Boobs: they feeds the babes. But, if that’s their primary function, why don’t they just plump up when women need them and shrink when they don’t, as is the case for other female primates? The nubility hypothesis argues that breasts are an adaptation in human females that resulted from sexual selection: men find breasts attractive because they show off a woman’s fat reserves; indicative of her potential as a solid baby carrier.
For some, breasts may be associated with femininity. Perhaps they’re a source of empowerment. Maybe a welcome mat for objectification. Hell, some may just find them a nuisance. Before diving in, stop and consider how you value breasts; not necessarily your own, but boobs in general (doing my darnedest to keep this article gender-neutral). Keep those values in mind as you read further.
In May last year Angelina Jolie was published as a guest contributor for The New York Times announcing in her article, My Medical Choice, that she had undergone a double mastectomy. Jolie’s mother, Marcheline Bertrand, passed away in 2007 at the age of 56 after a battle with ovarian cancer that lasted almost a decade. Although not presenting with any symptoms, but interested to determine her own disease risk, Jolie consented to have her DNA tested for genetic factors associated with increased susceptibility to breast and ovarian cancers.
Test results revealed that Jolie possesses a gene variant (allele) called BRCA1, which confers an 87% risk of breast cancer and a 50% risk of ovarian cancer (as opposed to average risks for women of 12% and 1.7%, respectively). Primarily, she decided to address her increased risk of breast cancer by having both breasts surgically removed. However, in an interview with Entertainment Weekly in March this year, she mentioned there being “still another surgery to have” that she would continue to seek medical advice about. Unconfirmed reports suggest Jolie intends to address her increased risk of ovarian cancer, too, by having both ovaries surgically removed.
Colour image courtesy of Gage Skidmore at http://flickr.com/photos/gageskidmore.
Forbes named Angelina Jolie Hollywood’s highest-paid actress in 2009, 2011, and 2013. Although, it was while filming Lara Croft: Tomb Raider in war-torn Cambodia way back in 2001 that Jolie developed an understanding of the world that would motivate her to put her tremendous fame and fortune to better use. Jolie features in the news almost as often now for her humanitarian endeavours as she does promoting films. Just this month she co-hosted a London summit attended by representatives of more than 140 nations seeking to declare an end to sexual violence in war.
Regardless of why her name is being splashed about in the media (if it isn’t her, it’s the power couple she belongs to), Angelina Jolie is extremely high-profile. So, when a public figure makes such a powerful statement in sharing their experiences with genetic testing and drastic preventive surgery, what are the ramifications?
Jolie intended to empower women by alerting them to their options; both in seeking genetic testing, and in addressing increased risk should genetic susceptibility factors be detected. Whilst her bravery was applauded by many for improving breast cancer awareness in general, her announcement may also have instilled a sense of panic in women and set a behavioural trend for those whose worst fears were realised after genetic testing; many high-risk patients hastily leaping to chop their boobs off before thoroughly examining their options (counterproductively limiting some options, rather than broadening them).
This two-part post takes a wee look at err’thang: breast cancer basics and humbling statistics, genetic testing (including the deets on those high-risk alleles), preventive measures, whether Ange’s best intentions were realised in the wake of her revelation and, finally, a romantic perspective on the potentially devastating disease that’s estimated to have taken the lives of 508,000 women in 2011.
Colour image courtesy of World Economic Forum at https://www.flickr.com/people/15237218@N00.
The cell cycle facilitates controlled cell growth and division. At different points in the cell cycle, regulatory checkpoints exist to ensure that advancing in the cycle is appropriate for a given cell, e.g. “Have I replicated all my DNA?” “Have my chromosomes aligned where they’re supposed to?” “Is there enough food around to nourish my daughter cells?” “Is it too cramped up in here to divide?”. If conditions aren’t ideal to advance in the cell cycle, regulatory proteins suspend proceedings to sort things out. However, when specific mutations exist in DNA associated with these checkpoint proteins, cell growth and division becomes unregulated; cells proliferate rapidly with limited differentiation (tumour development).
