HEALTH WOMEN’S HEALTH CARE

The Three Big Issues

Breast Cancer, Osteoporosis and Heart Disease

As a female, chances are you rank breast cancer as your #1 health risk. Are you right? The answer is a jolting no. Although women perceive breast cancer as their greatest threat, the truth is, more women die from cardiovascular disease than from all types of cancer combined. The major threats to a woman’s health are heart disease, osteoporosis and breast cancer.

Each has its own set of factors that increase our risk. Many factors, like genetics, are beyond our control. Others are controllable because they are linked to day-to-day choices, like the kinds of foods we eat, the amount of exercise we get, and how often we have regular checkups. Even with a genetic predisposition, smart choices can often delay the age at which we develop a disease. Making smart choices can also significantly improve our chance for survival.



A Breast Cancer Survivor’s Story of Denial

Debra Goldstein, a Dallas attorney, has Firsthand experience with exactly how personal decisions threaten health. She was diagnosed with cancer at the age of 44. “The most important thing I could say is don’t be fearful. Ninety percent of women who have a lump don’t have breast cancer. I did a very stupid thing,” confesses Debra, “I delayed. Catch it early.”

Debra found her lump while she was involved in a time-consuming out of town trial. “Even though my mother was a breast cancer survivor. I convinced myself the lump really wasn’t there and poured myself into my work.”

Four months later, when the trial was over, Debra made an appointment with her gynecologist who advised her to get it checked out right away. She scheduled an appointment with a radiologist who told her it was fine. When her gynecologist received the report, she telephoned Debra and said, “You have got to see a breast surgeon!” Debra argued. “Why is that necessary? The radiologist said it’s okay.” The gynecologist emphatically said, “Debra, listen to me. See a breast surgeon!”

Reluctantly, Debra scheduled an appointment with a breast surgeon. After examining her, he said, “I don’t think it’s anything to worry about, you probably just nicked it while shaving,” and sent her on her way. But the “imaginary” lump didn’t go away. Finally, at the urging of a friend, Debra made an appointment with Dr. Michael Grant. By this time, she was used to identifying the location of the lump for each physician. “See, it’s right here,” she said as she pointed to the lump. “You don’t have to show me,” he said, “I can see it, and it needs to come out!” Then he began discussing her options. “If it’s malignant, you seem to be a candidate for lumpectomy, a breast conserving surgery. This is how it’s done …”

At this point most women are terrified, but not Debra. She believed her risk was minimal because her mother’s cancer was diagnosed after the age of 60. She thought she was a candidate for breast cancer, but not until she, too, was at least 60. In her mind, that was 20 years away.

When a biopsy was suggested, Debra agreed, but asked for one more delay – until she relumed from a previously planned winter ski trip. As soon as the biopsy was over, Dr. Grant immediately told her it was malignant. All she could do was focus on the “dreaded” word, malignant. Now she was faced with multiple decisions.

With her parents by her side, she spent the next week considering her options. Should she choose a mastectomy or a lumpectomy? What if she made the wrong choice? Would the treatment work? She felt totally out of control. She cried. Her mother cried. They cried together. Ten days later, she had a lumpectomy. Then came the next hurdle – radiation. Confident that she could beat the cancer, Debra was on a high throughout treatment. Afterwards, she fell into the depths of depression.

“My coworkers would say, ’Oh isn’t it wonderful that it’s all behind you.’ I would smile and say, ’Oh yes,’ but inside I would be thinking – If that’s the case, then why do I feel so crappy.” Depression and a reordering of priorities go hand-in-hand with close encounters with death, and Debra was no exception. One way to cope, is to participate in a support group, but after attending her first meeting, Debra almost decided not to return. “Everyone was extremely depressed. I felt so down I didn’t think I needed to deal with their depression too.” Staying in the group turned out to be the best thing she could have done.

“The depression was almost a necessary part of recovery. Each of us had to hit rock bottom before we could get up and go on with our lives.” Now, members of her support group are some of her closest friends. They lean on each other through periodic checkups and the fear of recurrence. “1 know they will be there for me, no matter what,” says Debra, “as I will for them.”

