Your Best Breasts

Your Best Breasts
By Beth Howard

A decade-by-decade look at the latest news on cancer, the ups and downs of surgical enhancement--even how to find the perfect bra.

In the dramedy that constitutes a woman's life, the brain and heart play the starring roles--but breasts surely have a major part. They start turning heads as soon as they make their debut; they nurture babies with milk uniquely suited to an infant's needs. They provide pleasure, bolster body image, and inspire pride and satisfaction. But as you get older, all that front-and-center attention has a downside. Where they once heralded your youth, your breasts may now seem to announce your decline. They can be a source of discomfort--and as you enter the years of higher cancer risk, they probably cause you some worry now and then.

Despite this dramatic shift, you don't hear much about how best to cope with these changes. And except for frequent reminders about getting mammograms, there isn't even much info about how to keep your breasts healthy for the long haul. What's needed: an owner's manual for the over-40 breast, with a guide to cancer prevention and treatment, help with everyday problems, and a no-hype look at how to preserve perk--including surgical options and the lift you can find in a lingerie drawer (if you know what you're looking for). Got breasts? We've got answers.
INSIDE STORY: How the Breast Ages

* Your breast has more of the milk-producing glands called lobules in its upper outer quadrant. Result: That area is particularly prone to pre-period tenderness--and to the development of tumors.
* The milk ducts transport milk to the nipple. About 95% of breast cancers begin within the ducts.
* Fat fills the spaces between the lobules and ducts--more of it as you get older. That increases sag, but has a bonus: It makes mammograms easier to read.

BREAST PAIN: What's Normal, What's Not

In the run-up to menopause, your breasts can feel like a battleground--the scene of all manner of lumps, pains, and general aggravations. Thank goodness, most of these breast bothers have nothing to do with cancer. (Studies show that pain is the sole symptom of breast cancer in 2% of cases or less.) But don't just feel reassured--feel better. Here's how.

You have: Lumpiness or thickened and tender areas

It may be: Fibrocystic breast changes, a condition that affects so many women (more than 60%, estimates say) that it's considered a version of normal. Researchers don't entirely understand the cause, although they lay blame at least partly on hormones. The thickened, rubbery feeling comes from fibrous tissue--the same sort of tissue in scars. The lumps are due to fluid-filled cysts. Breasts may also feel full and achy and have a clear yellow or greenish discharge. Rest easy: Fibrocystic breast changes don't increase breast cancer risk. And though the problem typically worsens in the years before menopause, most women find relief as their hormones quiet down.

Try this: Reduce your caffeine consumption--it exacerbates soreness in up to 50% of women. NSAIDs (nonsteroidal anti-inflammatory drugs) such as aspirin and ibuprofen help some women, as do vitamin E (800 IU daily) and evening primrose oil (1,500 to 3,000 mg daily). Research on primrose oil is mixed, but it can't hurt you. If pain is severe, your doctor may prescribe a drug to block the effect of your reproductive hormones.

You have: A single, distinct lump

It may be: A cyst. In 80% of cases, a lump is not due to cancer. Cysts are usually firm and round; they can be smaller than a BB or as big as a grape, sometimes larger. They often disappear after your period but can recur with the next cycle.

Try this: Because there's always the possibility of cancer, tell your doctor about any new or dominant lump. NSAIDs may help ease pain.

You have: Thick green or black discharge

It may be: Mammary duct ectasia, which just means that one of your milk ducts has become inflamed and clogged. As many as 1 in 4 women develops the condition during or after menopause. Other signs of the problem: soreness, a lump or thickening, an inverted nipple, or the pain, swelling, and redness of mastitis (breast infection).

Try this: Warm compresses, NSAIDs, and a supportive bra often help. But you should have your doctor take a look. Antibiotics may be necessary--and you may need the duct surgically removed if the problem doesn't get better.
CANCER: The Best Detection & Care

40s Your risk of developing breast cancer in this decade: 1 in 70

You should know:

* After years of bickering, most experts now agree that mammograms save lives for women over age 40. Alas, only 64% of 40-somethings show up for regular screenings, according to the American Cancer Society (ACS).
* If cancer is found, be prepared for intensive treatment. Cancer in these years tends to be more aggressive and less likely to respond to estrogen-blocking therapies such as tamoxifen. But younger women typically can tolerate more treatment side effects, so you can get larger, more effective doses of chemo drugs, says Gabriel Hortobagyi, MD, chairman of the breast medical oncology department at the University of Texas M.?D. Anderson Cancer Center. "On average, chemo in women younger than 50 reduces recurrence rates by as much as 55%, compared with 20 to 30% in older women," Hortobagyi says.

Essential steps:

* Don't forget your mammogram. Even with the recent drop in incidence, your risk of developing cancer remains higher than for younger women--yet mammography rates in this age group have fallen 7% since 2000. Early detection pays off: Breast cancer that develops in a woman's 50s is more likely to be estrogen receptor positive, so there are more drugs available to treat it.
60s Your risk of developing breast cancer in this decade: 1 in 28

You should know:

* Though your risk is increasing, so is the power of one major weapon in your arsenal: Mammograms may be more effective now, because your breasts likely contain a greater proportion of fat than in younger days. (Fat typically appears as black on x-rays, while everything else--including cancer--appears as shades of white.) According to a new analysis from the Mayo Clinic, the breasts of women over age 60 are about half as dense as in the years before menopause.
* Cancer may be more common, but it progresses less quickly. It takes 2.1 years for tumors to double in size among women in their 60s, compared with 1.4 years for women in their 50s.

