1. What women can do to minimize their risk of developing breast cancer?
2. What woman can do to minimize their risk of dying of the disease?
3. What women can do to eliminate unnecessary disfigurement when breast cancer is suspected or diagnosed?

BACKGROUND
To answer these questions one must understand something about the behavior of breast cancer and some of the historical aspects of breast cancer treatment.

The single most important fact that confounds our understanding of breast cancer is that breast cancer is not a single entity. It is rather a disease process with a wide spectrum of behavior. This greatly complicates accurately assessing the effectiveness of different treatments. To understand why, it is helpful to consider the findings of a scientific study done long ago, one that could never be repeated today. The Manchester Study was conducted in the 1890s and concluded around 1930. Women who chose not to have any treatment for their breast cancers were observed from the time of their diagnosis until their deaths. This study showed that without treatment the average time course from diagnosis to death was about 2.5 years. A few women died within months of diagnosis, indicating either years of neglect before diagnosis or a very aggressive cancer. A small number, however, survived 20 years after their diagnosis without any treatment.

One can easily understand from this study that it may be difficult to determine how much of a woman's survival after treatment is due to the treatment and how much merely reflects the natural behavior of her individual breast cancer. To answer this question, scientific studies need to be designed with large enough numbers of women followed for long enough time to find real treatment differences. They also must look at a multitude of variables.

REDUCING RISK
Over the years we have learned much about what puts a woman at risk of developing breast cancer. Most important is gender. Women are at least 100 times more likely to develop breast cancer than men. Other factors include age, previous personal history of breast cancer, genetic makeup, and hormone milieu. Since these factors are all beyond an individual woman's control, what can she do to minimize her chance of developing breast cancer?

A large study recently found that women who are at high risk of developing breast cancer could reduce their risk 50% by taking tamoxifen for five years. Tamoxifen is the same medication that has been used for years to treat women who have been diagnosed with estrogen receptor positive breast cancers. Its safety record is well established. Any family doctor, gynecologist, or surgeon can help a woman determine if she is at high risk and help her determine whether tamoxifen for five years is a good option for her.

REDUCING MORTALITY
Bringing women's risk of dying of breast cancer to an absolute minimum is theoretically possible but impractical. To do so would require all women over the age of 25-30 to have both breasts surgically removed along with the lymph nodes in both armpits. If any cancer were found, the women should then receive both radiation and chemotherapy. Obviously no doctor would ever recommend such a drastic course of action. Few women would be willing to follow through with these recommendations even if they were made. Equally important to understand is that even were a woman to do this, she could not be guaranteed not to die of breast cancer. This is because, in a small proportion of cases, breast cancer spreads to distant organs and becomes incurable even before it has become large enough to be detected. In general, however, the earlier breast cancer is diagnosed and treatment is initiated, the greater is the likelihood for cure.

Currently, mammography performed annually, is the most effective tool for early detection of breast cancer. Because the likelihood of developing breast cancer increases with age, it has been found most practical for women to begin annual mammogram at 40 years of age. Women who are at particularly high risk may be advised to start earlier. Equally important, is that if either a woman or her doctor can feel a new lump or thickening in her breast, further evaluation is needed even though her mammogram may have been reported to be normal.

MINIMIZING DISFIGUREMENT
To minimize the chance for unnecessary disfigurement, we should look to the lessons of history. The modern era of breast cancer surgery began around 1900 when an American surgeon, Dr. William Halsted, developed and popularized the radical mastectomy. By the 1930s it was demonstrated that a less disfiguring operation, the "modified radical mastectomy", is equally effective treatment for most breast cancers. By the 1970s we learned that breast conserving operations, incorporating a surgical lumpectomy and postoperative radiation therapy, give women an equivalent chance of cure to that of radical or modified radical mastectomy with much less disfigurement. By the late1980s and early 1990s newer nonsurgical, less invasive breast biopsy techniques became available. Stereotactic and ultrasound guided core needle biopsies have been found to be as accurate as open surgical biopsy in many situations. They are now considered preferable options to open surgical biopsy in appropriately selected cases. Other techniques, such as sentinel lymph biopsy, skin sparing mastectomy, and a variety of breast reconstruction procedures have a role in eliminating needless disfigurement.

Unfortunately, for a variety of reasons, not all surgeons are equally willing to adopt new technology or new practices, even when their effectiveness has been clearly demonstrated. I suggest that women pose the following question, so that they can be sure that the surgeon they choose has adopted these new and less disfiguring techniques. "In general, if a suspicious abnormality is detected on mammogram but is not apparent on physical examination of the breast, what would you recommend?" The answer should be "a stereotactic core needle biopsy or an ultrasound guided core needle biopsy if the abnormality is more clearly seen by ultrasound." If this is not the answer given, I would recommend finding another doctor.

Women have many options when it comes to their breast health. Educating one's self about the available options is key to making the best breast health decisions.

1. To reduce the risk of developing breast cancer, women who are at high risk might consider using tamoxifen. This option needs to be discussed with your doctor.
2. Annual mammography after 40 years of age is the single most effective strategy for a woman to reduce her risk of dying of breast cancer. However, if a new lump or thickening is found on examination of the breast either by a woman or her doctor, further evaluation is needed, even if her mammogram is found to be normal.
3. If you are advised to see a surgeon, look for one who gives you a feeling of confidence, one experienced with minimally invasive biopsy and other less disfiguring procedures.