This is a topic for which I hope to never have personal or professional experience. Earlier this winter however, one of my closest colleagues brilliantly diagnosed breast cancer in one of her pregnant clients. Truly, to say she changed the life of this mother and child is a huge understatement; she literally saved their lives.
Two previous practitioners denied the presence of cancer, yet my colleague persisted. Her perseverance proved fruitful, as aggressive cancer was confirmed. Unfortunately, two subsequent practitioners overstepped their authority and earnestly sought to end the life of the unborn child. My colleague, committed to both the mother and child, reminded the physicians of her her role in coordinating care, as the client’s chosen primary care provider, and she proved an expert clinician.
The emotional turmoil of breast cancer overwhelms all involved, including the healthcare practitioners. Being in a position of support for this midwife reminded me of the important role we have as primary care practitioners. Breast cancer remains the most common cancer in women both in the United States and around the globe.
Family history, increasing age, exposure to ionizing radiation, and exogenous estrogen are all risk factors for breast cancer. Exposure to chemicals and viruses have also been correlated, as well as never having a full-term pregnancy or never having breastfed a child. The irony is that most women who develop breast cancer have few, if any, of these known risk factors.
Mammographic density is a newly identified risk factor that implies the role of the breast stroma, which accounts for much of the density reading. The greater the density, the greater the incidence of breast cancer. Indiana now requires patients be notified of their density screening, although to what benefit this offers is yet to be determined.
Two large tumor suppressor genes, BRCA1 and BRCA2, located on chromosomes 17 and 13, account for approximately 5% of all breast cancers. Women who carry one of these mutations have a lifetime breast cancer risk of 40-80%, depending on mutation, penetrance, and other host factors. Interestingly, women with either mutation, who have their fallopian tubes removed, reduce their risk of breast cancer by 50% (Mokbel, 2003).
Our practice does offer screening for BRCA1 and BRCA2, although universal screening for these mutations is not yet recommended. We also frequently refer for genetic screening when risk factors are identified.
Conventional strategies for prevention include a class of drugs called “selective estrogen receptor modulators” (SERM) which include Tamoxifen and Evista. Aromatase inhibitors and COX-2 inhibitors are in clinical trial. No random control trials are available for functional food or exercise programs for breast cancer prevention, as I am aware.
Surgery is a popular prevention strategy, as Angelina Jolie made popular more recently. As reconstruction surgeons improve their craft, prophylactic skin-sparing mastectomies are increasingly chosen with a success rate of greater than 90%.
Significant funds have been invested in educating the public to perform self-breast exams on a monthly basis. This investment may not have paid off, as evidence has demonstrated that the self-breast exam has not decreased mortality. In fact, a 2008 Cochrane Review suggested it may in fact lead to harm. Women who rarely perform breast exams, but do so prior to their annual exam, often find unfamiliar lumps, reporting them to their practitioner during their visit. The clinician responds by ordering diagnostic exams and biopsies which may impose greater risk, than benefit.
We are certainly an advocate for learning the norms of your own body and reporting any concerns to your clinician. However, the clinical breast exam provided by your nurse-midwife, should be performed annually. Evidence has demonstrated that trained clinicians, providing breast exams annually, find masses smaller than those discovered by women who consistently perform self-breast exams each month.
Clinicians have at their disposal a number of options for screening beyond the clinical exam. Magnetic resonance imaging (MRI), ultrasound, and breast PET scans are options, although costly. Thermography cameras and light source imaging are still investigational, so while intriguing, they should not be substituted for mammography quite yet.
Diagnostic & Treatment
Concern by either exam or mammogram leads to biopsy, where diagnosis is confirmed. Breast cancer treatment is a multidisciplinary field that includes nurse-midwifery, as my colleague above demonstrated. Too often it is assumed that nurse-midwives do not have a role in pathologic findings, but in fact, we may play the most vital role. We are the client’s best advocate. We are experts in providing informed consent. We are capable of educating and counseling the client, discerning the plan that best suits the individual, and extending a coordinated plan of care. Nurses are the most trusted profession because we are not only skilled clinicians, but also compassionate.
Surgery, radiation and oncology all play an important role in the treatment of breast cancer. Lumpectomy and mastectomy have offered fairly equivalent survival rates, and breast conservation has been preferred since the 1990 Consensus Statement. It is now standard of care to assess the most proximal lymph nodes to assure cancerous cells have not spread beyond the tumor. Systemic therapy can also be guided by molecular and genetic tests performed on the tumor itself.
