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VOL. 6 • NO. 8
© April 2012
BREAST CANCER:
Early detection still key to beating the odds
Ellvera Nusum (left) was diagnosed with inflammatory breast cancer, a rare but aggressive type of cancer. Nusum is shown here with her mother, Ursula Lovell. (Photo courtesy of Ellvera Nusum)
Ellvera Nusum, 56, had her routine down pat. She religiously underwent yearly mammograms and checked her breasts monthly for any changes. She even timed her self-exams correctly — a few days after her period — when her hormone level was lower. After all, she was always taught that breast cancer begins with a lump. The fact that both her maternal grandmother and aunt were diagnosed at a young age and eventually died of breast cancer kept her vigilant.
But in July 2010 she observed changes in her breast. At first she paid little attention. She had seen this before. When she breast-fed her children years ago she sometimes noticed similar symptoms. Back then she had mastitis, an inflammation of the breast tissue, which occurs most commonly in women who are breast-feeding. The symptoms eventually subsided. But not this time. The changes escalated. When her breasts became two different sizes,
making it difficult to wear a bra, she knew something was wrong. She visited her doctor. Without even a physical examination, the doctor came right to the point. “I know exactly what this is,” he said, and referred her for a biopsy. Nusum had inflammatory breast cancer (IBC), a rare but very aggressive form of breast cancer that tends to strike women younger than the typical age of onset and is seen more frequently in black women, according to the American Cancer Society. “I had never heard of IBC,” she said. “I had no idea there was more than one type of breast cancer.” She is not alone. Contrary to common beliefs, breast cancer is not just one disease; it’s an umbrella of many different cancers, some of which may differ considerably. As in the case of Nusum, many women initially ignore the symptoms of IBC, attributing the changes to a mosquito bite, a bruise or a transient infection. Breast cancer is the most common cancer in women and the second most deadly, trailing only lung cancer. And race matters. While the median age of diagnosis is 61, incidence rates in women under the age of 45 are higher among African Americans than whites. In addition, breast cancers diagnosed in black women are more likely to be advanced or aggressive, resulting in a poor prognosis. Overall, the incidence of breast cancer is highest in white women, but black women die of it at a greater rate. According to statistics from the National Cancer Institute, between 2004 and 2008, the U.S. death rate from breast cancer in black women was 32 per 100,000 women versus 23 per 100,000 in white women,
a difference of 39 percent. Yet, many surveys indicate that black women have a high rate of breast cancer screening. For instance, the Behavioral Risk Factor Surveillance System, a survey conducted by the Centers for Disease Control and Prevention, indicates that in 2008, over 87 percent of black women in Massachusetts aged 40 and older said that they had a mammogram within the past two years as compared to 85 percent of white women. In 2008, however, the death rate from breast cancer in black women in the state exceeded that in whites by 32 percent. The type of cancer is not the only factor that may contribute to poor outcomes. Disparity can be attributed to a gap between screening and follow-up for suspicious results. Researchers from the University of Alabama cited seven major barriers to following up on abnormal mammograms by black women: emotional, financial, social, religious, lack of transportation and even the vagaries of the healthcare system. But the most cited was lack of awareness or understanding of the disease itself. Regardless of the reason, survival rates differ significantly. The five-year relative survival rate of breast cancer is 90 percent for white women and 77 percent for black women. All females are at risk for breast cancer, and with each passing year, the risk increases. That’s why early detection is key. The American Cancer Society recommends that “women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health.” Women of very high risk, for instance, those with genetic mutations, are advised to get Nusum, continued to page 4
FORMER NFL STAR RAISES AWARENESS OF BREAST CANCER IN MEN Ernie Green, 73, was a force to be reckoned with on the football field. He played seven seasons for the Cleveland Browns, and has two Pro Bowl appearances under his belt. But seven years ago he had to reckon with a force that had nothing to do with football — breast cancer. He now has a clean bill of health but that was after surgery, eight rounds of chemotherapy and several years of tamoxifen to decrease the risk of recurrence. He laughs as he describes his yearly follow-up mammograms. Most men in the waiting room are there to support their wives, while Green is there patiently waiting his turn. The technicians have to clear the way for him before he goes back to avoid exposure of women in various stages of undress. He admitted that he knew that men could get breast cancer. Richard Roundtree, the actor who played the detective Shaft in three movies, was very vocal about his experience with the disease. But Green saw breast cancer a little closer to home. Two of his sisters as well as two first cousins had breast cancer. But despite the apparent genetic link, he reasoned it could not happen to him. “I was an athlete and took care of myself,” he explained. “I was doing all the right things and I wasn’t going to worry about it.” So much for being macho. By far, breast cancer is considered a woman’s disease, but men are not exempt. Misperception is a big part of the problem. Men do not realize they have breasts.
