The short answer is yes, it will be very safe. Why? The beach has wind, sun, the salty spray in the air, and people spread out. Let’s consider each of these separately.
Wind. Because the water of the ocean and the adjacent land have very different responses to the warming effect of the sun there is an almost constant wind at the beach. Is that good or bad for spreading SARS-CoV-2? A nice study 1 (not peer-reviewed however) looked at the rate of COVID-19 cases and various weather conditions in four cities in China and five locations in Italy. They then plotted wind speed versus the number of cases (because of the average five day incubation period they correlated cases and weather with a five day interval). In eight of the nine cities the higher the wind speed the lower the rate of cases. The effect was not huge but in the vast majority of the time, the more wind the fewer cases. So given that effect, being at a windy beach versus a still air part of town away from the beach, will have fewer cases.
Sun and temperature. Previous results on the relationship between respiratory-borne infectious diseases and temperature have indicated that both SARS and influenza need to survive under certain temperature conditions, and increasing temperature can reduce their ability to spread. The underlying hypothesis as to why warmer seasons tend to decrease the spread of viruses include: higher vitamin D levels, resulting in better immune responses; increased UV radiation; and no school in the summer (when children are clustered together, transmission rates of flu and measles increase). Reports of UV and respiratory diseases have also been considered, and previous studies have shown that high levels of UV exposure can reduce the spread of SARS-CoV virus.
However, in this study of UV exposure and COVID-192 which had a six-fold difference in UV radiation there was no effect of increasing UV. With respect to temperature, the first study1 showed a positive effect, with each increase in temperature of one degree having a 1% decrease in COVID-19 incidence. The second study, however, saw no temperature effect.
Salty spray. The spray from the ocean, the aerosol, contains water, salt, and lots of ocean microbes.3 Importantly, they also contain a large and diverse collection of fatty acids, those long carbon chain chemicals we all know commonly as soaps. If a human sneeze/cough/breath droplet were to merge with a sea aerosol and then it began to float on the wind two things would happen: as it ‘dried’ in the air the salt concentration would increase, and the fatty acids would attack the membrane of the envelope virus, SARS-CoV-2. Both of these actions would quickly destroy the virus! This will not happen with fresh water lakes, by the way.
Public bathrooms. Even before COVID-19 the public facility situation at the beach is far from ideal. Nothing special for COVID-19 here. Just wash your hands after and if you are really talented, hold your breath if you can!
Get even more tips on staying safe with COVID-19 by following my blogs at ElevatorMedicine or get my new book on Amazon Kindle, Your COVID-19 Survival Manual: A Physician’s Guide to Keep You and Your Family Healthy During the Pandemic and Beyond.
Menopause is a stage in the life of every woman. Beginning in her 40s or 50s, it is marked by the end of her menstrual cycles. The average age in the US is 51.
Strictly speaking, a doctor diagnoses it when she has gone 12 months without a period. As the chart shows, it is caused by a reduction in the production of estrogen by the ovaries.
It is a natural biological process. But the physical symptoms, such as hot flashes, and emotional symptoms of menopause may disrupt your sleep, lower your energy or affect emotional health. The chart here depicts symptoms and conditions associated with the change.
Menopause requires no medical treatment. Instead, treatments focus on relieving your signs and symptoms and preventing or managing chronic conditions that may occur with aging. There are many effective treatments available, from lifestyle adjustments to hormone therapy.
Today I want to discuss hormone replacement therapy.
In simplest terms it is the treatment, not of menopause, but of the symptoms of menopause, caused by dropping estrogen levels. For treatments that are systemic, taken orally or transdermally (that is, a skin patch), they consist of three kinds: estrogen only, a combination of estrogen and progesterone, and, rarely, progesterone only. For treatment of some “local” symptoms, such as vaginal drying, discomfort during intercourse, and some urinary symptoms, a vaginal cream containing estrogen can be effective.
