Endofound Medical Conference 2017
"Breast, Ovary and Endometriosis"
October 28, 2017 - Lotte New York Palace Hotel
The Environmental Risks of Breast Cancer: Common Ground with Endometriosis
Marisa Weiss, MD
Well, it's great to be here today with my new friends and I also see Dr. Mark Laufer, childhood friend, colleague and actually advisor to this presentation that worked along with his father who's an environmental scientist, so very proud of that connection. It's a small world. The longer you're in the field of medicine, there's so many great connections.
I'm here to speak to you today about breast cancer and it's causes and maybe start really thinking more rigorously about the overlap between breast cancer risks and the risk of endometriosis, and always look for shared insights to improve both areas.
When people look at this pink ribbon you think, "Oh my goodness, breast cancer. Pink ribbon, breast cancer. I got this." In fact, awareness is so high but knowledge is still very dangerously low. I actually think that awareness interferes with knowledge because you so quickly think, "I got it," when you see the pink ribbon, but in fact, what you really need to know is largely missed. You might not know that breast cancer was relatively rare 100 years ago. Even a half century ago it was much less common than it is today. It has since become the most common cancer to affect women. Truly, the breast is the favorite place for cancer to occur in a woman's body. What you see is 30% of all cancers in women start in the breast, contrast that to the next most common lung, then uterine cancer 7%, ovarian is about 3%, but there's something very unusual going on in the breast to make it so disproportionally affected by cancer.
The reality also is, is that the incidence of breast cancer continues to rise in large developing nations and including developing populations within our own country. It's not because of inherited genes. You probably know that only about 10% of breast cancers are due to one of those single rare genes like BRCA1 or 2, that increases your risk by up to about 85%, like what Angelina Jolie had. Yes, that there are some small to medium sized genes that may be inherited, but their risk level is more like 30 to 40%, so it's not the dominant reason why breast cancer occurs and breast cancer genes are not the reason why breast cancer has become so common. These are inherited ancient abnormalities, which are really unchanged over centuries, which means about 90% of breast cancers are largely due to other factors, epigenetic, environmental, lifestyle, factors like that. We'll explore that today.
Whenever you're looking at the most common cancer to affect women, you need to minimize this maximum risk. We call it mini max and medicine. We can't do everything, but at the very least, for each patient and at a public health level, we need to minimize the maximum risk, which is the mini max principle. We believe that prevention is the best form of cure. Prevention has such an impact so it's preventing, trying to risk reduce the chance of, the risk of getting breast cancer to begin with. If you've had breast cancer once, you're at a higher risk for not just having recurrence, but having another secondary cancer unrelated independent event. If you have metastatic breast cancer, you'd love to put the cancer in remission. That's form of prevention.
Then, of course, prevention has an impact on the next generation. Many people in the room remember the DES story, giving DES to women to lower the risk of miscarriage led to a higher risk of breast cancer later in their unborn daughters when they hit their 40s. We already know that what you do as a parent, as a mother during pregnancy can influence breast cancer risk. Untreated diabetes during pregnancy is associated with a high risk of breast cancer in your unborn daughter later on.
And also of course prevention affects our loved ones. If you can prevent a case of breast cancer, you spare your loved ones from going through the devastation of breast cancer. Now, finally, we have scientific evidence that prevention works. There's the Harvard data, the nursing data, that shows that if you were to intervene with a healthy lifestyle as a girl, you could lower the lifetime risk of breast cancer by 70% and the Colditz data, which I know went out to all OBGYNs, showed that even if you started age 50 and took five steps like getting to a healthy weight, exercising regularly, limiting alcohol, avoiding pharmaceutical hormones and eating well, you could lower the remaining lifetime risk by 50%.
Let's talk about why. Why is the breast the favorite place for cancer to occur in a woman's body and how we can use those insights for prevention? What you gotta know is that the breast gland itself is very unique from a biological point of view, different from every other organ including the endometrium, which is unique in its own way. So just think about the breast, its organogenesis. Yes, it's the nipple and the breast bud is sort of made during the first trimester of pregnancy, but then the project is sort of over for a while. Meanwhile, all of your other organs are fully made and get to work the baby's second trimester. The heart's beating. You can track it. Baby's drinking and peeing. You can see the kidneys doing their job. The baby starts kicking, bones, nerves and muscles are working. Baby is born. The lungs now work. But the breasts are not working.
