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Diana Dickson-Witmer, M.D., is the medical director of the Christiana Care Breast Center at the Helen F. Graham Cancer Center & Research Institute and serves on the advisory board of the Delaware Breast Cancer Coalition. She is past chair of the accreditation committee of the Commission on Cancer. This committee sets standards for the 1,500 approved cancer programs in the United States and surveys the programs every three years to assess the level of compliance with those standards.
An accomplished lecturer, writer and board-certified surgeon, Dickson-Witmer serves on the editorial board of Breast Diseases: A Yearbook Quarterly. She is a member of the National Cancer Institute’s Breast Oncology Local Disease Task Force, which advises the NCI regarding NCI-sponsored clinical trials in breast cancer. Here are her answers to some frequently asked questions about breast cancer.
DT: What is the average risk of getting breast cancer for a woman in the U.S.?
DDW: A woman at average risk of developing breast cancer has a 12 percent lifetime chance of developing breast cancer.
DT: What are some ways to reduce your risk of developing breast cancer or facing a recurrence, and what are some specific examples of living a healthy lifestyle?
DDW: There are several things a woman can do to reduce her risk of developing breast cancer. The California Teachers Study demonstrated clearly that sustained moderate physical activity can reduce the risk of breast cancer by as much as 30 percent. Moderate physical activity means something that causes you to work up a sweat, and to be just slightly out of breath, but still able to talk. The most benefit is derived from a minimum of 150 minutes each week, ideally divided into units of 30-minute blocks. We should also increase the amount of physical activity involved in all of our activities of daily living. That means changing our mindset, such as viewing walking from a far parking spot as an opportunity to move, not a punishment. In an office environment, that means physically getting up from the computer every 30 to 45 minutes to walk a little and spending as few hours sitting each day as we possibly can. We reduce our risk of developing breast cancer if we do not smoke, do not expose ourselves to second-hand smoke and keep the intake of alcohol to a minimum—ideally, no more than one alcoholic beverage a day. For post-menopausal women, there is very good evidence that keeping weight under control reduces the risk of breast cancer. Know what your body mass index is and work to keep it down to 25 (over 25 is generally considered overweight and over 30 is generally considered obese).
DT: I’ve heard breast cancer runs in families. Is that true?
DDW: Yes and no. About 10 percent of individuals may carry a mutation that makes them more likely to develop breast cancer. A person can inherit such a mutated gene from either a father or from a mother. We have not yet identified all of the mutated genes that increase the risk of breast cancer, but we have tests for several, including BRCA 1 and BRCA 2. Most people who develop breast cancer do not have a mutated gene. These 85 percent or more of all breast-cancer cases are called sporadic. Breast cells undergo many, many divisions, and that is part of why breast cancer is common. Every time a cell divides, there is an opportunity for the division of the chromosomes to be imperfect. Cancer is the product of multiple imperfect cell divisions.
DT: How often should I have a mammogram?
DDW: First, I would like to emphasize that there is no clear evidence that annual mammography is superior to having a mammogram every two years. That said, every woman who is 50 years old, and in good enough health to expect to live at least 10 more years, should have a mammogram. Again, it is not clear whether it should be every year or every other year. If the woman has any risk factors, such as a first-degree relative (mother, father, sister, brother, son or daughter) with breast cancer, a history of having needed a breast biopsy or extremely radiodense breasts on a mammogram, then screening mammography should be performed every year. In general, the more risk factors a woman has, the more likely she is to benefit from annual screening mammography rather than screening mammography every two years. A baseline mammogram at age 40 might be considered by women of average risk to see if she has extremely radiodense tissue, which would take her out of the “average risk category.” Any woman at above average risk of developing breast cancer should begin mammographic screening at 40, or 10 years younger than the age at diagnosis of her youngest blood relative with breast cancer.
DT: Will having hormone replacement therapy increase my risk of breast cancer?
DDW: There is a significant increase in the risk of developing breast cancer associated with taking the combination of estrogen and progesterone for over five years. Estrogen alone is not associated with such breast cancer risk, but estrogen alone does increase the risk of uterine carcinoma and estrogen either alone or with progesterone increases a woman’s risk of heart disease.
DT: Will I need a mastectomy if I get breast cancer?
DDW: Over 75 percent of women who develop breast cancer can be safely treated without removal of the whole breast.
DT: If I have a mastectomy, can I get reconstructive surgery?
DDW: Yes. With a few uncommon exceptions, breast reconstruction can be performed at the time that the breast is removed.
DT: I’ve just completed treatment for breast cancer. What can I do to reduce the odds of my cancer coming back?
DDW: If a breast cancer is considered “estrogen receptor positive,” you can take a pill that reduces the estrogen effect on breast cells, thereby significantly reducing a woman’s risk of recurrence. Risk of recurrence can be reduced by increasing physical activity and keeping weight under control after menopause.
