“Don’t Drink the Water and Don’t Breathe the Air”: A List of Breast Cancer Risk Factors

After some intense research on the risk of developing breast cancer, I’ve come to the conclusion that the factor with the greatest causal relationship to the disease is, quite frankly, life. In fact, I sometimes wonder how people manage to NOT get cancer.

For your reading pleasure, I surveyed a number of reputable sites to compile a list of commonly accepted breast cancer risk factors (links to the info): American Cancer Society, Mayo Clinic, Memorial Sloan Kettering Cancer Center, Dana Farber Cancer Institute, Centers for Disease Control, National Breast Cancer Foundation, World Cancer Research Fund and WebMD. There are some emerging risks that most sites didn’t list and although I have seen the research studies in support of those factors, I opted to exclude specifics for now. Perhaps that’s for a future post.

Here you go, not in exact order of importance:

  1. Being born female (well that covers about 50% of us)
  2. Getting older (um, inevitable…)
  3. Drinking alcohol (even moderate drinking has been shown to be harmful – find a different hobby)
  4. BRCA1 and BRCA2 gene mutations, which everyone talks about, but certain mutations in the following may also increase cancer risk, although to a lesser extent: ATM, TP53, CHEK2, PTEN, CDH1, STK11, PALB2
  5. Personal history of breast cancer (get it once and you’re a moving target)
  6. Family history of breast cancer (including both close and distant relatives)
  7. Personal history of breast lesions (even stuff that seemed benign-ish)
  8. Radiation exposure, specifically to the face and chest, before the age of 30
  9. Obesity (but mainly for postmenopausal women, see here; it’s complicated)
  10. Having dense breasts (sometimes this is considered a top risk factor)
  11. Beginning your period before age 12
  12. Going through menopause after age 55
  13. Having your first child after age 30
  14. Never having kids (remember that when you’re paying for their college)
  15. Taking hormone replacement therapy (HRT)
  16. Certain hormonal birth control methods
  17. Family history of ovarian cancer, especially before age 50.
  18. Being white (at least in the U.S., although the rates of African-American women are catching up, often with a worse prognosis)
  19. Having received diethylstilbestrol (DES) to prevent miscarriage, given either to you or your mother
  20. Being inactive (honestly, exercise is critical – don’t overthink it – MOVE!)
  21. Not breastfeeding (not only does nursing lower your risk, if you do get breast cancer, you’re less likely to get the aggressive triple-negative type)
  22. Being taller (this may have to do with faster growth at an early age)
  23. Doing night shift work (this may affect your hormone patterns, not to mention make you cranky during the day)
  24. Smoking (the evidence for this has been deemed “suggestive, but not sufficient”, but inhaling smoke sounds like a bad idea regardless)
  25. Exposure to cancer-causing chemicals (that’s, like, just about everything out there, and the connection remains unclear)
  26. Diet choices (this is unclear, although there have been some links drawn to both macronutrient proportions and some vitamins, but more research must be done)
Oh, for the day when we can be guaranteed that what we’re doing is helping (or hurting) us!

In a word, we really don’t know, but living a healthy lifestyle gives you the best chance for survival.

Finally, the things that seem to have no reasonable link (per WebMD and echoed on other sites):

  1. Antiperspirant (no need to stink)
  2. Bras, underwire and regular (feel free to support yourself)
  3. Abortion or miscarriage
  4. Fibrocystic breast changes
  5. Multiple pregnancies
  6. Coffee/caffeine (raise your mug in celebration!)
  7. Hair dye (unless it’s really radioactive, but come on, that would be silly)

Judging from the above info, it can feel like cancer is waiting around the corner to pounce on the next unsuspecting victim that wanders by. I thought I had ZERO risk factors, but I can easily pick out several there. At the same time, I know people who seem like they’d have a gazillion risk factors and they never get zapped. So.not.fair. But that’s cancer for you.

And the more we find out about the disease, the more we see how complex it is. We are all different, reflected by our DNA, so it’s not out of the question that we might be affected in unique ways by these risk factors. Research is uncovering new connections all the time, and it may be that in order to find a cure for cancer, we’re going to have to look at the disease in ways that we never have.

Pre- vs. Postmenopausal Breast Cancer Risk: There’s a Difference, But Does It Matter?

You’ve probably seen those plastic breast self-exam cards you hang on your showerhead as a reminder to feel for lumps on a monthly basis. I have one myself, and would read it over and over when I was trying to decide whether my lump was worrisome, reviewing the “reduce your risk” tips the card offered.