Essential steps:

* Learn about cancer preventives. (Age is a woman's biggest risk factor.) Raloxifene, already approved for preventing and treating osteoporosis, was okayed last October for postmenopausal women at high risk of breast cancer. Like tamoxifen, the first effective preventive for the disease, it also bolsters bones, says Banu Arun, MD, an associate professor in breast medical oncology at M.D. Anderson.

70s Your risk of developing breast cancer in this decade: 1 in 26

You should know:

* Although researchers say that practitioners are more likely to skip mammograms in their elderly patients, the screening can still save lives, according to data from the Albert Einstein College of Medicine. "As long as a woman is generally healthy," says breast surgeon Laura L. Morris, MD, MBA, medical director for Women's Health Services at Indiana University, "mammograms can benefit a woman in her 80s and even beyond that."

Essential steps:

* Don't settle for treatment "lite." Doctors used to be less likely to offer older breast cancer patients all the therapies recommended by the National Institutes of Health. Age increases the odds of other health conditions such as heart disease, which can make some treatments risky--but even if an elderly patient is healthy, her doctor may assume she isn't up for a punishing regimen. Fortunately, such bias is diminishing as doctors gain experience with treating older patients, says Richard J. Bleicher, MD, a breast surgeon at the Fox Chase Cancer Center in Philadelphia. If you're concerned, he suggests, ask if the treatments you're offered are the standard of care.

NIP/TUCK: The Fixes and Risks

A life well lived leaves traces on your body: laugh lines, crow's feet, and, yes, breasts that aren't as firm as they used to be. One perfectly good reaction: Shrugging at the changes--especially if the shrugging is done in the right bra (see box at right). But for some women, that gesture doesn't have the desired oomph. More than 163,000 women over age 40 got gravity-defying help from a scalpel in 2007, spurred on by improved surgical techniques and the return of the silicone implant. Here, Prevention investigates the benefits and downsides of nips, tucks, and more.
Lift

The rate of lift surgery has nearly doubled since 2000, according to the American Society of Plastic Surgeons (ASPS), with well over 53,000 procedures in 2007.

How it works: By removing excess skin and tightening the surrounding tissue, surgeons can raise and reshape the breasts. A new technique leaves a smaller scar that can be neatly camouflaged by the nipple's areola--although many factors determine whether this less conspicuous approach or the older anchor lift is right for you.

Downside: The procedure can't replace lost volume, so if breast deflation is a big issue for you in addition to sag, a lift may not be adequate.

Breast Implants

The number of women over 40 getting breast implants increased by 17% between 2005 and 2006; in 2007, more than 107,000 women in that age range got the procedure.

How it works: Adding implants during a breast lift helps with sag and loss of volume. A 1994 study from Washington University School of Medicine found that 95% of women felt better about themselves after the surgery. But it presents a tough choice: saline or silicone. Silicone implants look and feel more natural than saline, but in 1992, they were pulled off the market for use in cosmetic procedures because of concerns they might raise the risk of scleroderma or other disorders. Now, after several large National Cancer Institute studies, silicone is back. "Breast implants have been studied more extensively than any other medical device," says Donna-Bea Tillman, PhD, director of the Office of Device Evaluation at the FDA. "And our experts concluded that they're safe and effective."

Downside: About 10% of implants--saline or silicone--rupture within 5 years, and the rate goes up as time passes. To make sure ruptured implants are detected and removed, women should get an MRI 3 years after surgery and then again every 2 years (in addition to their annual mammogram). Implants can also harden--it happens with up to 80% of the silicone variety and 40% of saline ones. All told, most women need to replace or remove an implant within 15 to 20 years, says Walter L. Erhardt, MD, past president of the ASPS. Implants can also make mammograms harder to read, though technologists who perform the exam make adjustments. A study from the University of Washington found that mammograms missed 55% of breast cancers in women with implants, versus only 33% among women without them. Fortunately, there's no sign that the murky mammograms affect mortality. "Women with augmentation may be more breast aware and seek medical care more quickly," suggests study author Diana L. Miglioretti, PhD.

Reduction

More than half of reduction surgeries were in 40-plus women in 2007, according to the ASPS; more than 56,000 women over 40 got the procedure. Small wonder: By that age, the health effects of large breasts--chafed skin, back and neck pain, and grooves in the shoulders from ill-fitting bras--are mounting. In a recent study, discomfort was vanquished or greatly reduced 1 year after surgery for 88% of patients. "Women invariably say they wish they'd had it sooner," Erhardt says. Benefits go beyond comfort. Breast exams and mammograms are often easier to perform and more effective after surgery. And some research suggests it can even reduce the risk of breast cancer, especially in those over age 50.

