Dr. Bruce Feinberg

tg: So many people contract breast cancer today. Are there any known causes of this dreaded disease that we should know about and stay away from?
Dr. Feinberg: The simple answer is, no. Breast cancer is predominately a disease of women but it does also occur in men. It is a disease of aging, thus the chance of breast cancer increases as a woman ages. The lifetime risk of breast cancer, given the fact that women now live to be about 82 to 85 years of age in the Western world, is about one in eight. Although there are associated risk factors, there is not one simple thing that a woman can do to protect herself. Generally, we talk about a healthy lifestyle. Exercise on the order of 30 minutes of real exertion per day is probably the single best thing a woman can do for herself. The second most important thing is a healthy diet, lots of fruits and vegetables and maintaining normal weight. There have been associations of breast cancer with obesity, with excessive alcohol intake, with high-fat diets, but all of those associations are weak, they are not strong direct causative statements. They are weak associations that you can avoid if
you have a healthy lifestyle. The second group of risk issues are related to what researchers call unopposed estrogen. That would be the presence of estrogen in a woman’s body month after month, year after year, on a continuous basis. What interferes with estrogen? Childbirth interferes for one thing. When you give birth to children, you stop estrogen production temporarily. That is why there is an association of increased breast cancer risk with women who have no children. This is called a nulliparity. A woman who doesn’t have children or who isn’t planning on having children but does take birth control pills may have a benefit from the birth control pills. Although the birth control pills are a form of estrogen, they significantly decrease the higher levels of estrogen that accumulate during periods of the menstrual cycle. Thus, birth control pills may offer some protection. The only truly defined strong relationship is a heredity gene mutation called BRCA 1 and BRCA 2 that genetically predisposes one to breast cancer. That defect has been found in Ashkenazi Jewish women, but it is not restricted to them. The hallmark of the hereditary breast cancer, which only represents about 10 percent of all breast cancers, is breast cancer in multiple generations with the youngest family members contracting breast cancer at an age less than 40.

tg: Is the pill still considered a suspicious cause?
Dr. Feinberg: No, the pill is not considered a suspicious cause, just the opposite. If anything the pill may have some beneficial effects. That is different, of course, than hormone replacement therapy.

tg: Will you please comment on hormone replacement therapy? What is your thinking on women taking hormones and specifically about dosage?
Dr. Feinberg: Rather than the pill, which tends to diminish the high peak levels of estrogen during the menstrual cycle, if you extend the estrogen years by giving estrogen replacement therapy beyond natural menopause, it may predispose one to breast cancer. I think where we became confused in medicine is the fact that we thought there might be some additional benefits to estrogen replacement therapy beyond natural menopause. We thought taking estrogen replacement therapy might reduce Alzheimer’s disease, we thought that it might decrease osteoporosis and we thought it might diminish coronary artery disease. We thought it might be a wonder drug in the same way that we think of taking an aspirin everyday. We thought estrogen might provide that wonder drug effect for a woman. We learned recently, in two large studies with thousands of women involved, that taking estrogen replacement therapy was not a positive thing to do. It did not decrease cardiovascular events and it did not diminish dementia. Yes, it did help osteoporosis but there are many other ways to do that. It did increase the risk of breast cancer. Surprisingly, it decreased the risk of colon cancer, which is not explained at this point, but is an interesting observation. In sum total, looking at all parameters, overall continued estrogen therapy beyond menopause is thought to be detrimental to a woman’s well being, not beneficial. That said, there are women who have an extremely difficult time with menopause. I think what should be stated is that if you are having an extremely difficult time because of extremely symptomatic menopause, then the notion should be to use as little estrogen replacement therapy as possible to mitigate the symptoms and use them for as brief a period of time as
necessary.

tg: Why does it seem that so many younger women are getting breast cancer? What’s going on?
Dr. Feinberg: We are not convinced at this point that more young women are getting breast cancer. As our technology and education improves, it allows us to diagnose breast cancer earlier. Perhaps younger women are coming in earlier for screenings. So, younger women aren’t getting breast cancer earlier we are just doing a better job of diagnosing their cancer earlier. Two things happen from this: We are diagnosing breast cancer at an earlier age and usually treating it at an earlier stage. This is good news because we have a greater potential to cure the cancer. Essentially, the women who were being diagnosed at 55 are now diagnosed at 45. Instead of diagnosing a cancer that is the size of a golf ball, we are diagnosing women with a cancer that isn’t much larger than the head of a pin.

