Breast cancer is the most common cancer in women. Each year in the United States, more than 200,000 women are diagnosed and more than 41,000 women die as a result of the disease. Currently, an American woman’s lifetime risk of developing breast cancer is 12.4 percent—that’s one out of every eight women. Yet more than one out of eight women fear breast cancer and believe they are at risk for developing it. In other words, most women overestimate their likelihood of developing breast cancer. Women also overestimate their family history and genetics as risk factors. And our ability to cure breast cancer has also improved dramatically. As Avrum Bluming, M.D., and Carol Tavris, Ph.D., point out clearly in their well-researched book Estrogen Matters, “In 2016, researchers calculated that localized breast cancer, the form found in the majority of newly diagnosed cases, has a five-year survival rate of 99 percent.” And “by 2018 the cure rate for newly diagnosed breast cancer patients is 90 percent.”
The good news is this: women have a lot of power to lower their risk of getting breast cancer, and they have a lot of power to prevent breast cancer from occurring. And though women tend to underestimate this power over their risk factors, I want to reassure all of you again that you do not have to fear the use of estrogen: when used consistent with advice from your health care professionals, HRT does not cause breast cancer, HRT doesn’t increase your risk of breast cancer, and HRT doesn’t negatively interfere with breast-cancer treatments. Unfortunately, there are a lot of continued misconceptions about estrogen and its relationship to breast cancer. However, as world-renowned oncologist and professor at Hebrew University of Jerusalem Dr. Gershom Zajicek says quite clearly in his YouTube presentation, “Estrogen does not cause breast cancer.” Two other leading physicians, citing their own work and the research of other prominent doctors, support this stance. Dr. O. Ylikorkala says the “refusal” to give women with breast cancer HRT is “not … supported by the observational data available so far on this question, because HRT has not increased the risk for breast-cancer recurrence. In fact, it is well established that HRT abolishes hot flushes and improves significantly these patients’ quality of life.” In a significant 1999 study, Brewster et al. showed that the concern that HRT might activate growth in occult metastatic sites and promote a rash of recurrences in breast cancer was not confirmed. And as Michael Baum, world-renowned breast cancer expert, states (as quoted by Bluming and Tavris, 2018), “I find it intolerable and inhuman that we should have to carry on in ignorance about the benefits and risks of prescribing hormone replacement therapy to women who have had breast cancer.” Furthermore, Dr. W. T. Creasman, a prominent ob-gyn at Duke University, has said, “There seemed to be little if any risk in giving hormone replacement therapy to women who had breast cancer.”
And finally, as Bluming and Tavris also reported, Henk Verheul, a Dutch oncologist, stated in his 2000 paper, “None of the current treatments for breast cancer—surgery, radiation, chemotherapy—were negatively affected by estrogen.” He and his colleagues concluded that “the prevalent opinion that estrogens and estrogen treatment are deleterious for breast cancer needs to be revisited.” Multiple national and international studies on women with and without breast cancer confirm what I believe to be the absolute safety of HRT.
Indeed, recent studies have confirmed three significant findings:
Why do I implore you to pay attention to these studies and others (listed at the back of the book)? Because I want to underscore my understanding of the safety of bioidentical estrogen. Three important studies have affirmed this point of view:
Like most diseases, breast cancer is complicated. And estrogen’s relationship to breast cancer is also complex and, therefore, important to understand. Indeed, in this chapter I have chosen to address breast cancer not because other forms of cancer are unimportant but because breast cancer is so often misunderstood. I also want to share with you vital information not only about estrogen’s role in causing or preventing breast cancer but also about how your behaviors—how you manage stress, what you eat, how frequently you exercise, and even your choice of clothes, cosmetics, and home products—can affect your potential for either avoiding this disease or making yourself more vulnerable to it.
It is not my intention to mesmerize or confuse you with data and statistics. However, I believe it’s of the utmost importance that you have at your fingertips all the evidence of the safety of HRT. The following studies support the safety and protective benefits of HRT; please share with your physician.
Studies from basic research:
Studies that show estrogen does not aggravate breast cancer
Patricia and Isabelle: A Story of Two Sisters
When I first met Patricia and Isabelle, sisters three and a half years apart in age, they looked like twins. Their light brown hair was cut and styled the same way. Their hazel eyes were shaped very similarly. They were one inch in height and five pounds in weight apart. It was hard for me to tell which sister was fifty-two and which was fifty-five.
