A risk factor is anything that
affects your chance of getting a disease, such as cancer. Different cancers
have different risk factors. For example, exposing skin to strong sunlight is a
risk factor for skin cancer. Smoking is a risk factor for cancers of the lung,
mouth, larynx (voice box), bladder, kidney, and several other organs.
But risk factors don't tell us
everything. Having a risk factor, or even several, does not mean that you will
get the disease. Most women who have one or more breast cancer risk factors
never develop the disease, while many women with breast cancer have no apparent
risk factors (other than being a woman and growing older). Even when a woman
with risk factors develops breast cancer, it is hard to know just how much
these factors may have contributed to her cancer.
There are different kinds of risk
factors. Some factors, like a person's age or race, can't be changed. Others
are linked to cancer-causing factors in the environment. Still others are
related personal behaviors, such as smoking, drinking, and diet. Some factors
influence risk more than others, and your risk for breast cancer can change
over time, due to factors such as aging or lifestyle.
Risk
factors you cannot change
Gender
Simply being a woman is the main
risk factor for developing breast cancer. Although women have many more breast
cells than men, the main reason they develop more breast cancer is because
their breast cells are constantly exposed to the growth-promoting effects of
the female hormones estrogen and progesterone. Men can develop breast cancer,
but this disease is about 100 times more common among women than men.
Aging
Your risk of developing breast
cancer increases as you get older. About 1 out of 8 invasive breast cancers are
found in women younger than 45, while about 2 out of 3 invasive breast cancers
are found in women age 55 or older.
Genetic
risk factors
About 5% to 10% of breast cancer
cases are thought to be hereditary, resulting directly from gene defects
(called mutations) inherited from a parent.
BRCA1 and BRCA2: The most common cause of hereditary breast cancer is an
inherited mutation in the BRCA1 and BRCA2 genes. In normal cells, these genes
help prevent cancer by making proteins that help keep the cells from growing
abnormally. If you have inherited a mutated copy of either gene from a parent,
you have a high risk of developing breast cancer during your lifetime. The risk
may be as high as 80% for members of some families with BRCA mutations. These
cancers tend to occur in younger women and more often affect both breasts than
cancers in women who are not born with one of these gene mutations. Women with
these inherited mutations also have an increased risk for developing other
cancers, particularly ovarian cancer.
In the United States BRCA mutations
are found most often in Jewish women of Ashkenazi (Eastern Europe) origin, but
they can occur in any racial or ethnic group.
Changes in other genes: Other gene mutations can also lead to inherited breast
cancers. These gene mutations are much rarer and often do not increase the risk
of breast cancer as much as the BRCA genes. They are not frequent causes of
inherited breast cancer.
- ATM: The ATM gene normally helps repair damaged DNA.
Inheriting 2 abnormal copies of this gene causes the disease
ataxia-telangiectasia. Inheriting one mutated copy of this gene has been
linked to a high rate of breast cancer in some families.
- p53: Inherited mutations of the p53 tumor suppressor
gene cause the Li-Fraumeni syndrome (named after the 2 researchers who
first described it). People with this syndrome have an increased the risk
of developing breast cancer, as well as several other cancers such as
leukemia, brain tumors, and sarcomas (cancer of bones or connective
tissue). This is a rare cause of breast cancer.
- CHEK2: The Li-Fraumeni syndrome can also be caused by
inherited mutations in the CHEK2 gene. Even when it does not cause this
syndrome, it can increase breast cancer risk about twofold when it is
mutated.
- PTEN: The PTEN gene normally helps regulate cell
growth. Inherited mutations in this gene cause Cowden syndrome, a rare
disorder in which people are at increased risk for both benign and
malignant breast tumors, as well as growths in the digestive tract,
thyroid, uterus, and ovaries.
- CDH1: Inherited mutations in this gene cause hereditary
diffuse gastric cancer, a syndrome in which people develop a rare type of
stomach cancer at an early age. Women with mutations in this gene also
have an increased risk of invasive lobular breast cancer.
Family
history of breast cancer
Breast cancer risk is higher among
women whose close blood relatives have this disease.
Having one first-degree relative
(mother, sister, or daughter) with breast cancer approximately doubles a
woman's risk. Having 2 first-degree relatives increases her risk about 3-fold.
The exact risk is not known, but
women with a family history of breast cancer in a father or brother also have
an increased risk of breast cancer. Altogether, less than 15% of women with
breast cancer have a family member with this disease. This means that most
(over 85%) women who get breast cancer do not have a family history of
this disease.
Personal
history of breast cancer
A woman with cancer in one breast
has a 3- to 4-fold increased risk of developing a new cancer in the other
breast or in another part of the same breast. This is different from a
recurrence (return) of the first cancer.