If the dosing is appropriate then the “vasomotor symptoms,” hot flashes and night sweats, will be under control. In addition, because menopause leads to increased cardiovascular disease risk and to bone loss or osteoporosis, treatment can prevent or delay these important diseases and conditions.
Unfortunately there is a real increase in the incidence of breast cancer. There have been extensive studies but the most definitive was published in September 2019 by a group from the University of Oxford in England. They found four important findings:
Yes! You can reduce the frequency and/or severity of the hot flashes, night sweats, and other symptoms. Here are a few ideas:
Regular physical activity can reduce hot flashes and improve sleep. It’s also a good way of boosting your mood if you feel anxious, irritable or depressed. Weight-bearing exercises can help keep your bones strong
A balanced diet can help ensure you do not put on weight and can keep your bones healthy
Wear loose clothes and sleep in a cool, well-ventilated room if you experience hot flushes and night sweats
alcohol and spicy food, as they have all been known to trigger hot flashes
to improve mood swings, make sure you get plenty of rest, as well as getting regular exercise. Activities such as yoga and tai chi may help you relax
if you smoke – giving up will help reduce hot flushes and your risk of developing serious health conditions, such as heart disease, stroke and cancer
if you experience vaginal dryness – several different types are available to buy from shops and pharmacies
Today I want to talk about a class of foods that might prevent breast cancer.
I am certainly not the first physician to propose that health and disease are related to what we eat. That honor goes to Hippocrates, the Greek physician who wrote over 2500 years ago, “Let food be thy medicine and medicine be thy food.”
But the quest to identify foods and beverages that have a major impact on health or a specific impact on a certain disease has been a long journey. I like to imagine the chemist and physician working side-by-side over the centuries in their laboratories. The quest for the chemist, turning lead into gold. The physician grinds his plants into potions, hoping to stave off death.
So if I said I had read or reviewed over 1000 articles on the impact of food on health and specifically, preventing breast cancer, it would be no exaggeration. Many studies are in the laboratory and involve human cancer cells in the test tube or preventing mice from getting cancer. If I had a dollar for every ‘potion’ that prevented breast cancer in these studies I would be a rich man. So I won’t waste your time like some blogs, talking about these lab studies.
I look only for studies in real, live human subjects. I also look at the design of the study: is there something about how it was designed that contains a fatal flaw that makes the data unreliable? A lot of studies don’t pass that hurdle. And then I look at the data. A twenty or thirty percent reduction in breast cancer in a ‘food’ trial can certainly be published and is useful in advancing the field of cancer research. But it’s not good enough for me, and it’s not good enough for an ElevatorMedicineTM blog.
I don’t like wasting your time or mine playing ‘small ball.’
So I am very excited to share a food family that really gets the job done!
The genus Allium contains about 500 edible species including garlic, onions, leeks, and chives, foods which are commonly consumed worldwide. Onions (Allium cepa) and garlic (Allium sativum) are among the world’s oldest cultivated plants, and are popularly consumed in stews (“guisos”), beans, and rice dishes in Puerto Rican cuisine today.
Garlic forms an important component of the Puerto Rican diet, and is mainly consumed in the cooked form in various sauces and seasonings, the most common being a condiment, “sofrito.”
The study I am discussing was published in July 2019 in the journal Nutrition and Cancer and is entitled, “Onion and Garlic Intake and Breast Cancer, a Case-Control Study in Puerto Rico.” I like case control studies because they set up two groups with very similar demographics but with one difference, and then study the effect of that one difference on outcome. The Atabey Study of Breast Cancer, a population based case-control study named after the Puerto Rican goddess of fertility, was conducted in Puerto Rico between November 2008 and June 2014. In all, 660 women were included with about half having breast cancer (the case group) and the other half without breast cancer (the control group).
The difference between the groups was the frequency of eating Sofrito. The outcome examined was the incidence of breast cancer in the two groups. The eating frequency was divided into those who never ate Sofrito, to those with an increasing frequency; from once per week to more than once per day.