They came together, flying in from a city in the South, because they’d read about my bioidentical hormone treatments, which I believe are safe to use even for some women with family histories of breast cancer. Their mother had died from breast cancer the year before, and so they understandably did not want to take any chemicalized estrogen for their symptoms.
Patricia said, “I am sick and tired of feeling fuzzy-headed and not able to sleep. I’m married and want to stay that way. Can you help?”
“I certainly hope so,” I said. I then asked Isabelle, “As the older sister, are your symptoms similar to your sister’s?”
She blushed and said, “I’m the younger sister, and I think my symptoms are worse. I feel anxious and depressed.”
In the end, it was only Patricia who let me treat her with a combination of bioidentical estrogen and progesterone. Isabelle resisted, unable to get past her fear that HRT would cause breast cancer, based on the old interpretations of the Women’s Health Initiative report. I could see she was terrified, so I backed off.
I treated Patricia from afar, communicating a few times a year. After five years had passed, she came to see me in my office, accompanied by an older woman, who I thought must be an aunt or friend. But it was Isabelle, her younger sister. Isabelle’s low estrogen had declined rapidly and caused a cascade of problems, including an early stage of breast cancer. These two lovely women experienced remarkably different paths of health and disease.
I share this story as a cautionary tale. You will learn a lot more about breast cancer and your own risks later in this chapter. But for now, I simply ask you to keep an open mind.
There’s no more striking illustration of how estrogen protects breast health than pregnancy. During pregnancy, all forms of estrogen increase substantially. Both estradiol (E2) and estrone (E1) increase by a factor of ten. Estriol (E3)—recognized scientifically as a powerful protector against breast cancer—rises by a factor of one thousand. Progesterone, human growth hormone (HGH), and testosterone also increase significantly. Together, these hormonal surges offer long-term protection against breast cancer; take a look at these statistics:
I witnessed this protective effect of pregnancy firsthand when I worked as a physician in an ethnically diverse community in Israel, where women largely followed a traditional lifestyle, which involved pregnancies that occurred every eighteen months to two years. These women exhibited very few of the conditions that we encounter in the United States and other modern industrialized societies and, instead, exhibited a low incidence of heart disease, diabetes, and obesity. They also had very low rates of breast cancer and gynecological cancers. It was also uncommon for the women I treated to experience PMS, headaches, cramping, irregular periods, abnormal bleeding, fibroids, or endometriosis—gynecological problems that are widespread in our society.
Please understand: I am not advocating for women to adopt a lifestyle that is focused on pregnancy and childbearing, spending years of their lives pregnant and breast-feeding and raising ten or more children. For most women today, this is neither desirable nor feasible. I use this example solely to illustrate estrogen’s immense power as a protector of women’s health.
Unfortunately, this positive association with pregnancy implies that never having been pregnant—known in scientific terms as nulliparity—increases the risk of all forms of breast cancer. Further, longer duration of menstruation is associated with a higher risk of breast cancer, as is early puberty and menstruation. Several factors that you are already familiar with are also involved in this early spike in estrogen, including being overweight and eating a diet high in sugar and saturated fat and processed foods. Weight gain and fat accumulation are both linked to the early onset of puberty and an increased risk of developing obesity.
Further aggravating this early rise in estrogen is the consumption of estrogenic foods, including genetically modified soy or soy-based foods, refined sugar, processed foods, and nonorganic meat and dairy. All these nonorganic, genetically modified foods contain up to twenty different types of chemicals and additives, many of which mimic estrogen in the body when consumed and act like xenoestrogens. The danger for girls is early onset of puberty; the risk for young women in childbearing years is a disruption in their ability to conceive, if that is their wish. And, again, the longer a woman menstruates, the greater the risk over time of developing breast cancer.
