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*Breast Health This article includes a discussion of studies that have assessed whether certain vitamins, minerals, or other dietary ingredients offered in dietary or herbal supplements may be beneficial in connection with the reduction of risk of developing breast cancer, or of signs and symptoms in people who have this condition. However, this information is provided solely to aid consumers in discussing such supplements with their healthcare providers. It is not advised, nor is this information intended to advocate, promote, or encourage self use of these supplements for cancer risk reduction or treatment. Furthermore, none of this information should be misconstrued to suggest that dietary or herbal supplements can or should be used in place of conventional anticancer approaches or treatments. It should be noted that certain studies referenced below, indicating the potential usefulness of a particular dietary ingredient or dietary or herbal supplement in connection with the reduction of risk of breast cancer, are preliminary evidence only. Dietary changes that may be helpful: The following dietary changes have been studied in connection with breast cancer. Avoidance
of alcohol Some,3 4 though not all,5 studies have reported that alcohol increases estrogen levels. Increased estrogen levels might explain the increase in risk. In a preliminary report, drinkers with low intake of folic acid had a 32% increased risk of breast cancer compared with nondrinkers; however, the excess risk was only 5% in those drinkers who consumed adequate levels of folic acid.6 In the same report, women taking multivitamins containing folic acid and having at least 1.5 drinks per day had a 26% lower risk of being diagnosed with breast cancer compared with women drinking the same amount of alcohol but not taking folic acid-containing vitamins.7 Fiber In some studies, the protective effect of fiber against the risk of breast cancer has been stronger in young women than in older women.10 This finding might occur because fiber has been reported to lower estrogen levels in premenopausal women but not in postmenopausal women.11 12 Other researchers, however, report that fiber appears to equally reduce the risk of breast cancer in women of all ages.13 One leading researcher has suggested the active components in fiber may be phytate and isoflavones, substances that may provide protection even in the absence of a decrease in estrogen levels.14 If these substances do protect against breast cancer, they might be as helpful in older women as in younger women. Consuming a diet high in insoluble fiber is best achieved by switching from white rice to brown rice and from bakery goods made with white flour or mixed flours to 100% whole wheat bread, whole rye crackers, and whole grain pancake mixes. Refined white flour is generally listed on food packaging labels as “flour,” “enriched flour,” “unbleached flour,” “durum wheat,” “semolina,” or “white flour.” Breads containing only whole wheat are usually labeled “100% whole wheat.” Vegetarianism Fruits
and vegetables Tomatoes A review of published research found that higher intake of tomatoes or higher blood levels of lycopene correlated with a reduced risk of a variety of cancers in 57 of 72 studies. Findings in 35 of these studies were statistically significant.23 Evidence of a protective effect for tomato consumption was strongest for cancers other than breast cancer (prostate, lung, and stomach cancer), but some evidence of a protective effect also appeared for breast cancer. Meat
and how it is cooked Fish Coffee,
unrelated to risk Olive
oil The
dilemma over dietary fat High-fat diets increase the risk of mammary cancer in animals.45 From country to country, breast cancer risk in women is proportionate to the level of total fat consumed in the diet.46 Estrogen levels, body weight, and breast density have all been reported to decrease when women are put on low-fat diets—all changes that are thought to reduce the risk of breast cancer.47 48 49 50 Moreover, breast cancer patients have been reported to reduce their chances of survival by eating a diet high in saturated fat.51 (Saturated fat is found mostly in meat and dairy fat.) Similarly, breast cancer patients have been reported to be at increased risk of suffering a recurrence if they eat higher levels of fatty foods, such as butter, margarine, red meat, and bacon.52 Analysis of human trials, using a research design dependent on the memories of subjects, also has shown women consuming high-fat diets to be at high risk of breast cancer.53 In some cases, the correlation has been quite strong.54 However, most,55 56 57 but not all,58 “prospective” studies—which avoid problems caused by faulty memories—have not found any