The data and results below couldn’t be clearer:
The women who ate more sofrito had significantly fewer cancers. One ‘tell-tale’ I look for with good data is what I call the dose-response. Here it was absolute; the more sofrito that women ate, the fewer the cancers. The data crunchers said the likelihood of these results happening by chance was 1 in 50.
The implication is that if the 100 women who never ate sofrito had, in fact, eaten it twice a day, 67 of those women would NOT have gotten breast cancer.
Like the kids in the back seat on a road trip, the naive question ‘are we there yet?’ has to be answered in a sober, adult, professional fashion.
So two points:
But for now, I recommend that you find your favorite sofrito recipe online and enjoy it with the many foods of Puerto Rico that feature this versatile condiment, knowing you’re eating the best food group I have found to prevent breast cancer!
I hope you enjoyed this instalment of ElevatorMedicineTM!
With October ‘Breast Cancer Awareness Month’ comes the usual stories about breast cancer, tips on preventing the disease, and related topics. A perennial question that is asked almost every October is:
If you have wondered if wearing a bra can cause breast cancer, you are not alone.
A 2014 study of 748 adults in Cork, Ireland, was conducted to test for knowledge of risk factors for breast cancer. Fully 29% of the participants believed that wearing a tight bra could increase breast cancer risk. A more recent study in February, 2019, of women in Brazil placed the risk of breast cancer from wearing an underwire bra at 58.5%! In this study, the younger you were, the more convinced that breast cancer could be caused by wearing a bra.
So let’s see where this notion came from and what the scientists say is true.
The beginning of this theory was a one-two publication punch in the 90s.
First was a 1991 paper from the Harvard School of Public Health entitled, “Breast size, handedness, and breast cancer risk.” This paper described a study of about 15,000 women in which breast cup size and handedness (whether you wrote with your left or right hand) were related to breast cancer.
The strongest finding in the study was that, for premenopausal women, there was an association of increased breast size with increased cancer risk.
When the authors looked at whether women who got breast cancer wore a bra more frequently, they found a trend towards more cancer in these women. This trend was not big enough to be “statistically” significant however.
And the authors were careful to point out that the women who were more likely to wear a bra were also the ones with larger breasts and tended to be overweight. They said, “There was a suggestion that, among premenopausal women, those who did not wear a bra had a lower risk of breast cancer. The association, if real, could point to obesity or breast size as the relevant factor.”
This was followed in 1995 by the book, “Dressed to Kill: The Link Between Breast Cancer and Bras.” Here the authors, Sydney Ross Singer and Soma Grismaijer (a husband and wife medical anthropologist team) claimed that women who wore tight-fitting bras all day, every day, had a much higher risk of developing breast cancer than those who went au naturel. The authors claimed that by inhibiting lymphatic drainage, bras trapped toxins in the breast tissue, which caused cancer.
The problems with their theory are two-fold:
The authors’ observations that cultures where women did not wear bras also had a reduced cancer incidence did not take into account differences between these cultures in known risk factors for breast cancer, such as diet, weight, exercise, the age at which menstruation starts, pregnancies, and breast feeding.
The suggested mechanism is inconsistent with scientific concepts of breast physiology and pathology. The breast lymph system does not drain into the main part of the breast. The lymph system drains out of the breast into the underarm lymph nodes; and bras do not prevent the circulation of blood and lymph from the breast.
The authors’ proposal that bras block the lymphatic system which leads to accumulated toxins and cancer was likewise contradicted by scientific study. The National Institutes of Health examined cancer rates among women who had their underarm lymph nodes removed as part of melanoma treatment. The surgery, which is known to block lymph drainage from breast tissue, did not detectably increase breast cancer rates, the study found, meaning that it is extremely unlikely that wearing a bra, which affects lymph flow minimally if at all, would do so.
