Breast Health in Your 40s
Keeping your breasts healthy as you age is not a one-size-fits-all proposition. "The general principles are the same whether you’re in your 40s, 50s, or 60s," says Larry Norton, MD, deputy physician-in-chief for breast cancer programs at Memorial Sloan-Kettering Cancer Center, in New York City. "But how you apply them shifts over time." That’s because the changes and options you face in your 40s are different from those you confront in your 50s or 60s. Here’s a decade-by-decade guide to your breast health, including the best choices to make concerning everything from your diet to your bra size.
Breast Health in Your 40s
As you head toward menopause, your body starts a new phase of change. One result: 95 percent of all new breast cancers and 97 percent of all deaths from the disease occur in women over 40 (though both are more likely to happen at older ages). So if you haven’t paid much attention to breast health before, now is the time to start.
Expect Your Breasts to Feel Different Each Month
In this decade, women often have their first experiences with breast lumpiness, tenderness, and cysts.
"The hormone levels in your body are starting to fluctuate, and your breasts are responding to that," says breast surgeon Shawna Willey, MD, of the Lombardi Comprehensive Cancer Center, at Georgetown University. So from the time you ovulate until you menstruate, you may encounter lumps, bumps, and thickening. Report any new change to your doctor. The presence of cysts or lumps may lead to biopsies, but according to the American Cancer Society, the results of most biopsies (80 percent) are benign. "Seventy percent of women have fibrocystic changes in the breasts over time, and these will become more exaggerated in this decade," Willey says. "But they will diminish after menopause."
Keep Up Self-Exams
Although not many cancers are discovered by this method, of those that are, most are found by the women themselves. Self-exams are still a useful tool, says Jennifer Eng-Wong, MD, a medical oncologist at the Lombardi Comprehensive Cancer Center. Performing exams will keep you familiar with how your breasts feel, she says, which means you’ll be alert to any changes that do occur. Which changes should you investigate? "The ones that come and don’t go away," says Banu K. Arun, MD, associate professor of breast medical oncology at the M.D. Anderson Cancer Center, at the University of Texas. Schedule a visit to the doctor if you notice changes that linger after your period has ended. If your menstrual cycle is erratic and you experience something unusual, play it safe and talk about it with your physician.
Watch the Calendar
Systematic screening is crucial in your 40s: monthly self-checks, annual ob-gyn checkups, and yearly mammograms. On the one hand, your risk for cancer is lower than it will be in the next two decades. (According to the ACS, a 40-year-old woman has only a 1.43 percent chance of developing breast cancer over the next 10 years.) On the other hand, the tumors that do show up tend to be more aggressive, and less responsive to treatment, than those that appear later. That’s why, even though it’s unlikely you will develop a problem, you need to start annual screening once you hit 40, says Debbie Saslow, PhD, director of breast and gynecologic cancer at the ACS. Regularity is key: The more time that passes between screening tests, the longer cells can grow unchecked.
Keep Your Weight Steady
Women who get significantly heavier in midlife are more likely to develop breast cancer after menopause than those whose weight remains roughly the same, according to a study in the Archives of Internal Medicine last fall. "Those who gained 40 to 60 pounds between the ages of 35 and 50 had a 40 percent increase in risk compared with women who maintained their weight," says the study’s lead author, Jiyoung Ahn, PhD, research fellow at the National Cancer Institute. Over time, even a few extra pounds a year ups your odds of developing breast cancer, as well as a host of other chronic, even deadly, diseases. That’s why Ahn calls maintaining a healthy weight the key to cancer prevention.
Meet Your Calcium Quota
In May 2007, a study of 10,000 premenopausal women found that those who consumed 1,370 milligrams of calcium or more a day had a 40 percent lower risk for breast cancer than those who ingested 620 milligrams or less. And those who consumed a daily dose of at least 550 IU of vitamin D (which helps the body absorb calcium) had a 35 percent lower risk than those who consumed 160 IU. The vitamin intakes in the study were higher than current USDA recommended daily amounts (1,000 milligrams and 400 IU, respectively), so which number is right? "We will need to do a clinical trial to determine the optimum amount for breast health," says study author Jennifer Lin, PhD, assistant professor of medicine at Harvard Medical School. For now, hit the USDA quota, adding supplements if you can’t get it all from food. Even if it turns out that calcium doesn’t affect your breast cancer risk, you’ll make your bones stronger.
