Dr Lyronne Olivier
Consultant Breast Surgeon
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.
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, 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.
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.