tg: OK, so you get a diagnosis. What should be your first step? I’m sure your book, "Breast Cancer Answers" would be a big help.
Dr. Feinberg: Catch your breath and count to 10. Recognize that you can’t be rash in your decision-making, as these decisions may affect the rest of your life. Try to step back and be objective, possibly get two opinions, not just one. Become educated, both you and your family, and this is not that difficult to do. It is mind-boggling that people will educate themselves about high-definition television or the new type of plasma TVs before they go out and make that purchase. When it comes to health care decisions people act in shock and proceed wherever they are directed, not becoming invested in the process themselves so they can become their own best advocates. Unfortunately, although the internet may provide a lot of valuable information when you are searching for a technology solution, it doesn’t often do so for health care. There is so much information and so much misinformation that must be filtered from fact. That is why I wrote this book.

tg: A breast cancer diagnosis used to be a hopeless situation. I understand this is no longer the case.
Dr. Feinberg: I like to use a metaphor to speak about this. The general population today maybe doesn’t see breast cancer as those in the health care field do. In the health care field, we see it as a disease we are conquering. It is no longer a death sentence. Nowadays, the great majority of women who are diagnosed will survive and be well and have a normal fulfilled life. In the 1960s and ’70s, heart attacks were the life-ending disease. That was the talk at the dinner table. Today, we don’t speak that way about heart disease and we aren’t fearful of it. We’re comfortable with heart disease as something that can be cured; perhaps we aren’t as concerned as we should be.

tg: Talk a bit about reconstruction. Is this something a woman should have done at the same time she is
undergoing a mastectomy?
Dr. Feinberg: This is a very personal decision. The first question becomes how often should a woman have a mastectomy? We now know that for somewhere in the range of 80 to 90 percent of women who have breast cancer, conserving their breast will offer equal outcome to having the breast removed. That said, many of my patients will have both breasts off. For those women who make that emotional decision, they will have to decide if they want to wake up with a breast mound and also decide how emotionally upsetting will it be to wake up and not have a breast at all. I think this decision differs person to person but I think the majority of younger women prefer to wake up with that breast mound and not have to go through a period of time without one. For those women, immediate reconstruction is a great advance. I tell many of my patients to delay the surgery and have the chemotherapy first. If they begin chemo first, we don’t have delays in the total body treatment and we lessen the worry about waiting for wound healing. This is called neo-adjuvant therapy and it is becoming more and more popular. Neo-adjuvant therapy also gives the patient time to get more than one opinion about reconstruction. Reconstruction planning is not so easy. Two surgeons have to coordinate their schedules and hospital time and that can take time. After the surgery to remove and reconstruct the breast there is a need to wait for the healing to begin before starting the treatment for those cancerous cells that might still be in the body. So, we have another method to treat the breast cancer. First we stick a needle in the lump to confirm that it is cancer. If the confirmation is positive, then we do the chemotherapy and after we complete the chemotherapy, we continue with the surgery. That is also how we treat other cancers such as cancer of the rectum. It is not a unique concept, it is just relatively new to breast cancer management.

tg: Talk about resuming your sex life after breast cancer.
Dr. Feinberg: The sex life shouldn’t have to stop before, during, or after breast cancer. If a patient is on chemotherapy, the chemotherapy is not going to be transmitted by bodily fluids so there is no risk to the male partner. There is no risk to the female because of any exposure to the male during the treatment. The biggest issue is how breast cancer will affect a woman’s sense of sexuality, and, obviously sexual desire is a very complex phenomenon which is physical, biochemical and emotional. All of these things are affected by a cancer diagnosis and cancer management. You need a very understanding partner and you need to have a higher level of consciousness to sometimes see though all of that. Continue behavior as normal. What I do recommend to our patients is that they do not undervalue or underestimate the potential value of counseling. We think it is something that should be done early on.

tg: Talk about lumpectomy versus mastectomy.
Dr. Feinberg: If we look at the evolution of breast cancer management, we are evolving on different fronts. We are not only trying to find and destroy the rogue cancer cell that may have gotten into the circulation using different forms of chemotherapy, targeted therapy and anti-estrogen therapy, but we are also trying to make the surgical management less mutilating. Studies were done over the course of the last quarter of the last century and we have moved away from the radical mastectomy to doing what today is often no more than the removal of a lump and a single lymph node. With this approach the majority of the time we have adequate information to proceed with definitive treatment planning.

