Cancer liver photo

What you need to know about fighting one of this country's most feared diseases.

Q. How can I can figure out my breast cancer risk?

A. The National Cancer Institute (NCI) has created the Risk Disk--a floppy disk that can help you determine your risk of breast cancer. The questionnaire includes some of the following factors:

* Age. Four out of five breast cancers happen after age 50, according to the NCI. By age 40, one of 217 women will have breast cancer. By age 50, cancer reaches one of 50 women; by 60, one of 24; and by 70, one in 14.

* Family history. You are most at risk for breast cancer if you've had multiple first-degree relatives (mother, daughter, or sister) with breast cancer--especially if any of them were diagnosed before menopause. Indeed, your risk jumps ninefold if a close relative had cancer in both breasts premenopause. "Breast cancer that occurs later in life may relate to lifelong exposure to the environment, rather than genetics," says Dr. Clifford Hudis, chief of breast cancer medicine at Memorial SloanKettering Cancer Center in New York. "Early in life, it's more likely to be inherited."

Alas, the Risk Disk results don't take into account all cancer contributors and should be discussed with your doctor before drawing any final conclusions. "The test can significantly underestimate risk in certain populations," says Dr. Therese Bevers, director of cancer prevention at the University of Texas-M.D. Anderson Cancer Center in Houston. Dr. Bevers has a 35-year-old patient with the BRCA1 gene--found in families at risk for breast cancer--who has 12 family members with breast cancer and four with ovarian cancer. Only one is a first-degree relative. Since the disk only asks for first-degree relatives with cancer, only one out of these 16 cancers is taken into account on the disk.

The Risk Disk is free and available in PC and Macintosh formats. To order, call the NCI at 800/422-6237 and select #2 from the menu. Or, order the disk from the Web site at http://cancertrials.nci.nih.gov.

Q. Are there really two pills that can prevent breast cancer?

A. While studies have proven that tamoxifen prevents breast cancer and have suggested that raloxifene may prevent cancer, the drugs may not be for you.

Tamoxifen has been shown to slash the danger of breast cancer by about half and raloxifene up to 75 percent over five years. Both pills work by occupying breast cell receptors--loading docks for the female hormone estrogen. This makes estrogen unable to enter the cells where it would spur cell growth.

The recently launched Study of Tamoxifen and Raloxifene for the prevention of breast cancer, or STAR, will compare the drugs' abilities to thwart cancer's arrival and compare side effects. The study calls for 22,000 women in the United States and Canada to take either drug for five years and then continue follow-up for two more years.

You may be a contender for tamoxifen (sold as Nolvadex) if you have three or more relatives in one generation who've had breast cancer, or you've had a biopsy reveal lobular carcinoma in sim (LCIS) or atypical dysplasia, says Dr. Alexandra Heerdt, attending breast surgeon at Memorial Sloan-Kettering.

Unfortunately, there are potentially lethal side effects with both drugs. Women taking tamoxifen can get uterine cancer and blood clots in the legs and lungs, and raloxifene increases the chance of blood clots. These problems have led researchers to offer the drugs only to women assessed with a 1.7 percent or greater chance of getting breast cancer within five years.

At that level, it might be worth the risk since side effects affected only 40 of the 6,600 women who received tamoxifen in the earlier study. "For some women, including someone who already has had breast cancer, the lifesaving benefits outweigh the risks," says Dr. Hudis.

Not enough is known yet about raloxifene's anticancer benefits, which were discovered by accident in a recent study. The drug, sold as Evista, was created for an entirely different purpose: to strengthen bones in postmenopausal women with osteoporosis. Like its sister drug, raloxifene can lead to blood clots and stroke, but has not shown any link to uterine cancer. The Food and Drug Administration (FDA) approved the drug in December 1997, but only for osteoporosis.

