Breast Cancer

Breast cancer seems to be everywhere. Each of us knows someone—a mother, cousin, childhood friend—who has struggled with the disease, or succumbed to it. With an estimated 182,000 new cases diagnosed each year—and a quarter of these fatal—breast cancer is the leading cause of cancer death among women in the age range of 35 to 54.

A different statistical look at breast cancer shows that it has claimed, in the last two decades alone, more American lives than both World Wars, the Korean War, and the Vietnam War all together. It’s not that medical researchers are not fighting cancer (the National Cancer Institute and the American Cancer Society have spent over one billion dollars on fighting breast cancer in the last twenty years alone—though some women’s organizations express anger that the American Cancer Society has spent only 5% of its 1992 budget on breast cancer research; and the National Cancer Institute only 10%). It’s that, no matter what, the disease seems to be gaining on us.

Jewish women seem particularly aware of this frightening plague, and our fears are not, it seems, unfounded. Many reliable epidemiological reports, as well as popular news stories, list “Jewish” as one of the primary risk factors for developing breast cancer. It’s a trait that often looks incongruous, folded in, as it usually is, among other, more standard, risk factors.

In one typical report, for example, a 1982 epidemiological study for the American Cancer Society in New York, the authors note “a number of widely accepted risk factors for this dis- ease, which have been documented with a fair degree of consistency. These include family history of breast cancer; nulliparity [not ever having given birth]; late age at first live birth; early age of menarche; late age at menopause, high-dose radiation exposure; and being single, Jewish or obese.”

Another study, this one of Long Island women, conducted by the New York State Department of Health, Bureau of Cancer Epidemiology, concludes that most prominent among demographic risk factors are “increasing age, high socioeconomic status, urban residence. North American or Northern European residence, Jewish religion.”

A Johns Hopkins University School of Hygiene and Public Health study led by Dr. Susan P. Helmrich and published in the American Journal of Epidemiology concludes, “A positive history of benign breast disease, a positive family history of breast cancer, Jewish religion, and twelve or more years of education were each independently associated with an increased risk of breast cancer.” And a 1992-New York Times article simply states point blank: “Jewish women have a higher risk of breast cancer.”

With such a jumbled list of factors, how does someone figure out what it all really means? Jewish women living on Long Island are, in the words of one informant to LILITH, “generally in a state of low-level, ongoing panic in regard to their belief that they’re specifically vulnerable to breast cancer.” But is being Jewish truly a risk, independent of other categories, or does being Jewish simply encompass other high-risk factors—such as fatty diets, environmental factors and hormonal history? Is “being Jewish” just an artifact of improperly controlled studies, or is it an incontrovertible factor of high risk?

Additionally, are there factors Jewish women can control—like what we eat, what kind of birth control we use, whether we use estrogen replacement, where we live—or are the factors primarily beyond our control? Have scientific reports, in fact, appropriately controlled for the factor “Jewish?” Or should Jewish women be calling for more thorough research and more careful reporting before we give ourselves up as “victims” to an indomitable force?

Indeed, no research has been done exclusively on Jewish women to determine why we are more at risk than the general population. Some people who challenge the research quoted above (and other similar work) argue that a complicating issue is the “reporting” factor: Jews simply use doctors more, and therefore we are likelier to be diagnosed with breast cancer. Others question whether “age” has been fully controlled for in various studies. (Interestingly, though Jewish women are noted as being at higher than average risk especially over age 40, black women are at higher risk than white women under age 40.) The profile of Jewish women who are currently over the age of 40 (including what foods we were brought up on, what birth control we used in our twenties, etc.) may look quite different for Jewish women who will become middle aged after the year 2000.

Epidemiologists isolate breast cancer issues without a specific interest in the Jewish woman’s angle, and Jewish demographers look at women’s fertility and reproductive choices, for example, without relating these statistics to Jewish women’s high incidence of breast cancer. So who is interested in correlating these two sets of information? So far as we can tell, only LILITH.

We know, for example, that (according to the 1990 National Jewish Population Survey) Jewish women’s fertility is substantially below that of the general population— by ages 40 to 44, Jewish women average 1.6 children, considerably below the 2.1 average of all white women in that age group. We also know that Jewish women are the best educated women in America today—64% of us have college degrees, as compared to less than 15% of all other white women. Our careerism and our drive for education are two reasons why we delay childbearing and have lower fertility rates (two factors implicated as high breast cancer risks). Are fertility and educational levels, then, “Jewish” factors that put us at risk for developing cancer? (If you’re a Mormon woman, by the way, you are at less than average risk for breast cancer.) What is a truly independent variable, what codetermined, what a matter of insufficient controls?