association between fat intake and the risk of breast cancer. Why do some research findings suggest that fat increases the risk of cancer and other studies find no association? Some studies finding dietary fat unrelated to cancer risks have not factored out the effects of olive oil or fish fat; both may protect against cancer.59 60 61 62 Adding them to the total dietary fat intake and then studying whether “more fat causes more cancer” is therefore misleading. Some studies finding no association between fat intake and breast cancer have made one or both of these errors.63 64 Scientists know cancers caused by diet most likely occur many years after the causative foods are regularly consumed. When one group of researchers compared dietary intakes to cancer rates occurring ten years after the consumption of food, and also eliminated from consideration the effect of fat from fish consumption, they found a high degree of correlation between consumption of animal fat (other than from fish) and the risk of breast cancer death rates for women at least 50 years of age.65 In the debate over whether dietary fat increases breast cancer risks, only one fact is indisputable: women in countries that consume high amounts of meat and dairy fat have a high risk of breast cancer, while women in countries that mostly consume rice, soy, vegetables, and fish (instead of dairy fat and meat) have a low risk of breast cancer.66 The
complex relationship between soy consumption and risk Genistein, one of the isoflavones found in many soy foods, inhibits proliferation of breast cancer cells in test tube studies. Most animal studies report that soybeans and soy isoflavones protect against mammary cancer.69 However, the protective effect in animals have occurred primarily when soy has been administered before puberty.70 If the same holds true in humans, consuming soy products in adulthood might provide little, if any, protection against breast cancer. The findings of several recent studies suggest that consuming soy might, under some circumstances, increase the risk of breast cancer.71 72 73 74 75 When ovaries were removed from animals—a situation related to the condition of women who have had a total hysterectomy—dietary genistein was reported to increase the proliferation of breast cancer cells.76 When pregnant rats were given genistein injections, their female offspring were reported to be at greater risk of breast cancer.77 Although premenopausal women have shown decreases in estrogen levels in response to soy consumption,78 79 proestrogenic effects have also been reported.80 When premenopausal women were given soy isoflavones, an increase in breast secretions resulted—an effect thought to elevate the risk of breast cancer.81 In yet another trial, healthy breast cells from women previously given soy supplements containing isoflavones showed an increase in proliferation rates—an effect that might also increase the risk of breast cancer.82 The commonly held belief that consuming soybeans or isoflavones such as genistein will protect against breast cancer is, therefore, far from proven.83 84 85 86 87 Possibly, consuming soybeans in childhood may ultimately be proven to have a protective effect.88 Doing the same in adulthood, however, may have very different effects.89 90 91 92 93 Some scientists, at least under some circumstances, remain hopeful about the potential for soy to protect against breast cancer. These scientists recommend consumption of foods made from soy (such as tofu), as opposed to taking isoflavone supplements. Several substances in soybeans other than isoflavones have shown anticancer activity in preliminary research.94 Reduction
in sugar Lifestyle changes that may be helpful: The following lifestyle changes have been studied in connection with breast cancer. Exercise
and prevention Most,99 100 but not all,101 studies find that adult women who exercise are less likely to get breast cancer. Women who exercise have also been reported to have a reduced risk of high-risk mammography patterns compared with inactive women.102 Exercise in adulthood might help protect against breast cancer by lowering blood levels of estrogen or by helping maintain ideal body weight. In addition to the preventive effects of exercise, aerobic exercise has been reported to reduce depression and anxiety in women already diagnosed with breast cancer.103 Smoking
and risk The
