Less than half a century ago it was unthinkable to mention women’s undergarments in polite company.
Even today, in some sectors such as ultra-Orthodox (haredi) women or even more traditional populations in the Arab sector, it is still unconceivable to publicly raise the subject of breast cancer.
But for several hours at Jerusalem’s Cinema City, some 400 people turned up for an open, scientific discussion of the subject on the occasion of the end of October’s Breast Cancer Awareness Month, which is marked around the world. The lectures, which included many anatomical drawings and surgical photos that caused the more sensitive to flinch, was followed by the showing of the new movie Ma Ma starring Penelope Cruz focusing on coping with the malignancy.
There were even some men in the audience – more than the one percent of males who statistically contract breast cancer.
Breast cancer is a very old disease, going back to 16th-century BCE Egyptian society, said Hadassah Medical Organization acting director-general Prof. Tamar Peretz, a veteran oncologist. Then, at least according to papyrus drawings, women with the tumor underwent radical mastectomies without the benefit of anesthesia or trained surgeons.
“But today,” said Peretz, patients have an excellent chance of living with it as a chronic disease, or even recovering completely.
Advances in early detection, chemotherapy, radiotherapy, genetic analysis of tumors and biological and hormonal drugs have raised the survival and cure rates, said Perez.
“We are responsible for our health and our bodies. Pay attention to any changes.
When the wife and mother is well, feels well and eats healthful food, she will affect the whole family.”
The genetic nature of some breast cases has been known for many years, although genes cause a minority of cases, she said, and both parents can “contribute” to the risk. Tumor suppressor genes that are inactivated due to mutations can lead to actual cases.
Hundreds of genes have been described in families with breast and ovarian cancer.
In Israel, there are 30,000 carriers of “Ashkenazi mutations” of BRCA 1 or BRCA genes that can lead to breast cancer, but there are also mutations characteristic of Jews of Iraqi, Persian, Yemenite and other non-Ashkenazi origin. These mutations can also raise the risk for ovarian, pancreatic, colorectal and other cancers.
DR. TAMAR Sela, head of Hadassah’s Center for the Diagnosis of Breast Diseases, said that 20,000 Israelis are currently living with breast cancer, recovering or cured, while some 4,500 are diagnosed and 900 die in an average year. If diagnosed at an early stage, when the tumor is very small, the survival rate is as high as 85 percent to 90%, thanks to innovative and effective treatment that cannot be optimal when the malignancy is detected at a later stage.
Female staffers in the center applied pink nail polish through the whole month of October, while members of a local soccer team wore pink shirts to raise awareness of the topic. Fear and denial are the main enemies of efforts to bring down the prevalence of the disease.
Sela noted that claims such as a “magic bra” claimed to prevent or fight breast cancer; tumors smelled out by dogs or an electronic glove to quickly diagnose the disease are just nonsense.
Bracha Meisels, a breast cancer coordinator at Hadassah, added that women should keep an eye out for redness of the breast that doesn’t go away, inverted nipples, liquid oozing out of nipples that is not breast milk, and other unusual phenomena. These must be checked immediately. Contrary to claims on the Internet, “There is also no connection between cancer and the use of deodorant or antiperspirant or shaving one’s underarms.”
International studies, said Sela, have indicated a decline in mortality of up to 30% due to screening by mammography and supplemental techniques.
A national program of the Israel Cancer Association (ICA) established in 1992 to promote mammograms, other screening methods and heightened awareness has had a significant role in reducing death rates from breast cancer. The Israel Cancer Association invites the female public to contact the 24-hr. hotline service for answers to any questions they may have about breast cancer and other cancers, and to receive informative material free of charge.
The ICA launches every October an extensive public education and information campaign in all the media channels, focusing on the importance of early detection and ways of treating breast cancer, while hotlines and its website provide information year-round.
According to the association, gaps in mammography compliance rates that had been seen in Arab women have been completely eliminated, with compliance rates now identical to those of Jewish women; these demonstrate a narrowing of disparities between different sub-populations in Israel.
Current compliance rates in new immigrant and haredi female populations are about 5% to 10% lower than those observed among native secular Jewish female populations.
In 2001, nearly half of relevant Arab went for a scan, but today, the compliance rate is similar to that of Jewish women of about 70%. Hadassah also provides services, including phone numbers and clinics.