A Female Executive’s Unexpected Heart Attack

One of every 8 women will develop breast cancer over the course of their lifetime and 1 of every 25 women will die of it. But a surprising 1 of every 2 women will die of coronary heart disease. Although women are well aware of their breast cancer risk, most are shocked to learn how great their risk is for heart disease.

Linda Rogers, a “fifty-something” executive for a large Dallas company, was totally caught off-guard by her heart attack. “For six months or so,” she says, “I noticed that I was extremely tired. I have a high-pressure job and just chalked it up to on-the-job stress.” One Saturday morning Linda was working in her yard when she began having pain in the center of her stomach. “The pain,” remembers Linda, “became more and more intense.” She decided that she must be coming down with a virus. But by Monday, the pain had spread to her neck and jaw and she had a tingling sensation that ran down her left arm. Linda telephoned her doctor who immediately sent her to the emergency room. She was shocked when the cardiologist walked in and told her that she had just had a heart attack.

Linda fit the typical profile of a female most at risk for cardiovascular disease. “I began smoking as a teenager,” she explains, “and I had a job that required me to sit at my desk all day.” Linda worked excessively long hours, grabbed meals on the go, and could never find time for exercise. She had also rejected her doctor’s suggestion that she take estrogen.

As a result of her blockage, Linda had a stent – a device inserted into an artery to help hold it open – put in place. Today, she is an advocate of a heart-healthy lifestyle. She jogs two miles a day, eats a tow-fat diet, takes estrogen, and regularly sees her doctor. “I was lucky,” says Linda. “I had blockage in only one artery. But, if I had known then what I know now, I would have followed my doctor’s advice more carefully.”

A Wealth of Resources At Your Fingertips

When it comes to finding care for our health problems, we couldn’t live in a better city. With nationally-recognized research centers like the University of Texas Southwestern Medical School and Baylor University Medical Center, Dallas is blessed with some of the nation’s best physicians. Many Dallasites are unaware of the significance of this benefit. “Southwestern”, explains Karen Bradshaw, M.D., Chief of Staff at Zale Lipshy University Hospital and Director of Southwestern’s Women’s Center, “is considered one of the best five or six medical schools in the nation for clinical research and basic science research.” Much of that research is targeted at women. “This means we can offer women state-of-the-art information and care to help mem achieve an entire lifetime of good health,” says Bradshaw.

Two Dallas physicians involved in women’s research are George Peters, M.D., Executive Director of Southwest-em’s Center for Breast Care and Michael Grant, M.D. of Baylor’s Sammons Cancer Center. Both participated in the first National Breast Cancer Prevention Trial involving tamoxifen. The study showed that high-risk women who were given tamoxifen had a reduced risk of breast cancer when compared with women receiving a placebo (sugar pill). However, there was a down side to the drug -the women who took tamoxifen had a much greater incidence of uterine cancer and blood clots.

This fall, a new five-year Breast Cancer Prevention Trial will begin with raloxifene, a new “designer estrogen” and tamoxifen. Raloxifene, known by its brand name, Evista, appears to reduce the risk of breast cancer without raising the risk for other cancers, such as uterine cancer. Originally developed to treat osteoporosis, scientists studying its effects noticed that postmenopausal women on raloxifene had a two thirds reduction in breast cancer. The new study will compare the benefits and risks between the two drugs.

“We think the benefits will be about the same, but we’re hoping that the risks with raloxifene will be less,” says Dr. Grant. Women who meet the criteria -age 60 or older who are either breast cancer survivors, or have had breast lumps previously diagnosed as precancerous, with a family history of breast cancer -are currently being enrolled. One-half with receive raloxifene; one half tamoxifen. There will be two major study sites in Texas, one at Baylor Medical Center in Dallas and one at M.D. Anderson Medical Center in Houston. Southwestern’s Breast Center has also submitted an application to become a separate site. “It will be advantageous for the medical school to have a separate site,” explains Dr. Peters, “because we will be developing new prevention, diagnostic and treatment protocols at the same time.”

