The Game of Risk

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This article was originally published in More Magazine, October 2008. It was awarded an Honourable Mention at the National Magazine Awards in the Service: Health and Family category.

I am afraid of my breasts.

It isn’t because of anything they’ve done. It’s because of what I dread they might harbour.

Sometimes the news headlines fuel my fear: “Heavy women face greater threat from breast cancer.” “New cancer fear for women taking HRT.” “Alcohol may boost breast cancer risk.” The rest of the time, they confuse me about what I should do to lessen my fear: “Aspirin may reduce risk of breast cancer by a fifth.” “Do breast self-exams work?” “Vitamin D linked to lower breast cancer risk.”

My behaviour isn’t rational. Sometimes the headlines grab my attention and other times I flip quickly past them to avoid taking in the meaning of the words. I lose myself in reading the heart-wrenching survivors’ tales, tears coursing down my face — or I toss the whole section into the recycling bin, afraid that simply thinking about breast cancer will give some errant cell the wrong idea. And I just keep worrying.

The friend of a colleague puts it this way: “I figure it’s a matter of when, not if, I get breast cancer.” I laughed when I heard that, the kind of sad laugh of someone who possesses the same pessimistic gene. (I used to worry that pessimism would cause breast cancer too. Then I saw the headline “Breast cancer link to personality traits debunked.” That should have lessened my concern. But it didn’t.)

I’m tired of being afraid. It’s not that I expect to be able to stop fretting altogether: I just want to figure out what to worry about — and what steps I should take to mitigate my risks as effectively as possible. Is that really too much to ask?

“The biggest risk factor is being female and the risks increase as we get older,” says Diana Ermel, 63, president of the Canadian Breast Cancer Network, an information, education and advocacy group whose board members are all breast cancer survivors.

But gender and age aren’t the only risks. “I divide the risks into two general areas: the things you can’t really do a lot about and the factors we know we can affect,” says Julia Knight, an epidemiologist and researcher at the Samuel Lunenfeld Research Institute at Toronto’s Mount Sinai Hospital. Knight has the kind of no-nonsense approach of a friend who helps you write a pro-and-con list when you’re trying to figure out which job to take or whether you should dump your boyfriend. And as every worrier knows, when worry is chasing its tail in your head, a list can be a helpful tool for getting it to heel. Genetics — whether your relatives have had breast or other cancers — is on the “can’t do a lot about it” side, since even those who wish they could know they can’t pick their families.

Then there are what I think of as hormonal issues. “We know that women who start their periods at a younger age or start menopause at a later age have a higher risk. If you don’t have children or if you have your children at an older age — that increases your risk. But those aren’t things you really have much control over,” says Knight. Sure, this research helps scientists understand how hormones play a role in breast cancer, but since we don’t determine when we start menstruating or time childbirth for optimal breast health, these are the kinds of facts that can just add to the background hum of worry. Still, this knowledge isn’t completely pointless for those of us seeking personal insight as opposed to scientific overviews. The fact that I started my period at 14, have no children and, at 44, am premenopausal suggests that my baseline risks are, well, not that far from average.

The same principle applies to research about environmental factors: While direct links are incredibly difficult to prove, knowing that you were exposed to, say, high levels of pesticides as a child because you lived on a farm or grew up when DDT was in widespread use in the 1940s and ’50s arms you with the information to suggest that your risk of developing the disease might be higher. (Really, I’m not trying to confuse you with weasel words such as “suggest” and “might” — it’s just that the links aren’t well proven. Still, if I were raised on a farm where pesticides were regularly used, I’d factor that into my personal risk bundle.) Knight’s finished with the “can’t do much about it because the damage is done” side of the list.

But what about the other side? With all the conflicting information about hormone therapy (HT), many women have decided to manage their menopause symptoms in other ways. Still, the Canadian Breast Cancer Foundation says women considering HT shouldn’t panic: The latest research suggests that being on HT for five years or less poses minimal risk, especially if the therapy is estrogen-only. Long-term use, combination HT or use by women who have other significant breast cancer risk factors are all cause for concern.

Then there’s how you live. “There are some lifestyle factors that are becoming well established,” says Knight. Being overweight is one of them, but here the studies vary widely: Some suggest being fat as a baby is a risk, while others point to post-menopausal weight gain as the biggest risk of all. What concerns Knight most is post-menopausal weight. “I know it’s not necessarily an easy thing to change, but reducing your weight is a good idea.” The other factor to watch? Alcohol consumption. “A drink a day or less probably doesn’t increase your risk much, but more than that does.” How much? Knight uses this rule of thumb: Each drink per day increases your risk by roughly 10 per cent. One drink a day won’t make much difference (see “By the Numbers,” page four), but three or four will.

“I love wine,” says Nicole Beauchemin, 61, a professor of biochemistry and oncology at the McGill Cancer Centre in Montreal. “But I am very careful about the amount of alcohol I drink.” A seven-year survivor of breast cancer herself, Beauchemin limits herself to one glass during the week — not one glass a day, but one glass period — and treats herself to a bit more on weekends. She stopped HT when she was diagnosed with cancer, and struggles to manage what she sees as the two other biggest risk factors for women: lack of exercise and stress.