Choose the Right Technology
Typically, the breast tissue of premenopausal women is denser than younger women’s, which can make it more difficult to get a clear mammography image. "Because of that, there may be a small advantage for women at this age to get a digital mammogram rather than the traditional type," Saslow says. If your ob-gyn says you would benefit from this technology, the next step is to find a nearby center with the right equipment. This may be easy in urban areas and near teaching hospitals but harder in small cities and rural areas. One way to find locations is to check the equipment manufacturers’ Web sites: GE Healthcare (gehealthcare.com), Hologic (hologic.com), Siemens AG Medical Solutions (medical.siemens.com) and Fujifilm Medical Systems (fujimed.com). "If you don’t have access to a digital machine or if your insurance won’t cover it, you should still get an annual screening with a traditional machine," Saslow says. Pairing an ultrasound exam with a conventional mammogram is another option. Having both tests increased the number of tumor findings in women with dense breasts, according to a May 2008 study in the Journal of the American Medical Association. The downside: It also substantially upped the number of false positives (findings of something suspicious that later turned out to be normal).
Keep Hormones in Check
The more estrogen and progesterone your body is exposed to over your lifetime, the greater your risk for breast cancer. Hormone therapy and excess weight may increase your risk; breastfeeding, on the other hand, reduces it. But even if you take hormones and didn’t breastfeed (or never had children), there is still much that you can do to mitigate your risk. "Keep your weight steady, and get regular physical activity," advises Giske Ursin, MD, PhD, associate professor of preventive medicine at the University of Southern California. "Both have been shown to reduce hormone levels."
Fill in Your Family Health History
If you haven’t done so already, collect as much information as possible from relatives on both sides. "Go back several generations, if you can," Norton says. "It’s especially important to know if your mother or father carries cancer-predisposing gene mutations, including BRCA-1 or BRCA-2. So if your parents are alive, you might ask them to consider genetic testing." Even if there’s no breast cancer in your immediate family, you may still be at risk if you have first-degree relatives with other hormonally driven cancers, such as prostate and ovarian cancers, which are also linked to the BRCA-1 and -2 genes. "If you have a strong family history of breast or ovarian cancer, or any cancer in a parent or a sibling, it’s worth a trip to a genetic counselor to assess your personal risk," Norton says. Afterward, you may be advised to seek genetic testing. The process is simple (your doctor takes a regular blood sample and sends it to a special lab); the cost ranges from $300 to $3,000, depending on the test ordered, and many insurers will cover it. If privacy concerns have stopped you from considering such tests in the past, be aware that Congress recently passed the Genetic Information Non-Discrimination Act, which forbids employers and insurers to use DNA test results to deny coverage.
Breast Health in Your 50s
This decade marks your prime time for cancer: 77 percent of all breast cancers are detected in women of 50 and older, according to the American Cancer Society. Moreover, a study in the journal Breast Cancer Research in May 2008 found that tumors in women 50 through 59 doubled in size over an average of only 1.4 years, making annual surveillance a must.
Get a Shape Update
"As women age and go through menopause, their breasts can feel softer: The dense tissue is replaced with fatty tissue," Eng-Wong says. "But some women maintain density, even after menopause. Neither is abnormal; the key is knowing how your own breasts feel." In other words, keep up your self-exams. "Even women who are closely followed by a physician tend to discover their own lumps," Norton says, since they come into contact with their own breasts daily, while clinicians see patients only a few times a year at most. If you can alert your doctor to changes in your breasts, she’ll be better able to determine what needs further screening and attention. Be aware that caffeine and some asthma and migraine medications may also cause breast lumps. Toward the close of this decade, once you no longer have your period, the lumpiness, tenderness, and cysts you endured in your 40s and early 50s will start to subside. "In general, the older women are, the less active their breasts become in terms of cystic changes and nipple discharge, because of waning estrogen and progesterone levels," says Mary Jane Minkin, MD, clinical professor of obstetrics and gynecology at Yale University. "There are changes all the time in premenopausal women, and it’s no big worry. But if a postmenopausal woman who is not taking hormone therapy is experiencing changes, it’s more of a concern."
