Breasts
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That being said, the changes I’m about to suggest in this book don’t just serve your breasts well. Oh no, ladies. They also yield lower cholesterol, better triglycerides, perfect blood pressure, fewer heart attacks, a leaner body, less diabetes, painless joints, more energy, better sleep, a happier mood, an improved sex life, a sharper mind, less dementia, smoother skin, regular bowel movements, cleaner lungs, less cancer in every single organ in your body, a healthier planet, and a longer life. If you practice what I teach, you will radically reduce, if not completely prevent, many of the illnesses that ultimately lead to chronic and life-threatening diseases. You’ll feel a boost of happiness and satisfaction. You’ll implement your goals with ease—and never look back.
A PIONEERING APPROACH TO BREAST HEALTH
Since I founded the Pink Lotus Breast Center in Los Angeles in 2007 alongside my husband, Andy Funk, our mission has been to fuse state-of-the-art breast cancer screening, diagnosis, and treatment with preventive strategies and holistic, compassionate care. We’re out to save lives in a way that eliminates fear, instills confidence, and provides hope in a moment of panic. Pink Lotus aims to transform the delivery of breast health care in America and to help as many women as possible, regardless of their income or status in life. We see thousands of patients every year, with a wide range of concerns, and do our best to accept most insurances, including Medicare. For low-income uninsured or underinsured women, the Pink Lotus Foundation provides 100 percent free breast cancer screenings, diagnoses, treatment, and support to those who otherwise might not be able to receive any care at all.
I am incredibly grateful that occasionally working with prominent celebrity voices affords me the unique opportunity to get my message about breast health and risk reduction into the world. Three days after I removed Sheryl’s breast cancer, she arrived in my office with a paper in hand and revealed, “I want to go public about this. Can you please fact-check this press release?” And Angelina Jolie’s New York Times op-ed, “My Medical Choice,” led to a permanent increase in BRCA testing documented around the world.4 I consider it an honor and duty to continue the conversations they started.
While I’m best known as a surgeon, my ultimate mission as a physician is to get to people before they need to go under the knife. I do everything I can to teach others about breast health—I appear on television, contribute to our Pink Lotus Power Up blog, give lectures, publish articles, perform research, and sponsor campaigns. I want to empower you with facts and arm you with strategies to help you understand your breasts, reduce your cancer risk, and open your eyes to life-changing interventions and treatments if you are diagnosed with the disease.
HOW TO USE THIS BOOK
Educating yourself on breast health simply requires a commitment to living your best life. We should never die from something we can largely control. Can we control breast cancer? Admittedly, a percentage of breast cancer occurs in women who seem to have mastered all the things that promise to maintain health and wellness throughout life. Until that elusive cure or prevention vaccine shows up, our best efforts will occasionally be thwarted by uncontrollable mutations and unrecognized causes. Nevertheless, you do have significant power over this disease—let’s use it. A solid 50 percent—and perhaps as much or more than 80 percent—of all breast cancer could be eliminated from planet Earth if women understood that daily choices like food, drink, exercise, weight, toxic exposures, and mind-set create the environment inside the very cells of our breasts, which either stay healthy or turn malignant.5 Every single day, we make countless choices that bring us closer to cancer or move us farther away. The easiest cancer to cure is the one you never get.
Here’s what you can expect as you move through all these pages. I suggest reading the entire book to best comprehend all the important information it contains, but I certainly understand if you want to jump directly to the sections that apply to you and your interests. To that end, let me give you a little direction so you can navigate straight to the topics that intrigue you most.
In the first half of the book, I focus on boosting your breast savvy and teaching about lifestyle choices that reduce your breast cancer risk. In part 1, you’ll learn how to care for your breasts and never again mind the myths surrounding breast cancer’s causes. I have spent much of the last two decades researching the connection between lifestyle and cancer, and many of the things you’ve heard cause breast cancer are false. In part 2, we’ll discuss what else you can do besides showing up for your yearly mammogram and hoping that you don’t find a lump in the following 364 days. I’ll help you reduce your cancer risk based on food and lifestyle changes, particularly those that keep estrogen in check, since estrogen fuels 80 percent of all breast cancers. The healthiest meals are plant-based, low fat, and high fiber: an abundance of fresh fruits and vegetables (preferably organic), 100 percent whole grains like brown rice and oats, nonanimal proteins such as lentils, beans, and soy, with a cup of green tea on the side. I will also talk about choices like supplements, exercise habits, weight control, and hormones that can impact risk.
In the second half of the book, I’ll explore uncontrollable risk factors for breast cancer, plus outline your medical choices if you’re at elevated risk for, newly diagnosed with, living with, or navigating life after breast cancer. In part 3 specifically, I’ll detail the operations and medications that mitigate risk. I field a lot of questions from patients about genetics and BRCA mutations in particular, and will share the latest research on mutations and what they mean for you. The key with uncontrollable risks is to understand them and then to use them to inform controllable choices. And if you do have elevated risk, this doesn’t mean there is a one-size-fits-all protocol. Some patients choose prophylactic surgery. Others don’t want to go anywhere near the knife but take preventive medications. Still others decide to improve lifestyle factors combined with an aggressive screening regimen. If you’re struggling with medical choices, in part 4 I’ll help you find a path that leaves you feeling confident and comfortable with your decisions. I will review surgical options, explain the differences between lumpectomy and mastectomy, endocrine and immunotherapy, radiation and chemotherapy, and address specific questions I repeatedly hear at my center.
It turns out acronyms abound in medicine, and in the interest of keeping you easily moving through our time together in this book, I use a number of them. To that end, please reference the appendix, a handy-dandy table that puts all those acronyms into a tidy little list. I’ve been sure to back up every claim I make with reference to a study, a paper, or a text. These endnotes are quite extensive, so I’ve placed them online for easy searching at pinklotus.com/drfunkendnotes. Long quotes from studies or articles, and the endnotes attached to data in tables, have been retained at the back of the book.
So let’s get started! I firmly believe that knowledge is power, and power replaces fear with confidence and joy, which motivates you to implement changes—changes that I know could save your life, and in turn, make the lives of all those whom you love, and who love you in return, all the more joyful too.
PART 1
BREAST HEALTH BASICS
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.