Cancerous tumours can be characterised by abnormal cell growth with the potential to metastasise (spread from one organ to another). Cancer developing in breast tissue originates most commonly in the milk duct lining (ductal carcinomas) or the lobules that supply the milk ducts (lobular carcinomas). Although typically discovered when a dense lump forms in the breast tissue or armpit lymph node, other symptoms of breast cancer may include skin dimpling, changes in breast size or positioning, skin colour or texture, the appearance of the nipple, or abnormal nipple discharge (a clear or bloody fluid).
The National Breast Cancer Foundation in the US encourages women of all ages to perform ‘breast self-exams’ monthly and they provide a tutorial to aid these little checks. I’d recommend that all readers access the link and give it a once-over, even if it serves merely as an excuse to spend a minute longer in a steaming-hot shower. The New Zealand Breast Cancer Foundation estimates that 60% of young women don’t know the signs beyond a lump, so an even greater percentage of all young people could really benefit from an increased awareness of the broad range of breast cancer symptoms.
But! Keep in mind that symptoms can arise for lots of reasons (not just because there’s an unrelenting population of immortal mutant cells trying to hijack the body from ‘Base Camp Boob’). So, promptly seek medical advice regarding any suspected symptoms (or encourage others to if they disclose their concerns), but try not to flip out prematurely.
Symptomatic patients will receive a physical breast examination from a healthcare provider, who may then request a diagnostic mammogram. Mammograms or ‘breast x-rays’ (or boob-squishing nightmares) are also used in breast cancer screening and are recommended biennially (once every two years) for New Zealand women aged between 45 and 69, but their use is controversial. (Note that diagnostic mammograms involve image capture from multiple vantage points with zoom potential to provide a more detailed scan than a screening mammogram.)
Mammography involves compressing the breast between parallel plates and beaming low-energy x-rays from a transmitting plate to a detecting plate (either photographic film or a digital detector). The amount of x-ray radiation that passes through the breast will depend on tissue density and composition. Dense breast tissue blocks or ‘attenuates’ x-ray radiation (similar to the way bones do in x-ray radiography) and these areas appear lighter on a developed mammogram.
Breast tumours are characterised on mammograms by high-density, but in women with dense breasts (a lower proportion of fatty tissue to fibrous connective tissue), tumours can be hidden and breast cancer may go undetected. Increased breast density has been associated with an increased risk of developing breast cancer, but it’s likely that this association exists because tumours are so often missed through mammogram screening in these patients (rather than dense boobs necessarily fostering cancer cells).
Ladies will generally have different breast densities (affected by factors such as age and weight), but breast density can also be influenced by fluctuating estrogen levels during the menstrual cycle. Breasts become more dense late in the cycle when estrogen levels are highest, so it’s recommended that women schedule their mammogram during the first two weeks of their cycle to improve scanning accuracy.
(Highly recommend Deborah Rhodes’ TED Talk, A test that finds 3x more breast tumors, and why it’s not available to you. Seems breast cancer politics can get quite scandalous! Although, I’m a leetle bit skeptical that she stands to make absolutely no financial gain from promoting MBI.)
Colour image courtesy of Memorial Health Services at http://www.memorialcare.org/services/glossary/m/mammograms-digital-mammograms.
Let’s recap. So, if symptoms develop or if areas of concern appear on the screening mammogram of an asymptomatic woman, a comprehensive mammogram will usually be called upon to ‘fill in the diagnostic gaps’. Before we continue, there are a couple of other imaging techniques that you may have heard thrown around a bit.
Breast ultrasound is an imaging technique often used in conjunction with mammography, but not used in breast cancer screening. Ultrasound may miss early signs of cancer like microcalcifications (tiny calcium deposits), but it’s helpful when scanning dense breasts and for non-invasive examination of a suspected cyst.
High-risk patients may also undergo a breast MRI for a more sensitive scan. Increased sensitivity has its downfalls though: use of breast MRI in screening would result in far too many false-positive results; scans detecting suspicious features that turn out to be non-cancerous (not to mention how expensive it would be to equip screening stations with huge MRI scanners and fund use of its technology for so many women).
