ELLE BEAUTY Neurotica

Panic
Room
Misunderstanding
breast cancer risk
throws some women
into unnecessary panic
and gives others a false
complacency. Rachael
Combe sorts out who

M
should be worried
y sister-in-law Olivia
was 34 when she
found the lump. She
discovered it by acci-
dent, while adjusting
her bra strap. Her
aunt Deb—my hus-
band’s mother’s sis-
ter—had died of
breast cancer at 55,
and Olivia had always worried about the
disease, believing Deb’s cancer meant she
carried a higher than average risk. With
her aunt’s swift decline in mind, Olivia
went to her doctor the same day. Within
three weeks she had a diagnosis: stage-one
breast cancer—her worst fear come true.
“It was like nuclear winter,” she says of the
emotional blow.
Three weeks later, she underwent a
bilateral mastectomy and began chemo.
Her tumor was small and isolated enough ing proteins that stop cells from growing have to have my ovaries removed, which
that she could have had it removed, con- abnormally. About 13 percent of Ameri- was great,” she says. “But in other ways, it
Breast scan: Howard Sochurek/Corbis; woman: Image Source Black/Alamy

serving the rest of her breast tissue. Studies
show that for cancers like my sister-in-
law’s, mastectomy decreases the risk of
reoccurrence, but doesn’t necessarily in-
crease the rate of survival. For Olivia, the
decision was largely psychological. “I
wanted them off,” she says. She had a four-
year-old son, she intended to survive for
many years, and she didn’t want to spend
that time obsessing about breast cancer.
Because of her age and family history,
Olivia assumed she must be carrying one
of the “breast cancer genes”—mutations in
the BRCA1 or BRCA2 genes—that are
more common in premenopausal breast
cancer patients. Normally functioning
BRCA genes help prevent cancer by mak-
can women will be diagnosed with breast
cancer at some point in their lifetime, but a
BRCA mutation can bump that risk to 40
to 80 percent (and also increase the risk of
ovarian cancer, to 20 to 50 percent).
But the genetic counselor was not terri-
bly impressed by Olivia’s family history.
The strongest hereditary effects are gener-
ally found only in first-degree relatives,
which means a mother, sister, or daughter.
It was only because she was so young that
health insurance agreed to pay for the test-
ing. When the results came back negative
for a BRCA mutation, we were all relieved,
not only for Olivia, but for our kids. Still,
the result was more than a little confusing.
“I was glad—in a way. It meant I didn’t
left me wondering what in the world was
going on. Why did I have it so young?”
A survey last fall by the National Breast
Cancer Coalition found that 56 percent of
women believe that most breast cancers
occur among women with a family history
or a genetic predisposition to the disease.
But in truth, only 5 to 10 percent of breast
cancers are believed to be hereditary. The
other 90 to 95 percent implicate a hodge-
podge of factors, from hormone replace-
ment therapy to age; from weight to plain
old bad luck.
That’s not the only form of misinforma-
tion circulating. Younger women tend to
vastly overestimate their risk of breast can-
cer, while older women underestimate it,

