Breast cancer prevention should begin early in life

Breast cancer remains the second leading cause of cancer death among women. In the US it is estimated that 40,000 women will die from breast cancer in 2013. Just over 232,000 women will be diagnosed with breast cancer. Importantly, nearly a quarter of these new cases are diagnosed among women who are less than 50 years of age.

There are important successes with regard to detection and treatment of breast cancer. The rate of mortality has decreased by 30% over the last 20 years. The steady increase in incidence together with the aging population means that we have ever more total new cases of breast cancer diagnosed here and throughout the world.

Clearly, prevention is a much better choice than more diagnosis and treatment. It should be our first choice! We have the knowledge and tools to prevent more than half of breast cancer and avoid the pain and suffering that it causes. Prevention strategies will have the greatest impact when initiated early in life and sustained, but it is never too late for a woman to act.

Compelling scientific evidence shows that alcohol, obesity, and lack of exercise all cause breast cancer. Our recent posts here point to diet during adolescence and early adult years also offering important insights for prevention. Alcohol intake before first pregnancy increases risk of breast cancer throughout life. Further insights may help us understand how modifying other aspects of diet in this time frame could prevent the adverse effects of alcohol or reduce their impact on breast cancer risk.

Vegetable protein intake (including peanuts and peanut butter) show promise as does high soy intake through childhood and adolescence. We need to act on these findings now to bring prevention to women in their early adult years since much of breast cancer risk is set well before women enters menopause. We illustrate this in the figure below showing how reducing alcohol intake and sustained levels of physical activity from early life substantially reduce lifetime risk of breast cancer.

While higher levels of physical activity and weight loss after menopause can substantially reduce risk of breast cancer, we have not embarked on sustained population-wide efforts to increase physical activity and achieve sustained weight loss among middle aged women. Other strategies, such as selective estrogen receptor modulators (Tamoxifen and Raloxifene) are recommended to be considered by postmenopausal women at high risk. However, we should not wait till a quarter of breast cancers in a population of women have been diagnosed to think about starting prevention.

We have failed to harness our existing scientific knowledge to deliver effective prevention strategies. Its time to start!

See: 8IGHT WAYS to Prevent Breast Cancer

Preventing breast cancer: a diet with lots of fruits and vegetables

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Let's follow up on our recent post showing adolescent diet high in vegetable protein or nuts was associated with reduced risk of premalignant breast lesions in young adult women. (see previous post: Peanuts and lower risk of breast cancer)  This generated much interest and the potential of peanut butter to be of such major health benefit was noted by many. Of course peanuts are one of the leading sources of vegetable protein in modern US diets. We continue to explore ways to build on these findings to better inform prevention of the most common cancer diagnosed among women.

 A new report shows protection against breast cancer with diets that had higher intake of fruits and vegetables (a plant based diet) when consumed in midlife. The new report from the California Teachers Study followed 91,779 women for up to 14 years. 4140 women were diagnosed with invasive breast cancer.  A diet with higher plant based food intake gave significant reduction in risk of breast cancer. This study is consistent with the combined data from 20 prospective cohorts that included 993,466 women who were followed for 11 to 20 years and was published earlier this year (see paper). Over 24,000 cases of invasive breast cancer were diagnosed. Focusing on receptor status of the tumors, the investigators showed that higher intake of fruit and vegetables was related to lower risk of estrogen receptor negative breast cancer. Women in the top 20% of the population for intake of fruit and vegetables had a significant 18% reduction in risk of estrogen receptor negative breast cancer compared to the lowest 20% of the population.

Given we have fewer successful treatment options for estrogen receptor negative breast cancer the potential to prevent this subtype of disease becomes even more important.

Peanuts and lower risk of breast cancer

Media coverage today picked up on our paper published last week in breast cancer research and treatment (link). In that paper, we reported on the follow-up of women in the Growing Up Today's Study. Over 9000 women were recruited to the study in 1996 when they were 9 to 15 years of age. The unique contribution in this study is that the women reported their dietary intake every year from 1996 to 2001. They were followed to age 30 for the diagnosis of benign breast disease confirmed by breast biopsy. This real-time data collection on their dietary habits as they grew through adolescence overcomes potential limitations and concerns about the accuracy of diet recall. In the analysis, vegetable protein and vegetable fat were inversely related to risk of benign breast disease. The strongest protection came from peanuts or from the combination of peanut butter, nuts, beans, lentils, soybeans and corn.