A final way to think about it is: well if wearing a bra causes breast cancer, then before the bra was “invented” breast cancer should be rare? Since the bra was patented in 1914 we can ask if breast cancer occurred before then. In fact breast cancer has been reported in every time period going back into the distant past. Princess Atossa was the first woman with a written report of breast cancer and that was in about 500 BC! So breast cancer was occurring long before women began to wear the bra.
To settle the question, a team of scientists from the Fred Hutchison Cancer Research Center, in Seattle, WA, conducted a careful study of the question. In a 2014 study entitled, “Bra wearing not associated with breast cancer risk: a population based case-control study,” about 1500 women, two-thirds with breast cancer and one-third without cancer, were asked about their bra wearing habits. This population-based case-control study found no evidence that any aspect of bra wearing is associated with risk of breast cancer. In particular the risk did not vary by daily duration of wearing a bra, age when women started wearing a bra, bra cup size, or whether women wore a bra with an underwire.
The National Cancer Institute (US) states that bras have not been shown to increase a woman’s risk of breast cancer.
The American Cancer Society states, “There are no scientifically valid studies that show wearing bras of any type causes breast cancer.”
The U.S. National Institutes of Health states, “Breast implants, using antiperspirants, and wearing underwire bras do not raise your risk for breast cancer.”
It’s not clear why a theory that bras cause breast cancer, a theory that has been thoroughly disproven, persists. Perhaps it comes from the frustration of not knowing what causes the disease, coupled with a desire that the disease should come from the outside, from something a woman can control.
In any case, let’s stop worrying about breast cancer being caused by wearing a bra!
The topic of diet and breast cancer is an immense field of active research. A simple search of the US National Library of Medicine for articles about the effect of diet on breast cancer finds over 4000 articles. The same search for preventing breast cancer shows over 2400 studies. To do this justice would take a deep dive and a lot of time.
But if I had only a couple of minutes to give my best three tips to prevent breast cancer via diet and eating it would be:
You have probably been told that breakfast is the most important meal to drive your energy and accomplish your day. But did you know it is also the most important meal to get your daily “prevent defense” going to stop breast cancer? Well it is.
The two key foods in that plan are fiber and yogurt. Both have as their primary role to build a strong, healthy microbiome. The microbiome is the collection of bacteria that make up your GI tract. Did you know they out number all the “human cells” in your body by 10 to 1. So eating to take care of them, so they can take care of you, makes sense. So the one-two punch for a healthy microbiome is fiber plus a fermented food, like yogurt. Let’s discuss them separately.
Dietary fiber or roughage is the portion of plant-derived food that cannot be completely broken down by human digestive enzyme. Grains, cereals, etc. are all good fiber sources. There is a portion that is “soluble” and a portion that is “insoluble.”
A 2016 Harvard study of over 90,000 women who had different dietary fiber patterns and were followed for 20 years showed that women who had high fiber diets (28 grams/day) compared to low fiber diets (14 grams/day) had a 25% reduced risk of breast cancer. The research showed it was especially important to start good habits in the adolescent years. A good high fiber cereal can give you 50% of your needs in one bowl.
What about yogurt? A 2017 study from the Roswell Park Cancer Institute, in New York, showed a 39% reduction in breast cancer among women with high intake of yogurt. Why? We are not sure but one interesting theory is they can break down the estrogen in the gut as it circulates back to the liver to be reused. This would lower blood levels of estrogen, which we know is related to a reduction of breast cancer. The benefit here is with yogurt with live bacteria; either homemade or commercial live or active yogurt. Pasteurized yogurt has all the good microbes killed.