The two genetic variants most commonly associated with breast cancer, BRCA1 and BRCA2, are well understood in the medical community and have received a great deal of public attention, resulting in a high level of awareness among women about these genetic markers’ connection to breast cancer and to ovarian and other gynecological cancers. These two genetic mutations significantly increase the likelihood for developing breast cancer. Compared with the 12.4 percent of women in the general population who will develop breast cancer, women with BRCA1 variation have a 45 percent risk of breast cancer, and women with BRCA2 have a 55–65 percent risk. However, having the BRCA1 or BRCA2 genetic variation does not mean with certainty that a woman will develop breast cancer or other gynecological cancers.
If you are not sure whether you carry the BRCA1 or BRCA2 gene, consider the following risk factors and consult your physician. I recommend seeking out genetic testing to see if you carry the BRCA 1 or BRCA 2 genes if you or a family member
If any of the above applies to you, I also suggest that you speak with a genetic counselor to help you decide what other genetic testing options may be available based on your personal and family history.
However, these gene mutations are responsible for only a fraction of all breast cancer cases, accounting for somewhere between 5–10 percent of them. That means the overwhelming majority of breast cancers—at least 90 percent or more—originate from something other than BRCA1 or BRCA2 genetic factors.
Other genetic mutations that are less well known than the BRCA1 and BRCA2 gene variants but that affect a great many more women and increase their risk for breast cancer are single nucleotide polymorphisms, or SNPs, often referred to as “snips.” Several different SNPs affect breast health and the likelihood of developing breast cancer, in some cases raising risks significantly. These genetic mutations influence the way women metabolize estrogen and also affect how vulnerable a woman is to other risk factors—particularly to environmental pollutants. Certain gene mutations affect genes that control how robustly and effectively a woman’s body fends off the potential damage that chemical toxins can do to genes and cells that can lead to the development of breast cancer. Often, women with these SNPs have noticeable sensitivities to pollutants in the air, particularly those that arise from the burning of substances—exhaust from cars, tobacco smoke, smoke from a fire or a barbecue. Pay attention to these sensitivities if you have them and take steps to avoid exposure to these pollutants. A number of genetic tests can tell you if you have SNPs and also alert you to the presence of potentially harmful estrogen metabolites. Again, if you are at all concerned that you may have a genetic vulnerability, speak to your physician about genetic testing.
Depression and Breast Cancer
Depression increases the risk of developing a broad array of diseases, including breast cancer. Depression dampens immune function, slows treatment recovery time, and impedes healing. Major depression is associated with a 380 percent increase in the risk of breast cancer. To complicate matters further, many women with breast cancer feel depressed and are then put on antidepression medications such as an SSRI, which has been shown to increase the formations of both estrogen receptor and progesterone receptor tumors. In at least one study, the SSRI paroxetine was associated with a 720 percent increase in breast cancer. However, women are often given SSRIs during standard breast cancer treatment, which has been shown to increase deaths from breast cancer by 75 percent.
Some of the most underappreciated factors that contribute to breast cancer risk are related to your lifestyle—what you eat, how regularly you exercise, and how you manage stress. By eating well, exercising sufficiently, and making sure that your stress-busting techniques are working for you, you can not only sustain your hormonal balance but also protect yourself from developing breast cancer. In upcoming chapters, I will explain the many choices available to you—diet and supplements, exercise, stress management, and other daily actions—that can help you lower your risk for breast cancer and become healthier overall. Here, we will look at several lifestyle choices that are associated with an elevated breast cancer risk.
Being overweight or obese and gaining significant weight during adulthood can substantially raise your risk for breast cancer. Many studies have demonstrated this effect. A woman is at greater risk for breast cancer if she gains
Beyond its effects on weight gain, diet is also an important risk factor for breast cancer. A diet heavy in processed foods—that is, foods high in sugar and “bad” fats—puts women at higher risk for the disease. So does a diet that routinely includes red meat.
As you consider these statistics, keep in mind these are not meant to scare you but to help motivate you to reconsider how you eat.
