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CHAPTER 1

Breast Care ABCs

Take it from someone who’s around breasts all day, every day, and has been known to dream of them at night—women can have very emotional associations with their breasts. It takes a strong sense of self, which I hope we all strive to achieve, to say, “I am not my breasts,” because breasts connect in undeniable ways to femininity, sexuality, body image, and womanhood. Our feelings about our breasts run the gamut from pride in their shape and size, to awe over their milk-producing and life-affirming function, to trepidation and dread that someday they may give us cancer. To this last point, despite our fears, there have been few solid guidelines on how to improve your breast health, lower your risk of getting cancer, optimize your outcomes if you’re faced with a diagnosis, and make informed medical choices after treatment—until now.

I’d like to start off here with a few basics about breast health: the parts and functions of your breasts, surprising facts about the “girls,” and how to take good care of them so you live a long, vibrant life. Understanding the breasts you’re caring for will ultimately go a long way to reducing their cancer risk. While you can’t control all your risk factors—some, like being a woman and getting older, are nonnegotiable—you can influence and reduce more than you may know by recognizing the factors that are under your control and then adjusting your life choices accordingly.

BREASTS 101

When it comes to your chest’s general anatomy, breasts remind me of a funky Jell-O fruit salad. Imagine one of your breasts as many bunches of grapes that you’re holding by the top of the largest stems (at the nipple). As you picture these bunches, see all the tiny connecting stems as the tubes that carry milk out of the nipple during lactation (they exist whether you ever get pregnant or not). The stems all connect to grapes, which represent the milk-producing lobules of your breast. The entire breast has fifteen to twenty lobes (grape bunches), and all the stems coalesce toward the nipple, with eight to twelve milk ducts opening on your nipple’s surface.

Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist. https://commons.wikimedia.org/wiki/File:Breast_anatomy_normal.jpg.

Now, push that entire bunch of grapes and stems, which together comprise what we call glandular tissue, into a mold of Jell-O that’s shaped like your breast and sits on top of your chest wall muscles. (By the way, imagine if Tupperware actually made breast molds. They’d make a killing at “bye-bye breast” parties—or as one of my patients called hers, “Ta-ta, ta-tas!”) The Jell-O represents the supportive structures that surround the breast gland, composed of stroma (a kind of connective tissue), adipose tissue (fat), ligaments, lymphatics, and blood vessels. The lobules and ducts, or grapes and stems, are usually what become cancerous (milk ducts alone are responsible for 75 percent of all breast cancers), but the Jell-O rarely does. For example, a Mayo Clinic review of all breast cancers in women over fifty-nine years old showed that a stromal-based breast cancer, called primary breast sarcoma, accounted for only 0.0006 percent of breast malignancies.¹

Breasts range in size from absent, as seen in a rare disease called Poland Syndrome, to ones that swing down to your knees. Cups go from AAA to L—with the average American cup size being a D; Russia, Sweden, Norway, and Finland have cup sizes larger than D; Australia, France, Italy, the UK, Canada, and South America average a C; in Africa and Asia, women are A/B. Few women have a perfect match. In most, the left breast is up to 20 percent larger than the right (sudden one-sided changes in size are not normal, so if that happens, see your doctor). Your breast size and “perkiness” mostly come from a genetic patchwork of markers handed down from both of your parents to you, plus nutrition and the influence of estrogen, progesterone, insulin, and growth factors during your early years, puberty, pregnancy, lactation, and menopause. Fatness, exercise, aging, skin quality, and hormone use also influence size and shape. Since your breasts contain a genetically predetermined amount of fat, your breasts expand when you do. And contrary to what you may have heard, there’s no direct connection between the size of your breasts and your risk of getting breast cancer.

