Health Focus: Breast Cancer
A family history of breast cancer mobilizes Nicole Pesce to be proactive about lowering her own risk

By Kelli Rosen

Nicole Pesce
Status: 33, married, 1 son
Profession: Psychotherapist, doula
Issue: Preventing breast cancer Most women begin to worry about breast cancer as they enter their 40s and 50s, but Nicole Pesce is different. Breast cancer is something she worries about now, at 33. Nearly one year ago, Pesce's mother died from breast cancer at age 60 after a two-and-a-half-year struggle. Pesce's paternal grandmother received a diagnosis of breast cancer while also in her 60s; after a single mastectomy, she's been in remission for nearly 30 years, celebrating her 90th birthday this past July.

Reaching such a milestone is a goal for Pesce, who would love to live long enough to get to know her own grandkids. Although Pesce shows no signs of breast cancer herself, the thought of it is never far from her mind. "I definitely have a heightened awareness of the disease," she says, "because I know I'm at a greater risk, but I try not to let it negatively affect how I live my life." Rather than worry about what could be, Pesce leads an active lifestyle, taking care of her 2-year-old son, Quinn, going to play groups, working part-time as a psychotherapist, and serving as a doula to local parents. Amid all these activities, she cares for herself by eating well—which means plenty of fish and fresh vegetables—and exercising and hiking in the state park adjacent to her home. Pesce is also diligent about her clinical checkups and breast self-exams. But she, like all women in her situation, wonders if there's more she could be doing. Although experts don't completely understand the causes of breast cancer, every woman can take steps to help stay healthy.

Screening And Self-Exams
Excluding skin cancers, breast cancer is the most common cancer among women and accounts for nearly one of every three cancers diagnosed in American women, according to the American Cancer Society (ACS). In 2003 alone, the ACS estimates, doctors will diagnose 211,300 new cases of breast cancer in this country, and nearly 40,000 women will die from the disease. "The research shows us that as many as one in eight women will develop breast cancer in her lifetime," says Fran Pinault, ND, LAc, faculty member at Bastyr University and naturopathic physician in the Seattle area. "That risk nearly doubles when there is a family history of the disease." In light of this, the ACS recommends women age 40 and over have annual mammography, schedule an annual clinical breast exam by a health care practitioner, and perform monthly self-exams. Women with a family history, like Pesce, should seek testing earlier. In fact, this past May the ACS released new guidelines for breast-cancer screening, which suggest proactive steps for women who are at higher risk. (For the latest advice and information, visit www.cancer.org and search for "updated breast cancer screening guidelines.")

Although mammography is helpful in finding tumors in many cases, it's not always a viable option for younger women like Pesce, explains Susan Love, MD, author of Dr. Susan Love's Breast Book (Perseus, 2000) and past director of the Revlon/UCLA Breast Center, which she helped found. "Younger women have dense breasts, and the cancer is usually the same density as the breast tissue. So it's kind of like finding a polar bear in the snow."

Because of this, younger women with dense breast tissue should talk to their doctors about ultrasound screening. In a study published last year in Radiology (2002, vol. 225, no. 1), 11,000 women who had no signs of breast cancer received mammograms and clinical breast exams. Participants with dense breast tissue received an additional ultrasound screening. In women with dense breast tissue, mammography detected 9 percent of the cancerous tumors, and physical exams detected 3 percent. The additional ultrasound screening increased the number of diagnoses by an alarming 42 percent. Moreover, mammography detected 98 percent of cancer in women with fatty breast tissue, yet detected only 48 percent of the cancers in the women with dense tissue. These findings prompted the recommendation that women with dense breast tissue, especially ones at a higher risk for the disease, consider ultrasound in addition to mammography.

Experts have also been debating the benefits of monthly self-exams, and according to Love, they may not be as valuable a tool as once touted. She points to a randomized study conducted in China, a country where regular mammography is uncommon (Journal of the National Cancer Institute, 2002, vol. 94, no. 19). Half the women in the study received instruction on how to perform breast self-exams, while the other half did not. After ten years, researchers found no significant difference in death rate or in the size of tumors detected between those who performed self-exams and those who didn't, leading experts to believe the self-exam is not an extremely useful diagnostic tool. "The only difference discovered was that the self-exams led to an increase in biopsies and benign tumors being removed," explains Love. This doesn't mean women should never examine their breasts, she says, but self-exams should not be the only tool women rely on for detecting breast cancer.

Another complement to mammography may be ductal lavage, which was invented by Love. A practitioner threads a catheter into the milk ducts—the location where all breast cancer begins—and injects a saltwater solution. After washing out the cells, a technician collects and analyzes the fluid. Already FDA-approved, this test is suitable for high-risk cases, such as Pesce's. "The hope is we can find the cells that are precancerous and do something about them before they turn into cancer," says Love. Ductal lavage is currently available at centers throughout the country, and many women say it's no more uncomfortable than a mammogram.

Genetic Testing
Genetic tests that would enable Pesce and other high-risk women to know if they carry one of the two genes for breast cancer (BRCA1 and BRCA2) do exist. According to Love, if tests show a woman is carrying a breast-cancer gene, she has a 50 percent to 80 percent chance of getting breast cancer—and at that point may want to consider more serious options, such as having her breasts removed. If, however, she does not have a breast-cancer gene, that particular woman's risk is similar to that of women without any family history. And that's valuable information to have. "I've been in too much shock since my mother died to even think about genetic testing," says Pesce, "but I think it's something I'd consider down the road."

