From: ((Steven B. Harris))
Subject: Re: Breast Removal as Cancer Preventative
Date: 17 May 1995
Newsgroups: misc.health.alternative

In <3pbbe9$1klb@bigblue.oit.unc.edu> "a. phillips"
<a.phillips5@genie.geis.com> writes (quoting Duane Weed):

>>     This is not such a far-fetched notion. I saw an MD (can't
remember his name) on a nationally televised talk show who advocated
that all women over 40 have their breasts removed to prevent breast
cancer.  <<


Comment:  Well, Hell, Dr. Weed-- if you saw it on a nationally televised
talk show, then it MUST be representative of average reality.

  >>They are obviously quacks, but some people are taking them
seriously.<<

   Not as seriously as they take chiropractors unfortunately.  Which is
why you don't see that many chiropractors on talk shows, although they
naturally belong there.

>> (The doctor I saw on TV said nothing about a low fat, high fiber
diet--which has been show to decrease the risk of breast surgery.<<

   Actually it hasn't yet-- such a diet has been statistically
associated with less change of breast cancer, but that's not quite the
same thing.


    >>Worse yet, I saw a news feature on TV about a woman who, having
seen her mother die of breast cancer, chose to have both breasts removed
to avoid the same fate, even though there was no indication (other than
a speculative hereditary factor) that she would be likely to suffer the
same fate. Though I can appreciate her fear (terror, more likely), I
have great difficulty understanding a rational surgeon carrying out such
wishes, especially given the evidence and abundance of preventative
steps.<<

   The problem is that the "preventative steps" you mention are far more
speculative in their effect (which will small even if present) than the
surgery is.  There is also the fact that (until recently) a woman could
have prophylactive surgery, leaving nipple intact
(which you cannot do with cancer, often), then reconstructive surgery,
and come out looking about the same as before.  Crazy, you say?  In most
cases.  But consider the woman who comes from a family which really does
have one of the identified breast cancer genes, and has a risk of breast
cancer not 10% (which is the average), but more like 50% ?   What the
woman does there will depend on a lot of tradeoffs which are very
personal.  It isn't up to the doctor to do any demanding in such a
situation, but it's not immoral of a surgeon to operate on such a woman
if she wants it done.  Or even to tell her that she (for some surgeons
ARE women, remember) would have it done if SHE were in those
circumstances.  Of if a "he," would urge his wife to do it.

>I would welcome a Dr.'s comment/opinion as to whether or not removal
>of breasts as in the case above reduces the risk for cancer, or merely
>precludes a cancer from forming in (nonpresent) breasts...

Same thing, is it not?  Surely you didn't imagine that operating on one
breast reduces cancer risk in the other?

                                           Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: alcohol, estrogen, and breast cancer
Date: Wed, 10 Sep 1997
Newsgroups: alt.support.menopause,sci.med,sci.life-extension,sci.nutrition,
	sci.pharmacy

In <3416DD9E.35D6@library.wustl.edu> Roxanna Herrick
<roxanna@library.wustl.edu> writes:

>
>        Alcohol A Key Link Between Estrogen Therapy
>                    and Breast Cancer
>
>
>
>      BETHESDA, Md., June 2, 1997 -- Previous studies,
>including the Op/Ed piece by Susan Love in The New York Times,
>reporting a link between postmenopausal estrogen administration and
>breast cancer have been contradictory because, among other things, they
>neglected an important causal link: the consumption of alcohol,
>according to an editorial in the June issue of the
>Journal of Clinical Endocrinology and Metabolism (JCE&M).
>    The author of the editorial, Barnett Zumoff, MD, of the
>Beth Israel Medical Center in New York, based his conclusions on his
>close review of the findings of the Nurses' Health Study (1995) and the
>Iowa Women's Health Study (1992). Both studies found that only women
>who consumed alcohol manifested an increase of breast cancer with
>estrogen administration.
>    The Nurses' Health Study, a 14-year study of 121,700
>nurses aged 30 to 55 years, showed an overall increase in breast cancer
>incidence of 41 percent but also showed that women who did not consume
>alcohol had no increased risk of developing breast cancer.
>    The Iowa Women's Health Study, which studied 41,837 women
>aged 55 to 69 years, 493 of whom developed breast cancer, reported that
>only women who consumed an average of five grams of alcohol or more per
>day (the equivalent of 2/3 ounces of whiskey or 3 ounces of wine)
>manifested an increased risk of breast cancer with estrogen
>administration; those who consumed less alcohol or
>none at all showed no increased risk.
>      In the editorial, Zumoff emphasizes that no one has
>published data that disagree with the findings of these two studies. He
>also suggests that a 1996 study by E.L. Ginsburg may reveal the
>biological mechanism which accounts for this apparent link. According
>to that study, when a postmenopausal woman receiving estrogens consumes
>alcohol, her blood level of estradiol rises acutely,
>by as much as 300 percent.
>    Accordingly, Zumoff's hypothesis is that the combination
>of alcohol and estrogen therapy may raise estradiol levels above the
>threshold necessary to produce breast-cancer-causing effects.
>   "Dr. Zumoff's insights have provided the clinical endocrinologist
>with a major tool: the ability to educate women about the clear
>benefits of estrogen replacement therapy, while relieving their
>concerns bout breast cancer," said David Orth, MD, president-elect of
>The Endocrine Society.
>    Calling for a thorough study of the issue, Zumoff
>contends, "If we can assure our patients that consuming less than 5
>grams of alcohol daily will eliminate any breast-cancer-promoting risk
>of estrogen administration, we will have made a very important
>therapeutic advance."
>    Published monthly by The Endocrine Society, JCE&M is the
>foremost peer-reviewed journal serving the endocrine clinician.
>Based in Bethesda, Maryland, The Endocrine Society is comprised of more
>than 8,000 scientists and physicians in 65 countries. Founded in 1916,
>the Society is dedicated to the study and treatment of the endocrine
>system.
<<<<<<<<<<<<<<<<<<<<<<<<<