tg: What is your feeling about prophylactic breast removal for a family that has a history of breast cancer? What is the significance of multiple cases of breast cancer in the same family?
Dr. Feinberg: Again, we want to try to define high incidence. If your mom and your grandmom both had breast cancer and were in their 70s when they were diagnosed, that is probably an age-related phenomenon. Such a family history is likely not indicating an inherited genetic risk and probably does not necessitate having preventive breast removal surgery. Now, if your grandma was 50 when she was diagnosed and your mom was 42 and you are now 36 and newly diagnosed, then we are dealing with a different pattern of cancer that predicts a certain probability of hereditary risk. If that is the case, then there are a couple of things that can be done. First you can have genetic testing to see if you are a BRCA 1 or BRCA 2 carrier. If you do have that mutated gene, this would definitely reinforce the need for removing both breasts. If, on the other hand, you do the test and the test is negative, you may still choose to remove the breasts understanding that our testing is still in its infancy. There may be other mutations or abnormalities that predispose to breast cancer that we just don’t know about yet.

tg. You mentioned that men get breast cancer. Is this becoming more common?
Dr. Feinberg: About one percent of all breast cancers occur in men. We are not seeing an increase in this amount. In the upcoming year we will see about 250,000 new cases of breast cancer, there will be about 50,000 women who will have a noninvasive cancer of the breast that is called ductal cancer in situ or DCIS that can be cured by surgery and does not require additional treatment such as chemo. The other 200,000 of the breast cancers will be invasive breast cancer, which, although it can be removed surgically, carries the risk of some cells still being in the body and that usually requires additional treatment such as an anti-estrogen pill or chemotherapy. There will be about 2,000 male breast cancers diagnosed this year.

tg: What’s the best way to detect breast cancer? How often should you get mammograms and sonograms?
Are there any new tests on the horizon? Is there a blood test that can detect cancer?
Dr. Feinberg: It is unfortunate that we do not yet have a simple blood test. The good news is that mammograms have now been confirmed, without question, as beneficial. Mammography should be done initially at age 40, and every one to two years during your 40s then annually after age 50 unless a mother or sister has breast cancer. In that case, a woman should get a mammogram annually beginning 10 years younger than their relative’s age at the time of their diagnosis. Sonograms should be restricted to those mammogram abnormalities that require more evaluation. The last test is an MRI. The MRI is at this point not ready for prime time for most patients. When an MRI is done with a specific technical device called a breast coil, it is very, very sensitive. The problem with it is that it is somewhat too sensitive and not specific. Mammography is done beginning at age 40 and not earlier because a mammogram is most effective when breast tissue begins to be replaced by fat. When there is less fat in the breast, say in a 20- or 30-year-old, the breast is so dense that the mammogram has difficulty seeing though it well enough to delineate an abnormality. As the mammary tissue within the breast starts to become surrounded by more and more fat, that fat buffer helps to expose any abnormalities and will result in a clearer image.

tg: How important is diet in connection to breast cancer?
Dr. Feinberg: We think diet is important because we see that there are patterns of breast cancer that are very different in different parts of the world. In parts of the world where the diet is much lower in animal fats and much higher in vegetables and fruits in terms of the percentages of calories, we see many fewer breast cancers. Now you take a population from a country that is very low risk and move them to a country that is high risk, we typically see that within two generations their breast cancer incidence assumes that of where they are now living. One example is Japan, where the incidence of breast cancer is less than half of what it is in the United States. A Japanese family moved to the U.S. in 1950 and the generation that is growing up now is going to have the same breast cancer incidence as their neighbors whose families have been living here for the last two hundred years. We do know that there are some associations with types of foods and breast cancer. High fat seems to be an association, but that’s not yet proven. We think there is a biochemical explanation for alcohol relationships, and we are concerned about high alcohol content. We think because of the relationship between fat cells and estrogen production, there is a breast cancer relationship to obesity. So, eating lots of fruits and vegetables, maintaining a normal weight and moderating use of alcohol would be the key dietary guidelines.

tg: Do you foresee a magic bullet for prevention of breast cancer in the future?
Dr. Feinberg: Just this year a vaccine was introduced for cervical cancer. What makes cervical cancer unique is that we believe the cell’s DNA becomes damaged because of human papilloma virus infection and therefore you can vaccinate against the human papilloma virus and prevent the cervical cancer. We don’t have such clear-cut causation in breast cancer. Because we don’t have a clear-cut causation, that idea of a vaccination, an all-purpose preventative, seems much less likely. It is going to become a matter of lifestyle, behavior modification to lower risk, and utilizing the screening tools that are available so that when breast cancer is found, it is found at a stage before it becomes invasive and can spread, when it is no bigger than a pin head, and when it can be cured. Although we won’t be eradicating breast cancer completely, we will be eradicating the devastation that breast cancer can cause.