In short, a high-calorie, low-nutrient diet and a sedentary lifestyle will put you on a road to problems with your metabolism, which in turn contribute to increased risk for breast cancer. High glucose (blood sugar) levels (from a diet heavy in sugar and starchy foods) have a strong association with breast cancer and also have been scientifically shown to interfere with the effectiveness of chemotherapy in eradicating breast cancer cells. Insulin resistance, the metabolic disorder that stems from chronically high blood sugar, is linked to a 210 percent increase in certain breast cancer tumors. Women who develop metabolic syndrome—a condition that includes a cluster of symptoms involving weight, poor cardiovascular health, and unhealthful blood glucose levels—have a greater chance both of developing breast cancer and of dying from the disease. The presence of metabolic syndrome in women over sixty increases their risk of dying from breast cancer by 23 percent. For women of all ages, metabolic syndrome increases the risk of developing breast cancer by 52 percent, and research has found that women with breast cancer are more likely to have metabolic syndrome. Elevated cholesterol also raises the risk of breast cancer. A metabolite (by-product) of cholesterol acts like estrogen in a woman’s body and can encourage growth of breast cancer cells, causing breast cancer to be more aggressive.
Insufficient sleep has been shown to contribute to the development of more aggressive breast cancers. Sleep apnea—a form of sleep-disordered breathing that causes interruptions to normal breath flow during sleep—increases a woman’s risk of breast cancer by more than 100 percent. Sleep apnea is often regarded as a male sleep disorder, but it affects women as well, and women are at particular risk for going undiagnosed. Disruptions to normal circadian function—the body’s twenty-four-hour sleep-wake cycle—have been linked to increased risk for breast cancer. Women who have frequent night shifts at work, where the risks for circadian disruption are high, have a high risk for breast cancer. Research shows that female nurses who worked more than five years of six consecutive night shifts saw an 80 percent increase in their breast cancer risk. Recently sleep apnea has been found to increase the risk of breast cancer in women, in part due to the weight gain some women experience in menopause.
Stress compromises the immune system, triggers inflammation, and exposes women to greater risk for breast cancer. Stress increases the circulating tumor cell marker AGR2 and contributes to increased risk of metastasis.
Millions of women regularly use medications for health conditions that, unbeknownst to them, raise their risks for breast cancer. It’s important to be fully informed about the risks associated with the medications you take. An integrative medical doctor will be more informed than a physician who practices strictly Western medicine about the negative side effects of certain medicines and their interactions with cancer-causing triggers.
The use of antibiotics over a woman’s lifetime is a factor in her breast cancer risk. Indeed, the use of antibiotics for 51–100 days over a lifetime is associated with a 53 percent increase in the risk of breast cancer. Lifetime antibiotic use between 501 and 1,000 days results in a 114 percent increase in breast cancer risk.
In addition, women who use sedative medicines, such as Ambien for sleep and Valium or Xanax for anxiety, can elevate their risk for breast cancer. In one study, taking eighteen pills or more per year was associated with an increased risk for breast cancer and a higher overall mortality rate.
And, as mentioned above, SSRIs, a group of medications commonly used to treat depression and anxiety, have also been shown to raise the risk for breast cancer, especially for women already in menopause.
Statin drugs, which are used to lower cholesterol, can also significantly increase the risk of developing an aggressive form of breast cancer, as well as diabetes. Other medications that are widely used in the treatment of cardiovascular disease also lead to higher risks for breast cancer, including ACE inhibitors, which treat blood pressure, and calcium channel blockers, also used for high blood pressure. Women who spend more than five years taking high blood pressure medication face greater risks for an estrogen-positive form of invasive breast cancer. Digoxin, a medication that treats irregular heart rhythms, including atrial fibrillation, has also been shown in at least one study to increase breast cancer risk among current users. (This elevated risk does not appear to extend to former users.)
Breast cancer does not develop overnight. I sometimes ask my patients how long they think cancer cells must grow within a breast before the growth reaches a point where it can be picked up during a breast exam. Most women estimate somewhere between a few months to a few years. My patients are surprised to learn—as you also may be—that cancer takes much, much longer than that to grow. From the time of a first cell mutation to when a growth can be felt takes an average of fifteen years. This means, among other things, that you have time to influence your risk for breast cancer and how that cancer does—or does not—develop.
How You Can Help to Avoid Breast Cancer
We know a lot about cancer. We know that the body’s immune system fights off most cancers before they have a chance to develop. We know that certain lifestyle choices increase or decrease one’s chances for developing cancer. We know that certain genes increase one’s vulnerability to cancer. We know that it takes at least five to six mutations (even in the presence of carcinogens) for any cell to become cancerous. So though there is no guarantee that you won’t develop cancer—in particular, breast cancer—understanding how cancer is triggered is a very good first step to reducing your risk and possibly preventing cancer from ever taking root.