Your actual breast takes up more space on your body than you probably realize—a point to keep in mind when you do your breast exam every month, as I’ll discuss next. The girls aren’t limited to the two fleshy mounds nestled into your bra. Each breast technically goes all the way up to your collarbone (the clavicle superiorly), centrally to your breastbone (the sternum medially), down to the curve you associate with being the bottom of your breast (the inframammary fold inferiorly), and off to the side of your chest wall (the anterior border of the latissimus dorsi muscle laterally). Another bit of breast tissue extends like the point of a teardrop toward the armpit, called the axillary tail, located just beneath the hair-bearing part of your axilla. Sometimes this tissue actually extends into the armpit itself, which is called axillary accessory breast tissue. When rather pronounced, it bulges out, covered by skin. Depending on whether this happens on one or both sides, you might feel as though you have three or four breasts. An axillary accessory nipple could even connect that breast tissue to your skin, and yes, this means you could actually breastfeed from your triple nipple one day.

All breasts are lumpy, not just cancerous ones. Who in the world ever referred to breasts as melons? Did that person ever feel a breast before? Melons are uniformly firm, round, and very smooth—and they don’t budge when you poke them. The natural terrain of the breast is more like a mountain range with peaks and valleys covered in a blanket of snow (fat) and then wrapped in skin. When you run your fingers across that skin, the snow feels soft until you push deep enough to feel a mountain peak, and with a valley on both sides, that peak sure feels like a lump. The only way to trust that that’s a mountain and not a malignant intruder is to either see a doctor, or to know that it’s been there forever and it’s just your normal anatomy. All breasts have lumps, breasts are lumps, and they feel lumpy. The denser your tissue, the lumpier you feel. Genetics determine breast density, as do the estrogen levels in your body.

Lastly, there’s the surface of the breast. Arteries and veins circulate blood flow to nourish the breast skin, and in lighter-skinned ladies, sometimes we can see the veins rather clearly; also, conditions that increase blood flow will dilate those veins, making them more apparent—especially after exercise, or during pregnancy, or in certain cancers. Nipples can be dark or light, smooth or textured, pointing out, level, or inward, and range in size from flat to a pencil eraser or sugar cubes—it’s all normal. The colored skin around the nipple base is called the areola, and its diameter varies from dimes to saucers, generally 1.5 inches to 4 inches (4–10 centimeters). Some people have additional nipples, called supernumerary nipples, located along two vertical “milk line” arcs from the armpits to the normal nipples to the left and right groin. Occurring in 1 per 8,000 people, these either look like flat moles or have a raised bump.² Celebs with extra nipples include Mark Wahlberg (three) and Harry Styles (four), so no shame there.

If you zoom in on the areola, there’s so much more to see. All women have hairs that grow at the areolar edge coming from hair follicles. We have fifty million follicles on our skin, so sometimes a few unwelcome strays grow right there. They usually show up in response to hormone changes: puberty, pregnancy, menstruation, menopause, or birth control pills. You can safely tweeze them out or get electrolysis. Tweezing sometimes leads to ingrown hairs, which then cause tiny raised pimples and white sebum to collect. Makes you wonder why you thought tweezing would make the area more attractive. Areolar bumps called Montgomery glands are tiny sebaceous glands whose function is to lubricate the nipple (per textbooks), but since that seems like a fairly useless function and doesn’t even make sense anatomically since they are not on the nipple, I just tell people they are normal and benign and won’t go away no matter how much you squeeze them. You can also get tiny blackheads at the edge of the areola; just wash the area and occasionally exfoliate as you would do to your face at night. If you notice an itchy, scaly, flaky rash on your nipple or areola, call your doctor.

MORE NIPPLE FUN FACTS!

• Some people are born without nipples, which is called athelia. There are about seven thousand diagnosed cases worldwide.

• Nipple stimulation and genital stimulation affect the same part of the brain. One-third of women can reach orgasm solely through having their nips caressed.

• If you use a magnifying glass to examine the areola, you will find hairs growing on the areolar border of all adult living human beings.

• When supernumerary nipples occur outside the milk line, they’re called ectopic, and can be as far from your chest as the sole of your foot.

• Why do men have nipples? Because we all start out as girls! Nipples show up in utero before sex organs do. And then they just stick around (and out).