One of the best new breast cancer diagnostic tools is called sentinel lymph node mapping. Both Dr. Peters and Dr. Grant were involved in research using this new technique. Up until now, removal of twenty or so axillary {underarm) lymph nodes for biopsy has been the standard procedure. About 20% of women undergoing lymph node biopsy develop lymphedema, a painful, debilitating swelling. With this new technique, only the lymph nodes most likely to contain cancer, usually two to four, are removed. The success rate of finding those with cancer cells is very high. The most dramatic benefit is a reduction in the development of lymphedema, with only 1% of women developing it.



Living With Osteoporosis

Osteoporosis is a condition that causes bone to grow thin and brittle. If left unchecked, it often leads to spontaneous fractures in the vertebrae of the spine. The bones in the spine simply collapse. The fractures shorten a woman’s height, producing a “dowager’s hump.” Fractures are also common in the hip and wrist. These fractures often lead to permanent disability. Eight out of ten people with osteoporosis are women. Loss of bone accelerates immediately after menopause when the loss of estrogen produces changes in the way the body uses calcium. For this reason, it is most often – though not always – considered a disease of old age.

As advances in breast cancer continue, others at Southwestern Medical School are searching for new ways to treat osteoporosis. Khashayar Sakhaee, M.D. is Associate Clinical Director of Southwestern’s Center for Mineral Metabolism Research. He and his colleagues have been studying the effect of sodium fluoride on postmenopausal women with moderate to severe osteoporosis. Their results are amazing.

“In our first study,” says Dr. Sakhaee, “we gave slow-release fluoride (Neostin) along with calcium citrate to half of the women in the study. The other half received a placebo. A new technique developed here at Southwestern, which goes beyond the bone density test, allows us to measure both the quantity (amount) and the quality (strength) of bone. What we discovered was that the women receiving fluoride and calcium actually grew new bone.”

Until now, the available drugs -estrogen, calcium, Fosamax and calcitonin – have been successful in halting bone loss and keeping it from becoming worse, but no drug has been successful in reversing osteoporosis. “For the first time,” says Dr. Sakhaee, “we have found a drug that does just that.”

The women receiving fluoride had a 4% per year improvement in spinal bone density and up to a 70% reduction in hip fracture. Many who gave up activities long ago can now participate in those activities. Southwestern and other medical centers across the nation, are conducting ongoing fluoride research funded by the National Institutes of Aging. Application has also been made for FDA approval of the slow-release fluoride for treatment of osteoporosis. It is expected to be approved early next year for use in women with moderate to severe osteoporosis.

“Fluoride stays in the bone for quite some time,” explains Dr. Sakhaee. “We have 30 patients that we have followed for many years. They received four years of fluoride and have now been off fluoride for four or five years. Since going off, none of them have shown any evidence of bone loss and none have had any fractures. So, when the drug is approved, we will suggest that physicians treat their patients for four years and then stop the fluoride and follow them closely.”

Until this drug is approved, the experts agree that the best thing a woman can do to prevent osteoporosis is to take calcium, Vitamin D and estrogen (or one of the estrogen replacement drugs if she is at high risk of breast cancer or for some other reason cannot take estrogen). The kind of calcium one takes is an important issue. Frank Anderson, a Registered Pharmacist at Richardson’s Baylor Senior Center stresses that your calcium supplement doesn’t have to be an expensive brand. “Just look on the label for the amount of elemental calcium each tablet delivers” he says. “Elemental calcium has the highest rate of absorption. Then, choose the amount your doctor recommends.” Getting enough Vitamin D is also essential because it helps the intestine absorb calcium. “You can easily get enough Vitamin D by taking a daily multivitamin or a calcium tablet with added Vitamin D,” explains Anderson.

“In addition to estrogen, calcium. Vitamin D and regular, weight-bearing exercise,” says Carrollton Obstetrician/Gynecologist, Jane Chihal, M.D., Ph.D., “1 also recommend calcium-fortified orange juice. At my house, we drink it every day.” Dr. Chihal, who has a subspecialty in female endocrinology, encourages women to have a baseline bone density scan at age 50. “I think routine screening will eventually become the norm because it’s going to be very cost-effective to be able to prevent hip fractures and nursing home stays.”



