Breast Cancer

An integrative approach to care

Daniel Lander, ND
Sexual & Reproductive Health, CCNM
Outline
• Epidemiology
• Diagnosis
• Risk Factors
• Types
• Staging and other prognostic factors
• Treatment
• Prevention of Recurrence & mortality
• Primary Prevention
• Screening
Epidemiology
Epidemiology
• Breast cancer is the most common cancer diagnosis in Canadian
women over 20 years of age
• 1 in 8 Canadian women is expected to develop breast cancer

• Breast cancer is the 2nd leading cause of cancer deaths in Canadian

women
• 1 in 34 Canadian women will die from breast cancer
• Overall, 5-year survival rate for breast cancer is 89% in women

• 82% of women diagnosed with breast cancer are over 50 years of age
 Racial/Ethnic Disparities (U.S. stats)
• Incidence of breast cancer has increased in most of the past 40 years
• Breast cancer mortality rates have dropped 43% between their peak
in 1989 and 2020
• Racial/Ethnic Disparities
• Death rates declined similarly for women of all racial/ethnic groups except
American Indians/Alaska Natives whose rates were stable
• Despite a lower incidence rate in Black versus White women, the death rate is
40% higher in Black women overall and 200% higher in those <50 years of age
• For every molecular subtype and stage of disease, except stage I, Black
women had the lowest 5-year survival of any racial/ethnic group

Giaquinto AN, Sung H, Miller KD, et al. Breast Cancer Statistics, 2022. CA Cancer J Clin. 2022 Oct 3. doi: 10.3322/caac.21754.
PMID: 36190501.
 Breast cancer in men
• Breast cancer also occurs in men, but
they make up fewer than 1% of all cases
• Men diagnosed with breast cancer can
often feel like outcasts.
• They might not feel at home in breast
care centers decorated in pink, or in
waiting rooms where they are the only
male present.

• Excellent blog: “Entering a World of

Pink” by Dr. Oliver Bogler, PhD
• https://malebreastcancerblog.org
Diagnosis
Initial diagnostic work-up
• Medical history • Laboratory tests
• Signs & symptoms • CBC & chem panel
• Social history • Tumor markers?
• Family history
• Other risk factors • Imaging studies
• Diagnostic mammogram
• Physical exam • Ultrasound
• Breast exam • MRI
• Lymph node exam
• Heart & lung exam • Pathology
• Abdominal exam • Core Needle Biopsy
• Neurological exam • Fine Needle Aspiration
Signs & symptoms
• New breast mass • Redness or thickening of the
nipple or breast skin
• Breast or nipple pain
• Skin dimpling, irritation or
• Nipple retraction or deviation ulceration

• Swelling of all or part of a breast • Bloody or clear nipple

discharge
 DDx of breast masses
• Simple cyst
• Common, especially in women age 30 – 49
• Nodule is round or oval, fluid filled, movable, with well-
circumscribed borders
• Fibroadenoma
• Usually found in women age 15 – menopause
• Nodule is firm, rubbery, elastic, non-tender, lobulated,
variable size, mobile, with well-circumcised boarders
• Fibrocystic breast disease
• Common, especially with women age 30 – 49
• Nodule is a thickened lumpy area, painful, firm, mobile,
with well-circumcised borders
• Mass will fluctuate in size with menstrual cycle
• Intraductal papilloma
• Most common in women age 35 – 55
• Nodule is a small wart-like lump behind or next to the
areola
• Often associated with clear, sticky, or bloodstained nipple
discharge
DDx of breast masses
• Lipoma
• Common, especially in postmenopausal women
• Nodule is soft, movable, non-tender, with well-
circumscribed borders
• Breast abscess
• Typically secondary to mastitis,
• Nodule is localized, red, hot, painful, irregular,
firm. The whole breast may be involved
• Systemic symptoms often present along with
lymphadenopathy
• Must rule out inflammatory carcinoma
• Fat necrosis
• Due to trauma
• A hematoma results in a scar adhering to
surrounding tissue, causing retraction
• Nodule is firm, stellate, painless, and may be
dimpled
Common breast imaging studies
• Screening mammogram • Ultrasound
• X-ray examination of normal • Used to evaluate breast symptoms
breasts for cancer screening in younger people
• May be added to mammography for
screening in cases of dense breasts
• Diagnostic mammogram • Used to guide a needle biopsy
• X-ray examination of a breast
with an abnormality
• To determine the exact size and • MRI
location of a mass and to image • Uses vascular signals to look for
the surrounding tissue and cancers that may be too subtle to
lymph nodes identify on mammography or U/S
• May also be used for screening • More false positives than x-ray
in people with breast implants • Not routinely used for screening but
or a personal history of breast may be used in younger people at
cancer high risk and in people with breast
implants
 Thermography
• 132 patients who were Mammography Thermography
candidates for breast
biopsy were examined Sensitivity 80.5% 81.6%
by both mammography Specificity 73.3% 57.8%
and thermography
before tissue sampling Positive predicative value 85.4% 78.9%
in a referral center.
Negative predicative value 66.0% 61.9%
• At the present time,
thermography cannot Accuracy 76.9% 69.7%
substitute for
mammography for the
early diagnosis of breast
cancer.

Omranipour R, Kazemian A, Alipour S, et al. Comparison of the Accuracy of Thermography and Mammography in the Detection of Breast
Cancer. Breast Care (Basel). 2016 Aug;11(4):260-264. doi: 10.1159/000448347. Epub 2016 Aug 25. PMID: 27721713; PMCID: PMC5040931.
Risk Factors
Established risk factors – genetic/inherited
• Personal history of cancer or a precancerous • Ashkenazi Jewish Ancestry
lesion (i.e. breast carcinoma in-situ) • Higher risk of having a BRCA1/2 gene mutation.
About 1 in 40 Ashkenazi Jewish women carry a
• Family hx of breast or ovarian cancer BRCA gene mutation, compared to only 1 in 500
• Having one 1st-degree relative with breast cancer women in the general population
doubles a woman’s risk.
• Dense breasts
• Genetic mutations • Have more connective tissue, glands and milk
• Women with a BRCA1 or BRCA2 gene mutation ducts than fatty tissue.
have an 85% chance of developing breast cancer • Breast density is an inherited trait
• They also have a higher risk of developing breast • Breast density can only be seen on a
cancer at a younger age, and of developing mammogram, but dense breasts also make it
cancer in both breasts more difficult to identify cancers on a
• Other gene mutations: CHEK2, PLB2 mammogram
• Some rare genetic conditions are also linked
with a higher risk for breast cancer:
• Li-Fraumeni syndrome
• Ataxia telangiectasia
• Cowden syndrome
• Peutz-Jeghers syndrome
Established risk factors – hormonal
• Reproductive history • Oral contraceptives
• Early menarche (≤11 years of age) • Oral contraceptives that contain both
• Late menopause (>55 years of age) estrogen and progesterone can slightly
• Late or no pregnancies increase the risk for breast cancer,
especially among those who have used
• Those who have their 1st full-term them for ≥10 years.
pregnancy after 30 years of age have
a slightly higher risk compared to • The increased risk disappears after
those who have ≥1 full-term discontinuation of oral contraceptives.
pregnancy at an earlier age. However, current and recent (<10 years
• Becoming pregnant at an early age since last use) users have a slightly
(<20 years of age) further reduces greater risk compared with those who
breast cancer risk. have never used oral contraceptives.
• The more full-term pregnancies
someone has, the greater the
protection against breast cancer. • Hormone replacement therapy (HRT)
• This is especially true for HRT that uses
estrogen plus progestin also known as
combined HRT
 HRT & Breast Cancer Risk
• A large meta-analysis of 24 prospective trials1 • An observational study analyzing electronic medical
record data collected prospectively by general practices2
• 5 years of HRT starting at age 50 years, would
increase breast cancer incidence at ages 50–69 • Ever-use of HRT increased the risk of breast cancer by:
years by about: • 26% for estrogen plus progestogen therapy
• 1 in 50 users of estrogen plus daily progestogen • 6% for estrogen alone therapy
• 1 in 70 users of estrogen plus intermittent progestogen
• 1 in 200 users of estrogen-only preparations
• In women aged 50-59, those who used HRT for ≥5 years:
• 15 additional breast cancers per 10,000 person-years with for
• 10 years of HRT would approximately double these estrogen plus progestogen therapy
numbers • 3 additional breast cancers per 10,000 person-years with
estrogen alone therapy
• Authors’ conclusion:
• The risk for breast cancer with HRT was higher and • Authors’ conclusions:
persisted longer than had been previously thought. • Estrogen plus progestogen increases the risk of breast cancer,
but the increase is small and should be weighed against
benefits, including treatment of bothersome menopausal
symptoms and prevention of osteoporosis.
• For estrogen alone, if an elevated risk for breast cancer is
present, this excess risk is minimal.

