The Rationale for Preventive Mastectomy

Preventive mastectomy, done to reduce the risk of developing breast cancer, involves the surgical removal of one or both breasts. This procedure, also called prophylactic mastectomy, was in the news recently when actress Angelina Jolie announced her decision to undergo the procedure. Women with certain risk factors are much more likely to develop breast cancer than this risk by up to 90 percent.
women in the general population and preventive mastectomy has been shown to reduce

What are the risk factors that increase the likelihood of developing breast cancer? Having one or more of these risks does not mean that developing breast cancer is inevitable, but does increase the possibility by several times.

1. Having breast cancer in one breast increases the likelihood of developing cancer in the opposite breast.
   
2. A history of breast or ovarian cancer in a mother, sister or daughter increases the risk of developing breast cancer. This risk increases even higher if multiple family members were affected or if the family member was diagnosed prior to the age of 50.
   
3. Mutations of the BRCA1 or BRCA2 genes. BRCA genes 1 and 2 help to suppress the development of breast cancer. A mutation of one of these genes alters its ability to suppress tumor growth. This increases the risk for developing breast cancer as much as five-fold. According to press reports, a mutation of the BRCA 1 gene was the reason that Ms. Jolie chose to undergo preventive mastectomy. Genetic testing, using a sample of blood, is required in order to detect a BRCA gene mutation. Ideally, this is done in consultation with a Geneticist, an expert in hereditary diseases. Men can have mutations of their BRCA genes also, with an increased risk of developing breast cancer.
   
4. Having a pre-malignant breast condition. Lobular carcinoma in situ (LCIS) is a condition in which abnormal cells form in the lobules or milk glands of the breast. LCIS is not cancer but having it increases the risk of developing invasive breast cancer.
   
5. Undergoing radiation therapy. Receiving radiation to the chest (along with the breasts) prior to the age of 30 increases breast cancer development risk. This is commonly done to treat certain cancers, such as Hodgkin’s lymphoma.
   
6. Having dense breasts or microcalcifications. Although both of these conditions are benign, dense breast tissue and microcalcifications (tiny deposits of calcium seen on mammography), can make the diagnosis of breast cancer difficult. These conditions are usually not reasons by themselves to undergo preventive mastectomy, but may tip the balance toward surgery if other risk factors are present.

Has preventive mastectomy been proven to reduce breast cancer development? In women at high risk for the development of breast cancer, preventive mastectomy has been shown to reduce their chance of developing breast cancer by about 90 percent. Breast cancer will still occur in some women who undergo preventive mastectomy since it is impossible to completely remove all breast tissue during surgery.

Is preventive mastectomy disfiguring? Many women choose to undergo breast reconstruction at the time of, or shortly after undergoing preventive mastectomy. The goal of this plastic surgery is to reform the shape of the breast. Most commonly, a water or silicone-filled balloon is implanted. As with other surgeries, complications including bleeding, infection, pain, and development of scar tissue can occur. Adverse psychological effects due to change in body image can also occur following preventive mastectomy.

Are there alternatives to surgery in women at high risk for developing breast cancer? If a woman at high risk chooses not to undergo preventive mastectomy, close monitoring is recommended in order to detect breast cancer, should it develop, as early as possible. Such monitoring includes monthly self-examination, breast examinations by a health professional, and mammograms. Additionally, the American Cancer Society recommends that high risk women receive magnetic resonance imaging (MRI) of the breasts every year beginning at age 30. Medications that can reduce the risk of developing breast cancer in women at high risk include tamoxifen and raloxifene. These drugs work by blocking the cancer-inducing effects of estrogen on the breast, although taking them can produce menopause-like symptoms.

Learn more about breast cancer risks and prevention at the Susan B. Komen or American Cancer Society websites.