The questions are complex, and disentangling the many factors presents a formidable task. Yet it’s useful for each of us to look at the key risk factors presented here, to see what we as individual Jewish women can discern about breast cancer risk in our own lives.

ESTROGEN –AND LIFE CHOICES
High estrogen levels have been conclusively linked to an increased risk of developing breast cancer. The majority of women are genetically predisposed to breast cancer, according to Dr. Victor Herbert, hematologist and scientific editor of The Mount Sinai School of Medicine Complete Book of Nutrition. Whether the breast cancer will express itself depends on a women’s level of estrogen, the female sex hormone. “The cancer is triggered into active proliferation by estrogen,” Herbert says.

But do Jewish women have more estrogen coursing through their systems, thus putting them at higher risk? There are several factors contributing to high estrogen levels, some more common in Jewish women.

How your own body is programmed for fertility affects your risks of getting breast cancer. Early onset of menstruation (before II) and late menopause (after 55) are associated with having more estrogen in your body for more eyars, incresing the breast cancer risk. But neither of these determinants is much within one’s own control, and neither is particularly associated with Jewish women.

Another fertility factor related to estrogen levels—if, when, and how often we give birth-is also correlated with breast cancer. Never giving birth, or giving birth to a first child after age 30, elevates the risk of developing a malignant breast lump. Jewish women spend more years in college and graduate school than other women, so they are more likely to delay childbearing, and to have fewer children once they do decide to become parents. There is another correlation here, one often overlooked by demographers and epidemiologists alike: among Jews, having children is strongly associated with being married, and Jewish women are 50% more likely to remain single throughout their childbearing years than are non-Jewish women. (Even at the far end of fertility, between ages 35 and 44, 11 % of Jewish women are still in the “never married” category, as compared to 7% of other white North American women.)

One more factor related to estrogen may “look” Jewish, but may in fact be a simple function of economic class: Jewish women are more likely to have ingested estrogen in oral contraceptives or used hormone replacement therapy at menopause. While no conclusive evidence proves that prescription estrogen is harmful, there appear to be some risks.

Most physicians prescribe estrogen to women who have early onset of menopause (before 45) to prevent osteoporosis, the bone loss occurring after menopause). Prescription estrogen also alleviates some uncomfortable symptoms of menopause and benefits the cardiovascular system and a woman’s sexual pleasure. Women with other high-risk factors for breast cancer, such as a mother or sister with the disease, or a history of benign or malignant lumps, should be very cautious about seeking hormone replacement therapy when they approach menopause.

WHAT WE EAT
Diet, particularly a diet high in fat, has been listed as a causative factor in breast cancer for many years, according to epidemiologist Dr. Jennifer L. Kelsey of the Stanford University School of Medicine. It’s also true that the more body fat you have, the higher your estrogen level is likely to be.

Can fatty diets take much of the blame for breast cancer? For instance, Asian women in Asia, whose diet consists mostly of rice, and who have less body fat, also don’t get breast cancer, says Victor Herbert. The high-fat American diet plays a salient role in this country’s breast cancer rate.

Do Jewish women have particularly fatty diets? And do our diets account for our position in the high-risk group? With the variegated Jewish community of the ’90s, it is nearly impossible to put a finger on what comprises a so-called Jewish diet.

“Are Jewish diets today just upper-middle-class diets” asks Janet Wittes, a Washington, D.C., bio-statistician, “or are they different in their fat content or in their distribution of fats from the average diet of non-Jews?” Do Jewish women, in fact, eat differently from our non-Jewish neighbors?

Wittes, who chairs the Data Monitoring Committee for the Women’s Health Initiative at the National Institutes of Health, says that the lag time for the effects of diet is now being studied. The N.I.H. is currently trying to determine, among other things, whether a change in diet—such as less fat and more roughage—will lead to a decrease in breast cancer. It is not known, she says, whether a woman in her 60’s getting breast cancer today might be seeing the results of foods eaten 20 to 30 years ago.

The Women’s Health Initiative is hypothesizing, in their current breast cancer studies (the largest set of studies ever taken in the U.S.), that fatty diet is the most significant risk factor of all. Certainly, grown Jewish daughters tend to eat quite differently than did their mothers and/or grandmothers—does this change the “Jewish” breast cancer risk? And are dietary changes that we might make today in any way significant retroactively?

WHERE WE LIVE
According to a report in the Detroit Metro Times, three out of four women who develop breast cancer do not have any of the primary risk factors identified above. Perhaps the real culprit, this report suggests, is environmental pollutants.