1. Collaborative Group on Hormonal Factors in Breast Cancer. Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide
epidemiological evidence. Lancet. 2019 Sep 28;394(10204):1159-1168. doi: 10.1016/S0140-6736(19)31709-X. Epub 2019 Aug 29. PMID: 31474332; PMCID: PMC6891893.
2. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of breast cancer: nested case-control studies using the QResearch and CPRD databases. BMJ.
2020 Oct 28;371:m3873. doi: 10.1136/bmj.m3873. PMID: 33115755; PMCID: PMC7592147.
Established risk factors – other
• Exposure to ionizing radiation to the • Alcohol
chest, neck and axilla • Even low levels of alcohol consumption (>1 drink
per day) can increase the risk and the risk
• Primarily in women treated for Hodgkin increases with the amount of alcohol consumed.
lymphoma before the age of 30. • Alcohol increases estrogen levels and may lower
• The risk is further increased if the levels of some nutrients that protect against cell
radiation treatment was given during damage, such as folate, vitamins A and C.
puberty and if radiation therapy was
combined with chemotherapy. • Being obese
• The risk is less from diagnostic and • Obesity increases the risk for breast cancer in
screening radiation post-menopausal women. Those who have a
• Many women fear that regular BMI >31 have 2.5 times greater risk of
mammograms will increase their risk for developing breast cancer compared to those
breast cancer. However, modern with a BMI of ≤22.5
mammography uses very low doses of • Adipose tissue produces small amounts of
radiation compared to the dose used for estrogen and having more fat tissue can
treating cancer. Consensus is that the significantly increase circulating estrogen levels.
screening benefits of mammography • Physical inactivity
outweigh the risks of radiation exposure.
• Physical inactivity increases the risk of breast
cancer in both premenopausal and post-
menopausal women.
Possible risk factors
• Adult weight gain • Birth weight
• There is consistent evidence that adult • Some evidence suggests that a greater birth
weight gain is a probable cause of post- weight may increase the risk of developing
menopausal breast cancer. premenopausal breast cancer.
• It is not yet certain whether losing weight
would reduce the risk for breast cancer.
• Night shift work
• Night work and being exposed to artificial
• Smoking and second-hand smoke light at night lowers the amount of
• Active smoking is related to breast cancer melatonin in the body. Evidence suggests
in both premenopausal and post- that melatonin lowers estrogen levels in the
menopausal women. body and may slow the growth of breast
cancer cells.
• There is also a link between second-hand
smoke and breast cancer, particularly in • Some studies suggest that women who do
younger, mainly premenopausal women shift-work, especially night shifts, have a
who have never smoked. slightly higher risk of developing breast
cancer. However, other studies show no
increased risk.
Factors not related to risk of breast cancer
• Significant evidence shows no link between breast cancer risk and the
following:
• Antiperspirant/deodorant use
• Abortion
• Breast implants, although may make screening more difficult
• Wearing bras
Types of Breast Cancer
Types of Breast Cancer
• Invasive ductal carcinoma
• Arising in the ducts
• 70-80% of breast cancers

• Invasive lobular carcinoma

• Arising in the lobules
• ~10% of breast cancers
• Tendency to be multifocal and have
discontinuous areas of involvement
• Increased risk for bilateral breast
cancer
Development of breast cancer
Ductal carcinoma in-situ (DCIS) Invasive ductal carcinoma
Other types of breast cancers
• Medullary carcinoma • Papillary carcinoma
• Common in women with a BRCA1 gene • 1-2% of all breast cancers
mutation • Usually presents in women >60 yoa
• Typically high-grade lesions that are negative • Strongly ER/PR positive
for ER/PR and HER2 expression
• Cystic papillary: typically slower growing and less
likely to spread
• Mucinous (colloid) carcinoma • Invasive micropapillary ductal carcinoma: more
• <5% of all breast cancers aggressive and often involving lymph nodes (70-90%
of cases)
• Usually presents in women >60 yoa
• Tend to be ER/PR positive
• Slower growing and less likely to spread
• Metaplastic carcinoma
• <1% of breast cancers
• Tends to occur in women >50 yoa
• Tubular carcinoma • Higher incidence in Black women
• 1-2% of all breast cancers • Typically, larger and faster-growing
• low incidence of lymph node involvement & a
higher survival rate
• Sarcomas & phyllodes tumours
• Cancers of the breast connective tissues
• <2% or breast cancers
Inflammatory breast cancer
• Disease infiltrates the breast
dermal lymphatics
• Accounts for <3% of breast
cancers
• Redness, swelling, warm to
touch, pitted skin texture, pain
• Minimum clinical stage III
• Associated with more aggressive
behavior & a poorer prognosis
Paget’s disease of the breast
• Accounts for <3% of breast cancers
• Peak incidence in 6th decade of life
• Unilateral persistent & worsening erythema,
itching, scaling & thickening of the nipple
skin, leading to weeping, crusting and
burning pain
• Usually, symptoms are present for >6
months before the detection of an
underlying breast cancer
• A biopsy should be performed promptly on
all suspicious lesions of the nipple
Staging & Other Prognostic Factors
Staging
• T = tumor size
• T1 = Tumor 2 cm or less
• T2 = Tumor > 2 cm but < 5 cm
• T3 = Tumor 5 cm or greater
• T4 = Tumor of any size with direct extension to the
chest wall or skin
• Stage I = T1, N0, M0
• N = regional lymph nodes
• N0 = No regional lymph node metastasis • Stage II
• N1 = Metastasis to movable ipsilateral axillary lymph • A = T1, N1, M0 or T2, N0, M0
nodes
• N2 = Involved axillary lymph nodes fixed or metastasis • B = T2, N1, M0 or T3, N0, M0
in clinically apparen ipsilateral internal mammary
nodes • Stage III
• N3 = Metastasis to infraclavicular nodes, internal • A = T0-2, N2, M0 or T3, N1-2,
mammary, axillary nodes, or supraclavicluar nodes M0
• B = T4, N0-2, M0
• M = distant metastasis • C = T0-4, N3, M0
• M0 = No distant metastasis
• M1 = Distant metastasis • Stage IV = Any T, Any N, M1
Systemic spread
• Breast cancer most commonly metastasizes to the following distant
areas via the lymphatic and blood circulatory systems:
• Bones
• Liver
• Lungs
• Brain
Other important pathological findings

