Dr Ly­ronne Olivi­er

Con­sul­tant Breast Sur­geon

Med­ical As­so­ciates

Breast can­cer weighs heav­i­ly in the hearts of many house­holds. Fol­low­ing the dis­cus­sion last week in Health Plus on Male Breast Can­cer, I thought it nec­es­sary to re­turn to this top­ic and ex­tend aware­ness to the Risk Fac­tors.

Dai­ly in­ter­ac­tion with my pa­tients al­ways leads to some­one out­pour­ing their hearts about a rel­a­tive with breast can­cer. The preva­lence of this dis­ease has sig­nif­i­cant­ly risen and many of my pa­tients’ first con­cep­tu­al­i­sa­tion of their di­ag­no­sis ren­ders the fol­low­ing re­marks and ques­tions:

“...You know what caus­es it.......?”

“....I don’t smoke or drink….”

“.....I ex­er­cise dai­ly.....”

“......No­body in my fam­i­ly has this thing…”

The con­sul­ta­tion process

Af­ter the em­pa­thet­ic dis­clo­sure of the breast can­cer di­ag­no­sis, the oth­er chap­ter to the con­sul­ta­tion process al­ways leads to the di­vul­ga­tion of breast can­cer ori­gins and caus­es. It’s hu­man na­ture I be­lieve to for­mu­late in one’s mind the as­so­ci­a­tion of an out­come linked to one’s “fault”. In this sce­nario, the pa­tient ques­tions the ori­gins of this dis­ease, linked to her lifestyle and her fa­mil­ial back­ground.

The first state­ment to neu­tralise the “sense of in­ter­nal blame” em­a­nat­ing from my pa­tients nor­mal­ly struc­tures around the fact that 90 per­cent of breast can­cers are spo­radic and 10 per­cent gen­er­al­ly has a fa­mil­ial link. This sim­ply means that the ma­jor­i­ty of can­cer caus­es are un­known and there are risk fac­tors that may in­crease one’s risk whilst the mi­nor­i­ty may be as­so­ci­at­ed with one’s fam­i­ly his­to­ry.

The ter­mi­nol­o­gy of Spo­radic re­al­ly means the eti­ol­o­gy of breast can­cer is un­known. When the med­ical fra­ter­ni­ty dis­sect the pathol­o­gy of the process; a breast cell los­es its self-con­trol­ling mech­a­nisms and mul­ti­plies in­to growth, cre­at­ing ab­nor­mal can­cer­ous tis­sue. How­ev­er, the event and the point of this tran­si­tion of the nor­mal path­way still lingers in con­cep­tu­al­i­sa­tion.

Risk fac­tors have been iden­ti­fied for breast can­cer.

These pos­tu­la­tions are de­rived from re­search and ob­ser­va­tion of breast can­cer pa­tients. How­ev­er, the pres­ence of a risk fac­tor does not equate to get­ting the dis­ease. Fur­ther­more, some fac­tors pa­tients can con­trol and mod­i­fy whilst oth­ers are non-mod­i­fi­able. Lifestyle fac­tors such as reg­u­lar ex­er­cise, al­co­hol con­sump­tion, breast­feed­ing, nul­li­par­i­ty and di­et may in­flu­ence one’s over­all breast can­cer risk. Non-mod­i­fi­able fac­tors may be the fe­male gen­der, age, life hor­mon­al ex­po­sure and fam­i­ly his­to­ry.

“It’s not clear why some peo­ple who have no risk fac­tors de­vel­op can­cer, yet oth­er peo­ple with risk fac­tors nev­er do. It’s like­ly that breast can­cer is caused by a com­plex in­ter­ac­tion of your ge­net­ic make­up and your en­vi­ron­ment.”

–WHO Di­rec­tor, Tedros Ad­hanom Ghe­breye­sus.