Considering hormone therapy? Before deciding, weigh your family history against the severity of your symptoms (hot flashes, vaginal dryness, night sweats, and so on). "If relatives have had breast cancer, you may incur an increased cancer risk from hormone therapy’s combination of progesterone and estrogen," Willey says. If you do have a family history but symptoms are making you miserable, take the lowest dosage possible, for the shortest time possible, to ease yourself through the worst of your suffering. Talk to your ob-gyn about local therapy (creams or suppositories) that may ease symptoms with minimal whole-body hormonal impact.
Keep Watching Your Weight
The evidence is clear: After age 35, gaining 40 or more pounds is bad for breast health. And gaining 20 or more pounds after age 50 also has repercussions: In her research, Ahn discovered that women who gain that amount of weight in that decade have 40 percent greater risk of developing breast cancer. Underlining the point is a report released last year by the American Association for Cancer Research specifying that your risk for breast cancer increases four percent with every 11 pounds you gain. And you should literally watch your waist: If that measurement is more than 32 inches, you’re at risk for diabetes and heart disease as well as breast cancer. But while getting the message is easy, losing the weight can be hard. "As menopause begins, women who have been able to manage their weight at a younger age find that it’s harder now," says Karen Collins, MS, RD, a nutritionist with the American Institute for Cancer Research. Another decade of age means another step-down in your metabolism; as a result, it’s not unusual for women over 50 to gain a pound or two a year without eating more or exercising less. Nonetheless, Collins says, "If your weight is getting off track, now is the time to get it under control."
Think Before You Drink
The more alcohol you consume, the higher your risk for developing breast cancer. "We’ve been told that a drink a day is beneficial for heart disease prevention, but that’s not true for breast cancer," Willey says. The reasons aren’t clear, but moderate alcohol intake may affect estrogen and progesterone levels, particularly in postmenopausal women, whose bodies now make less of those hormones. In new research by the National Cancer Institute, postmenopausal women who took a drink or two a day had a 32 percent increased risk for breast cancer, and those who downed three or more drinks per day saw their risk increase by up to 51 percent.
Don’t Assume Calcifications Mean Cancer
At your annual mammogram, you’re told that the radiologist sees calcifications. Now what? Breast calcifications — small calcium deposits in the breast tissue that appear as white spots on a mammogram — are generally not a cause for concern. They have nothing to do with dietary calcium intake (so don’t stop taking calcium, which you need for bone health). Rather, they are deposited in areas of rapidly growing cells, and are usually benign. "They are worrisome when they appear in specific groupings or patterns," Minkin says. Your doctor can help you decide whether they require investigation.
Don’t Try to Overdose on Veggies
Every woman should aim to eat five to nine servings of fruits and vegetables every day (for the vitamins and the weight-control benefits), but eating more than that won’t score you extra cancer-prevention points. A July 2007 Journal of the American Medical Association study found that both pre- and postmenopausal breast cancer survivors who ate more than the recommended five servings a day did not lower their chances of recurrence more than those who stuck to the standard amount.
Start Taking Dietary Supplements
"After age 50, our bodies make many fewer essential nutrients, such as vitamins D and K," says Pamela Smith, MD, of the Crittenton Hospital, in Rochester Hills, Michigan. "Nutrition becomes more important overall, but we can’t get enough of everything we need from food, so supplements become important in bridging the gap." Coincidentally, one nutrient that is getting a lot of attention these days happens to be vitamin D.
Several recent studies have linked a deficiency in this vitamin to an increased risk of breast cancer; on the positive side, one study found that women may cut their risk in half by taking 2000 IU of vitamin D3 a day. As a good protective step, ask your doctor to check your vitamin D level (all it takes is a blood test, one that is usually covered by insurance) and then add supplements to attain the level she thinks is appropriate. You can also talk to your doctor about appropriate dosages of vitamin E, magnesium, fish oil supplements, and iodine, all of which will benefit your whole body as well as your breasts. A tip from Christiane Northrup, MD, best-selling author of The Wisdom of Menopause: "If you have breast tenderness, you may be iodine deficient."
Breast Health in Your 60s
There’s no getting around it: The number-one risk factor for breast cancer is age. In the U.S. in 2007, 16,150 cases of invasive breast cancer were diagnosed in women younger than 45 and 162,330 cases in those older than 55. Age 61 is the statistical mean for breast cancer diagnosis, meaning that’s when you’re most likely to be diagnosed. Some good news: Tumors grow slower in this decade; it takes an average of 2.1 years for a tumor in a woman 60 to 69 to double in size.