Race
and ethnicity
White women are slightly more likely
to develop breast cancer than are African-American women. African-American
women are more likely to die of this cancer. At least part of this seems to be
because African-American women tend to have more aggressive tumors, although
why this is the case is not known. Asian, Hispanic, and Native-American women
have a lower risk of developing and dying from breast cancer.
Dense
breast tissue
Women with denser breast tissue (as
seen on a mammogram) have more glandular tissue and less fatty tissue, and have
a higher risk of breast cancer. Unfortunately, dense breast tissue can also
make it harder for doctors to spot problems on mammograms.
Certain
benign breast conditions
Women diagnosed with certain benign
breast conditions may have an increased risk of breast cancer. Some of these
conditions are more closely linked to breast cancer risk than others. Doctors
often divide benign breast conditions into 3 general groups, depending on how they
affect this risk.
Non-proliferative lesions: These conditions are not associated with overgrowth of
breast tissue. They do not seem to affect breast cancer risk, or if they do, it
is to a very small extent. They include:
- Fibrocystic disease (fibrosis and/or cysts)
- Mild hyperplasia
- Adenosis (non-sclerosing)
- Duct ectasia
- Phyllodes tumor (benign)
- A single papilloma
- Fat necrosis
- Mastitis (infection of the breast)
- Simple fibroadenoma
- Other benign tumors (lipoma, hamartoma, hemangioma,
neurofibroma)
Proliferative lesions without
atypia: These conditions show excessive
growth of cells in the ducts or lobules of the breast tissue. They seem to
raise a woman's risk of breast cancer slightly (1½ to 2 times normal). They
include:
- Usual ductal hyperplasia (without atypia)
- Complex fibroadenoma
- Sclerosing adenosis
- Several papillomas (called papillomatosis)
- Radial scar
Proliferative lesions with atypia: In these conditions, there is excessive growth of cells in
the ducts or lobules of the breast tissue, and the cells no longer appear
normal. They have a stronger effect on breast cancer risk, raising it 4 to 5
times higher than normal. They include:
- Atypical ductal hyperplasia (ADH)
- Atypical lobular hyperplasia (ALH)
Women with a family history of
breast cancer and either hyperplasia or atypical hyperplasia have an even
higher risk of developing a breast cancer.
Lobular
carcinoma in situ
Women with lobular carcinoma in situ
(LCIS) have a 7- to 11-fold increased risk of developing cancer in either
breast.
Menstrual
periods
Women who have had more menstrual
cycles because they started menstruating at an early age (before age 12) and/or
went through menopause at a later age (after age 55) have a slightly higher
risk of breast cancer. This may be related to a higher lifetime exposure to the
hormones estrogen and progesterone.
Previous
chest radiation
Women who, as children or young
adults, had radiation therapy to the chest area as treatment for another cancer
(such as Hodgkin disease or non-Hodgkin lymphoma) are at significantly
increased risk for breast cancer. This varies with the patient's age when they
had radiation. If chemotherapy was also given, it may have stopped ovarian
hormone production for some time, lowering the risk. The risk of developing
breast cancer from chest radiation is highest if the radiation was given during
adolescence, when the breasts were still developing. Radiation treatment after
age 40 does not seem to increase breast cancer risk.
Diethylstilbestrol
exposure
From the 1940s through the 1960s
some pregnant women were given the drug diethylstilbestrol (DES) because it was
thought to lower their chances of miscarriage (losing the baby). These women
have a slightly increased risk of developing breast cancer. Women whose mothers
took DES during pregnancy may also have a slightly higher risk of breast
cancer.
Lifestyle-related
factors and breast cancer risk
Having
children
Women who have had no children or
who had their first child after age 30 have a slightly higher breast cancer
risk. Having many pregnancies and becoming pregnant at a young age reduce
breast cancer risk. Pregnancy reduces a woman's total number of lifetime
menstrual cycles, which may be the reason for this effect.
Recent
oral contraceptive use
Studies have found that women using
oral contraceptives (birth control pills) have a slightly greater risk of
breast cancer than women who have never used them. This risk seems to decline
back to normal over time once the pills are stopped. Women who stopped using
oral contraceptives more than 10 years ago do not appear to have any increased
breast cancer risk. When thinking about using oral contraceptives, women should
discuss their other risk factors for breast cancer with their health care team.
Hormone
therapy after menopause
Hormone therapy with estrogen
(sometimes with progesterone) has been used for many years to help relieve
symptoms of menopause and to help prevent osteoporosis (thinning of the bones).
Earlier studies suggested it might have other health benefits as well, but
these benefits have not been found in more recent, better designed studies.
This treatment goes by many names, such as post-menopausal hormone therapy
(PHT), hormone replacement therapy (HRT), and menopausal hormone
therapy (MHT).