   Comment:

    Fascinating!  A medline search gave me the cite for the
editorial, as well as a letter by Zumoff in the same issue (see
below).  There is strong evidence here for an estrogen threshold
effect.  For evidence of alcohol's clear influence on breast
cancer risk, I've also included some other recent abstracts
below.  It's a real effect, and happens in experimental animals
also.

    The effect of alcohol consumption on breast cancer risk in
studies is far greater than the effect of HRT, and (in fact-- as
I now see) the epidemiological effect of HRT does not show up
EXCEPT with alcohol consumption (which may explain some of my own
personal clinical experiential biases here-- I've already
explained that most of my own HRT patients are elderly Mormon
women who don't drink, and I really see very little breast
cancer).   That being the case with the breast cancer causing
properties of alcohol, even in very small quantities (5 grams a
day is about 2 ounces of wine, not 3, BTW), I suppose that the rage
we've seen in this group toward "drug companies," and "drug doctors"
will now be poured out, so to speak, upon vintners?

   Somehow, I doubt it.  We're not always talking about
rationality here on alt.support.menopause.

                   ...

 You know, my friends, with what a brave Carouse
 I made a second marriage in my house
    Divorced old barren Reason from my Bed
 And took the Daughter of the Vine to Spouse

                   ...


    In truth, some of the same tradeoffs between cardiovascular
risk and breast cancer risk show up on the question of wine
consumption, as they do on hormone consumption.  It seems that if
you want only to take care of your heart, as an elderly woman
you'd best do one or the other, not both.


                             Steve Harris, M.D.


[Quote above from Fitzgerald's translation of the Rubaiyat of
Omar Khayyam]




Abstracts and cites:


J Clin Endocrinol Metab 1997 Jul;82(7):2378
Alcohol, estrogens, and breast cancer.
[LETTER] Zumoff B


J Clin Endocrinol Metab 1997 Jun;82(6):1656-1658
The critical role of alcohol consumption in determining the risk
of breast cancer with postmenopausal estrogen administration.
[EDITORIAL] Zumoff B



Breast Cancer Res Treat 1997 Jul;44(3):235-241
Associations of alcohol, height, and reproductive factors with
serum hormone concentrations in postmenopausal Japanese women.
Steroid hormones in Japanese postmenopausal women.

Nagata C, Kabuto M, Takatsuka N, Shimizu H

Department of Public Health, Gifu University School of Medicine,
Japan. chisato@cc.gifu-u.ac.jp

We measured serum levels of estradiol (E2), sex hormone-binding
globulin SHBG), progesterone, and dehydroepiandrosterone sulfate
(DHEAS) in 61 postmenopausal women drawn from female residents in
a community in Japan to evaluate the relationships between these
hormone levels and potential breast cancer risk factors. The
information on reproductive history, body size, alcohol use, and
physical activity was obtained by means of a self-administered
questionnaire. There was a significant trend in increasing E2
level with increasing height after taking account of age and body
mass index (BMI) (p for trend = 0.04). BMI was inversely associa-
ted with SHBG level after controlling age (p for trend =
0.01). Decreasing progesterone with increasing BMI was observed
after controlling age and history of hysterectomy (P = 0.05).
Alcohol consumption was positively associated with E2 level and
there was a strong linear trend after controlling for age,
height, and BMI (p for trend = 0.001). Trend for increasing DHEAS
with alcohol consumption was also statistically significant
after controlling for age and history of hysterectomy (p for
trend = 0.01). Reproductive factors as well as physical activity
were not related to any of the hormone levels.



Epidemiology 1997 May;8(3):231-237
Alcohol consumption and breast cancer risk among women under age
45 years.

Swanson CA, Coates RJ, Malone KE, Gammon MD, Schoenberg JB,
Brogan DJ, McAdams M, Potischman N, Hoover RN, Brinton LA

Nutritional Epidemiology Branch, National Cancer Institute,
Bethesda, MD 20892-7374, USA.

