A recent study was done at Breast Cancer Surveillance Consortium (BCSC) facilities where researchers looked at the rate of breast cancer diagnosis in contemporary mammogram practice for the detection of nonprogressive cancer. Individual screening and diagnosis records were used to predict the rate of overdiagnosis among screen detected-cancer under biennial screening (every 23-26 months).

Participants were women between the ages of 50-74 at first mammography screen between 2000-2018. The cohort included 35,986 women, over 82,000 mammograms and 718 breast cancer diagnoses. The conclusion was that among biennially screened women aged 50-74, about 1 in 7 cases of screen detected breast cancer is over diagnosed. This included detecting indolent (benign) preclinical cancer and detecting progressive preclinical cancer in women who would have died of an unrelated cause before clinical diagnosis.

Mammogram screening can lead to breast cancer over diagnosis. This should be a personalized decision between you and you’re practitioner as to the frequency of screening mammograms so an informed decision can be made including the risks and benefits.

References:  Estimation of Breast Cancer Overdiagnosis in a U.S. Breast Screening Cohort

Ann. Intern. Med 2022 Mar 01;[EPub Ahead of Print], MD Ryser, J Lange, LYT Inoue, ES O’Meara, C Gard, DL Miglioretti, JL Bulliard, AF Brouwer, ES Hwang, RB Etzioni

Carlos, C., Margarita, P et al. Benefits and harms of annual, biennial, or triennial breast cancer mammography screening for women average risk of breast cancer: a systematic review for the European Commission Initiative on Breast Cancer (ECIBC). British Journal of Cancer, 126, 673-688 (2022). Published 11/26/2021.

Breast Cancer Prevention

There have been plenty of new medications and treatments for breast cancer. That is astounding news. Today, a woman’s overall 5-year relative survival rate for breast cancer is 90%. This means 90 out of 100 women are alive 5 years after they’ve been diagnosed with breast cancer. The 10-year breast cancer relative survival rate is 84% (84 out of 100 women are alive after 10 years). These survival rates are based on many things, most importantly the time of diagnosis. We have heard that the earlier the diagnosis, the better the prognosis. Early detection involves screening tests, most commonly a mammogram. Technological advances in imaging have created new opportunities for improvements in both screening and early detection. The problem: Breast cancer prevention has not been talked about enough.

I want to discuss prevention. What are the potential modifiable risk factors that we have control over? One thing we need to understand is that the 2 main risk factors for breast cancer is age and gender.  Clearly things we have no control over. But what can we do to be pro-active in reducing our risk as much as possible?

Approximately 67-80% of breast cancers in women are estrogen receptor (ER) positive. Also, about 90% of breast cancers in men are ER positive. So perhaps we should start there. Excess estrogen exposure can come from endogenous (what we synthesize in the body) and exogenous (environmental exposure) sources. Improving estrogen metabolism can be of benefit in reducing the risk of breast cancer. I have often said, “its not how much estrogen you have, but where is it gong…how is it being broken down?”

This brings us to the liver where the metabolism of estrogen takes place. It is complex but very important in that these metabolites vary greatly in biological activity. There is testing that can give us answers to this question of metabolites. Estrogen metabolite tests are completed through a 24-hour urine test which can personalize what your body needs to beneficially modulate estrogen metabolism. Another test that can give us insight into risks is a comprehensive stool analysis. It can identify a certain enzyme that can be modified as well as make sure you are digesting adequate fiber and nutrients that are important in affecting gene expression in the biological effects of estrogen.

Here are 10 things you can do right now to reduce breast cancer risk:

1. Get a screening test. Talk to your provider about a breast mammogram, ultrasound or possibly a thermogram (a risk assessment tool). As I tell women…it’s important to just do something!
2. Manage your weight and reduce your insulin level if it is high. Both estrogen and insulin are growth factors. Growth factors stimulate tumor growth and increase inflammation. Fat tissue also secretes estrogen. There are supplements that can help.
3. Consider time restricted eating. Studies show that fasting daily for 14 hours can reduce breast cancer risk by 40%. Fasting also decreases the incidence of Type 2 diabetes, non-alcoholic liver disease and esophageal reflux. Limit or avoid alcohol.
4. Eat plenty of fiber, especially lignin (found in flaxseeds, bran, beans and seeds). It binds to free estrogen in circulation in the digestive tract which then gets excreted in the feces.
5. Take the supplement Bioresponse DIM. A naturally occurring compound derived from cruciferous vegetables such as broccoli, brussel sprouts and cabbage that is protective to estrogen sensitive tissues.
6. Consume isoflavones such as soy or kudzu. Soy has gotten a “bad rap” with it’s association with breast cancer. They are phytoestrogens (plant compounds) that have the capacity to bind to estrogen receptors and appear to have both estrogenic and anti-estrogenic properties. The average daily intake of Japanese women is 20-80 mg and are associated with low rates of hormone-dependent cancers. American women consume 1-3 mg daily.
7. Exercise everyday to reduce excess fat deposition where the enzyme aromatase converts adrenal hormones, like testosterone, into more estrogen and allows it to be more freely available.
8. Reduce Environmental Estrogen (Xenoestrogen) Load. This includes avoiding foods and products with pesticides, herbicides, and fungicides, as well as non-organic cosmetics and soaps (which contain petrochemicals). Do not use plastic containers, especially when heating food in a microwave. For more information, check out Xenoestrogens
9. Minimize stress: I know that is hard to do with the current state of the world. But find ways of calming the mind, such as meditation, yoga, therapy, reading books that inspire you and STOP listening/watching the news!  Chronic stress raises Cortisol and depletes Progesterone leading to estrogen dominance and excess inflammation.
10. Get good sleep.  At least 7 hours/night is needed to clear toxic residue, repair damage from the brain and reduce cancer risk.

There are many other natural compounds and hormone-modulating herbs that have a significant benefit in promoting healthy estrogen balance. The percentage of inherited genetic mutations that cause breast cancer is less than 25%, whereas 65% -75% of breast cancers are traced to modifiable lifestyle factors. Talk to your practitioner about individual testing to identify what your risks might be in preventing breast cancer.

Reference: Cancer.gov. national cancer institute. “Hormone Therapy for Breast Cancer.

Hall, D.  Applied Nutritional Science Reports. “Nutritional Influences on estrogen metabolism”. MET451, 2001.

Lam, M. Estrogen Dominance. Preventative and Ant-Aging Medicine. www.designsforhealth.com.

 

Women are disproportionately effected by the complications and disease outcome of COVID-19 compared to men.

Gender-specific conditions have the potential to worsen the heart and lung damage caused by this virus. COVID-19 is a vascular disease. Women, compared to men, have smaller blood vessels, which can become dysfunctional and affect the body’s ability to deliver oxygen and nutrients to the heart. This microvascular dysfunction leads to ischemia which results in plaque erosion, clot formation and a potential cardiovascular event, such as a heart attack or stroke.

Other risk factors include polycystic ovarian disease, early onset puberty and the fact that women have higher incidences of autoimmune disease–putting them at risk for cytokine storms (hyper-responses of the immune system). Even though males have higher plasma levels of immune cytokines (immune cells called to the site of infection), women with higher levels of these cytokines were associated with worse disease progression and outcome than men.

The risks to women who have had problem pregnancies (preeclampsia, gestational diabetes) and women going through menopause are also notable. Estrogen helps prevent cardiovascular disease, and as their estrogen levels decline, menopausal women experience a higher likelihood of developing heart disease. Depression increases the risk of heart attack in women by 50% although researchers are unsure why. Severe shock can also take its toll on women. Broken heart syndrome, or takotsubo cardiomyopathy can cause fatal heart damage to mostly menopausal and postmenopausal women who have undergone a sudden stress such as losing a spouse, a car accident or being a victim of a violent crime.

Effective therapy and prevention is needed which starts with educating women in knowing their risks.

Gender differences for increased heart disease were already in place before COVID-19, but it is important to understand the increased risk factors for women that present themselves due to the nature of this virus.

https://www.nature.com/articles/s41586-020-2700-3

 

 

As legalization of marijuana spreads, 7% of pregnant women in the U.S. are using this unregulated drug to help reduce morning sickness. But is it safe?

In some states that legalize marijuana, dispensaries can be as common as coffee shops. Like smoking cigarettes or alcohol consumption, anyone over the age of 21 can easily walk into a store and buy a variety of compounds recreationally for their own use. But there are risks to be aware of, especially for pregnant women. Are the people behind the counter knowledgable enough to give sound advice to pregnant women seeking medical advice?

A study at the University of Colorado looked into the type of information being provided by staff members of marijuana dispensaries. Investigators posed as 8-week pregnant patients and called 465 dispensaries which resulted in useful information from 400 locations. Investigators asked employees if they had products that were “safe for morning sickness.” Other questions were about any known risks to the mother or baby with taking these products and whether they should check with their own health care provider. Results were: 69% of staff members recommended marijuana products for morning sickness, and 36% said that it was safe to use in pregnancy. Only 32% recommended that the patient check with her physician, but after prompting, 81% eventually recommended it.