Comments on other media platforms have suggested the study must have been funded by the food industry. In fact this study has never received funding from the food industry. The study was established with funding from the National Institutes of Health and has been assisted with funding from the Breast Cancer Research Foundation.

Last month we reported that alcohol consumption during the adolescent and young adult years is directly related to increased risk of both benign breast disease and invasive breast cancer (link to the full article on alcohol). The current study suggests that the adverse effects of our Western lifestyle (including higher alcohol consumption and less physical activity) may be counteracted by more intake of vegetables with an emphasis on vegetable protein including peanut consumption.

In this study, a serving of peanuts was either a peanut butter sandwich or a small bag of peanuts. For each additional two servings per week risk of benign breast disease was reduced by over half.

Replacing high fat snacks and junk food with peanuts can lower lifetime risk of breast cancer. examples of healthy menu options to include nuts include a recipe for green beans, tofu and crushed peanuts.

In the News: Office Visits Can Reduce Youth Smoking & More Benefits Found for Mediterranean Diet

Hot off the presses this morning are two important health-related releases from the US Preventive Services Task Force and the Cochrane Library.

From the USPSTF are updated recommendations that highlight effective approaches that primary care providers can use to prevent tobacco use in youth.  Because 90 percent of regular adult smokers begin smoking when they are under 18, targeting youth with effective prevention methods can have a significant impact on rates of adult smoking, and all the poor health outcomes that go with it.  The range of effective methods highlighted in the report range from minimal - a mailed packet of information or computer app, say - to much more involved face-to-face counseling.   Part of the importance of this updated reported is that it continues to keep a focus on tobacco.  While it can seem like the war on tobacco has been won - it hasn't.  Yes.  There have been great strides in lowering the rate of smoking in the US, but it's still quite prevalent and still a top contributor to death and ill health.  Stopping youth from taking it up is the best way to make sure they become and stay healthy and smoke-free adults.  

Next, from the always rigorous Cochrane Library is a new report on the health benefits of the Mediterranean Diet - the eating pattern inspired by traditional dishes in countries along the coast of the Mediterranean Sea, like Italy and Greece.  The focus is on healthy oils (like olive oil), fish, fruits, vegetables, legumes, and whole gains and lower amounts of red meat and dairy.  The report - one of Cochrane's systematic reviews - combined results from 11 different randomized controlled trials and found some modest but significant benefits to cholesterol levels (total and LDL "bad" cholesterol) and likely blood pressure.  No direct benefits were found in overall rates of heart disease.  Since the benefits of diet can be hard to assess in clinical trails - because subjects can have a hard time adhering to a regimented diet for long periods - these findings can be viewed as heartening - showing that diet alone - and one that is generally viewed as good tasting and sustainable - can have an important impact of key heart disease risk factors.  

Prevention of diseases like cancer and heart disease largely comes about by linking together small changes, which over time, can have a big impact on rates of disease and the burden they place on society.  These two releases can help us keep moving forward in that direction.

(Photo: Dimitris Papazimouris)

Annals of Short-Sightedness: Washington State Cuts Off Tobacco Quitline Access to Uninsured

Yesterday, we wrote about new lung cancer screening guidelines and the overarching health benefits of smoking cessation.  In a strange twist, there is news today out of Washington state that uninsured Washingtonians will now have their access to the state's Tobacco Quitline drastically cut.

Quitlines (1-800-QUIT-NOW) offer valuable resources to smokers who want to quit or are thinking about quitting.  Washington state legislatures cut back access to the Quitline to help balance the budget.  So beginning August 1, most uninsured smokers will get only a single call to the service.  This is short-sighted for multiple reasons.

Most smokers take multiple tries to quit for good, so a single call is unlikely to provide the support smokers need to quit.   That the highest rates of smoking are in those who are economically disadvantaged and who have lower levels of education means that groups who are most likely to benefit from Quitline services are being cut-off from them.  And, even though there is a perception that smoking is a public health issue that's already been addressed, it remains a huge issue, and success with cessation programs are likely to provide economic productivity and health spending benefits well beyond any modest savings by cutting back Quitline services.