Actually, both males and females are born with breasts, but they grow and develop differently. At puberty, while female hormones spur the growth of the mammary gland, male hormones stem its growth. Yet, the basic anatomy remains similar. All breasts have ducts — the most common site of cancer in both men and women. According to the American Cancer Society, about 2,200 new cases of breast cancer in men are expected in 2012 and an estimated 410 deaths. Experts at one time thought breast cancer in men was more deadly than the disease in women. Recently, it was discovered that survival rates are similar. The issue is that men are not looking or checking for breast cancer and once discovered, it is at an advanced stage when survival is lower. A study published in the Journal of Clinical Oncology in 2007, however, determined that, like breast cancer in women, black men die at a rate higher than white men. Certain factors increase the risk of breast cancer in men. It is most common between the ages of 60 and 70. Men who have a close family member with breast cancer have a greater chance of developing the disease. Those exposed to radiation or those born with a genetic defect that limits the production of male hormones are targets. Estrogen, the female hormone, impacts men as well. Men with liver disease may have lower male hormones and increased female hormones. As in women, obesity plays a part. Fat cells in males convert a male hormone into estrogen, thereby exposing Green, continued to page 4
Ernie Green played seven seasons with the Cleveland Browns. Green and his wife Della are known for their philanthropic work in the Dayton, Ohio area. (Photo courtesy of Ernie Green Industries, Inc.)
• changes in breast size or shape • dimpled or puckered skin • a nipple turning inward into the breast or leaking fluid other than breast milk • scaly, reddened or swollen skin on breast, nipple or areola (the darker circle of skin around the nipple) • ridges or pitting that looks much like the skin of an orange While the American Cancer Society no longer recommends doing monthly breast self-exams, it continues to emphasize breast awareness — that is, knowing how your breasts usually look and feel as you shower or dress so that you’ll notice changes like those described above. If this happens, call your doctor for advice.
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Mammograms can find every breast cancer.
❒ True ❒ False False. According to the National Cancer Institute (NCI), screen-
Myths about
MAMMOGRAMS Got a pencil? Great! Sharpen it, please, and take this quiz on mammograms. Quite likely, you’ve heard a lot about these breast X-rays, which may detect cancer long before it can be seen or felt. Just as likely, only part of what you’ve heard is true.
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If there’s no history of breast cancer in your family, you don’t need to have a mammogram. ❒ True ❒ False False. Just 5-10 percent of breast cancer cases can be traced to genetic glitches handed down through your family, says the American Cancer Society (ACS). Roughly 20-30 percent of women diagnosed with breast cancer have a family member who has had it, too. That means 70-80 percent of women who develop it have no family history of breast cancer. So mammograms are an important screening tool for all women. Talk to your doctor about when to start having mammograms and how often to have them. The answer varies depending on family history and other risk factors. BRCA1 and BRCA2 are the most well-known gene muta-
tions affecting breast cancer risk. They raise risks for cancer of the breast, ovaries, prostate and other sites. While these gene changes are most common in people of Ashkenazi Jewish descent, they occur more often than usual in Norwegian, Dutch and Icelandic people also. African Americans are not exempt, however.
ing mammograms may miss up to 20 percent of breast cancers in women who have no signs or symptoms. Called a false negative, this is more likely to occur in younger women, who generally have a higher proportion of dense breast tissue, which can hide tumors. That’s why it is important to have periodic clinical breast exams and to keep your mammogram appointments.