A multivitamin. There are definitely some folks who question the need for an oral multivitamin with the American diet but my philosophy is: it’s cheap insurance. Since several of the vitamins, especially the B-series, are helpers that are involved in DNA repair and DNA repair is needed to correct the many common mistakes that can lead to cancer, it’s important to be sure you have enough. Key detail: most multivitamins have either folic acid or folate as the form of B9 but this is not the one you want. What you need is methyl-folate (full chemical name is 5-methyltetrahydrofolate (5-MTHF)), which is made in the body from folate, but up to 30% of women don’t have the right genetics to do the conversion well. So be certain you have the sure-proof version, methyl-folate. In a 2014 review of the literature, there was about a 10% reduction in breast cancer with vitamin supplementation. In women with BRCA1 genes, which prevent DNA repair, a 55-61% reduction in breast cancer was observed with folate supplementation.
First let’s get the “800-pound gorilla in the room” out of the way. Namely, fresh, red meat and processed meat raise your risk of breast cancer about 10-20% and there is no way around it. So if you love red meat, eat it like they do in Asia, as a “condiment-like” portion to a largely vegetable meal.
With respect to vegetables, an interesting 1999 study from the University of Colorado compared DNA damage in women on diets with fruits and vegetables from a few botanical groups (the usual American diet) and diets with fruits and vegetables from 17 different botanical families defined by their biological diversity. The latter diet showed a significant reduction in all markers of DNA damage, exactly what you would want to prevent breast cancer.
In a similar vein, a 2015 clinical study compared the Mediterranean Diet with extra-virgin olive oil (MD+) to a control diet (advice to reduce dietary fat) in 4282 women for the incidence of breast cancer over a 4.8 year period. There was a 68% reduction in breast cancer with the MD+ diet compared to the control diet. That is quite dramatic!
Fasting, whether defined as a reduction of normal calories by about 60% at meals taken at the normal times over the course of the day or time restricted fasting, in which a normal calorie (or slightly reduced) diet is taken over a short period of the day, yielding a period of 13 to 16 hours of fasting with no food, may be the most significant single thing you can do to improve your overall health, including preventing breast cancer.
The reasons are complex and many are not well understood. One thing that is understood is that cancer stem cells are stressed by fasting in a way that normal cells are not. It can also serve to quiet the immune system. Finally, it does wonders to your glucose control and pre-diabetic tendencies, which are known to work against cancer initiation.
In one study of 2413 women with breast cancer, those women who fasted less than 13 hours a day had a 36% increase in recurrence and a 21% increase in mortality. Every 2-hour increase in fasting improved biomarkers of diabetes, which are themselves related to breast cancer risk.
Many researchers believe stretching from 13 hours of fasting a day to 16 is the optimal pattern.
It’s been two weeks since you had your mammogram and your “letter” arrives in the mail. You know that if they found something serious you probably would have been called by now to come back in but it still is nerve racking to open the letter.
This blog is intended to be your “buddy” to help you understand what your letter says. But more important, it shows you how to look behind the curtain and get ALL the information your doctors have about your mammogram, your risk of having cancer now, and your risk of getting cancer in the future.
Your letter will tell you two things: some language about what they found on the exam and some language about your overall breast density. These are very different results and you should focus on them separately. The first result is essentially “do you have cancer now?” The second result is “what is your future chance of cancer?”
With this overview let’s get into the weeds…
Following the rapid increase in mammograms in the 1980s, it became clear that a need existed for a standardized reporting format for the reports. A doctor in Nebraska needed to be able to talk to a radiologist in New Jersey about a mammogram from a few years ago in a common language. The community of radiologists developed the Breast imaging-reporting and data system (BI-RADS) for that purpose. The BI-RADS score on your mammogram provides a wealth of information; information you deserve to know.
At the same time, Congress passed a law that required that women who had a mammogram receive a “letter” within 30 days of the test, explaining the results. The good news is that almost all women are now getting this letter as required. The bad news is it doesn’t have all the information you deserve to know.
