About Breast Cancer & Early Detection

Risk Factors of Breast Cancer

(updated June 2014)

The specific cause or causes of breast cancer are not known, and it is highly unlikely that any single factor can trigger the disease. Researchers believe that it is most likely a combination of genetic and environmental factors. Much emphasis has been placed on identifying individuals who have a high risk of breast cancer. A number of factors that predict the occurrence of breast cancer have been extensively studied.

What are the implications of identifying the risk factors for breast cancer? The known risk factors for breast cancer may allow the identification of a high-risk group that could benefit from increased surveillance i.e. regular clinical breast examinations and screening mammography.

Before you read about the various risk factors, it is important to understand what is meant by risk factors. Read the article on WHAT I UNDERSTAND BY RISK FACTORS first.

Key Points

1. The two most important risk factors for getting breast cancer are being female and getting older

2. Risk factors do not accurately predict a woman will have breast cancer. Not having any of the known risk factors does not mean that you are “safe”! The majority of women who develop breast cancer do not have a family history of breast cancer and do not fall into any other special high risk category!

3. Knowing your risk profile could help to determine if you need screening examinations. It will also motivate to be more pro-active in your breast health awareness.

4. Since breast cancer cannot be prevented, an important strategy in reducing the mortality from breast cancer is earlier detection and treatment before the cancer spreads.

Established Risk Factors

Keeping all these in mind, the following briefly describes the established risk factors:

Sex/Gender

Breast cancer is almost an exclusive disease of the female. Being female is the single most important risk factor.

Age

An increasing age is associated with an increased risk.  Breast cancer is extremely rare before the age of 25 years.

Geographical variation 

Where you live is important. Breast cancer is more common in western countries compared to Asian and African countries.

A previous history of breast cancer  

If you have had breast cancer of one breast before, you now have 4 times the risk of developing breast cancer in the opposite breast.

A family history of breast cancer & genetic risks

A woman with a mother or sister (first degree relative) who develops breast cancer at a young age, has twice the risk of developing breast cancer herself, and this risk increases to 4 times if 2 first-degree relatives are affected.

For men, he is at higher risk if his father or brother or son has had breast cancer. Female relatives of men with breast cancer often have an increased risk of breast cancer. In some reports, 60% of men with breast cancer have female relatives with breast cancer.

It is important to know how old they were at the time they were diagnosed.

Only 5-10% of women with breast cancer have a genetic defect.  In 1990, the BRCA1 gene was discovered, and this was followed a few years later by the discovery of the BRCA2 gene.  The presence of either gene is associated with an 85% chance of developing breast cancer by the age of 65 years.  The BRCA1 gene is also associated with a risk of ovarian cancer. It is not an extra gene but a defective or mutated gene that promotes growth of breast cancer.

Families of women with BRCA1 often have a history of several generations of women suffering from early onset and even bilateral breast cancer (affecting both breasts).  However, they have also discovered women with BRCA1 gene that did not have family members with breast cancer.

A rare form of inherited breast cancer, Li-Fraumeni syndrome has been linked to mutation in the gene p53. Breast cancer in these patients is also associated with tumours of the soft tissues, bones, brain and adrenal gland.

A history of benign breast disease

The term “benign breast disease” covers many types of cellular abnormalities.  Women with proliferative breast condition with atypical hyperplasia, a type of benign breast disease where the cells are mildly abnormal, have a 4-fold risk of developing breast cancer. There are a variety of proliferative breast conditions which you can only tell if you had a lump removed for tissue evaluation, and the histopathology report comes back with the information of whether there are atypical cells or not. A history of proliferative disease without atypia only carries a very slight increased risk.

Menstrual cycle

Early menarche (onset of menstruation) before the age of 12 years old, and late menopause (cessation of menstruation) after the age of 55 years are associated with a 2-3 times increased risk of breast cancer.  This is related to the cumulative number of ovulatory cycles, and it is thought that the prolonged exposure to oestrogens may play a role is the causation of breast cancer.

Parity

Nulliparity (never having borne children) or late age at first childbirth (after the age of 30 years) increases the risk of breast cancer.  This is probably related to the number of uninterrupted menstrual cycles.