Grade Receptor status

• Nottingham score • Estrogen & progesterone expression
• Measure of cellular • 75-80% of breast cancers
differentiation • Behave less aggressively
• Tubular formation • Respond to endocrine tx
• Mitotic count
• Nuclear pleomorphism
• The higher the grade, the less • HER-2 overexpression
differentiated and the more • 20-25% of breast cancers
aggressive potential • Behave more aggressively
• Respond to HER-2-targeted
monoclonal Ab tx
Prognosis
• Prognostic Factors: Stage 5-year survival
• Tumor size
• Lymphatic/vascular invasion I 100%
• Axillary lymph node status
• Patient age II 93%
• Histologic grade
• Histologic subtype III 72%
• Response to chemotherapy
• Receptors IV 22%
• Estrogen/progesterone receptor status
• HER2 overexpression
Treatment
Standard of Care Management
Treatment

Early Endocrine Tx
Surgery Chemotherapy Radiation
(if ER/PR+)
Stage I, II, IIIA

Locally
Endocrine Tx
Advanced Chemotherapy Surgery Radiation
(if ER/PR+)
Stage IIIB, IIIC
Endocrine +
Metastatic CDK4/6 inhibitor
Chemotherapy
(if non-life
Stage IV threatening) *HER-2 targeted tx will be added
in each stages II-IV if the HER-2
protein is overexpressed
Surgery
Surgical treatment options
• Breast conserving surgery
• Lumpectomy or partial mastectomy removes the
cancerous part of the breast tissue and some normal
tissue around it
• Total or simple mastectomy
• The entire breast is removed, including the breast
tissue, areola and nipple
• Skin-sparing and nipple-sparing techniques can be used
in some cases
• Modified radical mastectomy
• The entire breast (A) is removed with levels I (B) & II (C)
axillary lymph nodes
• Radical mastectomy (rarely done)
• The entire breast (A) is removed with levels I (B), II (C)
and III (D) axillary lymoh nodes and the pectoral muscles
 Breast-conservation surgery vs mastectomy
• Breast-conservation surgery followed by radiation has been thought to be
equally effective as mastectomy for people early-stage disease.
• A recent cohort study of almost 50,000 women using prospectively collected
national data from several Swedish registries. The cohort included all women
diagnosed as having primary invasive T1-2, N0-2 breast cancer and undergoing
breast surgery
• Despite adjustment for previously unmeasured confounders breast-conserving
surgery with radiotherapy yielded better survival than mastectomy
irrespective of radiation therapy.
• However, lumpectomy may require additional surgeries if the margins are not
clear

de Boniface J, Szulkin R, Johansson ALV. Survival After Breast Conservation vs Mastectomy Adjusted for Comorbidity and Socioeconomic
Status: A Swedish National 6-Year Follow-up of 48 986 Women. JAMA Surg. 2021 Jul 1;156(7):628-637. doi: 10.1001/jamasurg.2021.1438.
PMID: 33950173; PMCID: PMC8100916.
Lymph node removal
• Axillary lymph node dissection
• Typically, a level I & II axillary node clearance
(~17 lymph nodes)
• Indicated if lymphadenopathy is palpated or
seen on diagnostic images
• Results in lymphedema of ipsilateral arm in
25% of pts

• Sentinel lymph node resection

• Removes only the first 1-3 drainage lymph
nodes
• Now standard of care for early-stage breast
cancer with no sign of axillary lymph node
involvement
Possible complications from breast surgery
• Infections
• Seroma formation
• Poor or delayed wound healing
• Neuropathy and decreased shoulder joint range of motion
• Secondary to damage to the costobrachial nerve or stretching of the brachial
plexus
• Lymphedema
• Especially with axillary lymph node dissection
Naturopathic treatment goals
• Decrease pain and use of pain medications
• Support immune function and lower risk of infection
• Support tissue healing and minimize seroma and excess scar tissue
formation
• Support recovery of mobility and full range of motion
• Monitor for early signs of lymphedema
Chemotherapy
Indications for chemotherapy
• Early-Stage • Stage IV, recurrent & metastatic
• Adjuvant chemotherapy cancers
• Axillary node-positive breast cancer • Palliative chemotherapy
• Axillary node-negative breast cancer • ER/PR-negative cancers
• ER/PR-positive (intermediate & • ER/PR-positive cancers
high-risk only)
• Aggressive, life-threatening cancers
• ER/PR-negative (all)
• Once progression occurs on at least 2
endocrine-based therapies
• Locally advanced
• Neoadjuvant chemotherapy
Benefit of chemotherapy in early-stage disease

Women <50 yoa Women 50-69 yoa

• 37% reduction in annual relative • 19% reduction in annual relative
risk of relapse risk of relapse

• 30% reduction in annual relative • 12% reduction in annual relative

risk of death risk of death

• 10% absolute improvement in • 3% absolute improvement in 15-

15-year survival (42% vs. 32%) year survival (50% vs. 47%)
Tumor genomic assays
• Oncotype DX
• A genomic assay of 21 genes used to
estimate the risk of recurrence of early-
stage, hormone receptor positive breast
cancer, and how likely adjuvant
chemotherapy will be of benefit.

• MammaPrint
• A genomic assay of 70 genes used to
predict the risk of recurrence or distant
metastasis within 10 years after diagnosis
of early-stage breast cancer that is
hormone receptor positive or negative
Treatment Decision Tools
• A tool designed to help make informed
decisions about treatment with
chemotherapy or hormone therapy
following breast cancer surgery.

• Developed using data from >5,000

women with breast cancer from
England and tested on data from
another 23,000 women with breast
cancer worldwide.