One reason all those other organs are more resistant to cancer is because they are developed fully over a short period of time. They are matured enough to do their job within a relatively short period of time. They are working 24/7 staying out of trouble for most the time, whereas the breast gland development stays on hold for a chunk of time until puberty. We're going through puberty earlier and then between 8 to 18, the breast gland is largely made. That's a long period of organogenesis.
And even between 18 and 25, the breast gland is still growing, the mound is maturing, getting wider and the fact is, is that when you're making a breast gland, it's like copying a key. You've got a set of DNA. You're copying that. You're copying a set of key, to copy the copy, copy the copy, etc. You know that the copy that you finally make may not open the front door. It may not function well. Every time you are in the middle of organogenesis the DNA is very sensitive to any disturbance or any insult that may persist, is not repaired and may lead to a higher risk of problems down the road.
It's also true that what our girls eat, drink, breath, and medicines they take, personal products they use are actually the ingredients that the breast tissue is made of. The fact is, is that you lay down the foundation of your future breast health during organogenesis, during adolescence. But what's also really unique about the breast is that even when the breast gland is fully made, it is an immature organ at the cellular level from a molecular point of view. It is incapable of doing its job of making milk until it goes through that first full term pregnancy. That is the first time at the molecular level that these cells are matured, they've grown up.
It's not until breastfeeding itself that the final maturation occurs. So when you think about the uniqueness of the breast gland, such a long period of organogenesis and even when the breast gland is made, you've got this immature organ that is highly sensitive to anything that looks like, smells like, tastes like a hormone and it's not until, as I said first full term pregnancy, breastfeeding, when that gland finally grows up, gets a job, gets to work, day and night, stays out of trouble and it becomes much more resistant to cancer genesis.
Look at the trends that you're seeing in your clinic. Today, the average age of puberty is nine or ten compared to 100 years ago, more like 16. Early puberty is a risk factor for breast cancer as it is for endometriosis and the earlier you have the breast, the sooner they're available to interact with the environment. Then, today, instead of having your first full term pregnancy around 19 or 20, like my mother, we're getting educated, we're getting jobs, we're developing ourselves, we're making our careers and we might not take our first crack at it until we're in our 30s. So now we've got organogenesis starting at eight or nine, fully grown maybe 25, then you've got another maybe five, ten years, maybe longer for these breast tissue to be hanging out.
If you talk to the environmental medicine people, they will tell you that the breast is a sponge for what is out in the environment and the breast gland is very promiscuous. It will fool around with really anything that looks like, smells like, tastes like a hormone. That's the breast gland, how unique it is and why it's biologically so much more vulnerable than any other organ that's made much faster, gets to work much faster.
So now, let's look on the other side. Given the vulnerability of the breast, why is modern life so dangerous? This idea of think pink live green, which is that we've got the inside environment of the breast, this pink tear drop, with a yin yang relationship with the outside environment. Inside of your body is an environment as is the outside environment. They're constantly, there's a flow back and forth. Everything you eat, drink, breath in, whatever you put on your skin. We deliver medicine to the skin, those things can alter the marinade in which your breast cells live.
So what's going on out there? This shows the dramatic increase in chemicals in the environment that are hormonally active, that never used to be there 100 years ago. It used to be chemicals were made, before World War II, mostly in laboratories, in manufacturing stayed there, but now all of a sudden, we've got rubber manufacturing, you've got nylons, repurposing of petroleum products, plastics, pesticides. All of these chemicals have been exponentially produced and they're ubiquitous. They're way outside the manufacturing in plants and farms and places like that. They're being used everywhere.
Just as a few examples that are relevant. Atrazine actually has aroma taste properties and it's thought to be hormonally active in that way and atrazine is the most commonly used pesticide to grow corn and soy. We also have plastics in our every day. You all know about BPA, Bisphenol A, which is a weak estrogen. It is present in the heavy plastic water bottles, number seven, that go upside down on a water cooler. They are also the plastic that's used to seal ink onto cashier receipts. They're also used in the lining of food cans to keep the metal taste of the can away from the food and the resin that they use to line the food cans.