However, there are two points that I wasn’t aware of at the time that I was diagnosed: (1) we know little about causal factors, as most studies that examine risk are only correlational; and (2) there’s a difference between being premenopausal vs. postmenopausal when talking about breast cancer.

Okay, there’s a third one too: (3) risk factors don’t mean squat when I’m talking about my personal diagnosis.

First, a well-known fact: postmenopausal women make up the majority (approximately 2/3) of these cancer cases, so it’s not surprising that the focus is on them.

I, however, was premenopausal when I felt the lump in my left breast.

Imagine my surprise, then, when I learned that while being overweight or obese is a significant risk factor for postmenopausal women, being overweight as a premenopausal woman seems to offer protection against the disease. Whereas I thought I didn’t have any risk factors for breast cancer, as suggested by that plastic card in my shower, perhaps I did.

There’s not much talk about that protective element of weight for premenopausal women. You would be hard-pressed to find a popular website that mentions it. And no doctor would encourage a premenopausal woman to carry extra weight on the off chance that it might lower her risk of breast cancer; it’s too much of a liability for other health issues, including other cancers.

This explains why, if you’ve gone to a gathering of newly-diagnosed breast cancer patients, you’ll see some younger, remarkably fit women looking a little dazed and wondering what they’re doing there.

The weight risk factor is often posed in the following way (from the Mayo Clinic site): “Overweight and obese women have a higher risk of being diagnosed with breast cancer compared to women who maintain a healthy weight, especially after menopause.” Well, that’s not wrong, but it doesn’t tell the entire story.

Harvard Health Online puts it differently, with a caveat: “Being overweight or obese has been linked to breast cancer risk, especially for women after menopause, but the relationship is complicated. It may be that risk is increased in women who gain weight in adulthood but not in those who’ve been overweight since childhood.” That seems even more confusing and less reassuring.

It’s true that everything about cancer is complicated. If it were straightforward, we would have found a cure by now. Furthermore, when it comes to guidelines to follow, people don’t want details, they want sound bites. But simplification cuts out information. For example, this CDC webpage about what you can do to lower your breast cancer risk posts recommendations geared for older women, including maintaining a “healthy weight”, but the photo that’s shown is clearly of two younger women.

Even a cursory glance at the research reveals what a difference menopausal status makes. In addition to extra weight seeming to have a protective effect in premenopausal women (Cold et al., 1998, Eur J Cancer; Lahmann et al., 2004, Int J Cancer), it’s also been determined that greater red meat consumption in adolescence is significantly associated with increased risk of breast cancer in premenopausal women (Farvid et al., 2015, Int J Cancer). Interestingly, higher quality diets have a more beneficial effect on the risk of postmenopausal women and seemingly no effect on premenopausal ones (Haridass et al., 2018, J Nutr). I would expect that a more exhaustive search would yield even greater differences.

Live as if your life depends on it.

So what does this tell us? This is less about the specific differences between pre- and postmenopausal breast cancer risk, and more that there simply is a difference. At this point in our knowledge, we are still putting together pieces of the cancer puzzle.

Additionally, many studies that offer preventative guidelines are based on other studies–they may be meta-analyses of previously collected data from a broad range of subjects. The data may be self-reported, which may result in recall error. And when you have a sample size of ~30,000 women, you’re talking about general risks for populations, not a specific risk for a specific, and very unique, individual: you.

All this sounds exasperating, but one concept holds true: no matter what your risks, the healthier you are before you’re diagnosed with cancer, the better your outcome compared to someone with less healthful habits, should you get the disease. Instead of obsessing about possible risk factors, give yourself the respect you deserve–put the effort into improving lifestyle habits to grant yourself the best chance for survival. In the end, that’s what matters.

What Do We Really Know About Cancer?

Some of the recurring themes in my conversations with my oncologist have been that there’s so much we still don’t know about cancer and that the truth will likely be much more complex than we realize.

The recommendations offered as ways to reduce the risk of cancer should not be misconstrued as sure ways of preventing the disease. Thinking we can prevent something gives us a sense of security, which is what we crave. With cancer, we don’t yet have a clear view of how the processes that initiate a DNA mutation translate into our everyday world behaviors or environmental influences, if they even do. What we know is mostly correlational, which means that there seems to be a connection between two things, that they occur together. But that does not mean that one causes the other.

Consider this example: the growth of grass that comes in spring is correlated with the appearance of robins searching for worms. But it would be incorrect to say that the appearance of robins causes the grass to grow. That’s confusing correlation with causation.

