Female Enemy Number One--Breast Cancer Hits Younger Women

Taiwan is by no means an isolated case. Reports by the World Health Organization in recent years indicate that breast cancer is currently the most common form of cancer among women around the world, with 1.15 million new cases every year and accounting for 10% of all cancer cases among women.

Although breast cancer is the top threat, there is no need for women to panic as increasingly advanced and standardized treatments have significantly increased the cure rate. We do, however, need to be concerned about the trend in Taiwan toward higher incidence of breast cancer among younger age groups and the apathy of women toward regular breast checkups.

Chinese Oncology Society president Chang King-jen, who is a professor in the Department of Surgery at National Taiwan University College of Medicine, explains that the incidence of breast cancer in Taiwan-48 in 100,000 people-is far lower than the 110 in 100,000 of the United States. Worth noting, however, is the fact that breast cancer incidence rates in Europe and North America have peaked and started to decline in recent years; while both the incidence rate and patient population in Taiwan are still on the rise.

Substantial increases in the number of breast cancer patients in Taiwan over the past few years are thought to be associated with the increase in the lifetime total of menstrual cycles among women today, caused by such factors as getting married later in life, not having children, lack of breastfeeding, and the popularity of the Western diet (high in fat and protein). "These factors suggest a close link between breast cancer and hormones," Chang King-jen affirms.

Tseng Ling-min, a physician in the Department of General Surgery at Taipei Veterans General Hospital (TVGH), states that the connection between hormones (estrogen) and the formation of breast cancer is firmly established. The concentration of estrogen in the blood of Western women, for example, is higher than in that of their Asian counterparts; incidence of breast cancer is also three to five times higher in the West than in Asia. Menstrual cycles that start earlier and cease later in life, and having no children (the menstrual cycle stops for nine months during pregnancy), cause cells in the breast to be exposed to estrogen for extended periods of time, increasing the risk of cancer. Excess bodyweight has also been shown to be a risk factor for breast cancer, because fat cells produce more estrogen. The lack of estrogen in women who have had both ovaries removed prior to the age of 40 makes them much less prone to breast cancer.

Younger victims

Taiwan has 6,000 new breast cancer cases each year and is seeing a worrying trend toward higher occurrence among younger women in recent years.

Chang King-jen points out that breast cancer in Taiwan is most common in the 40-50 age group-ten years younger than in the West. What's more, one out of every 11 breast-cancer patients is under the age of 35, almost three times as many as in the US (3-4%). The youngest breast cancer patient he has seen was only 18.

"The younger the patient, the closer the link with genetics," maintains Chang. The correlation between breast cancer and genetics in Taiwan, however, has never been confirmed by studies.

Breast cancer genes BRCA1 and BRCA2 were discovered in 1994. According to studies in the West, individuals that carry the BRCA1 gene have a 75-80% chance of being stricken with breast cancer over the course of their lives, while those with BRCA2 have a 60-70% incidence rate. Unfortunately, Taiwan has no major screening tests for or studies on these two genes. Chang believes that the occurrence of these genes among women in Taiwan is about 5%-lower than in Western countries (US: 10-15%). Regrettably, breast cancer incidence among Asians who do have these genes is higher and the cancer develops more quickly, explaining the growing incidence among younger age groups. The medical field is also concerned because higher incidence among increasingly young people is indicative of more malignant tumors, more invasive cancer cells, and more pessimistic prognoses.

Why is the cancer striking increasingly young people? "It could have to do with race," Chang says. Although the reason has not yet been discovered, the fact that the trend has been common among all Asians in recent years means it is probably related to ethnicity.

Touch: Place one hand behind your head and press your breast lightly with the pads of the three middle fingers of the other hand. Move your fingers in a clockwise spiral from the nipple to the outside of the breast.

A curable cancer

Despite rising incidence and increasing prevalence among younger age groups, breast cancer treatment is very effective. It is, in fact, one of the few curable cancers. The current five-year survival rate (cure rate) for breast cancer is just shy of 80% (US: around 85%)-very encouraging numbers indeed.

Dr. Chang, who also moonlights as chairman of the Foundation of Breast Cancer Prevention and Treatment (FBCPT), explains that the prognosis for breast cancer is excellent compared to other "solid tumors." Approximately 370,000 of the 1.15 million new breast cancer patients discovered worldwide every year die of the disease, as opposed to 700,000 of the 1.3 million new lung cancer patients. The chance of survival is clearly much higher for breast cancer patients.

"Not only can we extend life expectancy, various adjuvant treatments following surgery can effectively reduce breast cancer's side effects, allowing patients to continue to enjoy shapely figures and high quality of life," maintains Dr. Tseng Ling-min of TVGH.

Current breast cancer treatments include surgical removal, radiation therapy, chemotherapy, immunotherapy, and hormone therapy.

Ms Hung, a 30-year-old breast cancer survivor, reminds women of the importance of the "Six minutes that could save your life and the three ways to save your life." On the left is National Taiwan University surgery professor Chang King-jen.

Hormone therapy

Surgery is the primary treatment for breast cancer. After tumors are removed through surgery, however, over 80% of patients must undergo chemotherapy, radiation therapy, or hormone therapy to prevent recurrence or metastasis.

Tseng notes that statistics show that recurrence is most prevalent during the two to three years following surgery, so breast cancer patients need to do all they can to prevent recurrence. The adjuvant treatments for breast cancer are actually among the most effective for any type of cancer. The most successful and frequently used is hormone therapy.

One mechanism of carcinogenesis in breast cancer is female hormones promoting cancer cell growth. Hormone therapy attacks this mechanism.