In fact, when consumer's union did an analysis of food coming out of cans, it was Progressive turkey soup or vegetable soup that had the highest BPA level. While we've taken BPA, Bisphenol A out of baby bottles, we still have it in many other products in the environment and it's hormonally active. Not only that, but it's thought to be an obesogen. So it's one of those things. The scientists in the pediatric division are looking at BPA as a hormonally active substance that can help trigger the early onset of puberty and bypass the whole normal axis that we believe is what affects, what stimulates the start.
Hormones given to people. You know that 100 years ago, we weren't doing that. The story of the use of hormone replacement therapy, progestin with an estrogen after menopause is associated with an elevated risk of breast cancer, about 20, 25% increased risk over time, with extended use that goes away, pretty much can go away when you stop it. But it's also true that birth control pills are used ubiquitously for so many reasons other than just contraception. The risk of breast cancer it introduces is very low, a very small increased risk, but because breast cancer increases with age, if as young women, when we look at all the young women taking birth control pills, their breast cancer risk goes up with age.
So, if you're young, your risk is really low and you expose a large population to something that increases it just a little bit, you're not gonna really measure that big of bump, but when people continue to take birth control pills extended time and into their 30s, 40s when now the risk of breast cancer starts to increase substantially, then you're taking a population with a more measurable risk, increasing that a little bit. Now we're beginning to measure it.
We are seeing on the list of breast cancer risk factors, extended use of birth control pills contributing to that. We know for the younger women, of course, their risk again is low. The risk of birth control pills on breast cancer risk is small. They do get a benefit of reducing ovarian cancer risk when they're taking birth control pills for five years. As young women, that benefit, that protection isn't really increased substantially after five years. We'll look at that in a minute in terms of steps people can take.
It's also true that hormones are given to beef and dairy cattle in order to increase milk, not in all states. California has a rule against it, but this hormone does get into the milk. It is hormonally active, but there's another dairy practice, which we don't talk about as much which is that in order to keep the cows making as much milk as possible, they keep the cows pregnant, repeatedly impregnate, keep them pregnant because that's when a cow makes the most milk is right after she's had a colt.
The issue there is, that the dairy industry, the conventional dairy industry will collect milk from a cow during her pregnancy when endogenous hormonal levels are high. What's in a cow comes out of the cow and it comes out in the cow's milk, whereas, in the organic dairy industry, just so you know, a pregnant cow is penned after the second half of her pregnancy, when her hormone levels are the highest, so you're not gonna get as much endogenous estrogen in the milk that comes out of those organic dairy farms.
It's also good to know that estrogen is lipophilic, so the estrogen that's in dairy products does tend to be in the fat of the dairy product or the fat of the beef cattle, so that just gives you an insight into things you can do. We'll go in a minute what you can do to lower your risk.
It's also true that what comes around goes around. I don't know if you remember the concept of bio accumulation, which is that as you go up the food chain, these substances concentrate, so when the tiny plankton is eaten by the tiny fish, by then the small fish, then the medium fish and the big fish. As you go up the food chain, chemicals that we're concerned about concentrate. So, who's at the top of the food chain? We are, right? But who's in fact at the very, very, very top of the food chain? It's the baby in utero and the breast feeding baby that's feeding off of us. It's good to be mindful of the food chain when you're selecting your foods to select the healthiest foods with avoiding that bio accumulation phenomenon.
So given all these dangers of modern life and the vulnerability of the breast, we really do need to think pink live green. What's good news is, that our bodies do have amazing capacity to forgive and repair and for some of these risks to actually dissipate. Some of them though were introduced at a indelible time, like in utero or during puberty that we can't erase, but there's some risks that actually go away.
Here are 16 steps that have the greatest impact at lowering your risk of breast cancer through taking steps in the idea of think pink live green. Just so you know, at Breastcancer.org, my organization, we also have Breasthealth.org, which is about prevention. There's a huge section on think pink live green. We have a booklet that you can download on this and there's a lot of rich content written for consumers, but a lot of our HCPs consume it as well.
Let's look at the 16 steps. It's all guided, of course, by the precautionary principle, which means, better be safe than sorry. We know a lot, so we're making these recommendations on what we responsibly understand, but we're not gonna promise that you do this it's absolutely gonna have a benefit. But these are steps that we can do. In medicine, we're always advising our patients about what can you do that makes sense even if the data are not fully present?