In the case of cancer, we don’t have significant causal information when it comes to providing guidelines to humans about what to do and what not to do to prevent the disease. We can offer suggestions, although as in the case of the robins, we can be way off in terms of the way that one thing might affect the other.

Perhaps most unsettling is that as humans, we’re used to being the top predator. What we don’t have as protection inherently (claws, fur, huge teeth), we can use our big brains to manufacture. Cancer, however, still exerts its dominance over us.

We are trying, of course, and learning more all the time. Witness how far we’ve come with treatments, and how we’ve affected the survival rates. That’s a significant and positive step – as a breast cancer survivor, I can attest to that.

But not being able to effectively address the cause means that the treatments, as effective as they may be, take a huge toll on the patient both physically and psychologically. Many of us struggle in recovering from treatments that are considered highly effective, while others succumb to either the disease or the treatment itself.

So as the Breast Cancer Awareness Month of October comes to a close, it’s a good time to celebrate all the positives associated with our medical advances, but also keep an open heart for those who continue to suffer from any type of cancer.

And many of those do not have the benefit of being highlighted in pink.

Two Assumptions I Wish Doctors Didn’t Make About Cancer

Cancer can turn you into a stress-ball on its own, thankyouverymuch, but there are things that healthcare workers do that may worsen matters.

While there is always room for improvement in the many subtleties of physician-patient interactions (with subtleties being the operative term here, as anxious patients may be zeroing in on the “feel” of interactions and not just the spoken words), there are two big assumptions that I wish doctors would realize that they’re making:

Eat your vegetables and you won’t get cancer? I wish it were that simple.

The first assumption I’ve experienced has been made by non-oncologist physicians. They seem to be just as likely as the rest of the population to confuse correlations with causations. One doctor had been surprised that I had gotten cancer (hey, join the club) because my lifestyle “should” have been protective.

This physician, you could argue, was justified in saying what he did, as the messages we are bombarded with suggest that we have some control over our risk for cancer. However, read the fine print and you’ll see that in a great number of cases the risk factors that a cancer patient has don’t differ from those of someone who doesn’t develop cancer. But even doctors miss the fine print…

I brought this up to my oncology team which was quick to point out that as long as we don’t definitively know what causes cancer, we can’t make assumptions about whether or not someone will get the disease. So, yeah.

The other major assumption is one that I’ve gotten from the oncological community, and that is that on some level, most patients with a given cancer have the same health profile. Ironically, this concept is often mixed in with the conflicting assertion that everyone’s cancer experience is different. Granted, when you’ve seen a gazillion cancer patients, similarities emerge, and consciously or not there’s probably a tendency to pigeonhole people. Still it’s frustrating to be treated like I fit into a slot when I really don’t.

Effective communication is a critical part of quality physician-patient interactions.

My own oncologist has realized that, thankfully, but he has done a good job of listening and I do a (*cough cough*) good job of talking. Perhaps a bit too good, since he’s mentioned that it would be best if I scheduled my appointment to be his last of the day, so that we don’t face as many time restrictions. But therein lies my point: oncologists need to ask and patients need to share, otherwise, the patient remains a two-dimensional entity and it’s more likely that assumptions will be made about them.

So if there’s a take-home message from any of this, it’s that good communication is an essential part of effective treatment. This is not an easy feat, as physicians have a limited amount of time with each patient, and patients might not think that a given aspect of their experience is relevant. Believe me, it is, and the more that we talk about this and get into the nitty gritty of it, the easier it will be for everyone involved.

A Final Word On Risk Factors

Okay, maybe this post’s title is a lie, since I keep bringing this topic up. But I admit that I need to stop whining about getting breast cancer when I didn’t have risk factors, so I’m officially giving myself one last time to vent. And then it’s time to let it go.

First, what is a risk factor? The NIH National Cancer Institute dictionary defines a risk factor as “something that increases the chance of developing a disease”. However, that does not mean that it’s necessarily a cause of that disease. And that’s where the potential confusion (and in my case, irritation) arises.

While breast cancer has a number of risk factors, none of them are 100%-for-sure causal in nature. Even having the BRCA gene does not guarantee that you’ll get breast cancer, although your risk is quite high.

So why does this matter? Turn this around and look at someone with breast cancer. Based on risk factors, you’d expect them to be overweight, sedentary, a smoker, a drinker, an unhealthy eater…and you might be completely wrong. Ascribing unhealthy behaviors to an individual just because they are a cancer patient is potentially stigmatizing (it suggests that they are responsible for bringing on their disease) and ignores the fact that we still don’t know why cancer develops. And what of all those making poor health choices who do not get cancer?