Estrogen Replacement

Much of the work being done to help women protect themselves against breast cancer and osteoporosis also impacts the #1 killer of women, heart disease. “One of the most important things a woman can do to reduce her heart attack risk,” notes Baylor Cardiologist, Melissa Carrey, M.D., “is to take estrogen after menopause, or one of the estrogen-replacement drugs.”

Scientists have found that women who take postmenopausal estrogen have a 35-50% reduction in the incidence of coronary artery disease. However, a recently released study suggests otherwise. Southwestern’s Nina Radford, M.D., Assistant Professor of Cardiology, who also serves as First Vice President to the Board of Directors of the Dallas Division of the American Heart Association, explains the risks and benefits. “Estrogen appears to reduce LDL cholesterol (the bad kind) and increase HDL cholesterol (the good kind). It may also have a beneficial effect on the walls of arteries, which in turn, helps keep blood flowing smoothly through blood vessels.” However, in a new study released in August, women receiving estrogen had an increased risk of heart attack during the first year of estrogen therapy. After that, their risk dropped to levels equal with previous studies. All of the women in the study had diagnosed heart disease prior to receiving estrogen. “We don’t know why the increased risk,” explains Dr. Radford, “but it may be associated with blood clots, which is a risk with estrogen therapy.

If so, we may be able to control it by combining aspirin, a blood thinner, with the estrogen.” Meanwhile, the decision to take estrogen should be one that a woman makes with her physician, based on her individual risk factors. Estrogen is not recommended for women who have a very strong family history of breast cancer or have had breast cancer in the past. “And women who have not had a hysterectomy,” says Dr. Carrey, “should take a combination of estrogen and progesterone to protect against uterine cancer.”

Although most women have heard about the connection between estrogen and heart disease, many are unaware of the increased risk associated with diabetes. “Men with diabetes have a 2-3 times greater risk of heart disease than men without diabetes,” explains Dr. Radford, “but for women with diabetes die risk is increased by an astonishing 3-7 times.” Exercise and weight control help prevent diabetes. “The good news,” says Dr. Radford, “is that we’ve recently learned that you can exercise for ten-minute segments three times a day and get the same benefits you would get in a 30-40 minute workout – which is extremely helpful to busy women.”

One of the latest pieces to the puzzle regarding heart disease prevention is the discovery that an overproduction of homocysteine levels increases the risk for heart and vascular disease in both women and men. “About 20% of the population has this genetic predisposition,” explains Dr. Carrey. “It’s easily preventable by taking a daily multivitamin containing 400 micrograms of folic acid which helps maintain homocysteine levels within the acceptable range.”

What about treatment after a woman has a heart attack or is diagnosed with coronary heart disease? “One of the most exciting things we’ve recently learned is that women are very good candidates for stents” explains Dr. Carrey. Because of the protection estrogen offers women during childbearing years, women usually experience heart attack symptoms about ten years behind men. Since women are older, they often have other serious diseases. Because of multiple health problems, women have a significantly higher risk of dying during bypass surgery and a much higher rate of complications with angioplasty. “The good news,” says Dr. Carrey, “is that women who have stents inserted seem to have fewer complications and a recurrence rate that is just as low as men.”

Work in women’s health issues is progressing at a rapid pace. “One reason,” says Dr. Bradshaw “is that for the first time in medical history, most women can anticipate spending at least 1/3 of their lives after menopause.” Scientists are hard at work trying to figure out which part of estrogen is responsible for the beneficial effects in the heart, on bone, and on breast cancer, and which are responsible for the detrimental effects in the breast and uterus. New drugs are being developed to prevent osteoporosis, reduce the risk of heart disease and reduce the risk of breast cancer. New chemotherapy drugs are on the horizon which promise to provide fewer side effects with greater cancer-destroying ability.

“We are in the most exciting period in medical history,” says Dr. Peters, “there’s never ever been a time like this before. For the very first time, we’re looking at a real opportunity to be able to prevent disease.” Think about that. What if women like Debra Goldstein, Minnie Parker and Linda Rogers – and each of us – could take one pill that would prevent breast cancer, stop osteoporosis and dramatically cut our risk for heart attack. That possibility may be closer than you think.