Start Losing Weight
"Lots of women in their 60s start giving up on taking care of themselves. If they haven’t done a great job of it in their 50s, they think that at this point it’s too late to change and do any good," Collins says. "But the research shows the opposite: It’s never too late. The Nurses’ Health Study and another one focusing on a group of similar-aged women by the National Institutes of Health and AARP all say that if you have been overweight and you lose the weight, your risk factors for breast cancer go back down, as though you’d never had the extra pounds."
Keep Seeing Your Ob-Gyn
Many women in this age group stop going to the gynecologist annually. Minkin theorizes that money may be the reason: The ACS doesn’t recommend yearly Pap smears (beginning at age 30, any woman whose tests are normal three times in a row needs one only every two to three years), so Medicare won’t cover them. But older women do need yearly ob-gyn exams, Minkin says — and even having had a hysterectomy doesn’t get you off the hook. "You need your breasts and ovaries examined once a year, since cancer rates for both rise with age. If your GP or internist can do it, that’s fine." Yearly mammograms are a must too.
Be Brave About Biopsies
Tumors assessed by biopsies are more likely to be benign in younger women, since this age group is still producing hormones that cause breast tissue to change. "But when you see an abnormality in a 60-year-old, there’s more of a likelihood that it will be a malignancy," Willey says. And, Arun adds, don’t put off scheduling your annual mammogram. If you do receive an abnormal result, schedule a biopsy as soon as possible.
Keeping Breast Implants Healthy
Whether yours are cosmetic or reconstructive, Denver plastic surgeon John A. Grossman, MD, explains how to take care of them.
Remember Implants Have a Shelf Life
No matter if they’re made from silicone or saline (the FDA rescinded its ban on the former last year), the longer you have them, the more likely they are to break. "Implants experience wear and tear, since they bend and flex when you breathe and move," Grossman says. Manufacturers give them a life span of 10 to 20 years, so talk to your plastic surgeon about removal or replacement as that time nears its end.
Keep Doing Self-Exams
Many women whose breasts have been augmented worry that the implants will make it harder for them to detect lumps. The opposite is true. "The implant is placed behind the breast tissue, so everything you need to feel is sitting on top of a soft surface. Implants make BSE easier," Grossman says.
Don’t Fear Mammograms
Grossman says some of his patients worry that the compression required for this essential exam will rupture their implants. But those little sacs aren’t that fragile. "I once decided to perform my own durability test," Grossman says. "I drove my Mercedes SL 500 over a silicone implant and then parked the car on top of it for the day. It suffered no ill effects." Besides, he adds, women have to keep their perspective: Even if an implant were to break, dealing with that is much simpler than dealing with breast cancer — and the stakes are much lower. So definitely keep scheduling mammograms; just be sure to mention your implants to the radiology technician. (Any qualified tech would notice them anyway, but play it safe and spell it out.)
Stave Off the Sag
It is a truth universally acknowledged that over time, skin loses elasticity and gravity takes its toll. "When you’re menstruating, the glands in your breasts are stimulated by hormones, and that’s what gives breasts their firmness," Willey says. So when hormone production slows, breasts become slack. Short of plastic surgery, is there anything you can do? "I tell my patients to buy bras that will work for them," Minkin says.
The best approach is to find a specialty store or a department store that’s known for great customer service. "Those are the places most likely to have someone on staff who’s trained in bra fitting," says Sonja Winther, president of Chantelle North America, a manufacturer specializing in bras for women over 40. "Don’t be surprised if the fitter can judge your size without even measuring. They can see the shape, the type of tissue you have, how broad your shoulders are — and know what you need."
A good fitter will have you bend over, let your breasts fall into the cups and then stand up straight before she fastens the strap in the back (always on the middle hook; if you have to fasten yours on the last hook, the bra is too big). "What’s really important is distribution of support: The band that goes around your body gives 70 percent of the support, the cups give 20 percent, and the straps only 10 percent," Winther says. The bra fitter should be able to determine whether the distribution is correct. She’ll make sure the underwire rests against the rib cage, not the breast, and that the center of the front of the bra lies close to your breastbone. Finally, when you raise your arms, the bra should not lift up at all.
Originally published in MORE magazine, September 2008.