mind-body connection Exposure to psychological stress has been reported to weaken the immune system of breast cancer patients.116 Strong social support has been reported to increase immune function in breast cancer patients.117 These findings suggest a possible way in which the mind might play a role in affecting the risk of a breast cancer recurrence.118 119 In one study, breast cancer patients with strong social support in the months following surgery had only half the risk of dying from the disease during a seven-year period compared with patients who lacked anyone to confide in.120 After 10121 and 15 years,122 breast cancer patients with a helpless and hopeless attitude or with an attitude of stoicism were much less likely to survive compared with women who had what the researchers called a “fighting spirit.” In a five-year study, the same helpless/hopeless attitude correlated with an increased risk of recurrence or death in breast cancer patients, but a “fighting spirit” did not correlate with special protection against recurrence or death.123 One trial reported that psychological therapy for hopeless/helpless breast cancer patients was capable of changing these attitudes and reducing psychological distress in only eight weeks.124 Several trials using a variety of psychological interventions have reported increased life expectancy in women receiving counseling or psychotherapy compared with women who did not receive psychological intervention125 —even in women with late-stage disease.126 In a now-famous trial, late-stage breast cancer patients in a year-long, 90-minute-per-week support group lived on average twice as long as a group of similar patients who did not receive such support.127 Finally, relaxation training has been reported to reduce psychological distress in breast cancer patients,128 and group therapy and hypnosis have reduced pain in late-stage breast cancer patients.129 Even extensive psychological support (weekly peer support, family therapy, individual counseling, and use of positive mental imagery) has not led to a clear increase in breast cancer survival in every study.130 Why some studies clearly find mind-body connections in regard to breast cancer risk, recurrence, or survival, while other studies find no such connection, remains unclear. Overweight
and risk Nutritional supplements that may be helpful: The following nutritional supplements have been studied in connection with breast cancer. Folic
acid supplements The damaging effect alcohol has on DNA—the material responsible for normal replication of cells—is partially reversed by folic acid. Therefore, a potential association between both dietary folate and folic acid supplements and protection against breast cancer in women who drink alcohol is consistent with our understanding of the biochemical effects of these substances. A combined intake from food and supplements of at least 600 mcg per day was associated with a 43% reduced risk of breast cancer in women who consumed 1.5 drinks per day or more, compared with women who drank the same amount but did not take folic acid-containing supplements.134 No research has yet explored the effect of folic acid supplementation in people who have already been diagnosed with cancer. Cancer patients taking the chemotherapy drug methotrexate must not take folic acid supplements without the direction of their oncologist. Selenium
supplements In a famous double-blind trial that reported dramatic reductions in the incidence of lung, colon, and prostate cancers as a result of selenium supplementation, of the few women who got breast cancer during the trial, more were taking selenium than were taking placebo, though this difference may well have been due to chance.146 Thus, the findings of this famous trial also do not support the idea that selenium supplementation protects against breast cancer.147 In contrast, animal studies generally find that selenium helps protect against mammary cancer,148 149 and associations between higher selenium status and decreased risk of breast cancer in women have also occasionally been reported.150 151 Despite these hopeful findings, most studies suggest that higher selenium status confers no protection against breast cancer.152 153 154 155 156 157 158 Vitamin
E supplements Although one form of vitamin E—alpha tocopheryl succinate—has been touted as a potential treatment for women with breast cancer, only test tube studies suggest that it may have anticancer activity,166 and no trials have been conducted in breast cancer patients. Vitamin
D The following evidence indicates that vitamin D might have a protective role against breast cancer:
Activated
vitamin D The following preliminary, non-clinical evidence supports the idea that activated vitamin D may be of help to some breast cancer patients:
