women, beginning at age 40. Our experts make this recommendation having reviewed virtually all the same data reviewed by the USPSTF, but also additional data that the USPSTF did not consider. When recommendations are based on judgements about the balance of risks and benefits, reasonable experts can look at the same data and reach different conclusions” Otis W. Brawley, MD Chief medical Officer, American Cancer Society.

The American College of Obstetricians and Gynecologists (ACOG) also maintains its current advice that women in their 40s continue mammographic screening every 1 to 2 years and women age 50 or older continue annual screening, stating: “ All women, along with their physicians, should individually assess the benefits as well as the risks of mammographic screening”.

The American College of Surgeons (ACS) also affirmed the the American Cancer Society Guidelines have resulted in an effective approach toward dealinig with brest cancer and that women should continue to follow them in consultation with their physicians. Dr Lemar S. McGinnis, MD, President of the ACS, stated: “ While recognizing that mammography is not perfect and supporting continuing research for improved methods, the surgical community believes that the American Cancer Society’s screening guidelines offer an optimal approach to detecting breast cancer early, when it can be most successfully treated.”

The American Society of Breast Surgeons is strongly opposed to the recommendations released November 16, 2009 by the USPSTF. “We believe there is sufficient data to support annual mammography screening for women age 40 and older… these recommendations effectively turn back the clock to pre-mammography days by making the diagnosis of breast cancer occur only when the tumor is large enough to be felt on a physical exam. Mammography screening reduces breast cancer mortality and saves lives.”

Read the withering criticism that leaders in the field have made, and their recommendations that current guidelines be maintained:

“For women age 40 and over, the benfits of annual breast screening continue to outweigh the risks…age should not be an absolute when determining who should receive mammorgraphy screening. It is imperative to consider the patient’s individual risk factors when considering an appropriate screening routine. Therese B. Beavers, MD, Chair, Guidelines Panel for Breast Cancer Screening and Diagnosis, National Comprehensive Cancer Network.

“The UTPSTF recommendations are a step backward and represent a significant harm to women’s health. To tell women they should not get regular mammograms starting at age 40 is shocking. At least 40% of the lives saved by mammographic screening are of women aged 40-40. These recommendations are inconsistent with curtrent science and apparently have been developed in an attempt to reduce costs. Unfortuneately, many women may pay for this unsound approach with their lives!” W. Phil Evans, MD, President, Society of Breast Imaging. Oncology, 23:1214, November, 2009

The U.S. Preventative Services Task Force recommendations “have taken a tremendous toll, and I believe they set us back”. “After all we’ve done to urge people to get screened, now they hear maybe they shouldn’t bother. That’s dangerous”. Nancy Brinker, the Founder of Koman Foundation and a breast Cancer Survivor was quoted in the Washington Post (November 24th,2009) stated at the National Press Club

“These unfounded USPSTF recommendations ignore the valid scientific data and place a great many women at risk of dying unnecessarily from a disease that we have made significant headway against over the past 20 years. …The new recommendations seem to reflect a conscious decision to ration care……it could have deadly effects on women.” Carol H. Lee, MD Chair of the American College of Radiology Breast Imaging Commission. Oncology, 23:1214, November, 2009

“I can’t help but think that we are moving toward a new health care rationing policy that will turn back the clock on medicine for decades and needlessly reverse advances in cancer detection that have saved countless lives”. James H. Thrall, MD Chair of the American College of Radiology Board of Chancellors. Oncology, 23:1214, November, 2009.

There is no new data to support these guidelines –they are completely insane..as a women, I find the rhetoric about anxiety and unnecessary testing offensive and patronizing.”. Dr Elsie Levin, Medical Director, The Boston Breast Diagnostic Center (General Surgery News, December, 2009)

“The net effect of the recommendations is that screening would begin too late and would be too little. We would save money but we would lose lives,” Stephen A. Feig,MD, President-elect of the American Society of Breast Disease, (Elsevier Global Medical News. 2009 Dec 3,2009)

The fastest-growing cancers, and thus the ones likely to be missed with screening every two years occur in younger women. Thus, the implied suggestion that screening mammography be delayed until the age of 50 and then undertaken every two years, makes no sense… I wonder if the recommendations would have been the same had there been greater representation on the Task Force of physicians involved in the detection and treatment of breast cancer.” Dr Carol Fabian, Director, Breast cancer Prevention Center, University of Kansas Medical Center. (General Surgery News, December, 2009)

“What does this tell women in their 40s? It tells them basically that they can go back to the 1950s, when they waited until a cancer was too large to ignore any more and then bring it to their doctor’s attention,… They’re basically saying ignore your breasts until there’s an obvious cancer.” Daniel B. Kopans,MD, Breast Imaging Division, Massachusetts General Hospital and Professor of Radiology at Harvard Medical School. (Elsevier Global Medical News. 2009 Dec 3,2009)

“Recommendations as important as these should not be decided on narrow evidence that is not widely supported by the breast cancer and provider community,” Robert Rifkin, M.D., Chair, Patient Advocacy Foundation Scientific Advisory Board. Until there is much more conclusive evidence, we continue to join our non-profit colleagues, including the American Cancer Society, Susan G. Komen Foundation, National Comprehensive Cancer Network, and the American Medical Association, in recommending that women over the age of 40 continue regular, annual mammography screening.

This is an inspiring and informative interview with Congresswoman Debbie Wasserman Schultz (D-Florida) and Robin Roberts of Good Morning America. She shares her experience and discusses how she approached her children about her disease. I would recommend this to cancer patients as one approach to talking with your children about their cancer without it being a threatening, fearful experience.

Schultz reveals that she had her first mammogram at age 40, which was normal, but then found a lump in her breast a year later that turned out to be a breast cancer. There were many considerations that she discusses about her surgical treatment options, about the impact of her genetic testing and about the timing of telling her children, 9-year-old twin girls and a 5-year-old boy. She had an early breast cancer detected, and also obtained genetic testing and discovered she was positive for the BRAC 2 gene. She was heading for a lumpectomy, but instead decided on double mastectomy after learning the results of genetic testing. The removal of the opposite breast was a strong consideration in her circumstance, even though it is an extreme form of cancer prevention, because she faced 65% odds of having a later recurrence in her normal (opposite) breast. Since she was BRAC2+, she also faced a high risk of developing ovarian cancer, so she elected to have her ovaries removed as another component of cancer prevention surgery.

This is a patient education video that explains the anatomy of the female breast and the importance of breast self-examination as a part of screening. Here’s more information from our companion website, patientresource.net:

Screening mammography and clinical breast examinations are done to check for lumps or other signs that may indicate breast cancer. Detection of a lump is just the first step in the diagnosis of breast cancer. Next steps may involve imaging studies and/or a biopsy to determine whether the lump is benign or malignant; if the lump is cancer, a range of subsequent tests are done to identify tumor markers of breast cancer, such as estrogen and progesterone receptors, human epidermal growth factor receptor-2 (HER2), and others. Advances in technology now also enable testing the tumor for its genetic profile, which provides important information about the possibility of recurrence.

One of the most important factors in planning treatment is the extent of disease. Your physician and a pathologist will work together to determine the stage and grade of the tumor. If there are signs that cancer has spread beyond the breast, other imaging studies may be done to determine the location of metastasis.

Taken together, the results of tumor marker testing, the genetic profile, and the stage and grade of disease allow oncologists to practice personalized cancer medicine; that is, to develop a treatment plan that targets the unique characteristics of an individual’s tumor. The patient’s age and general health also contribute to the selection of “best” therapy.