GET HANDSY IN THE NAME OF HEALTH

Healthy breasts require regular at-home breast exams, but don’t let them stress you out. The goal here is to get a lay of the land and learn what all your lumps feel like. This way, if you develop something new or different, you’ll be the first to find it. Next to risk reduction, early detection ranks second as our best defense against cancer. I suggest starting a self-exam routine in your teens and doing one every month. Teenagers virtually never get breast cancer, but it helps them later to be familiar with their breasts now. Whatever your age, time exams to one week after your period since that’s when they’re the least lumpy, tender, and confusing. If you don’t menstruate anymore, make the first day of every month your exam day. The whole exam should take three minutes, and it may just be the most reassuring part of your day. If anything seems out of the ordinary, trust your intuition and see your doctor. Ready?

1. First, give your breasts a good stare. Disrobe from the waist up, stand in front of a mirror, and then scrutinize the breasts peering back at you. Visually scan them for shape, size, or contour changes, plus skin alterations like thickening, redness, dimpling, retraction, and bulging out. Your nipples should be pointing the way they always point—straight ahead, left, right, naturally inverted, or headed south checking for spare change on the floor.

2. Next, check to see if your breast tissue dimples or bulges out while watching your breasts in the mirror in two different positions. In the first posture, put your hands on your hips and push in so that you’re flexing your chest muscles. Any funny dents or bumps? In the second pose, raise both hands overhead like you’re getting arrested. All clear?

3. Exam time! Either reclining on your bed or standing in the shower—whatever is comfortable for you—put a little lotion or shower gel on your fingers to help them glide across the breast tissue. Pick one of the following four patterns to trace over your breast tissue: (1) up and down the length of the breast vertically, (2) left to right across the breast like words on a page, (3) concentrically in circles like a target sign, or (4) radially like spokes on a wheel. Whatever pattern you choose, the results will be the same—just be sure to use the same technique every month so your fingers develop an unconscious memory of the tissue.

4. Start with your left breast, and raise that left arm behind your head to flatten the tissue as much as you can (I know—some breasts are way too floppy to flatten). Use the fat pads of the three middle fingers on your right hand to do the exam. You’re feeling for a new lump or thickening. Start in your armpit, then transition to the upper outer part of your breast and make tiny circles gliding across the breast until you’ve evaluated the entire breast in whatever pattern you chose from number 3 above. Don’t ever lift your fingers off your breast skin as you do this. Repeat the entire exam three times—first with a light touch, then medium, then deeper still.

5. Gently squeeze your nipple a few seconds. At some point in your life, you will probably elicit discharge from your nipples due to tiny amounts of fluid always present in the breast ducts. It’s normal to have discharge when you squeeze or stimulate the nipples, but fluid should never come out by itself without touching the nipple (e.g., staining your bra cup or PJs). If you squeeze out bloody or clear-like-water fluid, or if discharge is spontaneous, see your doctor. I don’t care about nonspontaneous discharge that’s any color other than bloody or clear like water.

6. Repeat on your right breast. You’re done for the month!

7. Visit easybreastexam.com to watch a demonstration video.

WHAT TO LOOK FOR DURING A BREAST SELF-EXAM (BSE)

In 2017 an image from Worldwide Breast Cancer depicting bright, cheerful lemons in an egg carton went viral with the caption “What Breast Cancer Can Look & Feel Like.”

Worldwide Breast Cancer, “What Breast Cancer Can Look & Feel Like,” © Worldwide Breast Cancer, 2017. Used by permission. Knowyourlemons.org.

So smart. I love this! Certain signs of breast cancer are seen and not felt, so they should be seen. It’s said a picture is worth a thousand words. And looking at lemons, well . . . they don’t make you squirm or feel embarrassed, and it’s hard not to associate these yellow balls of fruit with sunshine and lemonade.