Bullish for Bikes

Sponsored by the League of American Bicyclists, May is National Bike Month and is an opportunity to celebrate the many reasons that people choose to ride. For some, bicycles represent their primary means of transportation. Many people ride bikes as

a means to health and fitness. Others yet find pleasure and perspective from a bicycle saddle as they ride along a bike trail. Of the many reasons for bicycling, I find that three in particular stand out---health benefits, economic savings, and environmental advantages.

Health Benefits: The health benefits of regular cycling include:

• Increased cardiorespiratory fitness - The increases in heart and respiratory rate produced by cycling will improve your overall fitness level. While many people choose bicycling as their primary means of exercise, time spent on a bicycle commuting can result in improvement in fitness also. The U.S. Department of Health and Human Services has determined that biking for transportation can count toward the minimum 150 minutes/week of moderate-intensity aerobic activity recommended for physical health.
  
  
• Reduction in heart disease risk - By now, everyone is aware that exercise can reduce the risk of heart attack. Cycling can help strengthen the heart muscles, reduce blood pressure and improve blood fat levels, all of which lower the risk for heart attack. One study found that increasing biking and walking from 4 to 24 minutes a day would reduce cardiovascular disease by 14%.
  
  
• Decreased body fat levels - Cycling raises the metabolic rate and burns body fat. Steady cycling burns about 300 calories per hour. Over the course of a year, a half-hour bike ride every day will burn over 10 pounds of fat. Studies show that school-aged children who bike or walk to school have a lower percentage of body fat and are more likely to remain at a healthy weight than those who are driven or take the bus.
  
  
• Reduction of risk for developing diabetes - Research in Finland found that people who cycled for more than 30 minutes per day had a 40 per cent lower risk of developing diabetes.
  
  
• Improved mental health - Regular exercise, including bicycling, has been shown to reduce stress and depression and improve our sense of well-being. Many people find that cycling serves as an escape to the stresses of everyday life. According to surveys performed by the Transportation Research Board, bike commuters report lower stress and greater feelings of freedom, relaxation, and excitement than car commuters.

Environmental Advantages: Motor vehicles consume the majority of oil used in the U.S. Along with fuel consumption comes the serious problems of carbon dioxide accumulation in the atmosphere and the potential for permanent climate change. It is sobering to realize that for a 10 mile round trip commute in a mid-size care averaging 20 mile per gallon, 1.3 tons of carbon dioxide are released into the environment over the course of a year. The potential for improvements in air quality with widespread bicycling commuting is dramatic. The same can be said of bicycling for exercise instead of the use of fossil fuel powered vehicles.
This not only provides health benefits to the rider but is better for the environment as well. For those concerned about the effects of breathing exhaust while riding a bicycle, a study performed in the Netherlands considered the risks and benefits of bicycling rather than driving for short trips on a daily basis. They estimated that the benefits of increased physical activity from bicycling (3 to 14 months gained) outweigh the effects of increased inhaled air pollution (0.8 to 40 days lost) and increased traffic accidents (5 to 9 days lost).

Economic Savings: With over half of the working population of the U.S. living within 5 miles of their workplace, bicycling becomes a realistic way of getting to work. In fact, it has been reported that from 2000 to 2011, the number of bicycle commuters in the U.S. grew by more than 47 percent. The League of American Bicyclists estimated that in 2012, bicycle commuters in the U.S. saved more than $4.6 billion over their car driving counterparts. Savings for the bicycle commuter comes from a variety of sources including parking fees, fuel costs, car maintenance expenses, and public transportation fares. Businesses benefit also in that cyclists take fewer days off work for illness than non-cyclists. Add to that the savings from treatment of chronic illnesses that bicycling could help prevent, and the economic benefits of bicycling are astonishing.