• https://breast.predict.nhs.uk/tool
Naturopathic treatment goals
• Avoid negative herb/nutrient-drug interactions

• Maintain nutritional status and prevent weight gain

• Associated with improved quality of life and fewer adverse effects

• Adverse effect management

• Improved quality of life
• Improved efficacy of treatment by preventing discontinuation, cycle delays, or dose-reductions

• Prevent long-term sequelae

• e.g. cardiovascular disease

• Increase efficacy of treatment

• By preventing drug resistance and increasing chemosensitivity, but this needs to be confirmed with
more well-designed clinical trials
Adverse effect management: fatigue
Exercise
• A meta-analysis of 32 studies, with a total of 2,626 women, concluded
that exercise during adjuvant treatments resulted in less fatigue,
improved physical fitness and cognitive function

Furmaniak AC, Menig M, Markes MH. Exercise for women receiving adjuvant therapy for breast
cancer. Cochrane Database Syst Rev. 2016 Sep 21;9(9):CD005001. doi:
10.1002/14651858.CD005001.pub3. PMID: 27650122; PMCID: PMC6457768.
Adverse effect management: nausea & vomiting
• A meta-analysis of 5 RCTs found that ginger was associated with a
reduction in chemotherapy-induced nausea and vomiting
• Subgroup and sensitivity analysis revealed that managing severity of
acute and delayed chemo-induced nausea and vomiting in breast
cancer patients with ginger was efficient.
• There were no serious side effects related to ginger use identified

Kim SD, Kwag EB, Yang MX, Yoo HS. Efficacy and Safety of Ginger on the Side Effects of Chemotherapy in Breast
Cancer Patients: Systematic Review and Meta-Analysis. Int J Mol Sci. 2022 Sep 24;23(19):11267. doi:
10.3390/ijms231911267. PMID: 36232567; PMCID: PMC9569531.
 Increased efficacy: vit D
• 469 stage 3 patients had vitamin D
measured at diagnosis and then
followed for an average of 7 years

• Significant improvements were seen

in overall, disease specific and
disease-free survival in the vitamin D
non-deficient participants (≥50
nmol/L) compared with vitamin
deficient participants(<50 nmol/L)

• This study also showed that improving

vitamin D status in those deficient at
diagnosis improved outcomes at one-
year follow-up

Lim ST, Jeon YW, Suh YJ. Association between alterations in the serum 25-hydroxyvitamin d status during follow-up and breast cancer
patient prognosis. Asian Pac J Cancer Prev. 2015;16(6):2507-13. doi: 10.7314/apjcp.2015.16.6.2507. PMID: 25824788.
Cautions & Contraindications
• There is a high risk for negative interaction between natural health
products and chemotherapeutics via multiple mechanisms:
• Antioxidants may interfere with oxidative stress mechanism: e.g. glutathione
• Altered cytochrome P450 metabolism: e.g. cyclophosphamide and hypericum
• Altered activity specific cell death signaling pathways: e.g. cyclophosphamide
and curcumin
• Contraindications with severe immunosuppression: e.g. probiotics
• Upregulation of cytotoxic mechanism: e.g. folic acid/5-MTHF and 5-
FU/capecitabine
Radiation therapy
Radiation therapy

Goal Mechanism of Action

• To eradicate residual disease • A linear accelerator is used to
thereby reducing locoregional direct gamma radiation to the
recurrence breast

• Formation of free radicals causes

DNA damage resulting in cell
death
Indications for radiation therapy
• Radiation therapy is typically recommended in 3 situations
• Following breast conserving surgery
• Following mastectomy in those at high risk for local recurrence
• ≥4 positive axillary lymph nodes
• Extracapsular nodal extension
• Large primary tumors (>5 cm)
• Very close or positive margins
• To manage metastatic spread
Benefits of radiation therapy
• In low risk, node-negative disease, adding radiation to breast
conserving surgery decreases risk of recurrence by 50% and improves
overall survival by 20%.
• This combination is thought to offer similar overall survival benefit as
mastectomy

• Radiation therapy after mastectomy in node-positive (stage II or III)

disease is associated with ~10% increase in 10-year overall survival
Timing
• Radiation is initiated 4-6 weeks after surgery to allow for surgical
healing time

• If adjuvant chemotherapy is required, radiation therapy is postponed

until this has been completed
Naturopathic treatment goals
• Avoid negative herb/nutrient-radiation interactions

• Maintain nutritional status

• Associated with improved quality of life & fewer adverse effects
• Prevent requirement to modify treatment field to account for weight loss

• Adverse effect management

• Improved quality of life
• Improved efficacy of treatment by preventing early discontinuation of treatment

• Prevent long-term sequelae

• Cardiovascular disease

• Increase efficacy of treatment

• By preventing increasing radiosensitivity
Potential adverse effects

Short-term Long-term
• Local • Smaller & firmer breast
• Sunburn-like skin changes in the treated area • Complications with reconstruction surgery
• Swelling and heaviness in the breast
• Impaired ability to breastfeed
• Systemic • Brachial plexopathy
• Fatigue • Numbness, pain, and weakness in the shoulder,
• Risk higher in patients with: arm, and hand
• Advanced-stage disease • Lymphedema
• Pre-existing anemia
• Poor nutritional status • Rib fracture
• Damage to heart and lungs
• Increased risk of angiosarcoma
• Increased risk of lung cancer, primarily in
smokers
Radiation-induced dermatitis: general advice
• Wash daily using a gentle, non-perfumed soap
• Pat skin dry using a soft towel to avoid friction
• The use of a plain, un-perfumed, aqueous, emollient cream can help maintain moisture, skin
integrity, and comfort
• Remember no oil-based creams and to always wash off anything applied topically to the radiation field prior
to each radiation treatment
• Wear loose fitting clothing
• Avoid exposure to the sun until healed and then use a high factor sunscreen of at least SPF30
• Avoid swimming until the skin reaction has completely settled and the skin is fully intact
• Avoid applying extremes of temperature e.g. hot water bottle/ice pack
• Do not ‘wet shave’ or use hair removing products. Electric razors are suitable if used with care.
Support for radiation dermatitis

Calendula Cream Aloe Vera Gel

• An RCT of 254 patients found • An RCT of 225 patients found aloe
acute dermatitis of grade 2 or vera gel was not more effective
higher was significantly lower than an aqueous cream, and in fact
(41% vs 63%; P <0.001) with the it was less effective at reducing dry
use of calendula (Boiron brand but desquamation and pain.
not Weleda brand) compared to
standard trolamine cream.

Pommier P, Gomez F, Sunyach MP, et al. Phase III Heggie S, Bryant GP, Tripcony L, Keller J, Rose P, Glendenning
randomized trial of Calendula officinalis compared with M, Heath J. A Phase III study on the efficacy of topical aloe
trolamine for the prevention of acute dermatitis during vera gel on irradiated breast tissue. Cancer Nurs. 2002
irradiation for breast cancer. J Clin Oncol. 2004 Apr Dec;25(6):442-51. doi: 10.1097/00002820-200212000-
15;22(8):1447-53. doi: 10.1200/JCO.2004.07.063. PMID: 00007. PMID: 12464836.
15084618.
Support for radiation fatigue: Exercise
• A meta-analysis of 9 RCTs (total n=738), revealed that combined
aerobic and resistance exercise was significantly more effective at
reducing fatigue in breast cancer patient receiving radiation therapy
than the control interventions

Lipsett A, Barrett S, Haruna F, et al. The impact of exercise during adjuvant radiotherapy for breast cancer on
fatigue and quality of life: A systematic review and meta-analysis. Breast. 2017 Apr;32:144-155. doi:
10.1016/j.breast.2017.02.002. Epub 2017 Feb 9. PMID: 28189100.
Contraindications
• Caution with all potent antioxidants, including
• Vitamin E & beta-carotene, especially in current smokers
• Coenzyme Q10
• Alpha-lipoic acid
• N-acetyl-cysteine
• Glutathione
Endocrine therapy
Endocrine therapy
• Selective estrogen receptor modulator (SERM)
• Tamoxifen
• Aromatase inhibitors
• Anastrazole, letrazole, examestane
• Selective estrogen receptor degrader (SERD)
• Fulvestrant