"Hormone therapy treats the entire body and has the fewest side effects," Tseng asserts. This treatment can be traced back to 1896, when Dr. George Beatson of Scotland reported how he had treated three patients with recurrent breast cancer by removing their ovaries. Their conditions improved markedly, but Beatson was relying mainly on his own instincts and experience as the concept of hormones did not yet exist.

Tseng explains that the linking of estrogen and estrogen receptors stimulates breast cancer cell growth. They are like a key and a keyhole. Once the key is inserted into the keyhole, the door is opened and a series of biological reactions take place within the cell, producing accelerated pathological changes.

If, therefore, examination of removed tumor tissue reveals hormone receptors, this indicates a close link between the two, prompting doctors to recommend hormone therapy to block the combination of estrogen and receptor. One method is aimed at filling the hormone receptors to prevent them from combining with estrogen (suitable for women of all ages); another is designed to block estrogen production directly (suitable for post-menopausal women).

Removing estrogen can prevent breast cancer recurrence, but it's not perfect.

While receiving hormone treatment (at least five years), the lack of estrogen induces menopause-like symptoms including a reduction in or even cessation of menstruation, infertility, dryness of the vaginal area, coarse skin, and hot flashes, leading to psychological frustration and struggles. Many patients that have not yet married or had children feel that they are "no longer women."

Despite this, the majority of breast cancer patients opt to undergo the complete series of treatments to halt the disease in its tracks. Dr. Chang explains that as people today tend to marry later and patients that undergo treatment can be infertile for as long as five years, it is quite possible that many patients miss the ideal childbearing years. There have, however, been examples of women conceiving and bearing children following therapy. Ma Yu-pei, 32, a well-known former anchorwoman, for example, gave birth to a boy and a girl after completing breast cancer treatment. Thus young breast cancer sufferers need not worry too much.

"For young breast cancer patients, this is obviously a very important issue," says Liu Yu-fen, a registered nurse with the FBCPT. While most women can decide for themselves whether or not and when to have children, breast cancer patients are forced to decide between having children and saving their own lives. With any luck, their partner and family will understand their situation and support them. The sense of loss and inner conflict these women feel is unique to this form of cancer.

After being diagnosed with cancer, Ms Lin, 30, considered breaking up with her boyfriend of many years. "My boyfriend wasn't concerned with whether or not the chemotherapy and hormone therapy would adversely affect my ability to have children, but my future in-laws were unaware of my situation," Ms Lin confesses. Her illness would be the biggest "unknown" in their relationship.

Although women who have already had children or who have already entered menopause aren't necessarily worried about not being able to become mothers as a result of hormone therapy, estrogen also protects bones, so the lack of it cannot be ignored, because it can lead to joint pain, osteoporosis, and even bone fractures.

Desserts and steaks are very tempting, but keep in mind that high-protein, high-fat Western foods like these are one of the major reasons for the surge in breast cancer incidence among Asians.

Three ways to save your life

Promotion of early breast cancer screening is imperative.

Professor Chang explains that the five-year survival rate for breast cancer is almost 100% if the disease can be detected and treated in Stage 0, and 85% if it is found in Stage 1. Obviously, early detection of breast cancer is of the utmost importance.

The three methods for preventing and detecting breast cancer early are changing diet and lifestyle, self-examination, and regular health exams (including clinical examination by a physician, ultrasound examination, and X-ray mammography).

Although the detection rate of breast cancer in Taiwanese women during Stages 0 and 1 has risen from 20% to 30% over the past decade, when compared with the 60% in the US, we obviously have our work cut out for us. What's more, more than US$8 billion is dog-eared annually for breast cancer prevention in the US. Breast cancer screening equipment and medical specialists can be found in municipalities of all sizes. In contrast, Taiwan's situation is much gloomier, especially when you realize the degree of apathy and ignorance among her people.

A 2005 survey on breast cancer awareness among Taiwanese women by the FBCPT showed that in excess of 80% of women between 25 and 50 years of age had never undergone a breast exam. The reasons cited by 60% of respondents were: "No time" and "Not worried" that they might have breast cancer!

Treatment for breast cancer is more effective than that for cervical cancer, but early breast cancer screening has been slow to gain attention compared to pap smear examinations, because promotion in the media and by health agencies in recent years under the slogan "Six minutes that could save your life" has drummed the latters' importance into the public's mind. Dr. Chang points out that breast cancer is hard to detect by touch in the early stages. X-rays are much more effective, but because Asian women's breasts tend to be smaller, the pain associated with having them squeezed in vice-like X-ray machines has turned many women away from having them X-rayed a second time. He hopes that the health authorities will consider offering ultrasound examinations as part of free regular screening programs.

"The 'Six minutes that could save your life' are obviously very important, but don't forget the 'Three ways to save your life.'" Liu Yu-fen of the FBCPT reminds women that early detection and treatment are the only way to beat cancer. Breast cancer is no exception.

Breast cancer risk factors

1.High-risk group (cancer incidence over four times higher than average)

Had cancer in one breast already

Family history of cancer in second-degree relatives

Abnormal cell growth in breast biopsy

2.Second highest risk group (cancer incidence two to four times higher than average)

Mother or sister has had breast cancer

First child born after age 30

Never had children

Excessive weight gain following onset of menopause

Has had ovarian cancer (without complete removal of ovaries) or endometrial cancer

Breasts have been subject to large amounts of radiation

3.Third highest risk group (cancer incidence 1.1-1.9 times higher than average)

Moderate drinker

First menstrual cycle before age 12

Menopause started after age 55

4.Possible risk factors (unconfirmed)

Long-term use of oral contraceptives

Hormone replacement therapy for menopause

Pinch: Pinch your nipple between your thumb and forefinger to check for any unusual excretions.

Look: Look into a mirror with both arms hanging at your sides to see whether your breasts are the same size and symmetrical.