A recent study suggested that screening women from 40 has the potential to save lives. A group at Queen Mary University of London looked at data on 160,000 women between the ages of 39 and 41 who were randomly assigned either to annual breast screening or had to wait until they were eligible for the usual NHS screening. They found that additional screening saved lives, especially in the first ten years.
But the Covid-19 pandemic has halted another major UK breast screening trial set up to determine whether extending the screening age bracket to include women aged 47-49 and 71-73 would reduce mortality.
Professor Kefah Mokbel, Chair of the Multidisciplinary Breast Cancer Program at The London Breast Institute explains, ‘The breast cancer mortality in the UK is higher than many western European countries due to less frequent mammography screening, which also starts at a later age.’
He adds, ‘In general the breast cancer risk is higher in western developed countries compared with developing nations. This difference is thought to be mainly due to lifestyle with higher consumption of processed food, animal fat and alcohol. In Europe itself, the risk is lower in the south, attributed to the Mediterranean diet and higher vitamin D levels.’
Mokbel also points to our GP system as problematic. He says, ‘GPs act as the gatekeeper and first point of contact for all patients with breast symptoms. In our experience, the GP tends to refer all patients with symptoms to specialist centres. Unfortunately, this leads to unnecessary delay in the specialist assessment. The delay introduced by the GP acting as a gatekeeper stems from limited resources, suboptimal GP education and a lack of targeted public education. In my opinion, the ideal solution would be for patients with worrying symptoms to contact designated breast care centres where a telephone triage can be performed immediately so that patients with symptoms suspicious for cancer can be seen promptly.’
So how can any of us in Britain – especially those with a family history – protect ourselves best?
First up is understanding your genetic risk profile. Both of my sisters had genetic testing but neither carry the BRCA 1 or 2 genes, most commonly associated with breast and ovarian cancer.
However, there are many others associated with breast cancer. If you have a family history you should speak to your GP, says Dr Anne Bruinvels, a biomedical scientist and founder of OWise, an app to help breast cancer sufferers navigate data. ‘If you have two or more first-degree relatives they should refer you to a clinical genetic specialist for testing.’
Those who can’t access genetic testing on the NHS, perhaps because they have only one relative, might opt to pay for screening privately.
Professor Mokbel says, ‘The cost of this type of screening has declined considerably in recent years. One can have panel testing (looking for 30 different genes known to increase your risk of breast cancer) for £500 including genetic counselling. If you have accurate genetic knowledge then you can design the best risk reduction and tailored screening strategy.’
Once you are as clear-eyed as possible about your genetic risk, the next thing to stay on top of is screening.
Some experts argue that mammograms are not necessarily the most precise diagnostic tool for premenopausal women.
In Toronto, my sister Anne was offered regular MRI (magnetic resonance imaging) screening as well as mammograms because of her family history. Her mammogram result was so clear they wanted to use it as a teaching tool for a non-cancerous result but just a week later, an MRI showed something awry. She then had an ultrasound followed by the lumpectomy that diagnosed her cancer – too small to show up on a mammogram.
As Dr Bruinvels says, ‘The UK is still very married to the mammogram model. Mammograms are better as a diagnostic tool for people who don’t have dense breast tissue. Premenopausal breasts are often denser. MRIs are quite expensive as a screening tool, but they are better at picking up small breast cancers in that kind of tissue.’
If you are high risk you may be offered MRIs in addition to mammography in the UK, but if you are only at moderate risk that usually isn’t the case, so it might be worth considering seeking out privately if you are premenopausal or know you have dense breasts.
Professor Mokbel adds, ‘Women who have dense breasts should have supplemental ultrasound scanning to improve screening accuracy.’
Dr Bruinvels adds, ‘What’s incredibly important is staying breast aware. Early detection saves lives, so you need to get used to how your breasts look and feel, seeking medical advice if you notice any changes.’
Many breast cancers are related to reproductive hormones, so whether or not to take HRT for menopausal symptoms is another consideration for women with a family history. Professor Mokbel says, ‘I advise women to avoid it if they can. If they really need it they should ideally take it through the skin in the form of a cream or a patch.’
In terms of lifestyle factors, exercise is important. Professor Mokbel says, ‘Three cancer types are shown to be associated with inactivity – breast, bowel for men and women and uterine. Breast cancer has the largest number of cases associated with inactivity of all three. The exact mechanism for reducing risk is not known. It could simply be down to healthy weight maintenance. Or it could be that exercise can reduce oestrogen levels or increase cell response to insulin absorption, both of which could affect breast cancer growth.’
It doesn’t need to be high-intensity exercise. A moderate amount – defined as one hour of brisk exercise three times a week – will reduce your risk.
Diet is also a consideration. Professor Mokbel says, ‘There is some evidence that animal fat, particularly overcooked red meat increases your risk because it contains chemical compounds called nitrosamines which are carcinogenic. So eating red meat only once or twice a week – and not overcooking it – is sensible.’
Other than that, the only food proven to help is a ‘Mediterranean’ diet rich in fresh fruit, vegetables, olive oil, nuts and fish. He dismisses the widely held notion that dairy products are dangerous as a ‘misconception’. ‘I would encourage women to eat low-fat yoghurt as it’s rich in calcium, very important for preventing osteoporosis, and contains vitamin D3 and useful bacteria.’
You might also consider supplementing with Vitamin D. Professor Mokbel recommends women take a Vitamin D3 supplement (1000 iu) daily. ‘Vitamin D3 is the active hormone,’ he says. ‘Vitamin D1 and D2 need to be converted into vitamin D3 by special enzymes in the kidney and this could be inefficient.’ He also suggests Omega 3 daily. ‘There is a growing body of evidence that this reduces breast cancer risk by decreasing inflammation, cell growth signalling and breast density.’
Alcohol, even in small amounts, raises risk. ‘We recommend a maximum of one unit a day. The less you drink the better and no drinking at all is better still,’said Professor Mokbel.
Finally, you might also want to consider ditching your aluminium-based antiperspirant. Consultant breast surgeon Mr Beechey-Newman says, ‘There is a profusion of synthetic chemicals in our modern environment with a synthetic oestrogenic effect – meaning they mimic the hormone. One of these is aluminium. It’s hard to prove a correlation but concerns can’t be completely dismissed and it could be worth seeking an alternative.’
My sisters’ experience was part of the inspiration behind my novel, For When I’m Gone. It explores the impact that breast cancer can have on a family and the unthinkable idea of having to say goodbye to your loved ones far too early.
For as Harding’s diagnosis shows, breast cancer doesn’t discriminate. Breast awareness saves lives and we should all stay vigilant.
Manage your risk of breast cancer by:
- Seeking genetic advice if you have a family history.
- Staying familiar with your breasts (more advice at coppafeel.org).
- Attending the appropriate screening and perhaps investigating private MRI screening if you are premenopausal.
- Only eating red meat once or twice a week and not overcooking it.
- Limiting alcohol consumption.
For When I’m Gone by Rebecca Ley is published by Orion Fiction in hardback, eBook and audio, out on 3 September