Source: Howell A. (2011) Fulvestrant. In: Schwab M. (eds) Encyclopedia of Cancer. Springer, Berlin, Heidelberg.
Tamoxifen
• Mechanism
• Selective estrogen receptor modulator (SERM)
• Antogonist effect in breast & brain
• Agonist effect in lung, liver, bone & uterus
• Binds estrogen receptors in the breast forming
a complex that inhibits DNA synthesis and cell
growth. This complex also induces apoptosis.
• Effective in both pre and post menopausal
women with ER+ breast cancer.
• Metabolism
• CYP 2C9, 2D6, 3A4 substrate with active
metabolites
Source: N Engl J Med. 2003 Jun 12;348(24):2431-42.
Aromatase inhibitors
• Mechanism
• Prevent the conversion of androgens to
estrone or estradiol
• Only effective in post-menopausal
women with ER+ breast cancer

• Metabolism
• Anastrozole has no CYP450 metabolism
• Letrozole: CYP 2A6 & 3A4 substrate
• Examestane CYP 3A4 substrate
Source: N Engl J Med. 2003 Jun 12;348(24):2431-42.
Fulvestrant
• Mechanism
• Selective estrogen receptor degrader (SERD)
• Inhibits ER dimerization
• Promotes accelerated ER degradation
• Reduced ER shuttling from cytoplasm to nucleus
• Considerably higher affinity for ER than
tamoxifen
• Has no estrogen agonist activity

• Shown to have activity in tamoxifen-resistant

cancers

• Metabolism:
• CYP 3A4 substrate
Source: International Journal of Molecular Sciences 13(11):14898-916.
Naturopathic treatment goals
• Prevent negative herb/nutrient-drug interactions

• Manage adverse effects

• Prevent long-term sequlae

Tamoxifen: pharmacokinetics
Negative interactions: tamoxifen
• Herbs that alter CYP2D6 or CYP3A4 • Indole-3-carbionol
activity • Increases the toxicity of tamoxifen by
increasing the formation of N-
desmethyl-tamoxifen which is then
• Vitamin E transformed to a genotoxic
• Decreases the inhibitory effect of metabolite
tamoxifen on the proliferation of ER+ • PMID: 15041081
breast cancer cells and prevents
tamoxifen-induced apoptosis
• PMID: 17011908 • Curcumin
• Increased effect of estrogen • May inhibit the CYP-mediated
stimulation when combined with metabolism of tamoxifen to its active
tamoxifen metabolites
• PMID: 18468636 • PMID: 22512082
Negative Interactions: tamoxifen

Herbs that may alter CYP2D6 activity Herbs that may alter CYP3A4 activity
• Active hexose correlated compound (AHCC) • Agaricus blazei • Morinda citrifolia
• Angelica sinensis • Camillia sinensis • Panax ginseng
• Cimicifuga racemosa • Cimicifuga racemosa • Piper methysticum
• Hydrastis canadensis • Citrus paradicii • Polygonum multiflorum
• Hypericum perforatum • Curcuma longa • Schisandra chinensis
• Salvia officinalis • Echinacea spp. • Trifolium pratense
• Valeriana officinalis • Ganoderma lucidum • Uncaria tomentosa
• Glycyrrhiza glabra • High allicin garlic supps
• Harpagophytum procumbens • Quercetin
• Hydrastis canadensis • Resveratrol
• Hypericum perforatum • Grape seed extract
• Matricaria chamomilla
Positive interactions with tamoxifen
• In a small open-label study of 14 patients with metastatic breast
cancer who were no longer responding to tamoxifen found that when
melatonin 20 mg nightly was added to their tamoxifen 4/14 patients
had a partial response (median duration of 8 months) .
• There was no increase toxicity, in fact most patients reported less
anxiety.

Lissoni P, Barni S, Meregalli S, et al. Modulation of cancer endocrine therapy by melatonin: a phase II study of
tamoxifen plus melatonin in metastatic breast cancer patients progressing under tamoxifen alone. Br J Cancer.
1995 Apr;71(4):854-6. doi: 10.1038/bjc.1995.164. PMID: 7710954; PMCID: PMC2033724.
Endocrine Therapy: Adverse Effects
Hot flashes (all) • Depression & anxiety
Nausea (all) (tamoxifen)
Arthralgia (AIs) • Common cold symptoms
(fulvestrant)
Sleep disturbance (AIs)
• Diarrhea and/or constipation
Weight gain (AIs) (fulvestrant)
Hyperlipidemia (AIs & tamoxifen) • Osteoporosis (AIs)
• Thromboembolism (tamoxifen &
fulvestrant)
• Endometrial cancer (tamoxifen)
Support during endocrine therapy
• Hot flashes • Arthralgia
• Vaginal estrogen is not recommended • Acupuncture (PMID: 29998338)
with aromatase inhibitor therapy • Vitamins:
(PMID: 35854422) • Vit. D (PMID: 27221206)
• Lifestyle: • Vit. B12 (PMID: 29442401)
• Identify and avoid triggers such as • Other natural health products
caffeine, alcohol, stress, etc.
• Maintain cooler ambient • Omega 3 FAs (PMID: 30159789)
temperatures, especially at night • Glucosamine and chondroitin (PMID:
• Regular exercise 23111941)
• Consuming soy (PMID: 26943176) • Homeopathics
• Paced breathing techniques (PMID: • Ruta and Rhus tox (PMID: 27914569)
22990758)
• Naturopathic approaches:
• Acupuncture (PMID: 2702211)
• Black cohosh (PMID: 25713759)
 Hot flashes: plant-based diet
• A small, nonblinded, randomized-controlled trial, 84 postmenopausal women
eating a reduced-fat vegan diet combined with a daily serving of soybeans (1/2
cup).

• The study found:

• Total hot flash frequency decreased by 78% in the intervention group and 39% in the control
group (P = 0.003),
• Moderate to severe hot flashes decreased by 88% versus 34% (P < 0.001)
• Among participants with at least 7 moderate to severe hot flashes per day at baseline,
moderate to severe hot flashes decreased by 93% and 36% in the control group (P < 0.001)

• The researchers found that greater the reduction in fat intake and the greater the
increases in carbohydrate and fiber consumption, the greater the reduction in
severe hot flashes

Barnard ND, Kahleova H, Holtz DN, et al. A dietary intervention for vasomotor symptoms of menopause: a randomized, controlled trial.
Menopause. 2022 Oct 18. doi: 10.1097/GME.0000000000002080. Epub ahead of print. PMID: 36253903.
Support during endocrine therapy
• Depression & anxiety • Sleep disturbance
• Lifestyle: exercise, meditation, • Melatonin (PMID: 2471877)
mindfulness practice • Acupuncture (PMID: 31081899)
• Melatonin (PMID: 24756186) • Also consider
• Reishi (PMID: 22203880) • Lavender (PMID: 26293583)
• Also consider • Magnesium (PMID: 33865376)
• Acetyl-L-carnitine (PMID: 29076953)
• Lavender (PMID: 31792285) • Hyperlipidemia
• Saffron (PMID: 30036891)
• Magnesium (PMID: 28445426, • CoQ10 (PMID: 18427979)
PMID: 28654669)
• Osteoporosis
• Nausea • Weight bearing exercise
• Acupuncture • Calcium and magnesium
• Ginger, mint • Vitamins D and K2
 Support during endocrine therapy: CoQ10
• An RCT of 30 breast cancer patients randomized participants to
receive either 100 mg Coenzyme Q10 or a placebo once a day for 8
weeks.
• Coenzyme Q10 supplementation led to a significant increase in the
following parameters, compared to placebo:
• Physical functioning (P=0.029)
• Emotional functioning (P=0.031)
• Cognitive functioning (P=0.023) compared to placebo.