Sandra Steingraber, a biologist at Columbia College in Chicago, told the Detroit Metro Times: “Cancer is caused by carcinogens. Astonishingly, you can read entire tracts about cancer and the word carcinogen never comes up…. Seemingly authoritative agencies have framed the cause of the disease as a problem of behavior rather than as one of exposure to disease causing agents.”

Several studies have shown that DDT and other chlorine-based chemicals commonly used as pesticides and in industry are known carcinogens. Areas of Long Island, where breast cancer rates stretch above the rest of the country’s—and where being Jewish was singled out as a high-risk factor—were routinely sprayed with DDT in the ’50s.

According to a 1991 study published in the British medical journal The Lancet, women working in a German pesticide plant had double the cancer mortality rate of the rest of the German population. And a U.S. Environmental Protection Agency study says that counties with hazardous waste sites were 6.5 times more likely than counties with no such sites to have higher breast cancer prevalence.

A recent study conducted by Dr. Mary Wolfe in the New York City found that women who developed breast cancer had higher levels of chlorine-based pesticides in their systems than did women without breast cancer.

A study in Israel paints a stark picture of the environmental contribution to breast cancer. Until 1978, Israeli dairy products were contaminated with extraordinarily high levels of carcinogenic pesticides. The chemicals ingested by women produced concentrations of the carcinogens in breast milk and body fat at levels as much as 800 times the United States average. After public outcry, an Israeli Supreme Court decision began a phase-out of the noxious pesticides. Levels of the chlorine-based substances in mother’s milk dropped quickly, and after a decade so did breast cancer rates among younger women.

Yet environmental factors have been all but dismissed by the National Cancer Institute and the American Cancer Society. Many women’s advocacy groups—both Jewish and non-Jewish—have challenged research funded by the chemical and cosmetics industries, saying that they have an incentive to ignore environmental factors, and that they instead orient women to blaming themselves.

Says Sandra Steingraber, “by emphasizing heredity [and diet] the cancer establishment encourages women to blame their mothers, which many are inclined to do anyway. Blaming the victim may be appropriate for diseases such as lung cancer,” says the Metro Times story, “where there is a clear behavioral culprit—smoking—but it simply doesn’t hold up against the evidence about breast cancer. It is, however, a convenient way to avoid larger environmental questions.”

Since Jewish women tend to live in urban areas, is this another confounding variable? Does our high risk “look” Jewish, but simply represent a function of geography?

OUR GENETIC PREDISPOSITION
A woman whose mother or sister had breast cancer has a significantly higher chance of developing a malignancy than does a woman from a non-breast-cancer family. “Of all the cases diagnosed in the United States each year, as many as 10 percent stem from hereditary defects,” Geoffrey Cowley wrote in a Newsweek cover story on breast cancer (December 6, 1993). Does this imply that there is a breast cancer gene passed from mother to daughter? Most studies have concluded that genetic predisposition is a prerequisite, especially for premenopausal cases. Whether or not the breast cancer expresses itself, however, depends on all the above mentioned factors such as estrogen levels, body fat and the environment.

The Newsweek article reports that researchers have come close to isolating the breast cancer gene, and that studies have revealed that members of families with breast qancer all have the same abnormal genetic marker. That defect, however, has not been isolated and can have so many mutations that isolating it will take years of more research.

Yet since genetic predictions can only help in early detection, not in treatment or prevention, reactions have been radical in the few families that have been researched and marked. One woman who had watched breast cancer strike her mother, two sisters and two cousins, opted for a prophylactic mastectomy, according to Newsweek. “I felt like to save our family, all the girls had to get their breasts off,” she said. And what health plan would want to cover women who know they will contract cancer- or will undergo a costly surgery to “prevent” being hit by the disease? “‘Finding the genes isn’t the end of the challenge,” epidemiologist Hoda Anton-Culver told Newsweek. “It’s the beginning.”

Are Jewish women more genetically prone to breast cancer? Dr. Vicky Seltzer, Chair of Obstetrics and Gynecology at Long Island Jewish Medical Center, says that her clinical observations lead her believe that Jewish women are genetically more at risk. “However, we are so close to finding a genetic marker for breast cancer that it doesn’t make any sense to separate out Jewish women as a specific group to focus on.”

It is clear, however, that if there is a connection it is not nearly as strong as with Tay-Sachs disease, for instance, which is a predominantly Ashkenazic Jewish genetic disorder. “And suppose we did discover there was an elevated risk in Jews, and it had to with genetics,” observes Janet Wittes. “I can’t imagine that we as Jews should do anything differently from what we do as women.”