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Mammograms cause cancer.
❒ True ❒ False False. Radiation is one cause of cancer. Like any X-ray,
mammograms use radiation to form images of breast tissue. The radiation doses are very small and the risk of harm is considered low although it can potentially rise with repeated exposure. The National Cancer Institute (NCI) states that the benefits of mammography nearly always outweigh the risks. Some people worry that bruising or even touching the breast can cause cancer. While mammograms require compression of the breast to get the clearest images, you cannot get cancer by bumping, bruising or touching the breast, notes the NCI.
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cancer. As a tumor grows, it can change how a breast looks or feels. That’s why it’s important to have regular clinical breast exams performed by your doctor or another clinician trained to check for worrisome changes, such as : • a lump or thickened area on the breast or underarm
mograms check for breast cancer when a woman has no obvious signs or symptoms. Diagnostic mammograms take a closer look at a suspicious area in the breast. Neither test can actually diagnose cancer. Only a biopsy — a procedure to remove breast cells or tissue via a hollow needle or scalpel — can do that. The cells or tissue must then be checked under a microscope for abnormalities that indicate cancer.
Having a mammogram is the only way to find breast cancer.
❒ True ❒ False False. Certain physical signs are warning flags for breast
All mammograms diagnose breast cancer.
❒ True ❒ False False. There are two kinds of mammograms. Screening mam-
HELPFUL TIPS “It’s impossible to eliminate all risks for breast cancer,” said Dr. Jan Cook, medical director of Blue Cross Blue Shield of Massachusetts. “You can’t change family medical history, for example, or whether you had your first period at an early age. But you can lower the odds for developing breast cancer by making certain healthy choices. The first three do double duty by improving your overall well-being.” BE ACTIVE. Regularly engaging in activities deemed moderate (brisk walks, dancing) to vigorous (jogging, biking) lowers risk for breast cancer. The U.S. physical activity guidelines for adults recommend spreading throughout the week 150 minutes of moderate activity, or 75 minutes of vigorous activity or a mix. Start small (five minutes of walking every hour) and build up. ATTAIN A HEALTHY WEIGHT. Fat cells are a source of estrogen, a natural female hormone. After menopause, they become the main producer of estrogen in the body and being overweight increases breast cancer risk. So does weight gain as an adult. To prevent weight gain and work toward shedding excess pounds if necessary, eat healthy, wholesome foods, limit calories and exercise more often. Skipping a daily can of non-diet soda, for example, cuts out 150 calories on average. LIMIT OR AVOID ALCOHOL. The American Cancer Society recommends no more than one drink per day for women. That’s a 12-ounce beer, 5 ounces of wine, or 1½ ounces of hard liquor (80 proof). RETHINK HORMONE THERAPY. Hormone therapy, which is used to quell certain symptoms of menopause, raises your risk for breast cancer. If you do have bothersome menopausal symptoms, such as hot flashes or vaginal dryness, talk to your doctor about other options for handling them.
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1. Is a lump in the breast always an indicator of cancer? A breast lump in a woman is not always a sign of breast cancer. For example, benign cysts can come and go according to the menstrual cycles and these do not turn into cancer. However, any woman who has a breast lump that does not go away after a few days should contact her health care provider to evaluate it. In addition, men who notice a breast mass should contact their doctor as well.
