Fibrocystic breast changes and breast cancer risk – interview with Thomas Frazier, breast health specialist
Emily M. McGrath
Most people in the United States have never heard of fibrocystic change, or fibrocystic breast disease, as it has also been called in the past. Yet the chilling fact is that about half of the women in the United States have it and do not know it. In most sources of information on breast health, the subject is given short, if any, notice, and many descriptions seem to assume that the reader is already familiar with it. In the following interview with Thomas Frazier, M.D., in Bryn Mawr, Pennsylvania, Nutrition Health Review has attempted to understand the disease from the point of view of a well-established doctor. Included in that understanding is the potential for dietary control over a condition that can make it fairly difficult to identify breast cancer.
We are interested in fibrocystic breast disease because it is fairly common and most people don’t understand exactly what it is or how it relates to the normal functioning of a woman’s body.
I think what you’ll find is that there’s a lot of misinformation about fibrocystic change. Most of us don’t call it fibrocystic “disease.” The older literature refers to it as “disease.” We tend to call it fibrocystic “change.” I mean, it’s pretty hard to call it a disease because half the women in the United States have it, and about a quarter of them will get symptoms of it.
The main symptom most women will notice is that they’ll get a fullness or tenderness in their breasts right before their menstrual periods, so fibrocystic change goes in with what we call normal hormonal flow or hormonal change.
I think that the history of dietary intervention has been going on for about 15 to 20 years.
With John Minton?
Yes, with Minton. John Minton was an interesting guy in Columbus, Ohio, who did a number of biopsies on women who had tender, painful breasts and then had that breast tissue analyzed. It was found that the biopsy specimens were very rich in what are called cyclic nucleotides. You probably remember somewhere along the line cyclic AMP and GMP(*) and that sort of thing. Then he went back and took a dietary history of these women and found that the vast majority of them were big caffeine users. He took this to mean that the caffeine was playing a role in the formation of the cyclic nucleotides. When you go back and look at it, it’s not only caffeine, it’s probably one of the precursors to methylxanthines. Methylxanthines are very prominent in a lot of caffeine-containing foods and also in a lot of asthma medicines, like theophylline.
What’s interesting is that if you talk to patients who have asthma, they love to drink a lot of caffeine because it gives them a [broncho] dilatation and makes their breathing easier. If you’ve seen asthmatic patients, they really have a lot of trouble. It also may be where the allergies come into asthma, as there’s a lot of allergic component to asthma as well.
What Minton did was take a lot of patients off caffeine, and in his original study he had about three quarters of the patients responding in terms of decreased tenderness. When we did a study about 12 years ago (1985), we took people off caffeine and then we had them back to see if they had improved. One of the things we had to be careful of was that if the doctor is too enthusiastic, the patient doesn’t want to hurt his feelings and will say, “Oh yes, I feel much better now,” and then go out and tell Sally, “This doesn’t work. It hasn’t helped at all!” What we did was have Sally, our nurse, interview them all as well. With this system, we had 64 percent of our patients who felt that they had improved off the caffeine.
The other proponents of vitamin or nutritional therapy for breast disease include a group that was originally in Baltimore who felt that vitamin E would block the enzyme reaction that’s fueled by caffeine. If you think of a biochemical reaction, you can either cut down on the reaction by cutting out the substrate, or the caffeine, or you can try to block it by taking vitamin E.
So vitamin E would be effective for people who are taking theophylline for asthma?
That is the whole idea. A doctor will suggest vitamin E if they’re on Theodor for asthma. Vitamin E will theoretically block that enzyme reaction and decrease the tenderness.
Now there’s a third component to this, and that is a British Group that uses an entity called Evening Primrose Oil. Nobody’s really sure why it should work, but it also tends to cut down on tenderness, and I presume it’s through a blocking effect too.
That is a nutritional approach to breast tenderness. Some things work for some people, and other things won’t, but it’s usually a trial and error type of thing.
Why in the past has it been referred to as a disease?
I think because a lot of blopsies were performed, and when doctors take a biopsy specimen, they look at it under a microscope and just use the label “disease.” But I don’t think that it’s necessarily a disease.
What is the technical definition, then? Is it just a thickening of the tissue, or is it more?
Under the microscope, you can see changes within the ducts and the lobules that seem to be what is called “proliferative,” and based on how proliferative these changes are, you may see the development of atypia under the microscope or hyperplasia (very thickened cells).
Hyperplasia and atypia can be precancerous, can’t they?
The cells can be. We think that’s part of it, but not everybody who has atypia or hyperplasia will go on to have cancer, so that we don’t really understand fully.
So does ribrocystic change increase the risk of breast cancer?
Most people would say that the normal risk of breast cancer in the United States is about one in nine (1:9), which is pretty, high. If you have active cystic change, it could be one in eight and a half to nine. Really, we don’t think of a cystic change as a precursor. When you figure, though, that everybody has been to a party with eight other couples, that means that one person in the room is going to get breast cancer. And breast cancer still kills a third of the women who get it, so it’s a very lethal disease. Another way to think of it is that in the next 15 minutes, as you and I are talking, three women in the United States will get breast cancer and one woman will die of it. So it’s a very aggressive disease in our culture.