Ge­net­ic in­her­i­tance

Fam­i­ly his­to­ry of breast can­cer gen­er­al­ly sig­ni­fies a ge­net­ic al­ter­ation that ren­ders an ab­nor­mal cell lin­eage and the for­ma­tion of patho­log­i­cal breast tis­sue. This ge­net­ic ab­nor­mal­i­ty is passed along var­i­ous fam­i­ly gen­er­a­tions and ren­ders an in­creased risk to its fam­i­ly mem­bers both male and fe­male to breast can­cer as well oth­er ma­lig­nan­cies. There are sev­er­al genes that have been iden­ti­fied such as BR­CA1, BR­CA2 and PALB2 that have a sig­nif­i­cant life­time risk for breast can­cer and there­fore would im­pact pa­tients’ on­co­log­i­cal man­age­ment.

The weight on women’s shoul­ders tra­di­tion­al­ly car­ries many un­told bur­dens. Breast can­cer is one such bur­den that every fe­male car­ries be­cause of her gen­der. One in every twelve women would get breast can­cer in her life­time, an eight per­cent life­time risk. There­fore, one’s gen­der is an ex­am­ple of a non-mod­i­fi­able breast can­cer risk fac­tor. How­ev­er, men can al­so get this can­cer but it is more preva­lent in fe­males.

As­cen­sion in age is an­oth­er fac­tor that in­creas­es breast can­cer risk ex­po­nen­tial­ly. To sim­pli­fy, as a fe­male gets old­er her risk for breast can­cer in­creas­es di­rect­ly.

Fam­i­ly his­to­ry of the dis­ease is al­so an im­por­tant risk but not sole­ly the cause of breast can­cer. Close rel­a­tives such as a first de­gree rel­a­tive, moth­er, sis­ter or daugh­ter, dou­bles this fac­tor. Whilst the pres­ence of two first de­gree rel­a­tives triples this risk.

Hor­mon­al ex­po­sure

Hor­mon­al ex­po­sure, par­tic­u­lar­ly es­tro­gen and prog­es­terone dur­ing a woman’s life is di­rect­ly linked to breast can­cer. Ear­ly on­set of men­stru­al pe­ri­ods (menar­che) and lat­er ces­sa­tion of pe­ri­ods (menopause) means longer hor­mon­al ex­po­sure. There­fore, the risk is ob­served be­fore the age of 12 and typ­i­cal­ly af­ter age 55 years for menar­che and menopause re­spec­tive­ly.

Nul­li­par­i­ty is the med­ical jar­gon for a woman who has not giv­en a live birth. Epi­demi­o­log­i­cal da­ta has al­so demon­strat­ed that this is an­oth­er risk fac­tor for breast can­cer. The ex­pla­na­tion for this ben­e­fit may be ev­i­dent in the es­tro­gen ex­po­sure and breast­feed­ing con­jec­tures.

Breast­feed­ing re­duces one’s risk

Breast­feed­ing may al­so slight­ly re­duce one’s risk for breast can­cer. Stud­ies have shown that this ben­e­fit is ob­served when nurs­ing has been con­tin­u­ous for greater than one year. Un­for­tu­nate­ly, west­ern­i­sa­tion and avail­abil­i­ty of an­cil­lary sub­sti­tutes im­pacts the du­ra­tion and en­su­ing ben­e­fits of breast­feed­ing. The phys­i­o­log­i­cal process­es are de­rived from nurs­ing cen­tred around the cur­tained es­tro­gen ex­po­sure and pe­ri­od of amen­or­rhea.

Lifestyles mea­sures that re­duce risk

Sev­er­al stud­ies have shown a sig­nif­i­cant re­duc­tion in breast can­cer risk with reg­u­lar ex­er­cise. Phys­i­cal ac­tiv­i­ty im­pacts one’s body weight and hor­mon­al lev­els which are di­rect­ly cor­re­lat­ed with breast can­cer risk. The Amer­i­can So­ci­ety of can­cer rec­om­mends 2 ½ hours of vig­or­ous in­ten­si­ty or 5 hours of mod­er­ate in­ten­si­ty ac­tiv­i­ty per week.