Wendy Y. Chen, M.D., M.P.H. Medical Oncologist Dana-Farber Cancer Institute
2. Should women do regular breast self-examinations? Currently, the professional guidelines including those from the American Cancer Society do not recommend that women do routine breast selfexaminations, since two large randomized trials did not show a benefit. However, if a women notices a mass in her breast that does not go away, she should contact her health care provider for evaluation. 3. If a person has a mutation in a BRCA gene does that mean that he or she will get breast cancer? The BRCA gene is not associated with 100 percent chance of getting breast cancer. Depending upon whether the mutation is in the BRCA1 or BRCA2 gene, the lifetime risk of breast cancer for a woman ranges from 40-60 percent, according to different studies. The risk of male breast cancer is also elevated with both BRCA mutations, although the risk is higher with BRCA2 mutations. The lifetime risk of breast cancer for a male BRCA mutation carrier ranges from 1-6 percent. 4. Why is obesity correlated to the incidence of breast cancer? Although there is a clear link between obesity and increased risk of postmenopausal breast cancer, the mechanism is not definitely known. One possible cause would be due to estrogen, since estrogen is mainly produced by the fat tissue in postmenopausal woman, and heavier postmenopausal women are known to have higher estrogen levels then thinner postmenopausal women. However, other mechanisms besides estrogen are probably involved as well.
April 16-21 is National Minority Cancer Awareness Week
A CLOSER LOOK
Questions & Answers
Lymph
Source: Virtual Medical Centre
The female breast contains lobes, which are made up of smaller sacs called lobules, in which milk is produced. Thin tubes called ducts carry the milk from the lobules to the nipple when a woman is breastfeeding. The breast also contains vessels that Source: National Cancer Institute carry clear fluid, or lymph, to small, round organs called lymph nodes. Most breast cancers begin in the ducts or lobules. Inflammatory breast cancer infiltrates the lymph vessels, causing noticeable changes to the breast. When breast cancer spreads, it travels through the lymph nodes to other organs — usually the bones, liver, lungs and brain.
RISK FACTORS A risk factor is a characteristic that increases a woman’s chance of getting breast cancer. Having one or more risk factors is not a guarantee that you will get the disease. In fact, many women with multiple risk factors never get breast cancer. However, having no identifiable risk factor other than gender or age does not make a women immune to breast cancer. Some of the major risk factors are: • Older age • Certain genetic mutations • A first-degree relative with breast cancer • A personal history of breast cancer • Race and ethnicity
• Dense breast tissue • Previous chest radiation • Hormone replacement therapy • Obesity, particularly postmenopausal • Excessive alcohol consumption
5. What is the link between alcohol and breast cancer? Regular alcohol consumption has been associated with an increased risk of breast cancer. However, low levels of consumption — three or fewer servings per week — have not been shown to be strongly related to breast cancer risk. There does not appear to be a difference by alcohol type (wine, beer or liquor) when it comes to breast cancer risk. In addition, it is long-term use that is associated with greater risk rather than short-term risk. 6. Does a father’s family history of breast cancer affect a person’s risk of breast cancer? Yes, a father’s family history of breast cancer does affect a person’s risk of breast cancer since the BRCA1 and 2 genes can be passed to a woman or a man through either the mother or father. 7. Does breast size increase the likelihood of getting breast cancer? Although a few studies have suggested that increased breast size may be associated with increased breast cancer risk, it is difficult to disentangle this from the effects of obesity. Heavier weight is associated with larger breast size.
RACE MATTERS Although the incidence of breast cancer is lower in black women than in white women, between 2004 and 2008, the death rate in blacks exceeded that of all ethnicities. Mortality rates 35
32.0
Age-adjusted Death Rates
30 25
22.8 20 15
15.1
17.2
12.2
10 5 0 Asian
Hispanic American Indian
White
Black
Race and ethnicity The age-adjusted rates are per 100,000 women Source: National Cancer Institute, SEER Research Data, November, 2011 The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.