In a preliminary trial, activated vitamin D was applied topically to the breast, once per day for six weeks, in 19 patients with breast cancer.175 Of the 14 patients who completed the trial, three showed a large reduction in tumor size, and one showed a minor improvement. Those who responded had tumors that contained receptors for activated vitamin D. However, other preliminary reports have not found that high levels of these receptors consistently correlate with a better outcome.176 177 178 With a doctor’s prescription, compounding pharmacists can put activated vitamin D, a hormone, into a topical ointment. Due to potential toxicity, use of this hormone, even topically, requires careful monitoring by a physician. Standard vitamin D supplements are unlikely to duplicate the effects of activated vitamin D in women with breast cancer. The patients in the breast cancer trial all had locally advanced disease. Melatonin Most cancer trials studying the effects of melatonin have used 20 mg of melatonin per 24 hours, all taken at bedtime.183 184 185 186 187 188 189 190 191 192 193 194 No one should take such a high amount of this hormone without the supervision of a healthcare professional. Coenzyme
Q10 (CoQ10) At first, 90 mg of CoQ10 per day was used. In subsequent reports, the amount of CoQ10 was increased until some women were receiving 390 mg per day.200 Initially, the CoQ10 was accompanied by the use of many other supplements.201 The researchers of this trial have attributed the therapeutic effects observed primarily to CoQ10 and, in later reports, no further mention of other supplements was made.202 203 204 This preliminary investigation has been conducted with no control group, and published reports have provided only sketchy details about the conditions of most of the women being studied. Some of the patients were given conventional treatments along with CoQ10. Therefore, CoQ10 remains unproven as a cancer treatment. Fiber Indole-3-carbinol Diindolylmethane Calcium
D-glucarate (D-Glucaric acid) IP-6 Soy
isoflavones, including genistein
Herbs that may be helpful: The following herbs have been studied in connection with breast cancer. Garlic
and onions Cloud
mushroom (Coriolus versicolor) Green
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Effect of different types and amounts of fat on the development of mammary tumors in rodents: a review. Cancer Res 1997;57:3979–88. 46. Armstrong B, Doll R. Environmental factors and cancer incidence and mortality in different countries, with special reference to dietary practices. Int J Cancer 1975;15:617–31. 47. Boyar AP, Rose DP, Loughridge JR, et al. Response to a diet low in total fat in women with postmenopausal breast cancer: a pilot study. Nutr Cancer 1988;11:93–9. 48. Bagga D, Ashley JM, Geffrey SP, et al. Effects of a very low fat, high fiber diet on serum hormones and menstrual function. Cancer 1995;76:2491–6. 49. Chlebowski RT, Blackburn GL, Buzzard IM, et al. Adherence to a dietary fat intake reduction program in postmenopausal women receiving therapy for early breast cancer. J Clin Oncol 1993;11:2072–80. 50. Boyd NF, Greenberg C, Lockwood G, et al. 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Fish consumption and breast cancer risk: an ecological study. Nutr Cancer 1989;12:61–8. 63. Jones DY, Schatzkin A, Green SB, et al. Dietary fat and breast cancer in the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study. J Natl Cancer Inst 1987;79:465–71. 64. Newman SC, Miller AB, Howe GR. A study of the effect of weight and dietary fat on breast cancer survival time. Am J Epidemiol 1986;123:767–74. 65. Saskai S, Moracsek M, Kesteloot H. An ecological study of the relationship between dietary fat intake and breast cancer mortality. Prev Med 1993;22:187–202. 66. Armstrong B, Doll R. Environmental factors and cancer incidence and mortality in different countries, with special reference to dietary practices. Int J Cancer 1975;15:617–31. 67. Wu AH, Ziegler RG, Nomura AMY, et al. Soy intake and risk of breast cancer in Asians and Asian Americans. Am J Clin Nutr 1998;68(suppl):1437–43S [review]. 68. Wu AH, Ziegler RG, Horn-Ross PL, et al. 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Stimulatory influence of soy protein isolate on breast secretion in pre- and postmenopausal women. Cancer Epidemiol Biomarkers Prev 1996;5:785–94. 75. McMichael-Phillips DF, Harding C, Morton M, et al. Effects of soy-protein supplementation on epithelial proliferation in the histologically normal human breast. Am J Clin Nutr 1998;68(suppl):1431–6S. 76. Barnes S. The chemopreventive properties of soy isoflavonoids in animal models of breast cancer. Breast Cancer Res Treat 1997;46:169–79 [review]. 77. Hilakivi-Clarke L, Cho E, Onojafe I, et al. Maternal exposure to genistein during pregnancy increases carcinogen-induced mammary tumorigenesis in female rat offspring. Oncol Rep 1999;6:1089–95. 78. Lu LJ, Anderson KE, Grady JJ, Nagamani M. Effects of soya consumption for one month on steroid hormones in premenopausal women: implications for breast cancer risk reduction. Cancer Epidemiol Biomarkers Prev 1996;5:63–70. 79. Nagato C, Takatsuka N, Inaba S, et al. 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