Here’s the list of signs shown in the picture:

• a thick area

• a dimple

• nipple with crusting, itching, pain, rash, cracks, peeling, flaking, scaly, or bleeding skin

• redness or heat

• new fluid from the nipple (especially bloody/brown or clear like water)

• skin sores (that are not typical skin conditions)

• a bump

• a growing vein

• a sunken nipple that is pointing in a new direction, getting flatter, or inverting (retracting inward)

• a change in size or shape (especially one side only)

• skin that looks like an orange peel (larger pores, orange/red discoloration)

• a hard lump deeper inside the breast

Also worth noting:

• swelling or lumps where lymph nodes are located: armpit, around the collarbone, in your neck

• pain or tenderness in one spot, constant, not changing with your periods

Any one of these findings is a good enough reason to check in with your doctor. No one will think you’re paranoid, and most times we discover a noncancerous reason behind the signs. So if your breast reminds you of one of those lemons in the egg carton, get it checked out. On the other hand, don’t fret that finding breast cancer is all up to you. That’s why you get breast imaging and annual breast exams with your doctor.

BREAST HEALTH BY THE DECADE

Though you can improve your breast health at any age, you’ll want to keep a certain level of vigilance in mind based on where you are in life. Let’s take a look at my recommendations for optimal breast health, based on the decades in life. The median age for breast cancer in the United States is sixty-two years old, so half of women are diagnosed at or after sixty-two, and half before sixty-two; so if you’re at, over, or under sixty-two, I want you to pay attention.

As a teenager, you’re in a sweet spot for breast health. With a lifetime of conscientious habits ahead, I don’t want you to worry about your breasts as they develop. Learn to do a breast self-exam (BSE) and do it every month, one week after your period starts, because the younger you learn to recognize lumps and bumps, the more familiar you will be with any changes that occur in the future. My unforgettable friend Mary Ann Wasil began the Get In Touch foundation to help young girls demystify and understand their breasts by teaching them the potentially lifesaving skill of breast self-exam. Check out their site, getintouchfoundation.org, to learn creative ways to spread knowledge and skill regarding BSE.

If you have a family history of breast cancer prior to age fifty, your mother or father (whoever is blood-related to the person with cancer) should schedule a genetic counseling and risk assessment visit for her/himself, the result of which will further inform you about your own risks. Know, though, that breast cancer as a teen is a reportable phenomenon, with chances being less than one in a million.

Women in their twenties and thirties need to take breast health more seriously than they did when they were younger. If this is you, do your BSE once a month, one week after your period starts or the first day of every month if you do not have a period. Visit the gynecologist for an in-office manual exam, called a clinical breast exam (CBE), every three years, plus schedule a genetic counseling and risk assessment visit if it’s appropriate due to family cancers. Women under the age of forty with breast cancer have more aggressive tumors, so it’s crucial to stay aware.

A decade or two later, in your forties, continue doing a BSE once a month, but start seeing your gynecologist annually for a CBE for the rest of your life. You’ll also need to add a mammogram once a year, and if your breasts are dense, get an ultrasound too. And from here on out, that’s the deal, ladies, whether you’re in your fifties, seventies, or nineties.

If you’re considered high risk, we layer a little extra on top of all this advice. Various factors determine what makes a woman high risk, with the most outstanding being whether any marker lesions have been identified in your own breast tissue, and how many of your relatives have had breast cancer, especially under age fifty. If this sounds like you, take our anonymous, free genetics quiz at pinklotus.com/genequiz. Talk to your doctor about more frequent testing beginning ten years prior to the age of your youngest relative with cancer, and be sure to inquire about CBE twice a year, annual mammograms, and possibly ultrasound and/or breast MRI. You might also want to discuss the benefits of risk-reducing medications and operations. More on this in part 3.

WHAT IT MEANS TO LOWER YOUR RISK FACTORS

We’re going to spend a lot of time discussing risk factors for breast cancer in this book, so I want to be sure you understand what I’m talking about straight away. Simply put, a risk factor is anything that increases your chance of getting a disease, but does not definitely cause the disease. We don’t understand all of what causes breast cancer, so it’s impossible to eliminate every last variable and declare, “There, I prevented it!” with the same assurance that you could cry, “Five in a row. Bingo!” In that way, prevention doesn’t exist, but risk reduction does—and you, my friend, are in the driver’s seat.