Anyway, if concerns persist in light of all breast imaging results, a biopsy will be taken so a pathologist can examine cells from suspicious dense breast tissue under a microscope. A technique called fine needle aspiration involves injecting a thin, hollow needle into the breast lesion and sampling cells with a syringe. Alternatively, medical professionals may just decide to whip a whole chunk out of there using a core needle, if not excising the entire lesion! Breast biopsies are commonly guided by ultrasound, so each dense mass can be targeted accurately, but many techniques have been developed; each specialised for tumour size, location, count, and predicted severity.
Pathologists (folks trained to recognise histological ‘red flags’ for cancer) will perform a gross examination of larger preserved biopsy specimens; assessing size, colour, and consistency to surveil for cancer characteristics, and perhaps determine which parts ought to be examined microscopically. Under the microscope, however, they look for things like: weird cells or nuclei (size and shape abnormalities), or a strange arrangement of cells, e.g. cells of glandular tissue in the breast are organised into lobules and ducts, but cancer cells can clump to form either really distorted looking glands, or an aggregate bearing no resemblance to glandular tissue at all. Features identified by the pathologist from the biopsy specimen contribute primarily to breast cancer classification.
To assess how best to treat a given patient and to gauge patient prognosis (likely disease outcome), classification draws on four major aspects of pathology: histopathology, grade, stage, and receptor status (other minor classification approaches exist, too). Histopathology denotes the type of tissue cancer cells were derived from and their spread from that origin, e.g. perineural invasive mammary ductal carcinoma: breast cancer derived from the epithelium lining the ducts of the mammary glands, that has spread to tissue surrounding a nerve.
Grading compares the appearance of cancer cells to normal cells; the less differentiated the cancer cells are (the less they appear like normal cells), the higher their grade and the worse the prognosis. Stages of breast cancer (0-4) are determined using the TNM system: tumour size (T), spread of the tumour to the lymph nodes (N), and metastasis (M); spread of the tumour beyond the lymphatic system. Whereas stage 0 is pre-cancerous, stage 4 is metastatic cancer with a poor prognosis.
Finally, receptor status refers to the receptor proteins expressed on and within cancer cells. Receptor proteins bind signalling molecules like hormones for cell growth and proliferation, but drugs that target these receptor proteins on cancer cells can interfere with hormone-binding, thus meddling in breast cancer development. Determining breast cancer receptor status means the right drugs can be prescribed (with other therapies) to fight the nasty cell population.
Although breast cancer can affect males, it is the most common form of cancer for women worldwide. Incidence rates vary from 19.3 per 100,000 women in Eastern Africa to 89.7 per 100,000 women in Western Europe. However, the incidence of breast cancer is increasing with urbanisation and extended life expectancy in the developing world. Survival rates for breast cancer are similarly variable to incidence, ranging from over 80% in North America to less than 40% in low-income countries.
The next post will delve into breast cancer treatment and some of the risk factors associated with breast cancer; both lifestyle ones and genetic factors that have been linked to the disease. Preventive measures will be explored and I’ll take a look at how practical the information about genetic testing actually is in New Zealand, i.e. Is it even available to us? If it is, who’s eligible and is it horrendously expensive? Then Ange will enter the equation once more. We’ll investigate how the general public have responded to her shock announcement and wrap things up by examining the interplay between romantic relationships and the breast cancer journey. Alls the things, plenty to read about alls the things.
Less than a fortnight after Jolie was published in The New York Times, her mother’s younger sister (her aunt), Debbie Martin, passed away at the age of 61 after a cruel bout with breast cancer. Although a tragic passing, I’m sure it would only have reassured Jolie that her decision to sacrifice all she valued about her natural breasts (although cosmetic surgery voided the aesthetic sacrifice) and, furthermore, the decision to share her story with the world was relevant, necessary, and had enormously far-reaching potential.
It’ll be interesting to see how the adverse effects of her announcement might have put a dampener on nothing but a best-intentioned tell-all. However, adverse effects would need to be pretty hefty to outweigh the immeasurable benefits of just getting people talking about their breasts in the first place. Until then!
(And, seriously, check yo’self. Not necessarily thrice-daily, but no harm in working out what’s normal down in the chest region, so you can promptly recognise any curious little changes that pop up.)