Knowledge and vigilance are key to ensuring breast health

By Sally E. Smith

In 1992, 24-year-old Veronica Bosc was carefree, working for Club Med and travelling to all the best vacation spots. While on a Club Med trip, Bosc visited a French-speaking Tarot card reader in eastern Mexico. Through a translator, the psychic told Bosc that at the age of 30, she would become very ill and that she should watch her health. The reader's words lingered with the healthy young woman, who this year eagerly anticipated her thirty-first birthday on April 22 in the hope of escaping the woman's prediction. "I was so happy that my thirtieth year was almost over," Bosc recalls.

Unfortunately for Bosc, who had just bought a house with her husband Gerard and has a four-year old son, Damian, the Tarot card reader's prophecy came to fruition on April 9, when Bosc was diagnosed with breast cancer. A shot of fear coursed though Bosc when she heard the diagnosis, not to mention a case of the heebie-jeebies. "That damned Tarot card lady told me. I had almost made it (to my birthday)," she declares.

Bosc's medical team found five lumps in her left breast. A needle biopsy and lumpectomy determined that all five lumps were cancerous, as well as three of her lymph nodes. Her surgeon then performed a mastectomy, and today Bosc has now completed six of eight chemotherapy sessions.

Despite her ordeal, which is many women's worst nightmare, Bosc is incredibly vibrant, cheerful and upbeat. She continues to work two jobs - at Sports Club of LA and Spago of Beverly Hills - and proclaims, "I'm fully energetic, we have a new house, and I have no time to be negative about anything.

Bosc is more fortunate than most women being treated for breast cancer are, in that other than hair loss, she has had no side effects from the chemotherapy. "I go to work the next day, and I feel fine," she explains.

Claiming "I haven't been scared once," Bosc attributes her positive attitude to laughter, support and faith in God. "Laughter keeps me going," she chuckles, saying that she brings funny videos to her chemotherapy sessions and that she "flashes" her 17-year-old brother.

When Bosc told Gerard the news, "My husband flipped out. He was devastated." But, she says, "God told me it wasn't my time. He didn't instill fear in me." So she told her husband, "I'm not going anywhere. I'm planning to drive you crazy for the rest of your life."

In her younger days, Bosc says she participated in track and field and ran hurdles, which she detested. From her perspective, breast cancer is "just like the hurdles. I just have to get over the last one - the race is almost over."

Risk Factors

Bosc, like many breast cancer patients, didn't consider herself at risk for the disease. Known risk factors for breast cancer include a genetic predisposition (a family history of breast cancer), being over 50 years old, having never had children or having your first child after the age of 30, and having had prior radiation therapy or Hodgkin's disease. But according to Dr. Alexandra Heerdt, attending breast surgeon at New York's Memorial Sloan-Kettering Cancer Center and director of the Special Surveillance Breast Program, "Seventy-five percent of women who have been diagnosed with breast cancer have absolutely no risk factors, other than they're women."

Indeed, one out of nine women in the U.S. will develop breast cancer in her lifetime. This year, according to the National Alliance of Breast Cancer Organizations (NABCO), a newly diagnosed breast cancer occurs every three minutes, and a woman dies from breast cancer every 12 minutes. Breast cancer is the leading cause of cancer death in all women between the ages of 40 and 55.

While research has indicated that pre-menopausal plus-size women may be at less risk for breast cancer that our more svelte sisters, the same research has indicated that we may be at slightly greater risk post-menopausally, especially if we experience weight gain during adulthood. According to Heerdt, "Gaining weight over the period of your late 20s toward menopause can lead to a slightly higher risk of breast cancer. Some researchers think that's because estrogen is stored in fatty tissue, and stored estrogen has been linked to breast cancer." Heerdt's suggestion is to acknowledge a possible increase risk and take measures to counteract it. "For example, exercise can decrease stored estrogen," she says.

Currently, there is no sure-fire way to prevent breast cancer. It is unclear whether tamoxifen, a drug that for 25 years has been used to treat breast cancer and which was approved for use in breast cancer prevention for high risk women by the Food and Drug Administration in October 1998, actually prevents the disease or simply delays its emergence. Roloxifan, Heerdt feels, "will eventually be found to be as effective as tamoxifen." Other drugs in development will eventually mean that "Women at significant risk and are concerned will have the option of taking medicine to decrease that risk," Heerdt says.