If fibrocystic change can’t affect the development of cancer, can the presence of cysts affect the detection of breast cancer?
Oh, it sure can. If you have a lot of cysts, your tendency is to presume that every lump you get is a cyst. Often women with cystic change will come in and say, “Well, I thought it was another cyst,” and it will be a solid lump. So you can’t presume that just because you’ve had cysts before, every lump you get is a cyst.
In many cases fibrocystic change resolves with menstruation, right?
Most people will tell you that when their menstruation comes along, most of the fluid that they’ve built up in their breasts and in the rest of their bodies will tend to “go with the flow.”
Does fibrocystic change end with menopause, or does it cease to resolve?
It will cease, but the problem is that most people tend to go through about three or four years to complete their menopause from the time that their periods start changing, which is called perimenopause. And if you don’t take hormones, your fibrocystic change will occur and breasts will really become less fibrous and more fatty. If you take hormones, you continue to complete the cycle, so that women who take hormones will continue to have cystic change.
Do women continue to menstruate while taking hormones?
Some do; it depends on the dosage they, get.
But the breasts will continue on that cycle regardless of menstruation.
Correct. If you look at hormones, the use of estrogen alone increases the instance of uterine cancer about four times, so that you must take some progesterone with it if your uterus is still there. If you’ve had a hysterectomy, you can just take Premarin, or estrogen. If you haven’t had a hysterectomy, you must take some progesterone or something to oppose the estrogen.
Estrogen replacement therapy basically continues the cyclical pattern of your breast changes as well as your uterine changes. The uterine lining is the same way.
You mentioned in a previous conversation that the restriction of xanthine and caffeine can relieve the symptoms of fibrocystic changes.
Dr. Susan Love doesn’t think that, but I can tell you that it worked for about 62 to 64 percent of our patients, which is effective enough for us. When you talk to patients, they’ll tell you that when they cheat, they really notice the pain coming back. It’s very interesting. I mean you’ve got to talk to the women who’ve gone off the caffeine. And most women will tell you that they don’t think it will do anything, that they don’t use that much caffeine, and then they go off it for a three-month period. It usually takes about three cycles.
At what point should a woman consult her doctor if she has had fibrous tissue before?
I usually tell women that if they have a lump that has been there for more than one cycle, they ought to see a physician. Most women come in with a lump they feel immediately, but if they have a lump that is there for more than one cycle, they definitely ought to be seen; Another thing is that if they go and get a mammogram and the mammogram is read as normal, that doesn’t mean anything. That lump can still be malignant because a mammogram will miss approximately eight percent of breast cancers. That doesn’t mean that the mammogram missed it, but the breast may be so dense that you can’t see the subtle changes. And they go along with breast cancer. And the one thing I will tell you is if you have a lump and you have a normal mammogram, that means that lurhp has to be investigated. Usually, that means that we put a needle in it. That’s a key thing.
Would you please respond to the following statement by Susan S. Weed: “Regular mammograms of women with fibrocystic breast disease are as likely to initiate cancer as to rind it.” Do you feel that to be true or false?
I think that is false, because with the low-dose rad units, to get a stimulating dose of radiation, you probably don’t get that until you’ve had your 150th mammogram.
You don’t cause breast cancer by the mammograms. I think what Ms. Weed is really trying to say is that when you have a woman with fibrocystic change, the breast is very dense. The mammogram, when we looked at a group of women with very dense breasts, was accurate only about 70 percent of the time.
That’s still fairly accurate.
Sure. It’s not as good at picking up masses, because the breasts are hazy, and it’s sort of like looking into a fog. And that’s the group that if we feel something or we see anything on the mammogram, we’ll use ultrasound or sonar to kind of look through the fog, just as a submarine under the water uses sonar.
How often are those methods generally used?
How often do we use sonar on patients? We use it on anybody who has an abnormal mammographic finding. In our particular practice, it’s probably about 20 to 25 percent. We see a tremendous number of women who are symptomatic’, so that we don’t do a large number of screens, we see primarily symptomatic women.
So if you see someone with fibrocystic changes, is she automatically going to have an abnormal mammogram?
No. Not unless she’s had a change. Maybe she’s had a change in her pain pattern or a change in something she’s felt; even though we don’t feel something, we’ll look at what may have caused the change. Even if we don’t see anything on the ultrasound, we’ll do an ultrasound-guided biopsy. We’re very aggressive in terms of performing biopsies in women. If a woman tells us she’s had a change, we really investigate it. That’s because I think, for the most part, women are good patients.
(*) Editor’s Note: Cyclic AMP and GMP are cyclic nucleotides related to adenine and guanine, two major building blocks in DNA and RNA. They act as “messengers” to mediate certain kinds of hormones, such as those that regulate ovulation, usually producing opposite effects.
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