Think of it this way: driving fast doesn’t automatically mean you will have a car accident, but it certainly increases the odds. Car accidents are caused by the collision of a vehicle with something else, and driving fast is just one risk factor for collisions. Deciding to drive fast backwards while also texting on a dark road in the rain combines multiple risk factors for a collision, but the actual cause would still be the undeniable imprint of that tree trunk smashed into your car trunk.

So how do you avoid colliding with breast cancer? Know your breasts, understand what they’re about, and take good care of them. This last point includes making the strategic and rather simple dietary and lifestyle improvements I outline in this book. After all, as I mentioned in my intro, researchers find that among women who, prior to menopause, (1) exercise, (2) don’t drink alcohol, (3) don’t smoke, and (4) shift their diet away from meat and dairy toward whole food, plant-based eating slash their odds of getting breast cancer in half. And postmenopausal women’s odds are sliced by 80 percent. In the medical world, this represents an incredible triumph when you consider that women endure chemotherapy for a mere 10 percent average improvement in survival over those skipping chemo.

How has all this powerful information eluded you so far? It’s hardly your fault. Evidence-based advice on breast health, particularly when it comes to cancer prevention, is publicly doled out in drips and drabs—a magazine article here, a brief morning show segment there. And when we do hear a tip, it’s often in isolation and gets lost in the shuffle of everyday life. So you might find out that consuming cinnamon improves breast health, but who, with so many spinning plates, remembers to make this part of her daily diet—and without guidance, who actually knows how? Our daily habits are set in stone or bring us comfort, so it’s hard to make changes to an established routine. But I will show you how.

I also need to point a manicured finger at our flawed educational system. During my four years of undergrad, four years of med school, five years of general surgery training, and my surgical breast fellowship, nutrition was a fleeting mention in the form of the Krebs cycle in the middle of one lecture—and for many of us physicians, that was twenty to forty years ago. Most doctors do not explore the science of eating or the impact of lifestyle choices to the degree that knowledge affects their own behavior, let alone yours. I know this is true because when I shared some of this book’s content with my cancer patients, countless times I heard, “Wow, I had no idea. You know, I asked my doctors what I should do and eat now that treatment has ended, and they just told me, ‘You did everything you were supposed to do. You’re fine; don’t worry about it. Live your life.’” Not so, my friend. You’re not done yet.

Even when doctors do recognize the nutrition–illness connection, part of the reason they don’t tell you much is a reimbursement issue. Just as insurance companies don’t pay for your gym membership, weight-loss program, or stress management course, they don’t reimburse us doctors to spend time detailing preventive strategies. Doctors already need to stay up-to-date on what you expect from them, like screening guidelines and the best treatments for all the diseases they handle, which leaves no time for researching and dispensing extra freebies like, “Hey, did you know that three cups of green tea a day cuts breast cancer risk in half?” (By the way, did you?)

So when you put all that together, the question isn’t how did you not know this—but how could you have possibly known at all? Nobody’s taught you to connect food and lifestyle to breast health the same way you might relate it to, say, the strength of your heart or brain. Which is funny, because your breasts coexist with the same body as these vital organs. The good news is that food science matters now more than ever, as the global health outlook becomes increasingly dismal. Both patients and doctors are becoming more interested in how nutrition and lifestyle affect risk reduction, causation, and reversal of disease processes.

Of course, my central concern right now is your breasts (well, and your heart, since the number-one killer of women is heart disease; lucky you, my advice helps both problems). Up to 90 percent of the risk factors that determine optimal breast health lie entirely in your hands—so you are in control of you. Not your doctors, genes, or fate. You are with your breasts all day long, every single day. If you spent that much time with anything or anyone—a child, a spouse, a pet, even a car—you’d make sure they were in good shape.

Why treat your breasts any differently?

TRUE, THAT’S FALSE

In coming chapters, we’ll discuss how to keep your breasts and body as healthy as they can be, but first let’s set the record straight on what does not cause breast cancer. Myths abound out there that puzzle my patients and the public, and they don’t hold up in studies. (Quoting studies is a theme you’ll find throughout this book because the pervasiveness of myths is such a peeve of mine.) If you’re aiming for optimal breast health, there’s no room for bogus claims.