In addition, Heerdt counsels, "moderate exercise could decrease your risk," as could eating a low fat, high fiber diet. While there is no research to support the low-fat, high fiber hypothesis, health care professionals anecdotally concur that these eating patterns result in lower recurrence for women who have had breast cancer. A recent study suggests that protein from poultry and dairy foods may reduce the risk of dying in those women who have already been diagnosed, but that lower fat consumption doesn't seem to make a difference.

In the time since researchers identified two genetic disorders linked to breast cancer, the BRCA1 and BRCA2 mutations, genetic testing has been made available to women at high risk. But Heerdt warns that genetic testing is not for everyone. Within Sloan-Kettering's Special Surveillance Breast Program, she says, "Our policy has been that we discuss it with any woman who we think is an appropriate candidate to consider it.... But in the counseling session, we ask them what they would do with the results before actually having the test." If, for example, a woman does not want to consider prophylactic mastectomy (the removal of a healthy breast in high risk women) or radiation, the information she gains from genetic testing may only serve to increase her fear and worry. On the other hand, if a woman knows she has a genetic mutation and will be extra vigilant in maintaining her breast health, then the screening may be helpful. "As long as you know why you're doing it and what you're going to do with the results, then go ahead with (genetic screening)," concludes Heerdt.

Sara Bowerman, 41, is considering genetic testing, and is planning to discuss it with her doctor during her next visit. A psychologist who is a clinical supervisor at a home for teenage boys, Bowerman grew up with a mother who had breast cancer. "My mom was diagnosed when I was five or six, when she was 39 years old. She had a radical mastectomy, and I remember being confused about the arm exercises she did, which I could tell were hurting her." After being in remission for about ten years, Bowerman's mom found a lump in her other breast. "When she got that second diagnosis, that was the first time I knew what cancer was." Five years later, Bowerman's mother died from the disease.

Today, Bowerman lives with a legacy of fear. "I don't do breast self-exams, and I'm scared," she confesses. She and her sister, Rita, discuss their ongoing fear of breast cancer, and since no other female relatives have had the disease, "We talk about our hope that it was smoking that caused our mom's breast cancer."

Bowerman did have a biopsy for a benign breast lump in 1991. "It was a terrifying time," she says, "but other than the fear, the surgery itself was nothing. Since I was conscious during the procedure, they were good at reassuring me and telling me immediately that it did not look cancerous."

Although she isn't conscientious about doing monthly breast self-exams, Bowerman does go in for mammography and a clinical breast exam once a year. And if she finds out, through genetic screening, that she has the indicators for breast cancer, "I'll go ahead and get a double mastectomy, and have reconstructive surgery at the same time. My health is much more important than my breasts."

Detection

Since breast cancer can't be prevented with any certainty, medical professionals stress the importance of early detection. According to Heerdt, "Screening is getting better every year." For high-risk women, blood tests to find breast cancer cells at an early stage, MRI exams and ultrasound are tools to find breast cancer at its earliest stages.

Because three-quarters of women who develop breast cancer have no known risk factors, even those of us who are not classified as high risk should also take steps to ensure our breast health. There are three prongs to early detection: monthly breast self-examination, yearly clinical breast exams, and mammography.

Unfortunately, only about one in ten women perform monthly breast self-examinations. According to Heerdt, you should do a self-exam three days after your period ends. "Just being aware of what your breasts are like is important. If there's a lump, you'll notice a difference," she says. In a breast self-exam, you check each breast for lumps using the pads of your middle three fingers and moving your fingers in either circles or rows. Check not only the breast itself, but also the area from your armpit to your collarbone, as well as below your breast. Also check for puckering of the skin, redness or swelling, a change in the size or shape of your breast, or a discharge from your nipple. Keep in mind, though, that many women detect lumps in breasts that look perfectly normal, so a visual inspection isn't enough. Tear out the breast self-examination card in this feature and keep it handy to help you do your monthly exams.