The Rights and Wrongs of Sunscreen Use

The topic of sunscreen use is rife with  strongly recommends sun avoidance practices including use of sunscreens year round to reduce the risk of developing skin cancer. Here are a few of the common misconceptions regarding the use of sunscreens preventing skin damage from sunburn:

controversy and misconceptions. Some authorities advocate against their use, believing that too little sun exposure will reduce the body's vitamin D levels with the increased risk of osteoporosis and certain cancers (breast, colon, and prostate). The American Academy of Dermatology, on the other hand,

Misconception #1 - The SPF is an indication of sunscreen protection across the entire ultraviolet light spectrum. The sun emits two types of ultraviolet light---UVB, which causes sunburn and can lead to skin cancer, and UVA, which causes wrinkles and deeper skin damage that can also lead to skin cancer. Most people know that SPF stands for sun protection factor. What is less well known is that this is a measure of how well the sunscreen deflects UVB rays only. Sunscreens that pass the Federal Drug Administration's (FDA) broad spectrum test, however, will have demonstrated that they also provide UVA protection that is proportional to their UVB protection.

Misconception #2 - The higher the SPF, the better. SPF values displayed on sunscreen labels range from 2 to as high as 50 (or higher). This refers to the product's ability to screen or block out the sun's harmful rays. Theoretically, a sunscreen with SPF 15 will allow you to be in the sun 15 times longer than you could without sunscreen before becoming sunburned. Protection from sunburn, however, does not increase proportionally with an increased SPF number. A SPF of 2 will absorb 50% of ultraviolet radiation, an SPF of 15 absorbs 93% and an SPF of 34 absorbs 97%. No sunscreen can block 100% of the sun's rays.

Misconception #3 - Waterproof sunscreens stay on even when swimming. There is no such thing as "waterproof" sunscreen. The FDA even prohibits manufacturers from labeling sunscreens as "waterproof" because these claims overstate their effectiveness. Sunscreens can be labeled as being "water resistant" if they maintain their SPF rating after 40 to 80 minutes of water exposure. Most sunscreens will not maintain their SPF rating after swimming or sweating heavily for much more than an hour.

Misconception #4 - Sunscreens are so concentrated that a thin coating is all that's necessary. Most people do not use adequate amounts of sunscreen. Studies have shown that people apply only about 25-50% of the amount required to reach the labeled SPF rating.

Misconception #5 - Vitamin A added to sunscreen is important for skin health. It's true that Vitamin A added to sunscreen will help hydrate skin and prevent skin degradation. Data from an FDA cancer study, however, showed that Vitamin A in a synthetic form called retinyl palmitate may also speed the growth of skin tumors.

Recommendations for effective sunscreen use. The ideal sunscreen would completely block all UV rays, remain effective on the skin for several hours, and not cause skin irritation. Unfortunately, the ideal sunscreen does not yet exist. Here are some tips for the more effective use of the sunscreens that are currently available.

• For most people, a sunscreen with a sun protection factor (SPF) of 15-30 will provide adequate protection.
  
• Look for sunscreen that says that it provides "broad spectrum" protection. Broad spectrum protection means that it has both UVA as well as UVB blocking properties.
  
• Perhaps more important than the SPF rating is appropriate application and reapplication of sunscreen. Be sure to apply sunscreen at least 15-30 minutes before exposure to the sun. Follow the guideline from the American Academy of Dermatology--- "one ounce, enough to fill a shot glass", is the amount needed to cover exposed areas of the body. This amount should be adjusted depending on body size and the amount of exposed skin. "Water resistant" sunscreens need to be reapplied every 1 to 2 hours when swimming or sweating heavily.
  
• If you are extremely UV-sensitive, get a sunscreen with an even higher SPF rating. For all intents and purposes, a sunscreen rated 50+ is as high as anyone needs.
  
• For maximum protection against UV rays, use a sunblock rather than sunscreen. These contain physical agents, such as titanium dioxide or zinc oxide keep UV rays from reaching the skin.
  
• One of the best ways to protect your skin from cancer and premature aging is by limiting sun exposure and wearing protective clothing. Avoid sun exposure between 10 AM and 4 PM, the time that UV radiation is at its highest. Remember also that UVA radiation is not significantly lower during morning hours or on overcast days.

If you have any questions about the rights and wrongs of sunscreen use, please log into your account and send us your question. We are here to help.