Exposure to ionising radiation

Exposure to ionising radiation eg xrays, particularly between the age of puberty and 30 years, can substantially increase the risk of breast cancer.  However, exposure to significant levels of radiation that are clinically important is rare.

Previous exposure to atomic bomb explosion will have a 3-fold risk of developing breast cancer compared to the person without such exposure. Radiation risk is estimated from data derived from high-dose exposures, such as in survivors of atomic bomb attacks, uranium miners, people exposed to radon gas, tuberculosis patients who have undergone multiple fluoroscopic procedures (a practice that is no longer done for many years), and patients who receive radiation treatment for post partum mastitis and Hodgkin’s disease. The radiation doses in these settings have ranged from 250mGy-20Gy (25 to 2000 rads) which are doses way above those received in the usual x-rays taken for diagnostic purposes.

Socio-economic status

Women of higher socio-economic status are at greater risk of breast cancer compared to women of lower socio-economic status.  This reflects differing reproductive patterns such as age at menarche, age at menopause, age at first childbirth and also diet.

Diet

The composition of the diet has been thought to influence the risk of breast cancer, and may account for the differences in incidence rates between countries.  However, only weak or non-existent associations have been found in case-control studies. There is also evidence that alcohol consumption results in a slight increase in risk of 1.4 to 2.0 depending on how much alcohol is drunk per day.

Body size

Obesity in postmenopausal women is associated with an increased risk of breast cancer.  This is because oestrogens can be produced in fat; hence postmenopausal obese women have higher levels of circulating oestrogens, and as mentioned before, breast cancer is associated with increased oestrogen exposure.

Oral contraceptives (OCP) and hormone replacement therapy (HRT). 

Prolonged oral contraceptive usage is associated with breast cancer diagnosed in premenopausal women; however the risk is only around 1.2 times. The risk returns to normal over time once the OCP is stopped.

Hormone replacement therapy is prescribed for postmenopausal women for a variety of reasons but these days are prescribed more judiciously to ensure benefits outweigh the risks.

A combination of oestrogens and progestogens are used.  The dose of oestrogens prescribed is very low, and the risk of breast cancer increases only after more than 5 years’ usage, and even then the risk of developing a tumour with favourable prognosis is about 1.8 times compared to those who never used HRT. Amongst women who have used HRT for more than 5 years, the relative risk is about 2.6.

The latest updated analysis of the Women’s Health Initiative (WHI) randomised trials have found that the combined estrogen plus progestin therapy doubles a woman’s risk of death from breast cancer, nearly doubles the risk of death from non-small cell lung cancer and increases the risk of death from colorectal cancer by 54%. The combined HRT also appears to increase the incidence of all subtypes of breast cancers, not just the estrogen-receptor positive breast cancers but also those which are estrogen-receptor negative, triple-negative, HER2-overexpressing as well as HER2-negative cancers.

The decision for women to begin HRT is dependent on many factors. HRT helps to improve the hot flushes, mood swings and other menopausal symptoms that can be severe in some women. The risk/benefit ratio requires careful consideration before HRT is used. Should HRT be needed because menopausal symptoms cannot be managed by other means, then, the duration of HRT intake should be as short as possible.

Breast feeding

Large studies have found no association between breast-feeding and breast cancer.  Breast feeding does not appear to confer a protective effect either although in 1999, data from the Carolina Breast Cancer Study suggests that breast feeding is associated with a slight reduction in the risk of breast cancer among both younger and older (childbearing) women. Still the authors caution that since the study results conflicts with previous studies, it is premature to advise women to breastfeed solely to reduce their breast cancer risk. Breastfeeding should be promoted because of its myriad benefits to both baby and mother.

Physical Activity

There is increasing evidence that any form of physical activity/exercise reduces breast cancer risk. However it is not certain exactly how much exercise is needed. Still, exercise is a good addition to your lifestyle modifications that has long term positive impact on your overall health.

The following DO NOT increase your risks of breast cancer (with information to date):

1. Wearing Bra

2. Breast Implants

Breast Cancer Risk Calculators

There are several methods for calculating risks.  For a technical write up on breast cancer risk assessment models:

http://breast-cancer-research.com/content/9/5/213

For online calculators –

http://www.cancer.gov/bcrisktool/

http://www.halls.md/breast/risk.htm

 

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