There are 2 main types of hormone
therapy. For women who still have a uterus (womb), doctors generally prescribe
both estrogen and progesterone (known as combined hormone therapy or
HT). Because estrogen alone can increase the risk of cancer of the uterus,
progesterone is added to help prevent this. For women who no longer have a
uterus (those who've had a hysterectomy), estrogen alone can be prescribed.
This is commonly known as estrogen replacement therapy (ERT) or just estrogen
therapy (ET).
Combined hormone therapy: Using combined hormone therapy after menopause increases
the risk of getting breast cancer. It may also increase the chances of dying
from breast cancer. This increase in risk can be seen with as little as 2 years
of use. Combined HT also increases the likelihood that the cancer may be found
at a more advanced stage, possibly because it reduces the effectiveness of
mammograms by increasing breast density.
The increased risk from combined
hormone therapy appears to apply only to current and recent users. A woman's
breast cancer risk seems to return to that of the general population within 5
years of stopping combined treatment.
The word "bioidentical" is
sometimes used to describe hormones that contain estrogens or progestins with
the same chemical structure as those found naturally in people.
"Bioidentical" or "natural" hormones that contain estrogens
or progestins must be prescribed, just as other hormone drugs are, and should
be assumed to have the same health risks as they do.
ET: The use of estrogen alone after menopause does not appear
to increase the risk of developing breast cancer significantly, if at all. But
when used long term (for more than 10 years), ERT has been found to increase
the risk of ovarian and breast cancer in some studies.
At this time there appear to be few
strong reasons to use post-menopausal hormone therapy (either combined HT or
ET), other than possibly for the short-term relief of menopausal symptoms.
Along with the increased risk of breast cancer, combined HT also appears to
increase the risk of heart disease, blood clots, and strokes. It does lower the
risk of colorectal cancer and osteoporosis, but this must be weighed against
possible harm, especially since there are other effective ways to prevent and
treat osteoporosis. Although ET does not seem to have much effect on breast
cancer risk, it does increase the risk of stroke.
The decision to use hormone therapy
after menopause should be made by a woman and her doctor after weighing the
possible risks and benefits, based on the severity of her menopausal symptoms
and the woman's other risk factors for heart disease, breast cancer, and
osteoporosis. If a woman and her doctor decide to try hormones for symptoms of
menopause, it is usually best to use it at the lowest dose needed to control
symptoms and for as short a time as possible.
Breast-feeding
Some studies suggest that
breast-feeding may slightly lower breast cancer risk, especially if
breast-feeding is continued for 1½ to 2 years. But this has been a difficult
area to study, especially in countries such as the United States, where
breast-feeding for this long is uncommon.
The explanation for this possible
effect may be that breast-feeding reduces a woman's total number of lifetime
menstrual cycles (similar to starting menstrual periods at a later age or going
through early menopause).
Alcohol
The use of alcohol is clearly linked
to an increased risk of developing breast cancer. The risk increases with the
amount of alcohol consumed. Compared with non-drinkers, women who consume 1
alcoholic drink a day have a very small increase in risk. Those who have 2 to 5
drinks daily have about 1½ times the risk of women who drink no alcohol.
Excessive alcohol use is also known to increase the risk of developing cancers
of the mouth, throat, esophagus, and liver. The American Cancer Society
recommends that women limit their consumption of alcohol to no more than one
drink a day.
Being
overweight or obese
Being overweight or obese has been
found to increase breast cancer risk, especially for women after menopause.
Before menopause your ovaries produce most of your estrogen, and fat tissue
produces a small amount of estrogen. After menopause (when the ovaries stop
making estrogen), most of a woman's estrogen comes from fat tissue. Having more
fat tissue after menopause can increase your chance of getting breast cancer by
raising estrogen levels. Also, women who are overweight tend to have higher
blood insulin levels. Higher insulin levels have also been linked to some
cancers, including breast cancer.
But the connection between weight
and breast cancer risk is complex. For example, the risk appears to be
increased for women who gained weight as an adult but may not be increased among
those who have been overweight since childhood. Also, excess fat in the waist
area may affect risk more than the same amount of fat in the hips and thighs.
Researchers believe that fat cells in various parts of the body have subtle
differences that may explain this.
The American Cancer Society
recommends you maintain a healthy weight throughout your life by balancing your
food intake with physical activity and avoiding excessive weight gain.
Physical
activity
Evidence is growing that physical
activity in the form of exercise reduces breast cancer risk. The main question
is how much exercise is needed. In one study from the Women's Health Initiative
(WHI) as little as 1.25 to 2.5 hours per week of brisk walking reduced a
woman's risk by 18%. Walking 10 hours a week reduced the risk a little more.
To reduce your risk of breast
cancer, the American Cancer Society recommends 45 to 60 minutes of intentional
physical activity 5 or more days a week.