Hosseini SA, Zahrooni N, Ahmadzadeh A, et al. The Effect of CoQ10 Supplementation on Quality of Life in Women with Breast Cancer
Undergoing Tamoxifen Therapy: A Double-Blind, Placebo-Controlled, Randomized Clinical Trial. Psychol Res Behav Manag. 2020 Feb
20;13:151-159. doi: 10.2147/PRBM.S241431. PMID: 32110123; PMCID: PMC7039424.
Prevention of recurrence & mortality
Prevention of recurrence & mortality
• A large review conducted through the World Cancer Research Fund International Global
Cancer Update Program was published in four papers in the International Journal of Cancer.

• The findings from these reviews strengthen the case for women with breast cancer to make
positive lifestyle changes including:

Maintaining a normal body weight

• As mentioned previously after menopause, being overweight or gaining weight are established risk
factors for developing breast cancer, yet the impact of excess body weight on those with a breast
cancer diagnosis is less clear.
• 226 studies with more than 456,000 women with breast cancer were reviewed and the researchers
found "strong" evidence (likelihood of causality: probable) that higher BMI after diagnosis is
associated with increased all-cause mortality (64 studies, 32,507 deaths), breast cancer-specific
mortality (39 studies, 14,106 deaths), and second primary breast cancer (11 studies, 5248 events).
• The review also found "limited-suggestive" evidence that higher post-diagnosis BMI is associated with
higher risk for breast cancer recurrence, nonbreast cancer-related mortality, and cardiovascular
mortality.
• One RCT shows the potential beneficial effects of intentional weight loss on disease-free survival, but
more trials are needed to draw firm conclusions.
Prevention of recurrence & mortality
Physical Activity
• 23 observational studies with more than 39,000 women were reviewed. Most of
the studies looked at recreational physical activity, such as aerobics, walking, and
running.
• Each 10-unit increase in metabolic equivalent of task hours per week (MET-
h/week) of higher recreational physical activity was associated with 15% lower
risk of all-cause mortality and a 14% lower risk of breast cancer-specific mortality.
• Recreational physical activity was not associated with breast cancer recurrence.
• There was a 48% lower all-cause and 38% lower breast cancer-specific mortality
with increasing recreational physical activity up to 20 MET-h/week, but little
further reduction in risk at higher levels.
• However, due to the methodological limitations of the studies it was concluded
that there is "limited but suggestive" data that recreational physical activity is
beneficial in lowering risk of all-cause and breast cancer-specific mortality
Prevention of recurrence & mortality
Dietary Factors
• 108 studies with more than 151,000 women were reviewed.
• The reviewers noted that meta-analysis for dietary patterns, vegetables, whole-grains, fish,
meat and supplements was not possible due to few studies, often with insufficient data.
• Meta-analysis was only possible for all-cause mortality with dairy, isoflavone, carbohydrate,
dietary fiber, alcohol intake, and serum 25(OH) vitamin D, and for breast cancer-specific
mortality with fruit, dairy, carbohydrate, protein, dietary fat, fiber, alcohol intake, and serum
25(OH) vitamin D.
• They concluded that there was “limited-suggestive evidence” that dietary patterns may
reduce the risk of all-cause and other causes of death:
• Isoflavone intake reduces the risk of all-cause mortality by 4% for every 2 mg/d, breast cancer-specific
mortality by 17% for high vs low intake, and breast cancer recurrence by 25% for high vs low intake
• Dietary fiber intake decreases all-cause mortality by 18% for every 10 g/day
• Serum 25(OH) vitamin D reduces all-cause by 7% for every 10 nmol/L and breast cancer-specific
mortality by 3% for every 10 nmol/L.
• The remaining associations were graded as "limited-no conclusion"
 Prevention of recurrence & mortality
Vitamin D
• A prospective cohort study of 1,666 breast cancer
survivors founds that higher serum vitamin D
levels were independently associated with better
overall survival after adjustment for clinical
prognostic factors (HR, 0.72; 95% CI, 0.54-0.98).

• Among premenopausal women, the association

with overall survival was even stronger (HR, 0.45;
95% CI, 0.21-0.96) (B) and there were also
associations with breast cancer-specific survival
(HR, 0.37; 95% CI, 0.15-0.93) and invasive disease-
free survival (HR, 0.58; 95% CI, 0.34-1.01).

Yao S, Kwan ML, Ergas IJ, et al. Association of Serum Level of Vitamin D at Diagnosis With Breast Cancer Survival: A Case-
Cohort Analysis in the Pathways Study. JAMA Oncol. 2017 Mar 1;3(3):351-357. doi: 10.1001/jamaoncol.2016.4188. PMID:
27832250; PMCID: PMC5473032.
 Prevention of recurrence & mortality
Diet and Exercise
• The Women’s Healthy Eating and Living
(WHEL) study followed approximately 1,500
women with early-stage breast cancer
• A combination of 5‐6 servings of vegies/fruit
per day and exercise equivalent to walking 30
minutes, 6 days/week, reduced the risk of
death from breast cancer by 44% among
early-stage breast cancer patients
• Risk reduction was observed in both obese
and non-obese women
• The effect was stronger in women who had Kaplan-Meier survival after WHEL Study enrollment by 4 diet & physical activity
hormone receptor positive cancers categories. Low vegetables–fruits (VF), <5 servings/d; high VF, ≥ 5 servings/d; low
physical activity (PA), <540 metabolic equivalent task (MET)‐min/wk; high PA, ≥ 540
MET‐min/wk. Survival is plotted as a function of number of yrs enrolled in WHEL Study.
Pierce JP, Stefanick ML, Flatt SW, et al. Greater survival after breast cancer in physically active women with high vegetable-fruit intake regardless of obesity. J
Clin Oncol. 2007 Jun 10;25(17):2345-51. doi: 10.1200/JCO.2006.08.6819. PMID: 17557947; PMCID: PMC2274898.
Prevention of recurrence & mortality
Overnight Fasting
• In a cohort of 2,400 women with early-stage breast cancer, fasting
<13 hours per night was associated with an increase in the risk of
breast cancer recurrence by 36% compared with fasting ≥13 hours
per night
• In multivariable linear regression models, each 2-hour increase in the
nightly fasting duration was associated with significantly lower
hemoglobin A1c levels

Marinac CR, Nelson SH, Breen CI, et al. Prolonged Nightly Fasting and Breast Cancer Prognosis. JAMA
Oncol. 2016 Aug 1;2(8):1049-55. doi: 10.1001/jamaoncol.2016.0164. PMID: 27032109; PMCID:
PMC4982776.
Primary prevention
Primary prevention
• “If girls and women of all
ages adopted healthier
lifestyle behaviors and
the highest-risk women
took preventive drugs
like tamoxifen, half of
breast cancers in the U.S.
might be avoided.”