Keeping in mind that it takes, on average, fifteen years for cancer to develop, we should want to take any precaution necessary to avoid triggering mutation. What does this mean in terms of breast cancer in particular?
You will read more about these steps in the diet and exercise chapters later in the book.
This year many women will receive a diagnosis of breast cancer and begin the arduous, frightening, often confusing pursuit of treatment. Today, medical doctors, researchers, and others have made a lot of progress when it comes to the treatment of this once fatal disease. I want you to understand the landscape of prevention and treatment options, some of which will help you recover faster and better, so that you can get the support you need during any stage of this process.
The current conventional approach to breast cancer treatment is often anti-estrogen. Estrogen—the single most important hormone to women’s health, the original breast cancer fighter—has become enemy number one in the current climate of breast cancer therapy. I’m hoping that a more complete and accurate understanding of estrogen’s health-enhancing role in both preventing and treating breast cancer will soon become more widely known and acknowledged, so that you can feel more hopeful and empowered if you ever do receive a diagnosis of breast cancer.
In 2009, the United States Preventive Services Task Force, or USPSTF, made significant changes to its mammography screening recommendations, recommending against it for women ages 40–49. The task force recommended biannual—not yearly—screening mammograms for women ages 50–74. These new recommendations caused an uproar. Media coverage was skeptical and fearful, demonstrating significant bias against these changed recommendations without, for the most part, delving into the scientific evidence that led to the changes. The USPSTF itself also was at fault, failing to do enough to make the recommendations and their scientific context clear—to women directly or to the media. It was a wasted opportunity to educate the public about the limited usefulness and serious risks associated with mammography.
The revised recommendations put the task force at odds with some (but not all) breast cancer and women’s health advocacy groups. Several were vehemently against the changes and remain so. Others—including the National Breast Cancer Coalition, Breast Cancer Action, and the National Women’s Health Network—supported and welcomed the new guidelines, which, if followed, would result in fewer mammograms for most women over the course of their lifetime. They were right to do so.
The steps taken by the USPSTF are an instance of policy coming closer into alignment with scientific evidence. For instance, consider these study results:
Breast density is its own risk factor for breast cancer, and for contralateral breast cancer—a relatively rare metastasis of cancer in the second breast. Women in the top 25 percent of mammographic density are five times more likely to develop breast cancer. However, breast density does not affect women’s mortality risks from breast cancer. The chemicalized hormones estrogen and progesterone together promote breast density, as does chemicalized progesterone by itself. (On its own, chemicalized estrogen does not increase breast density.)
Maternal characteristics appear to play a role in the development of dense breast tissue: women born to older mothers, age thirty-nine and over, are more likely to have dense breasts. So too are women who were relatively tall and thin before they underwent puberty. Dietary habits can also increase the likelihood of developing dense breasts: a high-fat diet, a diet high in red meat consumption, and alcohol consumption are all associated with the development of dense breast tissue. Dense breast tissue also makes it difficult to detect breast cancer, making mammograms less effective for screening and picking up early signs of breast cancer.
The earlier that mammography screening begins, the more likely women are to experience false-positive results. False-positive results are 60 percent more common in women who begin mammography screening at age forty. Research indicates that a third or more of mammography screenings will return abnormal results that ultimately do not correspond to actual cancer.
Estimates indicate that over the past thirty years more than one million women in the United States have been diagnosed with breast cancer that would have proved nonfatal if left undetected and untreated. What other health problems have those women suffered as a result of the invasive and toxic procedures used to diagnose and/or treat cancers that would have been okay to be left alone? Figures vary, but the estimates of overdiagnosis of breast cancer hover in the range of 20 to 30 percent of all breast cancers diagnosed. This is no small or isolated problem. Overdiagnosis of breast cancer is estimated to cost about a billion dollars annually.
BRCA1 and BRCA2 Are Special Cases
If you have BRCA1 or BRCA2, you are in a different treatment category than are women without these genetic markers. If you have inherited either of these gene mutations, you need to take special care and act as quickly as possible after a diagnosis, which often means surgery, a single mastectomy, or double mastectomies. These women are heroic in their courage to take the step of surgery. And with the sophistication of modern reconstructive surgery, many women, including some of my own patients, are very happy with their new breasts.