If tests show a woman is carrying a breast-cancer gene, she has a 50 percent to 80 percent chance of getting the disease. Because estrogen levels play a role in developing the disease, it may be wise for high-risk women to have blood work done periodically to check their estrogen levels. Increased amounts of estrogen cause the breast tissue to grow rapidly, and cancer usually develops in rapidly growing tissues. Breast cancer is often associated with high levels of harmful estrogens in the body, a condition called estrogen dominance, says Pinault, which can lead to uterine fibroids, endometriosis, and breast fibroids. "Although these conditions are not necessarily a precursor to developing breast cancer, the state of imbalanced estrogen may be," says Pinault. She suggests concerned women ask their health care practitioners to run the blood tests that examine estrogen breakdown products. "By examining the ratio of harmful estrogens to protective estrogens in a woman's body," she says, "we [practitioners] can take that information and devise an individual treatment plan to increase a woman's efficiency at metabolizing the harmful estrogen."

Researchers have also turned their attention to the levels of estrogen in birth control pills. Recent studies suggest a modestly increased risk of breast cancer among women who recently used oral contraceptives containing more than 35 mcg of ethinyl estradiol per pill compared with women who used lower-dose preparations or who didn't use oral contraceptives at all (British Journal of Cancer, 2003, vol. 88, no. 1). The good news is that most pills today contain lower doses of estrogen and therefore may pose a lower risk of breast cancer. Check the small print on your packet of pills to be sure each pill's level of ethinyl estradiol is 35 mcg or less.

Lifestyle Choices
Maintaining an ideal weight and eating a balanced diet are important in the fight against breast cancer, says Ginger Muscalli, RD, a breast-cancer survivor and clinical nutrition manager at the Johns Hopkins Hospital Nutrition Department. The ACS agrees. This is good news for Pesce, who hikes, bikes, and does yoga regularly—and weighs in at a mere 117 pounds. Being overweight or obese, especially as women get older, is a risk factor for breast cancer, according to the ACS, which estimates that up to half of all breast-cancer deaths among postmenopausal women may be attributed to these additional pounds. Fat tissue can morph other hormones into estrogen, so more fat tissue equals more estrogen and a higher risk of breast cancer.

Eat foods rich in antioxidants to help break down irregular cells that can progress into cancer. Eating habits are another critical area. Women who eat meat should consume a variety of animal proteins in moderation, adds Muscalli. "It's especially important to limit meat that has a high fat-content and to read the label." Pinault agrees. "An overall approach for all women to avoid breast cancer and an estrogen-dominance state is to avoid consumption of animal products that contain hormones, and most conventionally grown animals are given estrogens to promote growth," she says.

Both Muscalli and Pinault recommend soy as a good source of protein because the isoflavones present in soy products may balance natural estrogen levels, which may lower breast-cancer risk. But according to the ACS, this theory needs additional testing; consuming large amounts of soy could be harmful to women with a family history of breast cancer. Isoflavones, in high-risk women, may act as a weak estrogen and increase the chance of cancer growth. It's important to note that this is a theoretical issue; no clinical studies show that eating soy products in their whole form—such as tofu, tempeh, and soymilk—increases the risk of breast cancer.

Women concerned about estrogen levels should also consider increasing their intake of nutritional components that help break down estrogens into less harmful forms or balance estrogen metabolism in the body, adds Pinault. In addition to soy products and flaxseeds, which help break down estrogen naturally, she suggests the following: turmeric (Curcuma domestica) extract and rosemary (Rosmarinus officinalis) leaf; certain vitamins, such as vitamin B12, folic acid, and vitamin E; coenzyme Q10; and indole-3-carbinol, a compound found in cruciferous vegetables, such as broccoli, cauliflower, and brussels sprouts.

As for other beneficial foods, look to your fruits and vegetables. "Eat foods high in antioxidants—such as carrots; broccoli; and green, red, and yellow peppers—because they help break down irregular cells that can progress into cancer," says Muscalli. Also incorporate lots of foods rich in retinoids (a form of vitamin A), such as dark green leafy vegetables and orange and yellow fruits and vegetables, suggests Pinault. "This is changed chemically in the body to retinoic acid, which helps with normal cell growth," she explains.

Seize The Day
Taking these preventive measures to ward off breast cancer has become a part of Pesce's daily lifestyle, but she's careful not to let it overwhelm her. Pesce credits her husband for allowing her the space to grieve for her mother and for offering his compassion, which has enabled her to move forward. "If there's one thing my mom's death taught me," she says, "it's to live in the moment and be good to yourself and the people around you because you never know when your time here is up." Grateful for these life lessons, Pesce intends to honor her mother by living her own life to the fullest. Yet she knows the pain of losing someone so close is unlikely to fade anytime soon. "No one loves you like your mother," says Pesce, "and there's something very sacred in that."

A natural health and fitness writer in Lafayette, Colorado, Kelli Rosen has contributed to Mother Earth News, Hooked on the Outdoors, and Natural Home.