Once again, physical exercise can not be ignored. It absolutely reduces breast cancer risk, with evidence suggesting reduction by as much as 30% (Friedenreich and Cust, 2008). The more exercise the better, and the greater the intensity, the greater the benefit.
While scientists can’t detail a specific cause that links exercise with improved breast cancer outcomes, it is thought to be related to three important factors. First, exercise reduces endogenous estrogen. It also improves the body’s ability to regulate insulin. Inflammation may also be reduced with exercise. The emotional benefit can not be underestimated as well. Exercise benefits women through prevention, improves treatment outcomes, and assists with healing.
Nutrition is paramount to good health. One must strive towards a healthy weight. Obesity increases risk for breast cancer in postmenopausal women, with weight loss decreasing risk by 40% (Eliassen et al, 2006). Recommendations for specific dietary choices have yet to be revealed in the literature. The Mediterranean-style diet with high intake of whole grains, fruits and vegetables and olive oil is recommended simply because it encourages overall good health.
Alcohol intake of two or more drinks per day is known to be associated with an increased risk of breast cancer with a dose-response effect in both premenopausal and postmenopausal women. This is thought to be related to alcohol’s ability to increase estrogen and androgen levels, although folate has shown to neutralize this risk. Interestingly, grapefruit has been shown in one study to increase the incidence of breast cancer in postmenopausal women (Monroe et al, 2008). Experts believe this is due to an increase in endogenous hormone levels with the grapefruit. Neither coffee or tea have been found to increase breast cancer risk in the Nurses Health Study (Ganmaa et al, 2008).
Vitamin D deficiency should be assessed in all women, at various points in their life cycle, but particularly as they reach perimenopause. Vitamin D3 has been identified as a playing a significant role in breast cancer prevention (Gissel et al, 2008). Again, we recommend food-based supplementation to enhance absorption.
Melatonin supplementation has been suggested as a method for preventing breast cancer. Poor sleep certainly impacts health negatively, and disrupted sleep has been associated with increased risk for breast cancer. Nighttime shift workers specifically have a higher risk, potentially because increased light at night reduces levels of melatonin. Supplementation of 3 mg prior to bed may prove beneficial. Doses as high as 20-40 mg/day have been studied in women with solid, metastatic tumors (Mills et al., 2005).
Cruciferous vegetables have been shown to be a potent antiproliferative agent in human breast cancer cells. The active phytochemical is indole-3-carbinol (I3C) which can be taken as a supplement at 400 mg/day.
Tumeric might be one of my first recommendations, as it has apoptosis properties and is a strong aromatase inhibitor with antiinflammatory and antioxidant properties. This botanical has only minimally been studied, but because it has a long history of traditional use, its safety is trusted. Standardized extracts providing 1-2 g of curcuminoids per day are typically used for inflammatory conditions.
Five glasses of green tea daily was shown to reduce the incidence of breast cancer in one study (Sun et al, 2006). Iscador and Helixor, trade names for commerical preparations for mistletoe, and mushrooms shiitake, maitake, and reishi may all benefit those with breast cancer, although admittedly, these are outside my own expertise. Ginger of course, has a long history of offering pallative treatment for the nausea associated with chemotherapy.
Certainly exercise, proper nutrition and sufficient sleep is vital to overall health and improved outcomes in breast cancer women. Stress reduction is also imperative to healing. Interestingly, stress reduction is important beyond improving one’s experience and even improving one’s health outcomes, but it has recently been shown to change gene expression (Dusek et al, 2008). All women suffering with breast cancer should be offered some avenue of support, whether spiritual, talk-therapy, group therapy, dance, yoga, art, or journalism.
Nurse-Midwives & Breast Cancer
Nurse-midwives are not typically experts in breast cancer treatment, although we are in breast cancer diagnosis and advocating for our clients. Coordinating such care is not only within our scope, but is part of the expert role we take responsibility for as primary care providers. Understanding the various treatment options and being familiar with community resources is an important part of offering informed consent. Optimizing care for women who endure breast cancer includes acknowledging the need for a multidisciplinary approach, which may easily be overlooked among individual specialists. Nurse-midwives are trained to provide a holistic approach to care, and our nurse-midwives can do so with an integrative mindset.