Just so you know, weight. Weight is a huge risk factor for breast cancer, so about 30% of breast cancer is thought to be due to increased weight. Right now you know that three quarters of the American women population are size 14 or greater, which is almost the same as saying two thirds of women are over weight or obese. That extra weight produces a whole mix of potent extra hormones, estrogen, insulin growth factors, as well as these cascade of inflammation, which is implicated in every illness as well as condition. Endometriosis, there are probably inflammatory factors that we share between both. So getting to and sticking to a healthy weight is really important.
Extra weight also is correlated with recurrence of breast cancer. So this is pretty much, if you were to say to a patient, what is the one thing that you can do to most effectively lower your risk of breast cancer, it is going to be to get to and stick to a healthy weight.
Exercise three to four hours a week, five to seven is better. The reality is, when it comes to weight management, 80% is what you eat. 20% is exercise. That's true, because it would take four hours to burn off a cheesecake that you eat. So 80% of weight management is what you eat. 20% is exercise, but when you actually evaluate what helps people be most effective at managing their weight, it's exercise. Of course, these two go together, mixing it up, making it social, no excuses.
It is true that after a diagnosis of breast cancer or after a life altering condition, we as doctors have to give our patients a reality check, no judgment, no waiving the finger, but we do have to say, that because of this situation, we have to make some choices and there's certain things that are no longer optional. They actually become mandatory. I'm in a very active practice taking care of women with breast cancer. I say, "Weight management is no longer optional. It's mandatory and we will work together to get you there. It's one step at a time but we need to move in that right direction."
Alcohol consumption. The more you drink the higher the risk. This is a proven risk factor. My understanding is it's also associated with an elevated risk of endometriosis. What we tell patients is stick to three or fewer drinks per week. At the bottom, it actually explains what the alcohol equivalence between various drinks. This is an extremely unpopular message. Usually the shoes start flying. We actually did a survey online of all the women ... Breastcancer.org, by the way, has 20 million unique users. We're not just number one in the world, we're the number one trusted place where doctors send their patients. We're medical experts providing medical expertise 24/7. I started the organization 19 years ago, and we have 200,000 conversations going on in our community where people connect with each other. We need to moderate those so that they stay therapeutic.
But when we asked our people what would you be willing to do to lower your risk, of everyone who said I'm gonna do something, only 14% said they were even interested in hearing about alcohol reduction because it's self medication. It's the reward you get. It's any fun social party there's alcohol. It tastes really good. It's great with food. I'm sure we're gonna have it tonight, the speakers, whatever. But I'm just saying, it's good stuff, right? I have three kids in the 20s. There's no way I could take them out and not go to a good drinking hall. It just doesn't happen.
And also, as soon as you start drinking, not only the calories or the alcohol, but then you're de-inhibiting and you start eating a lot more food. Alcohol is not a great thing for a lot of reasons. But in any case, alcohol reduction is important. There's way to do it practically without being punished.
Smoking is a risk factor for breast cancer. It's not a major one. It's not like it's the same as for lung cancer, other diseases, even colon cancer, but stopping smoking. There's every reason to do that obviously.
Avoiding or taking breaks from prescription hormones. I know that the absence of estrogen after menopause causes a ton of symptoms, but we can sometimes piece together effective ways to manage the biggest issues that women are facing. If it's vaginal dryness for example, like really great lubrication. There's a book called She Comes First, which is that women should be stimulated first so their vaginas are much more receptive to intercourse, as an example. Then if the vagina really needs estrogen, we can do it more locally than systemically.
When it comes to birth control pills, okay, five years, ovarian cancer risk is reduced, but rather than go on extended birth control pills, let's look at a ParaGard IUD or another method of effective contraception that doesn't use estrogen, particularly in women for whom that's an issue, because of breast cancer risk or history of breast cancer or breast cancer gene in the family kind of thing. Let's use other methods for treating bad skin than just that. We should just have that conversation.
When it comes to radiation exposure, we know that radiation exposure during organogenesis is associated with a high risk of breast cancer in the future. We know the story about treating with radiation therapy for Hodgkin's disease in girls. That was associated with a high risk of breast cancer when they become mature women. We like to avoid the use of medical radiation for girls 8 to 18 up to 25. That includes CT scans with or without contrast. If a girl goes to the ER with pelvic discomfort, she should be examined by an OBGYN or a general surgeon, ultrasound first, if you can before you put her in for a CT scan with or without contrast.