CA Cancer J Clin. May-Jun 2014;64(3):186-94.

Risk factors

Non-modifiable Modifiable
• Sex • Obesity
• Age • Physical inactivity
• Race & ethnicity • Alcohol consumption
• Personal cancer history • Smoking
• Family cancer history & genetics • Exogenous hormone exposure
• Age of menarche & menopause
• Breast density • Pregnancy & breast feeding?
• Other breast conditions • Radiation exposure?
Prevention: exercise
• A meta-analysis of 38 cohort studies (total n= 68,416)
• Physical activity was associated with an overall 13%
decreased risk
• In a subgroup analysis by menopausal status:
• Premenopausal women had a 17% reduction in risk
• Postmenopausal women had a 9% reduction in risk
• A linear relationship was found between breast
cancer risk and physical activity and the risk was
reduced by:
• 3% for every 10 metabolic equivalent of energy hours per
week increment in recreational physical activity Wu Y, Zhang D, Kang S. Physical activity and
• 2% for every 10 metabolic equivalent of energy hours per risk of breast cancer: a meta-analysis of
prospective studies. Breast cancer research
week increment in total physical activity and treatment. 2013 Feb 1;137(3):869-82.
 Prevention: Mediterranean diet
• Adherence to the Mediterranean diet
appears to be inversely linked to breast
cancer incidence and mortality.
• A large RCT of 4,282 postmenopausal
women who were randomly allocated to
a Mediterranean diet supplemented
with extra-virgin olive oil, a
Mediterranean diet supplemented with
mixed nuts, or a control diet (advice to
reduce dietary fat).
• The study found that women with a
higher adherence to the Mediterranean
diet supplemented with extra-virgin
olive oil showed a substantial reduction
of their risk for breast cancer compared
to the control group.

Toledo E, Salas-Salvadó J, Donat-Vargas C, et al. Mediterranean Diet and Invasive Breast Cancer Risk Among Women at High Cardiovascular Risk in the PREDIMED Trial: A Randomized
Clinical Trial. JAMA Intern Med. 2015 Nov;175(11):1752-1760. doi: 10.1001/jamainternmed.2015.4838. Erratum in: JAMA Intern Med. 2018 Dec 1;178(12):1731-1732. PMID: 26365989.
Prevention: whole-foods plant-based diet
• A study of more than 65,000 postmenopausal women found that plant-
based diets that were high in fruit, vegetables, whole grains, nuts, and
legumes were more protective against breast cancer than plant-based diet
comprising higher intakes of primarily processed products of plant origin,
such as refined grains, fruit juices, sweets, desserts, and potatoes.
• Over the 21-year study period, 3968 women were diagnosed with breast
cancer. Those who adhered to a more healthful plant-based diet had a 14%
lower risk than average of developing breast cancer, while those who
adhered to a less healthful plant-based diet had a 20% greater risk of
developing the disease.

NUTRITION 2022: Abstract OR07-03-22. Presented June 14, 2022.

Prevention: ultra-processed foods
• A 10% increase in the proportion of • Breast cancer risk was elevated by
ultra processed foods in the diet is 24% among higher consumers of
associated with an 11% increase in nitrates from food additives.
risks for breast cancer. • Breast cancer risk was increased by
25% for total artificial sweetener
intake, 33% for aspartame and 39%
for acesulfame-K intake.
• Dietary intake of trans fatty acids was
associated with a 35% higher breast
cancer risk overall and a 68%
increased risk before menopause.
Fiolet T, Srour B, Sellem L, et al. Consumption of ultra-
processed foods and cancer risk: results from NutriNet-
Santé prospective cohort. BMJ. 2018 Feb 14;360:k322. doi:
10.1136/bmj.k322. PMID: 29444771; PMCID: PMC5811844.
 Prevention: Low-Fat Diet
• A secondary analysis of the Women's Health Initiative RCT of • A subsequent 20-year follow-up, with 3,374
48,835 postmenopausal women with no previous breast incident breast cancers, found a 21%
cancer and dietary fat intake of greater than 32% by food reduction in deaths from breast cancer in the
frequency questionnaire dietary intervention group.
• 40% of participants were randomized to a dietary intervention • Conclusion: “these findings provide the first
group with goals to reduce fat intake to 20% of energy and randomized clinical trial evidence that a
increase fruit, vegetable, and grain intake while the remaining dietary change can reduce a postmenopausal
60% continued their usual diet for an average of 8.5 years. woman’s risk of dying from breast cancer.”
• After 16 years of follow-up, of the 1,764 women diagnosed
with breast cancer 10-year overall survival was 82% for
women in the dietary intervention group compared to 78% in
the control group (P = 0.01).
• In the dietary group there were 14% fewer deaths from breast
cancer, 24% fewer deaths from other cancers, and 48% fewer
deaths from cardiovascular disease.

Chlebowski RT, Aragaki AK, Anderson GL, et al. Association of Low-Fat Dietary Chlebowski, R. T., Aragaki, A. K., Anderson, G. L., et al. Low-fat
Pattern With Breast Cancer Overall Survival: A Secondary Analysis of the Women's dietary pattern and long-term breast cancer incidence and
Health Initiative Randomized Clinical Trial. JAMA Oncol. 2018 Oct 1;4(10):e181212. mortality: The Women’s Health Initiative randomized clinical
doi: 10.1001/jamaoncol.2018.1212. Epub 2018 Oct 11. Erratum in: JAMA Oncol. trial., et al. "Low-fat dietary pattern and long-term breast
2019 Apr 1;5(4):580. PMID: 29800122; PMCID: PMC6233778. cancer incidence and mortality: The Women’s Health Initiative
randomized clinical trial." (2019): 520-520.
Prevention: Alcohol
• Alcohol consumption is the dietary • Ethanol has been found to promotes
variable which is most consistently epithelial-mesenchymal transition, tumor
associated with breast cancer incidence growth and metastasis formation and has
and overall mortality. also been shown to increase estrogen
concentrations through several
• There is strong evidence that alcohol mechanisms:
intake, regardless of the type of alcohol • Increase of aromatase activity
consumed and menopausal status is • Inhibition of enzymes involved in estrogen
consistently associated with increased degradation
breast cancer risk. • Decrease of melatonin secretion which
inhibits estrogen production
• Increase in hepatic oxidative stress that
• For every 10g ethanol consumed per day, leads to inhibition of steroid metabolism
there was an associated statistically
significant increased risk of about 5% for
pre-menopausal women and 9% for post-
menopausal women.
Prevention: other foods