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metastasized but is responding to therapy. Overmoyer is no stranger to IBC. “It’s known by its very rapid onset,” she explained. “Usually three to six months.” Or even overnight. The breast becomes enlarged and red, and the skin of the breast thickens, she added. Usually there is no mass, which causes it to escape a mammogram’s detection. “A better imaging tool is the MRI,” she said. But she admits that a good old fashioned physical examination works well. “You can see it,” she explained. While other types of cancers can affect one section of the breast allowing the possibility of breast-conserving surgery, IBC encompasses the entire breast. It enters the lymph vessels of the breast, which empty into the lymph nodes, allowing quick and ready access to the rest of the body. That’s how cancer cells spread. That also explains why once IBC is detected, it has progressed to Stage III or Stage IV, indicating that it has moved beyond the confines of the breast. IBC constitutes no more than 5 percent of all breast cancers, but, according to Overmoyer, its numbers are increasing. The problem of detecting IBC is two-pronged. Women have been educated to look for lumps — not physical changes in the breast itself. Unfortunately, because of its rarity, many doctors often do not recognize it either. Because its symptoms mirror those of an infection, the first line of attack is typically antibiotics, but the results can be deceiving. “Sometimes redness waxes and wanes,” said Overmoyer. “Two weeks of antibiotics Dr. Beth Overmoyer (left) is the director of the Inflamis not harmful,” she said. If matory Breast Cancer Program at Dana-Farber Cancer the medicine has not done its Institute. (Photo courtesy of Dana-Farber Cancer Institute) job in two weeks, however, it’s best to see a surgeon that specializes in breast care. In addition, women should consider the There is some good news. A change increased risk of breast cancer associated with in order of treatment strategy has increased combined estrogen and progestin menopausal survival rates. When chemotherapy precedes hormone therapy use when evaluating treatment surgery, followed by radiation and hormone options for menopausal symptoms. treatment, the five-year survival increased For her part, Nusum keeps a positive attitude. Her 21-year-old daughter accompanies her from about 10-15 percent to over 50 percent, for her treatments in Boston — visits that Nusum according to Overmoyer. And that is what Nusum is counting on has called their “Boston Boob Adventure.” — good news. But she is practical as well. “I Nusum was referred to Dr. Beth Overput my will in order and divided up the house moyer, the director of the Inflammatory Breast Cancer Program at Dana-Farber Cancer Institute, and jewelry,” she said. But she is not letting her IBC to get the better of her. and has undergone a very aggressive treatment “I survived two divorces,” she said. “I regimen that consisted of chemotherapy, surgery, radiation and hormonal treatment. The cancer has will survive this.” Nusum, continued from page 1
an MRI as well as a mammogram. In addition, yearly breast examinations by a health professional are recommended for all women. Though it’s not possible to absolutely fend off the disease it is possible to reduce its risk by monitoring three factors — weight, physical activity and alcohol consumption. Fat produces estrogen and many breast cancers are estrogen-based. Keeping a healthy weight thereby reduces a woman’s exposure to the hormone. The 2008 Physical Activity Guidelines for Americans recommend 150 minutes of moderate activity, such as walking, every week. Physical activity not only improves cardiovascular health, it keeps the pounds from adding up. Too much alcohol was found to be another culprit. In a recent study published in the Journal of the American Medical Association, the researchers found an increased risk of breast cancer with consumption of just three to six drinks a week.
DANA-FARBER/HARVARD CANCER CENTER INITIATIVE TO ELIMINATE CANCER DISPARITIES Boston Public Library Cancer Awareness Display - April 1- 30 Lower Mills Branch 27 Richmond Street, Dorchester Charlestown Branch 179 Main Street, Charlestown Grove Hall Branch 41 Geneva Avenue, Dorchester West End Branch 151 Cambridge Street, Boston Alternative and Complementary Health and Wellness Fair April 11, 11 a.m. — 2 p.m. University of Massachusetts Boston Campus Center, 1st Floor Terrace All Programs are open to the public. For any additional information, please contact Athene Wilson Glover at 617-632-4860.
NUTRITION Cook Healthy with Chef JD Walker April 14, 12 — 2 p.m. Twelfth Baptist Church 150-160 Warren Street, Roxbury Ethnic Cooking with Tara Mardigan, R.D. April 25, 12 — 1 p.m. Hope Lodge 161 S Huntington Avenue, Jamaica Plain Boston Organics - Differences between organic vs conventional produce Amy Levine April 27, 12 — 1 p.m. The Historic Charles Street AME Church 551 Warren Street, Roxbury INFORMATION ON CLINICAL TRIALS Mark Kennedy May 2, 12-1 p.m. Roxbury Comprehensive Health Center 435 Warren Street, Roxbury Seniors on the Move May 21, 11 a.m. — 1 p.m. Roxbury YMCA 285 Martin Luther King Boulevard, Roxbury
April is National Minority Health Month 4 BE Healthy • http://behealthy.baystatebanner.com
T S A E R B R E C N A C G N I N E SCRE01 1
Cancer screening is recommended for women without breast symptoms. Screening can often detect tumors before they spread, which increases the probability of successful treatment. The Affordable Care Act mandates mammograms at no cost.