Engaging in the opposite behaviors — being a lean, active, non-smoker, non-drinker with a plant-based diet — likewise is not guaranteed to protect you from breast cancer. And yet, that’s exactly the feeling you get from reading all the recommendations, which leads to a potentially dangerous false sense of security.

Risk factor, schmisk factor! Putting in the effort to live as healthfully as possible is well worth it, no matter what.

Certainly, no matter what disease you have, the more healthy behaviors you engage in, the better your outcome. However, even being a paragon of healthy living is not the “get out of cancer jail free” card that we are led to believe it is. So get yourself checked out and don’t take your health for granted!

What brought all of this up? At a recent gathering, I had an interesting conversation with another former cancer patient who also happens to be a medical psychologist. She felt as frustrated as I did about the way cancer risk factors are presented, so I felt a vindication of sorts. We both agreed that it is critical to highlight the difference between cancer risk factors and causes. And of course, no matter what your perceived cancer risk, to live as healthfully as possible.

Now that I’ve gotten that off my chest, I will do my best to shut up and move on.

Exercise, Eat Right and Get Cancer Anyway

I need to get this off my chest (no pun intended), because it drove me absolutely nutso for a long time. As far as I was concerned, there was no reason whatsoever for me to get breast cancer, and a gazillion reasons for me not to. I had fantasies of taking the breast self-exam instructional card that hangs in our shower and running it through the shredder, flipping it off as it disappeared into the steely maw. That’s because on the backside of the card were guidelines to reduce one’s risk of getting breast cancer, and it was infuriating how anemic the suggestions were, as in, they were setting the bar pretty low: “maintain a healthy weight” (been doing that for a long time), “add exercise into your routine”, (are you kidding me? Strength training, rowing, the whole nine yards!), “limit your alcohol intake” (WHAT? I don’t even freakin’ drink!!!). Every time I looked at that card, I fumed. I had gone to great lengths to follow health rules to a T, always erred on the side of caution to the point of being anal about it. When my doc felt the breast lump that I pointed out to her–the one that I’d felt for a good six months but had not gotten checked out because I had no risk factors and I was always fretting about health stuff that turned out to be nothing and I didn’t want to waste the co-pay and the lump was probably going to go away on its own soon, blah blah blah–I was shaken by both her obvious concern and the warning not to put off getting the diagnostic mammogram done.

Obviously, things did not turn out as I’d hoped. Ergo, this blog…

Following all these guidelines touted to reduce your risk of breast cancer, and then being the one among all my relatives to get it was intensely frustrating. I was the health nut, the vegetarian, the exerciser, habits for which I’d gotten my share of ribbing.  I spent a lot of time angry about this, searching for answers why. Maybe there was something I had missed? Was it the plastic straws? Contaminated toothpaste? Radiation from outer space?

Then there was the emotional fall-out, an effect of my perfectionist tendencies. I felt shame, as if I were being judged and people would think that I must not have been “following the rules”. Were they gloating at me? Other women who were not paragons of healthy living didn’t have cancer. But I did? I felt the need to explain myself, as if I risked getting kicked out of some “healthy persons’ club”. There is a popular expectation that the only time people my age exert themselves is when they’re chased by their neighbor’s pitbull. Or running down a Black Friday special. But to actively work at maintaining a healthy existence for the sake of maintaining a healthy existence and presumably a healthy future? Not the typical 50-something. I prided myself on being different and was free of health problems for years, but getting smacked down by cancer…that’s a pretty big one. So was all the effort and exercise and veggie consumption worth it?

Undoubtedly.

What helped calm my anger was looking at my situation this way: Would I not have gotten breast cancer if I ate meat? Or was overweight? Would I have been spared if I drank alcohol or smoked? Or led a sedentary existence?

While following all the rules and recommendations didn’t prevent my cancer, I can unequivocally say that it accelerated my recovery. And I do not for a second regret the effort that went into that focused mindset. Yes, I still wanted to feed the breast self-exam card to the shredder. Many times. But that’s because I forgot that statistics are great for defining populations, but ultimately they don’t matter when it comes to the individual. When you have cancer, your chance of having cancer is 100%. I wanted answers, but so does every cancer researcher out there. As my surgeon reminded me, “If we knew why, we could cure it.” And I’d be up for a Nobel prize.

So, I don’t know why. Of course, since I’ve mulled this over and over, I’ve got a load of theories, some more convincing than others. It’s part of my nature to want to know the why so that I can feel a sense of control over what is a very frightening disease. But I don’t have that. I do, however, have a determined nature and am happy to eat plant-based foods and find pleasure in exercise, and for the time being I will be content in that.