Vitamin D. So many of us are now Vitamin D deficient, being inside on the computer working too long, using sunscreen, covering up, etc. Vitamin D seems to be associated with normal cell regulation. We don't know the whole story yet, but it looks like Vitamin D may be protective so you do want to talk to the women that you take care of about getting adequate Vitamin D. Oily fish is not really enough. Food is not enough. You do need to use D3 in order to avoid the requirement of sun exposure to activate Vitamin D.
Eating mostly vegetarian based diet and really asking our patients to look at their fruits and vegetables beyond the apple and the broccoli, really to grains, seeds, nuts, spices, and the full range of the rainbow, because each different color provides a micronutrient. Fish, chicken, pork, whatever you eat like meat, on the side. Think of it as a side thing. Then when it comes to choosing your produce, you may be aware of what we call the dirty dozen, which is that when they analyze which fruits and vegetables have the highest pesticide levels when grown conventionally, it is the dirty dozen that you see there. Basically, apples that you would see in the grocery store year round, they're only grown during part of the year, but you expect them to be there year round without any boos boos because you want to buy a nice looking apple. Well, that's because it's been treated multiple times and it's been waxed a lot of the time.
Berries don't last long in the grocery store. They're expensive. No store wants to take that risk. They're usually treated in some way. If you want to stick to the best produce, you would buy the dirty dozen types from organic sources and then you wouldn't worry so much about the clean 15. Those are the fruits and vegetables that are grown, on the right, that are grown without much pesticides, even the conventional way. All this stuff is at Breastcancer.org's think pink live green section. We also work with the environmental working group that regularly evaluates this through government reports.
When it comes to the choice of meats, because of what I said about how beef cattle are raised, with hormones, it's not just to increase milk production, it's to get beef cattle bigger to market faster. Try to buy it from organic sources. Look for the words like never exposed and never treated with antibiotics. Then to remove the fat because again, these hormones are lipophilic as are a lot of the environmental chemicals. Lipophil will be in the fat, so if you trim the fat off you're better off and removing the skin.
When it comes to fish, try to aim low on the food chain. Yeah, enjoy tuna every once in a while, but try to do salmon and smaller fish more regularly at the bottom of the food chain because at the top of the food chain, the older the fish is, the bigger it is, the much higher concentration of chemicals that are in it's flesh. Again, removing the skin and not eating the brown meat at the bottom of the fish. That's a very good way to avoid where the fish itself concentrates these chemicals.
When it comes to dairy products, even organic, try to get the fat free whenever possible. Enjoy cheese every once in a while, but I'm just saying, that generally speaking, nonfat organic sources are the best.
When it comes to foods like this and particular edamame or soy products that have the isoflavones that are hormonally active, they're very weak, estrogens. It's like one one thousandths the strength of estradiol. I usually tell all my patients to have the whole food, the edamame. Soy milk is just a concentrate. You squish out the milk from the edamame. That's soy milk. Then you make a curd of that, that's tofu. That's not really a highly processed thing, but when you start having your patients taking soy proteins, powders, those are pharmaceutical grade concentrations of soy protein, which contains the isoflavones. I recommend that you stay away from that. Just eat whole foods. That is a better way to go.
Then just for weight management to help people eat well in between and for children as they get their habits going. When it comes to cooking, cast iron, stainless steel, glass and ceramic and not cooking in plastics, even the microwave especially. That's what our kids are doing and not using those nonstick surfaces. The Teflon is hormonally active. It will get into the food, particularly at high heat, so you never use these pans at high heat.
When it comes to plastics, the three, six and seven, that's the recycling code at the bottom. You want to avoid those plastics. Most of our water bottles are number one, so they don't have the chemicals that we know are an issue. But for the environment, it's much better to use a glass or metal water bottle or another form of reusable water bottle.