Over the years there have been a number of modified versions of the BI-RADS system adopted. But the overall format is a scoring system from 0 to 6 which correspond to increasing likelihood of a cancer being present. The categorization provides an approximate risk of cancer to a lesion from essentially zero to greater than 95%. This table is a “simplified” version of the scoring system that you can use.
|Score||Meaning||Likelihood of Cancer||What You Should Do|
|0||Incomplete evaluation with further imaging required including additional mammographic views including spot compression or magnification and or ultrasound||Not Applicable||Be sure they do more studies; either more mammograms or ultrasound or MRI|
|1||A negative examination. meaning that there are no masses, suspicious calcifications or areas of architectural distortion. There can be no description of a finding in the report if it is categorized as a BI-RADS 1.||Essentially 0%||Great news! Unless you have a change in your monthly self breast exam or other change, return for your next scheduled mammogram|
|2||Benign findings. Benign findings include secretory calcifications, simple cysts, fat-containing lesions, calcified fibroadenomas, implants and intramammary lymph nodes.||Essentially 0%||Routine screening interval|
|3||Probably benign. Should have shortened interval follow-up to determine stability.||<2%||Requires a diagnostic mammogram|
|4||Suspicious abnormality. which can represent the chance of being malignant (in percent). The BI-RADS category 4 is subdivided into a, b, and c. The subcategory of (a) has a low probability of malignancy with a 2% to 10% chance of malignancy. The subcategory of (b) has an intermediate change of malignancy ranging from 10% to 50%. The subcategory of (c) has a high probability of malignancy ranging from 50% to 95%.||2 to 10%; 10 to 50%; 50 to 95%||Requires a diagnostic mammogram and perhaps a biopsy|
|5||Highly suggestive of cancer.||>95%||Requires a diagnostic mammogram and a biopsy|
|6||Known cancer.||100%||Requires a diagnostic mammogram|
In addition to the above classification system, the last component of a mammography report under the BI-RADS classification system is management recommendations. There are only four options for management under the BI-RADS system. These recommendation options are: (1) additional imaging studies, (2) routine interval mammography, (3) short-term follow-up, and (4) biopsy.
The majority of mammograms are BI-RADS 1 or 2 and require only routine interval mammograms. About 7% will be BI-RADS 3 and only 2% will be BI-RADS 4 or 5 and require a biopsy.
In Summary: With respect to your current mammogram, you need to ask your doctor:
Until a few years ago, the above information was all that was reported by mammography. But after decades of exams and lots of research, a new finding emerged. It turned out that the “background” density of the breast, even in women with no current cancer lesions, was predictive of future breast cancer. This was a way to say: “based on all we know about you, your family history, and your breast density, you are at [low, medium, or high] risk of future breast cancer.
This year Congress has written a law that women need to be told in their mammogram letter about their density. So after the first paragraph about your current exam the letter will tell you if you have dense breasts or not. Most of the letters will just say you do or do not have dense breasts. And don’t panic if it says you have dense breasts; about 50% of all women have some level of increased density.
So what should you do with your information? Get the added information that your doctor gets about your density! Just like with the above system of BI-RADS scores for cancer suspicion there is a BI-RADS score system for density. Here it is:
|Score||What it means||Percent of Women||Sensitivity to finding Cancer||Risk of future breast cancer|
|A||Almost entirely fat; <25%||10||88||1.0|
|B||Scattered densities; 25-50%||43||82||<2.0-fold higher|
|C||Heterogenously dense; 50-75%||39||69||About 2.1-fold higher|
|D||Extremely dense; 75-100%||8||62||About 4.6-fold higher|
As you can see, there is differences in both how sensitive the mammogram is with different densities and the risk of increased breast cancer with density. Sensitivity is expressed as a percentage and means, if you tested 100 women with “known” breast cancer, how many cancers would you find? So 88% sensitivity means you would find 88 cancers and miss 12 cancer in that hypothetical example. With respect to risk of future cancer, the lowest risk is in the lowest density risk group and it goes up from there. These risk levels are similar to having a sister or mother with breast cancer.
In summary: With respect to density, you need to ask your doctor simply: “What is my density, A, B, C, or D?”