Flaxseed Mushrooms
• Consumption of flaxseed or flax bread was • Women consuming at least 10 grams of fresh
associated with a significant (18-23%) mushrooms every day (about one mushroom
decrease in the risk of breast cancer per day) were 64% less likely to develop
breast cancer.
• Women who combined eating mushrooms
with regular consumption of green tea saw an
even greater benefit with an 89% reduction in
their risk of breast cancer.
Lowcock EC, Cotterchio M, Boucher BA. Consumption of
flaxseed, a rich source of lignans, is associated with reduced
breast cancer risk. Cancer Causes Control. 2013
Apr;24(4):813-6. doi: 10.1007/s10552-013-0155-7. Epub
2013 Jan 25. PMID: 23354422.
Zhang M, Huang J, Xie X, Holman CD. Dietary intakes of
Flower G, Fritz H, Balneaves LG, et al. Flax and Breast mushrooms and green tea combine to reduce the risk of
Cancer: A Systematic Review. Integr Cancer Ther. 2014 breast cancer in Chinese women. Int J Cancer. 2009 Mar
May;13(3):181-92. doi: 10.1177/1534735413502076. Epub 15;124(6):1404-8. doi: 10.1002/ijc.24047. PMID: 19048616.
2013 Sep 8. PMID: 24013641.
Prevention: vitamin d
• 2 large RTCs have been conducted
• One found that supplementation with 1,100 IU vitamin D + 1,400mg calcium daily
over 4 years reduced risk of all cancer by 60% but effects on individual cancer types
were not evaluable
• The other found no significant effect of supplementation with 400 IU/d

• 6/6 case control studies assessing circulating 25(OH) vitamin D reported

an inverse associations between 25(OH) vitamin D & risk of breast cancer.
There was a threshold for protective effects seen at:
• >60 nmol/L compared to <30 nmol/L
• 75-150 nmol/L compared to 50 nmol/L

• 2 cohort studies assessed 25(OH) vitamin D and risk of breast cancer; both
showed no impact on risk on development of breast cancer
Prevention: Genetic Testing
• BRCA gene mutations are found in 5-10% of breast cancer cases

• Women who carry the BRCA gene mutation have an estimated 85% lifetime risk of
developing breast cancer

• Prophylactic mastectomy provides a 90% reduction in risk, bringing it down to ~1%

• The alternative is ongoing surveillance, which involves monthly breast self-

examination, biannual clinical breast examination by a physician, and annual
mammography plus breast MRI.

• However, because BRCA carriers are prone to developing fast-growing tumors,

even with this surveillance, about 25-30% of carriers are diagnosed when the
primary tumor is already >2 cm in diameter
Screening
Screening: CTFPHC Guidelines (2011)
• Mammography
• For women 40–49 recommend not routinely screening
• For women 50–69 recommend routinely screening every 2-3 yrs
• For women 70–74 recommend routinely screening every 2-3 yrs

• Magnetic Resonance Imaging (MRI)

• Recommend not routinely screening with MRI

• Clinical Breast Exam

• Recommend not routinely performing clinical breast exam alone or in conjunction
with mammography to screen for breast cancer

• Breast Self Exam

• Recommend not advising to routinely practice breast self exams
Screening: CTFPHC Guidelines Update (2018)
• The direction of each recommendation on screening with
mammography is the same as in the previous
recommendations

• Updates emphasize shared decision-making and

are conditional on the relative value a woman places on
possible benefits and harms of screening.

• Tools to support shared decision-making are available

at www.canadiantaskforce.ca.
Screening: Cancer Care Ontario Guidelines
• Average risk women ages 50-74 should be screened every 2 years with
mammography.
• High-risk women
• Ages 30 to 69 should be screened annually with mammogram and breast MRI
• Ages 70-74 identified as high-risk should be screened with mammography only
• High-risk women include:
• Women known to have a gene mutation that increases your risk for breast cancer
• Women who have a 1st-degree relative who has a gene mutation that increases their
risk for breast cancer
• Women who have a personal or family history of breast or ovarian cancer
• Women who have had radiation therapy to the chest to treat another cancer or
condition (e.g., Hodgkin lymphoma) before age 30 and at least 8 years ago
Screening in dense breast
• Cancer Care Ontario
• Breast density >75% should be followed up with repeat screening
mammogram in 1 year

• National Cancer Institute

• Risk increases with increasing breast density
• Patients with dense breasts are no more likely to die from breast cancer than
breast cancer patients who have fatty breasts
• The value of supplemental, or additional, screening tests is not yet clear
Screening: balancing the risks

Risks of over-screening Risks of under-screening

• Increased anxiety • Missing cancers that would have
• Unnecessary biopsies been be curable if caught earlier
• Overdiagnosis
Risks of over-screening

In women ages 50-74, for every 200 women screened in the Ontario Breast Screening Program, about 17
are referred for further tests and 1 will have breast cancer.

~from Cancer Care Ontario website (https://www.cancercareontario.ca/en/guidelines-advice/cancer-

continuum/screening/breast-screening-guidelines-summary)
 Breast cancer screening in men
• Mammograms are more effective at detecting breast cancer in
high-risk men than in women who are at average risk

• This is likely due to the low density of breast tissue in men. Dense
breast tissue in women can make it more difficult for the
radiologist to detect abnormalities.

• Normal-risk men should not be screened, high-risk men should

talk to their primary care physician about the risks and benefits of
screening.
Gao Y, Goldberg JE, Young TK, et al. Breast Cancer Screening in High-Risk Men: A 12-year Longitudinal Observational Study of Male Breast
Imaging Utilization and Outcomes. Radiology. 2019 Nov;293(2):282-291. doi: 10.1148/radiol.2019190971. Epub 2019 Sep 17. PMID: 31526252.
Transgender men and chest cancer screening
• It is recommended that transgender men who have not had top surgery
should follow the same screening guidelines as cisgender women.

• Transgender and nonbinary people are medically underserved and less

likely to be up to date with chest (and cervical) cancer screening.

• This is likely due to a number of reasons:

• The process can be at odds with their gender identity
• Fear of experiencing transphobia at screening facilities
• A lack of trans-specific cancer screening recommendations
• A lack of trans-specific health awareness campaigns
Screening in transgender women
• Taking estrogen for more than five years increases the risk of developing
breast cancer in transgender women
• Transgender women who have taken gender-affirming hormones for > 5 years and are
between the ages of 50 and 69, should be screened for breast cancer every two years.
• Transgender women who have never taken gender-affirming hormones or have taken
hormones < 5 years do not need to be screened regularly for breast cancer.

• Transgender women may face additional barriers to breast cancer screening:

• More likely to think that they don’t need screening
• Could be concerned that they might experience transphobia at the screening facility
• Could be concerned that having a mammogram could be uncomfortable or upsetting
Take Home Message
• Breast cancer is the most common cancer diagnosis and the 2nd leading cause
of cancer deaths in Canadian women

• Prevention is the best treatment, and this relies primarily on minimizing

established modifiable risk factors

• Naturopathic medicine can offer significant support during and after

conventional care to prevent and treat the adverse effects, improve quality of
life, prevent recurrence, and potentially improve outcomes

• Naturopathic co-management with chemotherapy or radiation therapy

requires extensive research and understanding about the therapies in order
to understand the adverse effects a patient may face and how to minimize the
risk of negative interactions