Have clinical breast exams — exams by a health professional — at least once every three years starting in your 20s and 30s. Become familiar with how your breasts normally feel so you can detect changes. Initiate yearly mammograms and clinical breast exams at the age of 40. Get a yearly MRI as well as mammogram if you are at very high risk for breast cancer. Establish a screening schedule with your doctor that accommodates your personal risk. Some people may start screening before the age of 40. Source: American Cancer Society
CELEBRATING 10 YEARS OF SERVING THE WOMEN OF BOSTON
The Dana-Farber Mammography Van comes to your neighborhood. April 10 Harvard Street Neighborhood Health Center
April 19 Geiger Gibson Community Health Center
632 Blue Hill Ave., Dorchester
250 Mount Vernon St., Dorchester
April 11 The Dimock Center
April 24 Bowdoin Street Health Center
55 Dimock St., Roxbury
230 Bowdoin St., Dorchester
April 12 South End Community Health Center
April 26 Mattapan Community Health Center
1601 Washington St., South End
1425 Blue Hill Ave., Mattapan
Green, continued from page 1
Green said his eight sessions of chemen to a greater risk of estrogen-fuelled motherapy were harsh and implied that breast cancer. getting beaten up on the football field Green knew something was wrong was a walk in the park in comparison. in July 2005 when he noticed a lump in He is not embarrassed to discuss his right breast. “Initially, I didn’t think his breast cancer; nor does he see it as a it was anything,” he said. “The last thing threat to his manhood. I thought about was breast cancer.” As a matter of fact, it’s the exact That’s when his wife, Della, opposite. He’s on a mission. He made stepped in. He immediately saw a doca vow that if he could get through his tor, who assumed it was a cyst. The treatment he would “come out” and let doctor explained to Green that in his men know about this problem. 37 years of practice, he had never had a Green imparts words of wisdom male patient with breast cancer. to all men. “Do breast self-examinaGreen took it tions,” he advised, one step further. It’s and “demand that a a good thing he did. doctor examine your The next doctor was breasts as well.” not so cavalier. “It He emphasizes could be a cyst,” he the importance of said, “but it should knowing your famnot be there.” He ily tree and to look recommended surat both parents for gery to take a better a history of breast look at it. cancer. The geGreen rememnetic link can come bers the day well. from one’s mother When he woke up or father. “And Edward W. Brooke, the first African from surgery, the American to be elected to the Senate don’t look at just doctor was standyour parents,” he since the Civil War, was diagnosed ing over him with a with breast cancer in 2003. Brooke advised. “Find out look on his face that served two terms as the U.S. Senator the history of aunts from Massachusetts. spelled trouble. “I and uncles and first have good news and cousins.” bad news,” his surgeon said. The good Green says he will keep on preachnews was that they got “it” all; the bad ing. He has to. An elderly woman news was that the “it” was cancer. approached him and confessed that her Green said he fell apart. “I was husband died of breast cancer because he never afraid of dying from football,” refused to seek treatment. Green said he he said. “But I knew that people died wants to make sure these scenarios are of breast cancer.” One of his sisters had not repeated. “There’s no need to get to already succumbed to the disease. stage III or IV if we are vigilant,” he said. The news wasn’t all that bad. His An unexpected result of his cancer breast cancer was stage I, which meant is increased empathy. “I’m more sensithat cancer cells had invaded surroundtive to women’s issues,” he explained. ing breast tissue but had not reached the And that must make Della very lymph nodes. happy.
Comments on Be Healthy? Contact Health Editor Karen Miller at kmiller@bannerpub.com.