This may not be happening in every state, but this study gives you a glimpse of how many pregnant women are likely not asking their provider for advice on the safety of using marijuana for morning sickness. But instead are seeking medical advice from marijuana sales people who not only have a conflict of interest and lack of medical knowledge but also a lack of cautionary approach on the topic.

Currently marijuana products contain from 0.3% tetrahydrocannabinol (THC) up to 15% and, even some concentrations up to more than 50% THC. THC acts on CB1 receptors that have psychotropic effects. Cannabidiol (CBD) acts through its effects on serotonin and not CB1 receptors for the most part. Cannabis, the marijuana plant, contains up to 100 cannabinoids with the two that we most know about described above. Dependence and addiction affects about 9% of users. This is compared to 15% of the population addicted to alcohol. This can lead to the risk of addiction to the newborn, let alone other potential consequences of cannabinoid exposure in utero.

There have been studies showing that children exposed in utero to cannabis performed more poorly in visual problem solving, motor coordination, had attention deficits and childhood sleep problems for up to a decade compared to unexposed children. Yes, thats right. According to a University of Colorado, Boulder study and lead author John Hewitt, director of CU’s Institute for Behavioral  Genetics, marijuana use can impact children’s sleep long term!!

Other potential effects include increased risk of stillbirth, low birth weight (if using cannabis more than once per week) and  preterm labor (those using cannabis and smoking cigarettes). A few older studies have not shown any differences in adverse outcomes with pregnant users vs nonusers. With marijuana products not being regulated and not knowing the specific ratios of THC/CBD,  it can be very confusing to know what may harm mother and/or baby.

One thing for sure, marijuana use has not been proven to be safe in pregnancy. It is recommended not to use cannabis products during pregnancy-whether for recreational or medical purposes. Consult your practitioner about other safe and effective natural options for nausea and vomiting of pregnancy.

The medical use of cannabis is legal with physician prescription in  35 states. The recreational use is legal in 14 states.

Even though the use of cannabis is federally illegal, some of its derivative compounds have been approved by the Food and Drug Administration fo prescription use. For non-prescription use, cannabidiol derived from industrial hemp is legal at the federal level, but legality and enforcement varies by state. This map can identify what your state laws are regarding the use of marijuana  State map of marijuana.

References: https://disa.com/map-of-marijuana-legality-by-state

Dicson, B, et al. Recommendations from cannabis dispensaries about first-trimester cannabis use. Obstet Gynecol. 2018;131: 1031-1038.

Hudson, T. Marijuana in Pregnancy-Please Don’t. Townsend Letter. Women’s Health Update. Feb/March 2019. p. 30-33.

 

About 6- 15% of myocardial infarctions (heart attacks) are associated with nonobstructive coronary disease on angiography. This means that far less than 50% of heart attacks are due to blocked arteries. Also, these types of heart attacks occur more commonly in women.

A multinational study was done in which investigators enrolled 170 women with myocardial infarction with nonobstructive coronary arteries (MINOCA). These women were scheduled to undergo cardiac magnetic resonance imaging (MRI) and coronary optical coherence tomography (OCT). The OCT test uses infrared light to acquire cross-sectional images of the coronary artery using an intravascular catheter. This allows it to have a higher resolution than intravascular ultrasound.

In 145 women who underwent OCT, 67 had a possible or definite culprit lesion, such as plaque rupture or layered plaque. In 116 women who had an MRI, 62 had an ischemic (reduced blood flow) pattern of abnormalities and 24 had a nonischemic pattern, such as myocarditis or nonischemic cardiomyopathy (heart disease causing an enlarged heart). Overall,  A cause for MINOCA was identified in 98 women, with an ischemic etiology in 74, and nonischemic in 24 women.

This study shows the benefit of using multiple imaging tests to identify the mechanism of MINOCA in most cases. It showed almost two thirds of cases related to an ischemic cause, despite the absence of severe obstructive coronary disease by angiography. Women tend to have microvascular disease which affects them four times more than men. They also have different symptoms of myocardial infarction than men. Both genders can exhibit symptoms of chest pain or discomfort but women are more likely to experience shortness of breath, nausea/vomiting and back or jaw pain. It’s best for physicians to order multimodality imaging especially for women with these symptoms to prevent the progression of a heart attack.

Reference: Reynolds, HR et al. Coronary optical coherence tomography and cardiac magnetic resonance imaging to determine underlying causes of MINOCA in women. Circulation 2020 Nov 14; [e-pub]. (https://doi.org/10.1161/CIRCULATIONHA.120.052008).