When it comes to personal care products. We only have to worry about the stuff that people use regularly and that you coat your whole body with, so for example, we're not gonna worry about shampoos, conditioners that come on, that come off. Toothpaste. Most people don't eat toothpaste, so we're not gonna worry about that as much. There's some issues there, but we are gonna be concerned with our patients that are covering their body with moisturizers or sunscreen, because what goes on you does go in you. We know that we're applying medicines through one little patch. You do absorb what goes on you. We do tell people to avoid products that contain hormones.
There are actually a lot of women who use placental extracts. Those are hormonally active. And to avoid the fragrances, which are an issue, the phthalates, that contains phthalates and preservatives. Don't buy big vats of stuff from Costco. Spend more time being careful buying smaller amounts of product. If your patients want a fragrance, dab on a little perfume here and there. That will give you what you want, but don't cover your body in stuff, because your skin absorbs everything it's exposed to pretty much.
Sleeping well. We know that active cells experience about 1000 DNA hits a day through the wear and tear, stress and strain of living and we're always trying to repair that stuff. Night time is a big time for our body's to heal itself as we go through life, but aging of course is through the wear and tear, stress and strain of living, the accumulation of genetic defects, alterate damage and also stem cell regression, all that. But getting a good night sleep is associated with so many good things, health, reduction in obesity, and there's evidence that it's associated with a lower risk of breast cancer. It's one of those things that's associated with many different things, of course you know good sleep.
Breastfeeding. Breastfeeding lowers the risk of breast cancer. In fact, it lowers the worst kind of breast cancer, which is triple negative. And the population in this country, who's most at risk for getting triple negative breast cancer is actually the least likely to breast feed, which is young black women born here, are the least likely to breastfeed and the most likely to get triple negative. They can lower the risk substantially by breastfeeding even as young mothers. It is not just connected to black women to breast cancer risk. It is any woman who is young, has a pregnancy and doesn't breastfeed is at high risk for triple negative breast cancer. Breastfeeding lowers the risk of breast cancer. Even a month of breast feeding, lowers the risk. So we really need to encourage our patients to do it.
The Affordable Care Act does have provisions that help our women be more likely to start it, stick to it with lactation coaches, pumps provided, time off of work that's protected. We can't let that go in this administration. And also breastfeeding lowers the risk of endometriosis, which we know is a shared area where people can be protected.
It's also important to know your family history of breast cancer. Tamara, you mentioned that your father and his father were diagnosed with breast cancer. Breast cancer in men is of course more likely to be associated with a breast cancer gene. Genetic testing is required there, but any woman who is 50 or younger diagnosed, breast or ovarian cancer in the family, or a combination of other things, like other malignancies clustered together, triple negative breast cancer requires breast cancer genetic testing.
Anybody of Jewish background, Ashkenazi Jewish background, at any age, is a candidate for breast cancer gene testing, with or without a family history. That really helps us lower the risk, because if you know that there's a breast cancer gene going on, you can absolutely help her reduce her risk of breast cancer by 90%. And if she's diagnosed with breast cancer, it really helps guide her treatment choices. If you are at extra risk, you want to take extra steps to reduce that extra risk and be monitored with extra steps as well.
I think you'll agree as we come to the end of my presentation, that in order to reduce the risk of breast cancer, the most common cancer to affect women, it will take a movement. When we think about other movements that were successful, stopping smoking to reduce the risk of lung cancer, they've had huge success. Gardisil to reduce risk and Pap smears to reduce the risk of cervical cancer. Wow, was that disease turned around completely. It used to be the most common cancer to affect women, now it's not.
Mothers against drunk driving. We don't even have to go in the cancer space. The designated driver campaign so successful, unbelievable. When you think about today what's possible, the most common cancer to affect women, women usually live to become a champion. There's the next generation listening to all of these messages. Now we have social media, the web. We have so many different ways to engage people.
When you think about how you start a movement, one of our advisors, Lori David, who did Inconvenient Truth with Al Gore, and a good friend said even at the grass roots of well, you do one thing, and this is true for all of our patients. They say, "Where do I start?" Start with one thing. Do good at it. Feel the success. Feel that movement, that momentum. Take up a second thing while you're going. You're rocking it out. Feel good about that and now you're ready for the third thing and by this time, everyone on Facebook has noticed what you're doing. Everyone around you in your household sees your change, how it's affected you. It becomes contagious and people copy what you do and that's how you start a movement. That's what we're committed to. We ask our people, you gotta believe in yourself.