Bonus: Because of the health problems that can result from uncomfortably large breasts, insurance often picks up the tab.

Downside: The surgery can cause a loss of nipple sensation, and in some cases, can result in asymmetry of the breasts.
6 habits That Can Save Your Life

Some risk factors for breast cancer--such as the age you started menstruating--can't be changed, but these key habits help keep cancer at bay, no matter when you start.

1. Keep moving "Exercise lowers levels of estrogen, which is linked to breast cancer," says the ACS's Debbie Saslow. It's best to get 45 to 60 minutes of heart-thumping activity most days of the week, but moderate levels (30 minutes, 5 days a week) can make a difference. You're never too old: A recent study in the British Medical Journal showed that postmenopausal women (along with those with a normal body mass index, or BMI) get more of a benefit from regular sweat sessions than other women.

2. Get--and stay--slim After menopause, obese women have double the risk of breast cancer compared with women of a healthy weight. But weight gain among previously trim women also bodes ill. "Gaining even 20 pounds of weight as an adult increases risk," says Heather Spencer Feigelson, PhD, MPH, strategic director of genetic epidemiology at the ACS.

3. Take vitamin D More and more studies demonstrate the cancer-fighting power of this vitamin. The latest piece of evidence, reported at the recent meeting of the American Society of Clinical Oncologists: Breast cancer patients who were deficient in vitamin D were 94% more likely to have their cancer spread than women with adequate D levels. "I advise women to take 800 to 1,000 IU a day," says Andrew Kaunitz, MD, a professor of obstetrics and gynecology at the University of Florida College of Medicine-Jacksonville.

4. Drink lightly, if at all New data from the National Cancer Institute shows that women who have one or two drinks daily increase the risk of the most common kind of breast cancer by 32%--and those who drink more hike their risk by 51%. Experts recommend no more than a glass a day.

5. Keep hormones temporary Long-term use of HT can increase breast cancer risk, the Women's Health Initiative demonstrated--and new research shows the heightened risk persists several years after you stop. Take hormones only if menopausal symptoms are unmanageable, and limit time on the therapy to no more than 5 years. Consider alternatives, such as SSRI antidepressants for hot flashes and vaginal creams with estrogen for dry genital tissues.

6. Forget self-exams, but be self-aware After hearing for years that you should do a monthly breast self-exam, you might be surprised to learn that it's now considered optional. Studies have found that it doesn't save lives and can increase the odds of an unnecessary biopsy. But many doctors are reluctant to completely abandon it. "About 15% of breast cancer is detected by women themselves," says Eva Singletary, MD, a professor of surgical oncology at M.D. Anderson. So doctors still want you to get to know your breasts--and alert your provider to anything outside the norm for you.

6 habits That Can Save Your Life

Some risk factors for breast cancer--such as the age you started menstruating--can't be changed, but these key habits help keep cancer at bay, no matter when you start.

1. Keep moving "Exercise lowers levels of estrogen, which is linked to breast cancer," says the ACS's Debbie Saslow. It's best to get 45 to 60 minutes of heart-thumping activity most days of the week, but moderate levels (30 minutes, 5 days a week) can make a difference. You're never too old: A recent study in the British Medical Journal showed that postmenopausal women (along with those with a normal body mass index, or BMI) get more of a benefit from regular sweat sessions than other women.

2. Get--and stay--slim After menopause, obese women have double the risk of breast cancer compared with women of a healthy weight. But weight gain among previously trim women also bodes ill. "Gaining even 20 pounds of weight as an adult increases risk," says Heather Spencer Feigelson, PhD, MPH, strategic director of genetic epidemiology at the ACS.

3. Take vitamin D More and more studies demonstrate the cancer-fighting power of this vitamin. The latest piece of evidence, reported at the recent meeting of the American Society of Clinical Oncologists: Breast cancer patients who were deficient in vitamin D were 94% more likely to have their cancer spread than women with adequate D levels. "I advise women to take 800 to 1,000 IU a day," says Andrew Kaunitz, MD, a professor of obstetrics and gynecology at the University of Florida College of Medicine-Jacksonville.

4. Drink lightly, if at all New data from the National Cancer Institute shows that women who have one or two drinks daily increase the risk of the most common kind of breast cancer by 32%--and those who drink more hike their risk by 51%. Experts recommend no more than a glass a day.

5. Keep hormones temporary Long-term use of HT can increase breast cancer risk, the Women's Health Initiative demonstrated--and new research shows the heightened risk persists several years after you stop. Take hormones only if menopausal symptoms are unmanageable, and limit time on the therapy to no more than 5 years. Consider alternatives, such as SSRI antidepressants for hot flashes and vaginal creams with estrogen for dry genital tissues.

6. Forget self-exams, but be self-aware After hearing for years that you should do a monthly breast self-exam, you might be surprised to learn that it's now considered optional. Studies have found that it doesn't save lives and can increase the odds of an unnecessary biopsy. But many doctors are reluctant to completely abandon it. "About 15% of breast cancer is detected by women themselves," says Eva Singletary, MD, a professor of surgical oncology at M.D. Anderson. So doctors still want you to get to know your breasts--and alert your provider to anything outside the norm for you.