Prevention vs. Screening
As breast cancer awareness month arrives and pink ribbons blanket the community, I want to make clear the difference between screening and prevention as these terms are not interchangeable. The big push during breast cancer awareness month is to encourage women to undergo mammography. While early detection can be helpful in preventing some breast cancer deaths, it does nothing to prevent breast cancer from occurring in the first place.
The healthcare industry is currently moving aggressively toward the practice of “population health.” In theory, this shift will encourage healthcare providers to focus more on creating and establishing health in their served population as opposed to treating disease. I hope that the trend will lead to a concerted effort to prevent disease but worry that it will simply automate the screening process which can be done very efficiently through computer algorithms and automated telephone reminders. The true art of medicine lies not in running tests but in actually helping patients to be well.
Screening can be beneficial to a population, but prevention often requires a more nuanced look at the individual characteristics, genetic and environmental, which dictate an individual’s risk. Having your blood cholesterol checked every 5 years is not the same as minimizing your risk factors for cardiovascular disease just as having a mammogram does nothing to reduce the obesity, inactivity, and estrogen dominance which increase an individual’s risk for breast cancer.
Risk factors come in two flavors, modifiable and non-modifiable. A woman can do very little about her gender, age or family history -- these are her non-modifiable risk factors for breast cancer. The higher the risk based upon non-modifiable factors, the more vigilant the woman needs to be -- both with respect to her screening protocol AND her modifiable risk factors.
So, what are some modifiable risk factors for breast cancer? To answer this question it helps to think about estrogen. High estrogen levels is a known risk factor for breast cancer. As a hormone, estrogen needs to be produced, moved, used and removed by the body. Estrogen also needs to exist in balance with all of the other hormones. Hormones such as insulin, cortisol testosterone and progesterone all affect the production, transport, signalling and metabolism of estrogen, so balance in these hormone systems becomes important too. This basic understanding helps us to see how risk factors such as obesity (increased insulin and inflammation), inactivity (increased insulin), poor sleep (increased cortisol), and exposure to environmental chemicals including those in common self-care products like shampoo, soap, and cosmetics (interference with estrogen signalling and breakdown) impact breast cancer risk .
As a provider, when I see those pink ribbons flying, I think about a lot more than mammograms. I think about the genetic variabilities known as SNPs (single nucleotide polymorphisms) which may impact how my patient metabolizes estrogen or breaks down environmental toxins. I think about the stressors that my patient is experiencing and the obstacles she may need to overcome to sleep through the night or initiate a regular exercise program. I also think about her screening regimen - should we be looking even more closely due to high risk or is it OK to minimize radiation exposure based upon a low risk profile. Screening options such as MRI and ultrasound can be employed in parallel with mammography based upon risk.
As the leaves change color and pink ribbons pop-up on every imaginable consumable, I challenge you to really consider your own breast health plan. What steps are you going to take to keep your breast tissue healthy and be an active partner in your own health. Collaborate with your healthcare provider to move beyond awareness. Working together you can practice the true art of medicine -- the art of prevention!