Dr. Susan Love is president and medical director of the Dr. Susan Love Research Foundation and author of Dr. Susan Love's Breast Book (Da Capo; $22), the fifth edition of which is being released this month. Love recently sat down with Spry to give us perspective on the latest news in breast cancer research.
Spry: New guidelines recommend that women start mammograms at 50 instead of 40, and get the scans every two years instead of once a year. Why?
Dr. Love: Before menopause, breast tissue is dense, which makes it harder to see cancer on a mammogram–dense tissue and tumors are both white on the scans. After menopause, tissue turns to fat, which is darker, making it easier to spot cancer. For women under 40, the radiation from mammograms causes more cancer than it finds. Between 40 and 50, it's a wash. After 50, mammograms catch more cancers than they cause. If you are at very high risk for breast cancer and have a family history you should probably have a mammogram sooner.
Spry: Some research has linked the increase in breast cancer to chemicals in household cleaners and cosmetics. Should we worry?
Dr. Love: There's no evidence supporting a link between these products and breast cancer. Studies have been observational, meaning a researcher observes something but it doesn't tell you it's the cause. If you want to minimize your use of these products, fine. But they're not harmful.
Spry: A National Cancer Institute study found a reduced risk of breast cancer in postmenopausal women who exercise. How does exercise help?
Dr. Love: If I knew the answer, I'd get the Nobel Prize! If the key to preventing cancer is creating an environment in your body that is not conducive to cancer cells growing, then exercise helps. Is it absolutely going to guarantee that you won't get
breast cancer? I wish. But it does reduce your chances.
Spry: Another study has found that fish oil supplements can lower breast cancer risk. Should women take the supplements?
Dr. Love: If you are already taking fish oil for your heart, that's fine. But you can't focus on one little thing like fish oil and say "That's the answer." We need to test this theory on animal models and cells. If that works, then do a randomized clinical trial to see if it really helps.
Spry: How important is stress reduction in improving quality of life and survival in women whose breast cancer has recurred?
Dr. Love: There has always been this suggestion that people are more likely to develop cancer when they are under a lot of stress, but this hasn't actually been proven. What could happen is if you have dormant cancer cells that are happily asleep and you are under a lot of stress, the cancer that might not have happened then occurs or recurs. It's tricky, and life is stressful–that's just the way it is. What probably matters more than stress, though, is how you cope with it. That's where stress reduction groups, exercise and meditation come in. All of these alternative things we have been pooh-poohing for years may well have a biological impact.
Spry: Some experts believe a woman diagnosed with breast cancer should have an MRI so her surgeon can find potential tiny tumors that mammogram may have missed and that need to be removed. However, last year a study found that MRIs were more likely to result in mastectomy rather than breast-conserving surgery. What should a newly diagnosed woman do?
Dr. Love: MRI is very sensitive, but it isn't specific. It finds a lot of things, many of which are not cancer. It also finds cancer cells that aren't going to do anything. The downside of MRI is that it leads you down that path, and once you find something, it's not easy to forget about it. It's generally recommended not to do an MRI before breast surgery. If the doctor suggests it, ask why it's needed, how it will change things, and what the benefits are. You can also get a second opinion. I'm not sure that doing everything so you don't kick yourself later is the best way to make a decision.
Spry: A recent study reported that women who gain 30 or more pounds boost their breast cancer risk. And heavy women have a poorer prognosis when they are diagnosed. Why is the news so bad for heavy women?
Dr. Love: The risk for breast cancer is higher for heavy women who are post-menopausal. When you are pre-menopausal most of your hormones, including estrogen, are made by your ovaries. After menopause, pre-cursors of estrogen are made in the ovaries and converted into estrogen in organs and cells. Your muscle makes estrogen, your brain makes it, fat makes it. The more fat you have, the more you make. Fat changes the local environment, making it easier for cancer to develop. That is one theory.
Another theory is that being heavier changes insulin resistance, inflammatory markers, and all of those things that lead to an environment that is more inductive of cancer. We don't know, but if you're heavy, losing weight might well reduce your risk as will being careful not to gain weight.
Spry: Earlier this year a study reported that breast cancer survivors who regularly took aspirin after treatment were less likely to have recurrence or die. Should women start taking aspirin if they don't already do so for heart health?
Dr. Love: One theory is that aspirin changes the environment in the breast, but the benefits aren't dramatic. If you are taking aspirin anyway for heart health or arthritis, well, maybe there's a bonus to it, but this was another observational study. The people who took aspirin may be healthier or more likely to go to the doctor. So I wouldn't take aspirin just because of this study.
Spry: Where do we stand with safe consumption of alcohol in women? How much is too much?
Dr. Love: It does seem that women who drink a lot of alcohol have a higher risk of breast cancer. It affects the liver, which may affect estrogen metabolism, but we don't really know for sure. In general– and I like my glass of wine–we shouldn't be over drinking. A good guideline is to have no more than three to four glasses of alcohol per week.
Spry: According to a large study, a single dose of radiation during surgery to remove a cancerous tumor is as effective as longer post-op whole-breast radiation. Are shorter, targeted treatments the future of breast cancer treatment?
Dr. Love: I certainly hope so. We used to remove and treat the whole breast because we thought that was necessary. Now we can conserve the breast, and particularly for some smaller tumors, treating just the area of the tumor may be enough. We have studies showing a week's worth of radiation seems to be as good as six weeks. This study takes it another step. What if right at the time of the surgery we treat the tumor? There is certainly a push towards shorter, targeted treatments. The goal may not be to kill every cancer cell but to get rid of most of them and change the rest.
Spry: What is one of the most promising developments in breast cancer detection and treatment?
Dr. Love: One big push is personalized medicine. The key is to figure out which kind of breast cancer a woman has and which treatment will be best for that kind.