So, can we, in fact, label cancer as a “Jewish women’s disease?” The Long Island breast-cancer survivors group. One in Nine (named for a woman’s chance of getting the disease in her lifetime), objects to the classification of Jewish women as high risk. Some claim there is not a higher incidence of cancer among Jewish women, but simply a higher detection rate that is being revealed, since Jewish women are more likely to see a physician on a regular basis. One in Nine members suggest that Jewish women are being separated out from a pool of other educated, white, upper middle class urban women without adequate research that controls for these factors. Others claim that a call-to-arms for Jewish women may unnecessarily be exacerbating Jewish fears.

Should Jewish women be calling for studies specifically of Jews before we push the panic button? Or do we merely need better controls and more accurate analysis of the data in broader research? Wittes believes a global study in which information on ethnicity and religion is collected might be helpful in determining whether being Jewish is indeed a risk.

“Is it a red herring to say that being Jewish is a risk factor for breast cancer?” asks Wittes. “Sometimes when we researchers say, ‘This is a disease of blacks or of Hispanics,’ it’s the same kind of red herring. If there’s a disease that stems from poverty, we look instead at ethnicity, because that is politically correct. Politically, when a disease is related to poverty, we look at ethnicity. My own feeling is that what we ought to be looking at is not “blacks,” or “Hispanics.” or, in the case of breast cancer, “Jewish women,” but variables that relate to diet, poverty, access to health care. There are diseases of the poor, and diseases of the rich.”

Whatever the case, the gravity and scope of the illness is enough to make all women and all Jewish organizations have a stake in increased research. Some people, though, actually fear that if, indeed, “being a Jewish woman” becomes accepted as a high-risk factor for breast cancer, it might have a negative impact on our ability to get health insurance.

If Jewish women are at higher risk, studies of possible causes and prevention should be undertaken immediately. If we are not at higher risk, but less than thoroughly controlled studies and data collection are claiming that we are, then it is time to examine that, too. Either case means more research. And perhaps a different look at the statistics we already have.

LILITH believes that much can be learned in the unexplored territory between breast cancer epidemiology and Jewish demographic data. A fine correlation of variables, and a differential “ruling out” of factors that seem independent, but perhaps are not, is what all women deserve.

Yael Green is a freelance writer living in New York City.

Mammography. Listen up

Willa Morris, a writer in Great Neck, Long Island, was diagnosed with breast cancer 2 years ago, at 47.. Her cancer was found by a routine mammogram, and she has some very strong comments on being vigilant about one’s own core:

“I was really fortunate, if you believe in a silver lining. I had wondered about the advice given to women under 50—that maybe mammograms weren’t useful, or that they needn’t be done every year, but should be done every 2 years. I asked a radiologist, who said ‘Split the difference.’ It had been 18 months since my last mammogram, so I went. And they found white spots on the film. Look at the statistics that say that women under 50 don’t need mammography—where would / be?

“For me the nightmare—and I think for lots of women—is in not getting the best of medical care. I am not casual about wanting to make sure that I’m getting the best, and I sometimes feel that the statistics are just not good enough to reassure me. I want to know that the person is well trained and that the equipment is perfect. It’s your job to make sure that people don’t screw up. What if someone not so competent had rood my mammogram? I could be in much worse shape.”

Synagogue sisterhoods and Jewish women’s organizations often encourage their members to stop by for a mammogrom at a mobile facility temporarily set up near a meeting site (in a “mammography van” parked outside the synagogue, in some cases). Does it matter whether you take advantage of the convenience of a mobile facility or arrange for a mammogram at a radiologist’s office? Possibly. Here is what to look for when you have a mammogram:

Ask who the radiologists ore. Ask who’ll be reading the x-ray. Get her/his phone number in case you have questions. Ask when and how will you find out the results. You also should have the film looked at right there to avoid a second trip if the mammogram is unreadable. Ask if the equipment is checked—and, if necessary, recalibrated—between uses.

You are not being unreasonably demanding if you want to make sure that your health is being attended to in the best way possible.

WHO GETS BREAST CANCER IN ISRAEL?
Each year, breast cancer attacks 17 non-Jewish women in Israel out of every 100,000, compared to 80 Jewish women, reports the Israel Cancer Registry. The incidence is also significantly higher among Ashkenazi immigrants than among Sephardi newcomers. For Israeli -born Jewish women, irrespective of their ethnic background, the level of breast cancer approaches that of Ashkenazi immigrants. Why are Ashkenazi women more susceptible? Why ore levels rising among Israeli-born women? Why are non-Jewish Israelis (largely Arabs) comparatively safe? Hadossab-Hebrew University Medical Center oncologists implicate- as American researchers do lifestyle, diet and environment.