https://www.nytimes.com/2020/08/24/well/live/breast-cancer-prevention.

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By Jane E. Brody

Aug. 24, 2020

Medication and Lifestyle May Lower

Breast Cancer Risk
There is compelling evidence that two classes of drugs normally prescribed following
breast cancer treatment can also help prevent the disease.

Mammography is a valuable tool for finding breast cancer when it is still confined to
the breast and highly amenable to cure. But no matter how good the odds for survival
may be with early detection, I’m quite certain women would rather not develop
breast cancer in the first place.

Yet, even though one woman in eight will eventually receive a breast cancer
diagnosis, only a minority currently take advantage of the well-established lifestyle
measures for reducing chances of developing the disease, and far fewer take
medications that can help prevent it in women at higher than average risk.

Part of the problem may well be the confusion wrought by periodic reports of
conflicting evidence for what raises — or lowers — a woman’s chances of developing
breast cancer, ranging from the drugs she uses to the foods and beverages she
consumes. Another inhibiting factor is the limited amount of time doctors can devote
to assessing a woman’s risk of breast cancer and explaining the complex trade-offs
involved in breast cancer prevention.

In the latest report published in JAMA, experts at the University of California, San

Francisco, reviewed compelling evidence for two classes of drugs normally
prescribed following breast cancer treatment that can also help prevent cancer in
some women not yet affected by this disease. One class consists of two drugs,
tamoxifen and raloxifene, that inhibit the action of estrogen in selective tissues. The
other consists of three aromatase inhibitors, anastrozole, exemestane and letrozole,
that reduce the levels of circulating estrogen that could stimulate the growth of
estrogen-sensitive breast cancers.

Whether a woman might consider such drugs depends in part on lifestyle measures
and medical history. Although some women may choose to ignore existing evidence
and continue to do what they enjoy regardless of the associated risk, experts say
women should at least be able to weigh their chosen behaviors against a raised breast
cancer risk. Their decisions should also consider their personal health history and
the ailments that run in their families to which they too may be susceptible.

Consumption of alcohol is a classic example. Even a small amount of alcohol — less

than one drink a day — can raise breast cancer risk, and the more a woman drinks,
the greater her chances of developing this disease. A friend recently treated for an
early-stage breast cancer quit drinking wine, which resulted in weight loss that may
also reduce her risk of a new or recurring breast cancer.

On the other hand, moderate consumption of alcohol, and wine in particular, is

associated with a reduced cardiovascular risk, so if heart disease figures more
prominently than cancer in your family, you may decide to have that daily glass of
wine. With smoking, however, there is no health benefit, only risk — to your breasts
as well as every major organ and your life.

Another modifiable breast cancer hazard is being overweight, especially after

menopause, when body fat becomes the major source of cancer-promoting
hormones. The good news here is that the two measures that can help you lose excess
weight — a healthy diet and regular physical activity — also protect against breast
cancer and reduce the risk of heart disease.
Strive for a mostly plant-based diet of vegetables, fruits, whole grains, beans and
nuts; healthy sources of fats like olive and canola oil; and fish in lieu of red meat. And
include a weekly minimum of two and a half hours of moderate physical activity, or
75 minutes of vigorous activity, plus strength training twice a week.

Alas, two long-known protective factors — early childbearing (in the teens and 20s)
and prolonged breastfeeding — run headlong into the life goals of many modern
women who seek graduate degrees and professional advancement, as well as young
women financially unable to support a family.

Many older women run into another confusing and controversial decision: whether
and for how long to take hormone therapy to counter life-disrupting symptoms of
menopause. Barring an earlier history of breast cancer, current advice for women
who have not had a hysterectomy is to take combination hormone therapy (that is,
estrogen and a progestin) for as short a time as needed to control symptoms but no
longer than a few years.

A recent study, published July 28 in JAMA, described the long-term effects on breast
cancer risk among 27,347 postmenopausal women randomly assigned to take
hormone replacement or not. The authors, led by Dr. Rowan T. Chlebowski at UCLA
Medical Center, reviewed the health status of the participating women more than two
decades later.
Among the 10,739 women who had no uterus and could safely take estrogen alone
(progestin is typically added to prevent uterine cancer), menopausal hormone
therapy significantly reduced their risk of developing and dying from breast cancer.
However, among the 16,608 women with a uterus who took the combination
hormone therapy, breast cancer incidence was significantly higher, although there
was no increased risk of death from the disease.
In commenting on these results, Dr. Christina A. Minami, a breast cancer surgeon at
Brigham and Women’s Hospital, and Dr. Rachel A. Freedman, an oncologist at
Dana-Farber Cancer Center, wrote that the new findings “are unlikely to lead to the
use of hormone therapy for the sole purpose of breast cancer risk reduction.”

But Dr. Freedman said in an interview, “If I’m counseling a patient who’s really
miserable with menopausal symptoms and is a candidate for estrogen only, these
findings are reassuring that her breast cancer risk will not be any higher over time.”
Then there’s the possibility of taking a daily drug to suppress a potential breast
cancer in high-risk women who have not yet had the disease. Dr. Jeffrey A. Tice, an
internist at the University of California, San Francisco, suggested that women’s
doctors use one of the several risk assessment calculators to determine how likely the
patient might be to develop breast cancer within the next five or 10 years.

The United States Preventive Services Task Force concluded that the benefits of
medication outweigh the risks for postmenopausal women with a 3-percent or
greater chance of receiving a breast cancer diagnosis within five years.

Starting at age 40, younger women with a strong family history of breast cancer and
those who have had precancerous findings on a breast biopsy should consider
preventive drug therapy, Dr. Tice and Dr. Yiwey Shieh suggested in JAMA. Dr. Tice
said women in the top 5 percent of breast cancer risk for their age might also evaluate
the benefit of preventive therapy and its possible risks, which can include blood clots
or bone loss, depending on which drug is used.

“Five years of therapy can reduce their breast cancer risk for up to 20 years,” he
reported.