While women ages 20 to 29 should receive a clinical breast examination performed by a doctor or nurse every three years, and women 30 and older should receive one yearly, researchers have found that plus-size women delay obtaining clinical breast exams. If you're nervous or uncomfortable about going in, ask a friend to go with you for support. "My patients have said that going with a friend has helped them overcome the obstacle to getting a clinical exam. She doesn't have to go in the exam room with you, but having a good friend there can put your mind at ease a lot," Heerdt observes.

If you feel your doctor is biased because of your size, talk to your doctor ahead of time about your feelings. If your concerns aren't adequately addressed, find a health care provider who will help you to feel comfortable.

Although there has been some debate in recent years about the age a woman should be to begin mammography and the frequency of the tests, NABCO recommends annual mammography screening for women beginning at age 40 and continuing at least through a woman's 70s. A woman with known risk factors, however, may be urged to begin getting annual mammograms at a much earlier age.

A mammogram is basically a x-ray of the breast, and is essential in the early detection of breast cancer. Generally, a mammogram can pick up a lump two years before it can be felt during a breast self-exam. This early detection means more treatment options.

You should schedule your mammogram about one week after your period begins, when your breasts will be the least tender. You'll be asked to not use deodorant or lotions on the day of your mammogram. A radiological technician, who will ask you to undress from the waist up and stand next the machine, will perform the screening. In turn, each of your breasts will be compressed (read: flattened like a pancake) between two plates of glass while the images are taken. As plus-size women are often large-breasted, it's fortunate that the procedure is less uncomfortable for us than for small-breasted women. According to Heerdt, "Fortunately, mammography is just as easy - if not easier - in large-breasted women."

What If....

Okay, so you're doing your monthly breast self-exam and you feel a lump. What next? "Don't panic!" exclaims Heerdt. "Eighty percent of all lumps that occur are benign. It's important to keep that in perspective when you feel a lump."

Instead, she suggests, speak to a doctor you trust, such as your gynecologist or internist. "Probably what will happen is that you will have a mammogram, and potentially an ultrasound evaluation. You don't automatically have to see a surgeon."

Breast lumps can take many non-cancerous forms. Fibroadenomas, which are common among women in their 20s or 30s, are often tested through ultrasound or a needle biopsy, and generally not removed. Cysts are often drained with a needle and no further action is necessary. Sclerosing adenosis, a solid growth of glandular tissue, is common among women in their 30s and 40s, and is usually biopsied and watched.

If, however, your lump is biopsied and found to be malignant, there are many treatment options. According to Heerdt, surgeons most often try to do breast conservation therapy, particularly on women with larger breasts. "Because cancer is found at an early stage these days," Heerdt says, "surgeons will try and do a lumpectomy and radiation therapy."

And by no means is a diagnosis of breast cancer equivalent to a death sentence. These days, survival is the norm rather than the exception, and there are two million breast cancer survivors living in the U.S. today. According to NABCO, more than 90% of women who find and treat their breast cancer early are cancer-free five years later.

That wasn't true back in 1983, when at the age of 40, Gloria Aponte was taking a shower and she felt something near her sternum. "It's amazing how well you know your own body," she recalls. "I had absolutely no symptoms, discharge, swelling, pain... nothing." Although she had two children and was going through a separation and divorce at the time, Aponte was disturbed enough by her discovery to make an appointment with a doctor who had cared for her sister years previously. Luckily for her, he specialized in breast surgery. "By pure chance, I went directly to a specialist," she says.

Within 24 hours of seeing the surgeon, Aponte had her mammogram and was scheduled for a biopsy. "They didn't really do any lumpectomies 16 years ago, so I gave him the go-ahead for me to stay under anesthesia until the pathology was done, and if it was cancerous, to do the mastectomy. I woke up in the recovery room and looked at the clock and realized I'd been in (surgery) for six hours, so I knew it had been more than a biopsy."

Saying, "I was more preoccupied with the breakup of my family than I was about the illness," Aponte now feels she was quite naÔve about breast cancer. "Sixteen years ago, you didn't really talk or think about breast cancer unless it was in your family. To show you how naÔve I was, I asked the surgeon, on a scale of 1 to 10, how severe my illness was. He says, '10!'"

After following up the mastectomy with four months of chemotherapy, Aponte has had no recurrences of the cancer. "I'm one of the very fortunate survivors," she observes.