elle 000 w w w.e ll e.c o m

 ELLE BEAUTY Neurotica
says Debbie Saslow, PhD, director of breast
and gynecologic cancer for the American
Cancer Society, which leaves legions of
young women wracked with guilt if they’re
not performing monthly breast self-exams
(which, by the way, have never been shown
to reduce fatalities) and postmenopausal
women perhaps too lax about getting their
annual mammogram. Saslow blames
some of these misperceptions on the
media. “It’s much more compelling to read
a magazine story about someone who has
young kids and was diagnosed with breast
cancer,” she says, or about prophylactic
mastectomies rather than a story about an
older woman with the disease. And she ad-
mits that increased awareness “makes it
seem like breast cancer is so common,
when heart disease is actually the main
killer of women.”
Poor understanding of personal risk
can also interfere with proper screening.
Studies have shown that women who ini-
tially overestimate their breast cancer
risk are actually less likely to get regular
mammograms. Part of this may be that
when women learn that their actual risk
is lower, they don’t think they need
screening. “When you ask women in
studies, on average they think their breast
cancer risk is about 40 percent,” says
Angela Fagerlin, PhD, a professor of
internal medicine at the University of
Michigan Medical School. “So when
they find out it’s really only 13 percent,
they get this sense of relief.”
On the other hand, some women can
also become “frozen by anxiety,” she says.
“Research shows that when people are
really anxious about something it’s hard
for them to perform a health behavior.
They won’t get screened. They think it’s
better not to know.” This is especially the
case for people who don’t think they can
do anything about a diagnosis, such as
those without health insurance who can’t
pay for treatment.
For women with a more neurotically
vigilant psychology (like, uh, myself),
overestimation of risk can lead to unnec-
essary panic. Sharon Rosenbaum Smith,
MD, breast surgical oncologist at St.
Luke’s-Roosevelt Hospital Center in
Manhattan, says she sees a lot of false
alarms among young women who are
more alert to breast cancer than ever.
“Every day I have somebody in my office
who’s hysterical, sobbing. They have a
little dry skin and they think they have
inflammatory breast cancer,” she says.
But, she notes, the flip side of this is
women like my sister-in-law, whose
panic turned out to be warranted. “Most
lumps are not cancer, but every lump
elle 000 w w w.e ll e.c o m
needs to be taken seriously,” she says.
While Olivia’s cancer was rare (4 per-
cent of breast cancers are found in women
under 40), her inability to find a smoking-
gun cause was not. Most young breast
cancer patients do not carry a known ge-
netic mutation. “For Olivia at 34, she had
about a 10 percent chance of having a
BRCA mutation,” says Judy Garber, MD,
MPH, director of cancer risk and preven-
tion at Dana-Farber Cancer Institute in
Boston. For a postmenopausal woman,
it’s 3 percent.
The mutations are most often found in
women of Ashkenazi Jewish origin, Afri-
can-Americans, and Hispanics, but they
can be found in all races and ethnicities.
And having a second-degree relative such
as an aunt or grandmother who had breast
cancer doesn’t necessarily increase your
chances of carrying a mutation. Saslow
said Olivia’s aunt Deb’s breast cancer was
probably “irrelevant” to Olivia’s cancer
and that the fact that they were both diag-
nosed is possibly just chance.
The BRCA genes are not the only ones
involved in hereditary breast cancers.
There is an alphabet soup of genes that
have been found to slightly increase risk
(CHEK2, PTEN, ATM, p53), but these
are nowhere near as powerful as the BRCA
mutations, and are far rarer. Researchers
are also starting to identify mutations that
may work in concert with each other (un-
like BRCA mutations, which increase risk
on their own), but these are more predis-
positions than actual breast cancer genes.
“It seems likely that there are some forms
of genes that up the ante a little bit,” Garber
says. “If you think about smoking, some
people get lung cancer, some get heart dis-
ease, and others get nothing, even though
they’re all exposed to the same carcino-
gen. Some of that is related to chance and
other lifestyle factors, and some of it is re-
lated to genes.”
So if family history isn’t the culprit in
the vast majority of breast cancers, what
is? Age is the biggest factor—77 percent of
breast cancers are found in women over
50. As time goes by and our cells duplicate
over and over, we have more opportunities
for a cancer to grow.
Aside from age, “almost all breast can-
cer is somehow tied to estrogen levels,”
Saslow says. Gaining a lot of weight as an
adult is a risk factor because fat produces
estrogen. Getting your first period young
and reaching menopause late also in-
crease risk because they prolong the
body’s estrogen exposure. Hormone re-
placement therapy can increase risk, as
can taking birth control pills (slightly),
though the effect fades within a few years
of going off the Pill. Drinking alcohol in-
creases risk, possibly because it interferes
with estrogen metabolism. And giving
birth before 30 —the younger, the bet-
ter— offers a protective effect against the
disease. On the other hand, women who
don’t have their first full-term pregnancy
until after 35 actually increase their risk of
breast cancer over women who’ve never
had a child at all, according to the Ameri-
can Cancer Society.
Some of these factors are controllable
(weight, alcohol consumption). Others are
not (age). And nobody in her right mind is
going to plan a teen pregnancy to reduce
breast cancer risk (“Oh, no, all of life should
be planned around breast cancer,” dead-
pans Garber). One factor you wouldn’t
want to change: Being wealthy adds risk.
People in richer countries grow up with
better nutrition and girls tend to reach
puberty earlier. “If you were to talk to Wal-
ter Willett [a Harvard epidemiologist], he
calls breast cancer the price of progress,”
Garber says. (To find out your actual risk,
go to www.cancer.gov/bcrisktool.)
The best thing you can do to prevent
breast cancer is to lead a generally healthy
lifestyle, doctors say. Exercise, eat a heart-
healthy diet (lots of fruits, vegetables, and
whole grains; limit meat), drink moderate-
ly (no more than a drink a day for women);
don’t smoke, and keep your weight under
control. “Don’t do it just to prevent breast
cancer,” Saslow says. “Do it to prevent ev-
erything: diabetes; heart disease; breast,
colon, and lung cancer—to focus on just
one is shortsighted.” Further, while most
organizations no longer push breast self-
exams now that their effectiveness is in
doubt, you should be familiar enough with
your body that you’d notice a change, such
as a lump or dimpling. All women should
report anything suspicious to their doctor,
and the ACS and National Cancer Insti-
tute recommend annual mammography
for women over 40 (women with first-de-
gree relatives with the disease should start
mammography 10 years before the young-
est diagnosis in their family). If you do find
a lump, try to remain calm. Most are not
cancerous, and even so, most cancers are
caught early; in such cases, survival rates
are roughly 97 to 98 percent.
I’m thrilled to report that Olivia has
been cancer-free for four years and is even
starting to go for long stretches without
thinking about cancer. It used to be if she
had a toothache, “I’d be like, ‘I have stage-
four mouth cancer,’ ” she says. But then a
couple months ago, she pulled her sciatic
nerve. “My first thought wasn’t, It’s can-
cer. I thought, I slept on it wrong. I was so
proud of myself.”