While the American Cancer Society changed its guidelines for breast cancer screening to start at age 45 because screening at earlier ages is mostly inaccurate and can involve unnecessary and even harmful procedures, the ICA has long advocated a more balanced policy of beginning mammography at age 50 and continuing biennially until the age of 75; young women at high risk, who have been struck with breast cancer or who have a family history (a mother or sister) of early breast cancer (most likely due to BRCA 1 or BRCA 2 carrier status) should start at 40 and have a breast scan annually. Asked about women over 75 who want a mammography, Sela said that they do not get it automatically but have to have a referral from their family physician to make sure they would benefit from the scan and are physically able to undergo it.
According to the ICA, it is highly imperative that starting from the age of 20, women become acquainted with their breasts and the changes that take place in them. The better acquainted they are with their bodies, the better they will discern the changes should they occur; the next step is to consult with one’s physician to clarify the nature of such changes. A manual breast exam should be performed periodically by one’s physician who specializes in breast examinations, but the ICA no longer advocates that women do their own manual exam every month because of the anxiety it can cause.
Breast tissue in younger women is usually dense, making mammograms less sensitive and effective in detecting tumors than in older women with fatty-tissue breasts. By the way, a fatty breast is not dependent on the amount of fat in the body in general (as in overweight and obesity) but on age and various genetic factors.
Young women are offered ultrasound and/or magnetic resonance imaging (MRI) scans in addition.
“Mammography is our workhorse, and nothing replaces it,” said Sela. “Every women is different, and if a friend is sent for an ultrasound or MRI scan, it doesn’t mean that you need it. Most – 75% to 80% – of the lumps found in an ultrasound are perfectly normal and non-malignant.”
MRI scans are sensitive, but not everybody can have one; the procedure is ruled out if one has a cardiac pacemaker, renal [kidney] insufficiency or claustrophobia.
It is also very expensive, and so not performed for ordinary cases. When it is performed, she continued, “MRI shows all kinds of things that are not cancer, so it is only for women at the highest risk.”
As for women (and some poorly informed doctors) who believe that radiation from mammography can actually cause breast cancer, Sela declared: “This is not true. We don’t do any mammograms before age 40 or 50 so as not to expose younger breasts to radiation. But the chances at older ages of it causing breast cancer are extremely low.
The risk of getting cancer from a mammography is equivalent to the risk from being naturally exposed during a single flight from Tel Aviv to New York. Around 136 women will die one year prematurely from mammography radiation out of 100,000 who undergo the screening, but almost 11,000 will be saved from breast cancer if it is discovered early.”
DR. EINAT Carmon, a Hadassah breast surgeon, said that policies have changed significantly since the 1980s. Then, oncologists advocated removing the whole affected breast; today, lumpectomies removing the tumor and some healthy margins are generally recommended unless cancer cells are found in the lymph nodes near the armpits. If the first lymph node (out of 12) is found to free of malignant cells, surgeons don’t look for them in subsequent nodes.
“We do less radical surgery and are more conservative, removing the tumor and affected nodes. This is the policy especially if the tumor is diagnosed early. We also have more effective non-surgical treatments available.”
Oncology researchers have found that if the whole tumor is removed, there is only a minuscule difference in survival rates between lumpectomies and radical mastectomies. Many women who undergo major surgery want to undergo breast reconstruction using artificial implants or fat tissue taken from other parts of the body while having the tumor removed, instead of during an additional operation.
ODELIA SASSON-AVRAHAM , a senior Hadassah dietitian who stood out in a suitable hot-pink blouse, said that at least a third of all cancers can be prevented by eliminating or reducing environmental factors such as not smoking, avoiding overweight or obesity, consumption of vegetables and fruit daily, eschewing alcohol (even red wine) and air pollution, exercising regularly and protecting oneself against infection of hepatitis B virus (there is a vaccine given to all babies).
“Having a normal weight is very important throughout one’s life. It’s the responsibility of parents to raise their children so preserve their health, to prevent diseases and maintain a high quality of life,” the dietitian said. Overweight and obese women have more female hormones that raise risk factors after menopause. Fresh produce contains natural fibers, vitamins, phytochemicals, minerals and antioxidants that fight inflammation and carcinogens.
Legumes, nuts, low-fat dairy products and leafy greens are all valuable in a healthful diet.
She recommended eating eight portions of fresh produce a day, especially vegetables (too much fruit adds a lot of natural sugar), preferably a variety of colors because they represent different minerals and other nutrients. Whole veggies and fruits are much preferred over juices, which lack the fiber. One should also take vitamin D supplements regularly if one’s level in the blood is insufficient.
In addition to eating a minimum of processed and grilled fresh meat, make sure that containers used in the microwave are approved and thus do not create carcinogenic dioxins absorbed into the food, she advised.