Nonetheless, Aponte's life changed profoundly because of her experience. While she didn't participate in breast cancer support groups or therapy during the time of her diagnosis and treatment, she did, she says, "put on my makeup and wig and go dancing. I danced my way to health."

Aponte considers herself fortunate that she didn't get a case of the "Why mes?" and reveals that being a cancer survivor has put many of life's daily frustrations into perspective. "My fuse is a lot longer," she says. "I don't waste my energy on things that are insignificant. Very rarely do I get angry. I think I'm a nicer person to be around."

She has also learned to value herself and her life. "I've gotten a lot more selfish," Aponte says with a laugh. "I treat myself to things - an extra pedicure, three vacations a year - that I used to deny myself."

She has also come to terms - and more - with the loss of her breast. After having had poorly-done reconstructive surgery many years ago, Aponte had the reconstructed breast removed, and this year reclaimed her body by having a tattoo created where her breast used to be. "I felt a thousand percent better," she exclaims. "It was this new me."

Aponte's emphatic that her decision to sit for photos to accompany this article came not from a sense of exhibitionism, but rather, "It's my message to women to give them hope that there are options other than reconstruction to beautify an area of mutilation."

In all, she concludes, "For a very negative (experience), a lot of plusses have come out of (having had breast cancer)."

Like Aponte, Olympia Cotto's brush with breast cancer has profoundly changed the way she lives her life. The 41-year-old Cotto found a lump in her breast just before her 39th birthday, and underwent a mastectomy, eight months of chemotherapy and seven weeks of radiation. "I take it day by day now," Cotto proclaims. "I used to be a workaholic, and now I try to take it easy."

Cotto remarks that following treatment, a breast cancer patient can expect that "For the first two years, to get re-checked every three months; for the third to fifth year, every six months; and after five years, once a year." She says she had a scare last year, when her medical team thought they saw an abnormality in her mammogram. "Last year, I had to have three (mammograms). You always have that fear of recurrence. You think, oh God, they're going to find something." As it turned out, Cotto was fine.

Married for eight years to Edwin, who acted both as her support system and her nurse during her treatment, Cotto has become very active in the breast cancer awareness movement. She began working for SHARE, a New York-based support center for women with breast cancer, a year ago, and has participated in the National Breast Cancer Coalition's lobbying efforts to get more federal money for breast cancer research and funding to serve low-income women. "They can get free mammograms, but if they're diagnosed with breast cancer, there is no money for treatment," Cotto says with passion.

Although Gloria Aponte didn't participate in support groups while undergoing treatment, she is now a volunteer with Latina SHARE. As part of SHARE's educational efforts, Aponte speaks to groups about her experience as a breast cancer survivor. "I know the trauma of breast cancer," she says, "so I can educate other women." She often speaks at meetings and church groups, and brings along Spanish language literature on breast cancer awareness and treatment. "If there's a lack of awareness in the Anglo community, there is even more lack of awareness in the Hispanic community," she declares.

Second Opinions

Aponte and Cotto share a commitment to educating women about getting second opinions from health care professionals. Cotto says that her initial breast cancer screening experience is "what empowers me to help other women." Initially, Cotto went to a New Jersey surgeon recommended by her gynecologist, who, she says, "wasn't very competent." She says the surgeon did a biopsy of the lump, but "he didn't get any breast tissue, even though he had a sonogram right on the tumor." Cotto was eventually treated at Memorial Sloan-Kettering, and raves about her medical team there. But she emphasizes, "You shouldn't go by what the first doctor tells you, because you're dealing with a life-threatening illness. If you want to get two or three or four other opinions, that's fine."

Cotto's sentiment is echoed by Veronica Bosc, the Los Angeles woman who is currently undergoing treatment for breast cancer. Bosc found a lump in her breast In November 1998, but was not diagnosed until April of this year. "I immediately made a doctor's appointment, but they told me it was nothing. They said come back in six weeks and we will monitor it. I went back and they said there were no changes and to come back in six weeks. They told me this three times." That didn't sound right to Bosc, who says, "I'm African-American. I'm a (breast cancer) statistic. So I finally demanded a mammogram."

As for her breast cancer and mastectomy, Bosc says philosophically, "You live with it; you don't die with it. I'm going to be okay. What's a boob?"

More on Breast Cancer