In a population-based case-control study of women younger than 45
years of age, we obtained a detailed lifetime history of alcohol
use to evaluate the effects of drinking during different periods
of life in relation to breast cancer risk. This analysis focused
on interviews obtained from 1,645 cases and 1,497 controls.
Breast cancer risk was not influenced by drinking during the
teenage years or early adulthood. Contemporary drinking (that is,
average intake during the recent 5-year interval) was directly
associated with risk, but the adverse effect of recent drinking
was restricted to women who consumed > or = 14 drinks per week
[relative risk (RR) = 1.7; 95% confidence interval (CI) =
1.2-2.5]. The effect of alcohol was most pronounced among women
with advanced disease. Compared with nondrinkers, the risk
estimate associated with recent consumption of > or = 14 drinks
per week was 2.4 (95% CI = 1.6-3.8) for women with
regional/distant disease. Our data add support to the accumulat-
ing evidence that alcohol consumption is associated with increa-
sed risk of breast cancer and further indicate that alcohol acts
at a late stage in breast carcinogenesis.

[Comment: at least in pre-menopausal women.  But in these women
estrogen may be more of a cancer promoter than initiator]



Alcohol Clin Exp Res 1997 Apr;21(2):334-339
Ethanol and experimental breast cancer: a review.

Singletary K

Department of Food Science and Human Nutritior, University of
Illinois, Urbana 61801, USA.

There is considerable evidence from epidemiological studies to
support a positive association between alcohol intake and risk
for breast cancer. Yet, experimental evidence has provided less
convincing evidence to support this relationship, although much
less attention has been focused on elucidating the effect of
ethanol on breast carcinogenesis in animal models. Although the
number of reports are limited, information on the effect of
ethanol on mammary carcinogenesis in spontaneous, chemically
induced and metastatic models has been published. In addition, a
small number of reports provide insights into an influence of
ethanol on the physiological processes associated with the
initiation, promotion, and progression stages of breast
carcinogenesis in animals, as well as on the growth of human
breast cancer cells. This information from the literature is
summarized, and specific recommendations put forth so that
greater progress can be made in this controversial and complex
research area.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: Question to the Docs
Date: 24 May 1999 23:32:32 GMT

In <3749416A.42C8EEBE@hotmail.com> rosemariejackson@hotmail.com writes:

>I'm an RN and this morning I treated a tran flap breast reconstruction
>secondary to appr. 1 year hx of radical mastectomy. This is the first
>time I've felt that what I should be telling my patient is that she
>should seek legal counsel and start photographing the wounds. (My history
>is in law). As I'm thinking about this, the issue question is, what is
>the success rate for these types of surgeries?



   I think it's been proven that the classic Halsted radical (with
removal of underlying muscle) doesn't do any better than the modified
radical (muscle left in place).  And for lots of lesions, lumpectomy
plus radiation is as good.

   It's hard to define success rate, as breast cancer is so slow.
Probably you have to look at at least 15 year survivals, and perhaps
even 20 year survivals.  These figures are not available for many of
the less disfiguring procedures.  Also, the stage of the initial tumor
is important.  Probably your best bet is to collect more information on
this lady.  What did she have (how big the tumor, how advanced), what
options was she offered, etc.  If she had a large tumor going into the
muscle, they may well have had no choice but a radical.  Some women
have progressed so far by the time they seek attention that they can't
even do that.  I've seen several of these terrible cases.

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Question from Medical Professional
Date: 19 Mar 2005 16:36:57 -0800
Message-ID: <1111279017.618631.30030@z14g2000cwz.googlegroups.com>

>Jeff,
>I downloaded the reports and will send them to my sister ASAP. Thanks so
>much. I read the information related to tubular carcinomas. I know that
>"ductal carcinoma" begins in the milk ducts of the breast. Do you know
>whether or not tubular cancinomas also begin in the milk ducts or could
>they occur anywhere in the breast? I was under the impression that
>"tubular" meant "tubes". However, it's possible that the cancer cells are
>shaped like tubes.


COMMENT:

Tubular carcinoma is just a ductal carcinoma that hasn't got going yet,
and is only one-cell thick, lining the ducts. So the prognosis is even
better. These are epithelial cells lining the milk ducts (which are
tubes, you see), that have become cancerous. When they section them,
they look to see what fraction of the cells are next to the duct lumen.
If it's more than 70% (meaning 70% of the cancer cells are actually
lining the duct, 1-cell deep), and the cells are not too screwly
looking, you get the good diagnosis of tubular carcinoma. As the
fraction of cells which are more than 2 cells "deep" from a duct goes
up over 30%, then you have ductal carcinoma. But this still hasn't
pentrated the smooth muscle of the ductal wall, and prognosis is a
little poorer, but still VERY good.  All this is very much like the
various grades of cervical cancer, and looks a lot like them. This
tubular stuff is like grade I cervical cancer "in situ". Anyway, tell
everybody in your family to calm down. If you gotta have breast cancer,
this is what you want to have.

SBH