Healthy di­et has al­ways been linked to a healthy lifestyle and sub­se­quent­ly re­duced over­all can­cer risk. How­ev­er, the causative link with breast can­cer daw­dles around obe­si­ty and be­ing over­weight. Di­et and ex­er­cise may be the cor­ner­stone in most pa­tient’s over­all weight and body adi­pose tis­sue con­tent.

Fat tis­sue is the sole pro­duc­er of women’s es­tro­gen af­ter menopause. The ovaries pri­or to this life event were in­te­gral sources of this vi­tal hor­mone. Ex­cess fat tis­sue di­rect­ly cor­re­lates to in­creased es­tro­gen ex­po­sure and suc­ceed­ing in­creased breast can­cer risk as pre­vi­ous­ly dis­cussed.

Over­weight women al­so demon­strate high­er in­sulin lev­els with­in the blood. This has been amal­ga­mat­ed to an in­creased risk in breast can­cer. As such, I would rec­om­mend a healthy lifestyle, bal­anced phys­i­cal ac­tiv­i­ty and food reap­ing the ben­e­fits of re­duced ex­cess fat tis­sue and can­cer risk.

Al­co­hol Con­sump­tion in­creas­es risk

The so­cial­i­sa­tion of al­co­hol con­sump­tion in­to dai­ly lives is an in­te­gral com­po­nent of the Caribbean cul­ture and her­itage. Al­co­hol con­sump­tion has a lin­ear re­la­tion­ship with breast can­cer. Sev­er­al stud­ies have demon­strat­ed a rel­a­tive risk of 7 per­cent for every 10 grams of al­co­hol. One stan­dard drink con­tains 14 grams of pure al­co­hol; 12 ounces of 5 per­cent al­co­hol(Beer), 5 ounces of wine 12 per­cent al­co­hol and 1.5 ounces of dis­tilled spir­its (40% al­co­hol).

There­fore, one will rec­om­mend re­duc­tion in al­co­hol us­age or even con­sid­er­a­tion for ab­sti­nence in pa­tients with sig­nif­i­cant risk for this ubiq­ui­tous dis­ease.

In sum­ma­ry, the patho­log­i­cal changes that man­i­fest in­to breast can­cer are be­ing elu­ci­dat­ed but the pre­cise caus­es that trig­ger these events are still not quite un­der­stood.

How­ev­er, from the ap­praisal of many breast can­cer pa­tients, we un­der­stand the risk fac­tors that may in­crease the like­li­hood of this dis­ease. There­fore, breast can­cer aware­ness as well as re­duc­tion in these fac­tors may be im­por­tant tools in the ar­ma­men­tar­i­um against this preva­lent dis­ease.

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ABOUT THE AU­THOR

Dr LY­RONNE OLIVI­ER

Breast Sur­gi­cal On­col­o­gist

Con­sul­tant On­coplas­tic and Re­con­struc­tive Breast Sur­geon

As­so­ciate Lec­tur­er UWI

Dr Olivi­er’s ca­reer and per­son­al goals have been aligned with im­prov­ing Breast dis­ease and Breast can­cer care in Trinidad and To­ba­go. From 2007, he has been in the field of surgery; and com­plet­ed the Doc­tor of Med­i­cine in Surgery to be­come Con­sul­tant Sur­geon in 2016. Dr Olivi­er was award­ed the Prakash Schol­ar­ship by the Uni­ver­si­ty of Toron­to, Cana­da in 2020 to pur­sue his Fel­low­ship in Breast Sur­gi­cal On­col­o­gy.

He is a fel­low of the Caribbean Fel­low­ship of Sur­geons, Amer­i­can Col­lege of Sur­geons, as well as a mem­ber of the Amer­i­can So­ci­ety of Breast Sur­geons. He cur­rent­ly works as a Con­sul­tant Breast Sur­geon/Gen­er­al Sur­geon in the pub­lic and pri­vate sec­tor as well as an As­so­ciate Lec­tur­er in the De­part­ment of Clin­i­cal Sur­gi­cal Sci­ences, UWI. Train­ing of Gen­er­al Surgery res­i­dents in Breast Sur­gi­cal On­col­o­gy is an­oth­er pas­sion of Dr Olivi­er.