The link between exercise and reducing breast cancer risk isn’t conclusive, but the evidence is growing. And stress? Here, the proof is fuzzier, but Beauchemin looks at it from a purely pragmatic point of view: Busy women tend not to look after their own health. She knows from personal experience that it can be easy to let physicals slide. Her mother — a nurse — had instilled in Beauchemin the need for regular checkups, but when her doctor retired, it took Beauchemin, then 53, some time to find a new one. And while her original doc had allowed yearly mammograms, her new one wanted her to conform to Quebec’s biennial guideline (although she was happy to pay for the extra screening herself). Beauchemin pushed for her test, which caught an aggressive tumour that likely would have advanced if she’d waited that extra year.

Still, as she ticks off the list of things she monitors, Beauchemin stops herself. “When you compound everything that we should be watchful of — obesity, HT, alcohol, stress — it’s a wonder that most women don’t develop breast cancer, because if they’re not at risk from one factor, then they may be at risk from another,” she says, hitting a bull’s eye on my dart board o’ worries. I know she’s joking — sort of. But the joke’s dark truth is that many of us don’t believe, deep down, that we’ll be lucky to navigate these risks — even though eight out of nine of us do.

Here’s another way of looking at the numbers: Of those diagnosed today, close to 70 percent will survive the disease. What does that really mean? Out of 90 women, 80 won’t get breast cancer. Of the 10 who do, seven will beat it.

And just knowing that those odds are actually in your favour can make a difference. “It’s counterintuitive, but some women are so controlled by fear that they delay going to their doctors because they’re afraid the lump they’ve found will turn out to be cancer,” says the Canadian Breast Cancer Network’s Ermel. A 16-year survivor of the disease, she knows so much about it that a conversation with her is like chasing an iron woman on an info marathon. “Breast cancer is treatable, but you have to spot it to treat it.” One of her biggest concerns? The number of women who skip mammogram screening, recommended for all females between 50 and 69 (and depending on risk factors, for some women under 50). Ermel’s not sure whether it’s fear of what they’ll find, discomfort with the mammogram itself or just plain not looking after themselves, but she is certain of this: “Mammograms find tumours we wouldn’t find with other exams.” It’s as simple as that.

So what’s a “trying to reform” worrier to do? When you trim back the studies that “require more study” — and frankly, that’s what gets most of the headline news treatment — you’re left with the kind of health strategy that seems almost ridiculous in its familiarity. “It’s everything your mother always told you to do,” says Ermel. “It’s very simple and kind of boring — and never too late to start.” Drink less alcohol. Reduce stress. Exercise regularly. Avoid long-term hormone therapy. Maintain a healthy weight. See your doctor for regular checkups and screenings.

I swear it’s a coincidence that the acronym for these steps ends up being “DREAMS.” Still, the good news is that it isn’t “nightmare.” At least not anymore.

By the numbers

Confused by the numbers when it comes to sorting out what it really means to increase or decrease your breast cancer risk by 10 per cent? Epidemiologists talk about “relative risk” or the “risk ratio” — how much a behaviour or exposure increases or reduces your risk of harm compared to those who haven’t been exposed to that risk factor or engaged in that behaviour. Here’s the math.

One is the magic number: Relative risk is really a ratio. It’s the probability of harm among those who’ve been exposed, divided by the probability of harm among those who have not been exposed. If the ratio is one, then exposure to that substance or behaviour holds no risk or benefit: Those who’ve been exposed and those who haven’t have the same outcome.

Percentages can sound big but be small: Studies indicate that drinking a serving of alcohol a day increases your risk of breast cancer by 10 per cent. If you’re in the drink-a-day crowd, compared to those who don’t drink, your relative risk is now 1:1. Two drinks a day brings you up to 1.21 — not great, but still not that much higher than average. Still, combined with other risks — being post-menopausal and overweight or taking HT for more than five years — the numbers can start to add up.

Tipping the odds in your favour: If the average woman has a one-in-nine chance of developing breast cancer at some point in her lifetime, but you’ve been exposed to risk factors that boost your relative risk to 1.5 — 50 per cent higher than the norm — your lifetime risk is now closer to one in five. So cutting the risks you can control — especially the proven ones like alcohol consumption, post-menopausal weight gain and HT exposure — and boosting your protective factors, like exercise and a balanced diet, simply makes good sense.

Do breast self-exams matter?

Belinda Stronach, 42, credits a breast self-exam with catching her cancer. It’s a powerful example of how women can be proactive about their own health — but one that research doesn’t bear out. The studies are conclusive: Self-examination doesn’t save lives. Part of the explanation lies in the fact that by the time a lump is large enough to be found during a self-exam, it’s just as likely you’ll discover it simply while getting dressed, or your partner will notice it during sex, or your doctor will find it at your annual exam. And since most tumours are slow-growing, epidemiologists tell us the gap between a woman finding a lump in her monthly self-exam and her doctor detecting it at her annual checkup doesn’t make much difference to survival rates. Still, while self-exams are no longer de rigeur, breast cancer survivor Diana Ermel, president of the Canadian Breast Cancer Network, isn’t about to abandon hers. “Knowing your own breasts and what’s normal to you is important.” And just as essential: “an annual clinical breast exam by your doctor and mammogram screening as soon as you’re eligible for it in your province.”