Another concerning genetic marker for cancer is the KRAS-variant, a biologically functional, microRNA-binding site variant that is associated with recurrent breast and ovarian cancer, lung and pancreatic cancer, and head and neck cancer. The KRAS-variant is often overlooked, despite its being very common—on average, one in twenty people carry this biomarker and one in four people with cancer show this genetic variation. Researchers have found that when patients with KRAS-variant discontinue hormone replacement therapy, there is an increased risk of triple negative breast cancer. In addition, KRAS-variant breast cancer patients had greater than an eleven-fold increased risk of presenting with MPBC (multiple primary breast cancer) compared to nonvariant patients (45.39 percent versus 6.78 percent). Thus, estrogen withdrawal and a low estrogen state appear to increase breast cancer risk and predict aggressive tumor biology in women with the KRAS-variant.
Before tamoxifen was discovered in 1966, most women with breast cancer were treated with estrogen, a synthetic version of estradiol (E2). And today, when anti-estrogen medications stop working, physicians often return to very high doses of estrogen to jump-start treatment—again, this points to the ultimate safety and benefit of treating breast cancer with estrogen. Recent studies have shown both the safety and effectiveness of estrogen for preventing and healing breast cancer. Specifically, estradiol has been used to bind with estrogen receptor cells and thereby decrease breast cancer growth, and estriol is used to target estrogen beta-receptors, which also decrease breast tissue proliferation.
Tamoxifen is probably the most well-known breast cancer medication. It functions by binding with estrogen receptors, thereby short-circuiting the cancer from developing or spreading. However, though tamoxifen can cut off cancer’s ability to grow, the medicine does pose some serious side effects. If your oncologist recommends tamoxifen, discuss the possible side effects that include the following:
Aromatase inhibitors (AIs) are a class of drugs used to treat breast cancer and ovarian cancer in postmenopausal women. They disable the conversion of androgens to estrogen. Like tamoxifen, these drugs can cause problems with cognition and memory, as well as cardiovascular problems and deterioration of bone health. In addition, aromatase inhibitors increase expression of a protein (HER2/neu) that is an important biomarker for breast cancer, which can contribute to the growth and aggressiveness of breast cancer, ovarian cancer, and endometrial cancer. The presence of this protein is linked to higher rates of recurrence.
Again, if your oncologist recommends AIs, I encourage you to ask about the possible side effects, which include
One particular side effect of AIs is aromatase inhibitor musculoskeletal syndrome, or AIMSS, which is often a disabling condition that has been found to occur in approximately half of women who take aromatase inhibitors. Caused by the estrogen deficiency these drugs induce, AIMSS causes widespread pain, stiffness, and swelling at joints throughout the body, often in the hands, wrists, ankles, and feet. AIMSS causes pain and restriction to movement and flexibility and is frequently treated with opioids, drugs that themselves can promote tumor growth and the spread of cancer.
But I do urge caution here. You should always get a second and even a third opinion to gain a complete understanding of your own individual situation and the risks involved. Breast cancer, thankfully, is becoming more of a chronic disease requiring long-term management instead of one that is always life-threatening. As you consider your own genetic, lifestyle, and other risks, I hope that you can keep in mind the limitations and dangers that arise from some of the established treatments described here. Even scientists who study the efficacy of cancer treatment reveal their own bias in reporting accurately on the limitations and dangers associated with chemotherapy and radiation. For instance, scientists tend to underreport the limits of usefulness and the toxicity of treatments for breast cancer by putting the information in less visible places in their reports. As a result, physicians and their patients don’t get a complete picture.
YOUR HEALTH JOURNAL: WHAT ARE YOUR RISKS?
Although I do not want you to fall into a well of fear about developing breast cancer, it is important that you consider any of the risk factors related to your genetic heritability (especially for BRCA1 and BRCA2, as well as KRAS-variant), your lifestyle (including your diet), and other health issues that may increase your vulnerability. Remember, cancer takes a long time to develop; your body comes with its own layers of protection—you have the power to strengthen these protections and lessen your overall risk of disease.