Q. When should I start getting an annual mammogram?

A. The current recommendation is at age 40. "Breast cancers do grow faster in your 40s," says Dr. Stephen A. Feig, director of the Breast Imaging Center at Thomas Jefferson University Hospital in Philadelphia. A mammogram is an X ray of the internal structure of your breasts.

If your mom had breast cancer before age 50, you may want to have your first mammogram a decade earlier than the age at which she was diagnosed. This isn't a rule, so discuss the issue with your doctor.

Begin yearly physical exams of your breasts by a doctor or nurse at age 20, regardless of your history. Anyone who has had radiation therapy for Hodgkin's disease should begin within a decade after being treated for the disease.

It pays to catch breast cancer early: If the disease is caught while localized, you have a 97 percent chance of survival, according to the National Institutes of Health. Once the disease spreads to the liver and beyond, your chances drop to 22 percent--or about 1 in 5.

Some good news: A recent federal ruling requires doctors to send a written report within a month after a patient has a mammogram.

Q. What's new in breast cancer detection? Is it readily available?

A. Mammograms remain the gold standard in detection. Other tests, such as ultrasound, may be used to detect breast abnormalities. This painless exam uses high-frequency sound waves to show whether a lump is a harmless, fluid-filled cyst or a solid, possible tumor.

"For women with dense breasts (two-thirds of premenopausal women), cancer can hide on mammograms since both the dense tissue and cancer appear white," says Dr. Thomas M. Kolb, a breast cancer radiologist in New York. His studies of more than 3,600 women with dense breasts caught 11 cancers missed by mammogram and physical exam. The drawback--and the reason why ultrasound is not used alone--is that ultrasound missed 25 to 55 percent of cancers.

Magnetic resonance imaging (MRB is a noninvasive technique that uses radio waves to create a greatly detailed picture of the body's internal structures. At this point, MRIs are expensive and time-consuming--and often don't catch smaller cancers, Dr. Feig says.

Still on the drawing board are other techniques, including digital mammography, in which images can be displayed on a computer monitor. Dr. Feig says the new digital technology is like comparing TV to a photo. "After the picture is taken, there's very little you can do with a photograph. But with a digital mammogram, like a TV, you can adjust the brightness and contrast." The images can also be transmitted to other medical offices. Today, the monitor images aren't as sharp as those on X-ray film. This problem may be resolved within five years.

Even more exciting is a blood test that may find breast cancer through a tumor marker known as LPC, Dr. Bevers says.

Q. What should I do if I find a lump? Is there a better alternative to surgical biopsy?

A. if you've got a lump, don't wait more than a few weeks. Not only will your anxiety expand, but so might the cancer. You can take comfort that in the unlikely event you need a biopsy, the ones done today are kinder and gentler.

"Surgery biopsy is infrequently necessary," Dr. Kolb says. Using a needle instead of a scalpel, today's biopsies leave no scar and don't require hospitalization or anesthesia. A radiologist removes suspicious tissue through a "large core" needle--three-eights of an inch thick In some cases, a vacuum-assisted "mammatome" sucks the tissue into the needle, which may be guided by a computer, mammogram, or ultrasound. The procedure takes less than an hour, costs less than $500, and is just as accurate as surgery, reports the Journal of the American Medical Association (JAMA).

Even needle biopsies may be passe one day soon. But today, a tissue sample is still required to make a cancer diagnosis.

Last April, the FDA approved the T-Scan 2000, a handheld scanner that detects tumors by passing a tiny electric current through the body. Differences in structure between healthy tissue and tumors make the latter about 40 times more conductive. The device should become available at some cancer centers later this year.

Q. Can I avoid the disease through diet?

A. What you eat may matter. A recent University of Texas Medical Branch study in Galveston, Texas, shows that peak blood levels of estrogen dropped 40 percent in nearly 20 women who drank more than four glasses of soy milk a day for over a month. Soybeans contain isoflavones, weak estrogens that block the estrogen receptors, thus lowering the amount of estrogen--and cell growth--in a woman's body.