Economic and health disparities continue to climb in the United States, taking a toll not only on the economy but most importantly on the health of its citizens.  For a largely progressive state like Washington to cut back on an important health service to its underserved is a disturbing move that will broaden disparities rather than narrow them.

Quitting smoking at age 40 can add nearly 10 years to a smoker's life.  Quitting at 60 can add three years.  These are years spent with family, friends, and rewarding work that every smoker should have the chance to experience equally.

New Lung Cancer Screening Guidelines and the Continued Benefits of Stopping Smoking

Yesterday, the US Preventive Services Task Force released a draft report recommending that older heavy smokers be screened annually for lung cancer using low-dose CT scans.  These guidelines - which closely reflect recommendations released by the American Cancer Society in January and which we wrote about here - mark a major shift in views on screening for lung cancer.

 Chest x-rays were used for many years as a screening test for lung cancer, but studies eventually found that they were ineffective.  Then, a 2006 study showed that low-dose CT screening in smokers significantly lowered the rate of death from lung cancer, but the study came under a cloud of suspicion when it was revealed that the study's primary funder and principal investigator had tobacco industry ties.  Yet, in 2008, a federally-funded randomized controlled trial largely confirmed the earlier results - showing that regular screening extended the lives of heavy smokers.

A Task Force recommendation in favor of screening typically means insurers and Medicare will begin reimbursing for the procedure.  As currently written, current and past heavy smokers age 55 - 79 are recommended for annual screening.

Being able to find lung cancer early when it is most treatable is a great advance for such a deadly cancer, which typically has a low rate of survival five years after diagnosis.  Quitting smoking, however, remains the best way to lower the risk of lung cancer and improve survival in smokers.  Compared to smokers who don't get screened, those who do have a 20 percent lower risk of dying from lung cancer over 6 years.  Compared to smokers who don't quit, those who do have a similar benefit over 5 years, and the longer someone has not smoked, the greater the benefit (see figure).  

The benefits of stopping smoking is an old story - not likely to grab many headlines any more - but it's one that should be trumpeted along with these new guidelines on lung cancer screening. 

Bloomberg Continues Fight Against Obesity One Step (or Stairway) at a Time

One thing is clear about New York City mayor Michael Bloomberg, he doesn't shy away from a good fight, especially if the health and well-being of citizens is at stake.  Whether it's getting food establishments to post calorie counts, cut back on trans fats, or limit the size of sugary sodas, he and his administration charge full steam ahead, all the while providing a great example of one of the main tenets of public health:  our surroundings  - the people, the choices, the places around us - make a real difference in our health behaviors.

In his latest push, the mayor signed an executive order focused on improving physical activity by promoting easier access to stairs in new buildings or those under significant renovation. Good evidence shows that stairways can be an effective and practical venue for increasing activity levels - improving fitness and hopefully combatting weight gain and obesity.  We've previously posted about an unscientific - but very entertaining - project showing how stairs can me made more engaging, likely increasing their use (see video).

Though building design has begun to slowly change as green design and smart design have started to take hold, most existing buildings built since the 70s seemingly hide stairways from regular use, and even when you can find them, they are often dark and uninviting and accessed by doors that may or may not let you return through. Not a recipe for daily use, to be sure.

Under Bloomberg's initiative - and in two proposed bills - stairways will be brought back into the fore - with the hope that being able to see and easily access stairs will increase their use.

There will be hiccups along the way as these initiatives are put into practice.  Change is always difficult.  This movement, though, may meet less resistance than some of the mayor's others, building as it does on the current design ethos to create healthy and energy-efficient structures.Time will tell.  One thing is sure, however, Bloomberg will keep moving ahead one step at a time.

References

Meyer P, Kayser B, Kossovsky MP, et al. Stairs instead of elevators at workplace: cardioprotective effects of a pragmatic intervention. Eur J Cardiovasc Prev Rehabil. 2010;17:569-75.

Nicoll G, Zimring C. Effect of innovative building design on physical activity. J Public Health Policy. 2009;30 Suppl 1:S111-23.

Soler RE, Leeks KD, Buchanan LR, Brownson RC, Heath GW, Hopkins DH. Point-of-decision prompts to increase stair use. A systematic review update. Am J Prev Med. 2010;38:S292-300.

Photo: PracticalHacks