My sister had breast cancer (BC), my mother had BC and a female cousin had BC. That is it on my Mum’s side, where I also have a fair few aunts and other female cousins who are BC free. On my father’s side, his sister battled BC for many years, eventually dying from it. I also had another aunt on my Dad’s side and various female cousins who are BC free. So although my Mum and sister had it, neither of them died from it, and I have many female family members who didn’t or don’t currently have BC.
Men can also get BC too but it is a lot more common in women. It would be fair to say I have always been pretty anxious about getting BC myself. However, this didn’t stop me starting HRT about six years ago. It didn’t stop me because I read books on it and listened to smart people speak about the risks, and for me the risk of not taking HRT was far greater than any small risk of taking it. It didn’t stop me continuing to take it when I needed to have a biopsy after suspicious looking calcifications were found. It even didn’t stop me when ALH was found after the biopsy. ALH is atypical lobular hyperplasia, which means abnormal cells growing in the lobules of the breast and it increases your risk of BC. However, coming up to six years now that I have been taking HRT, it is an understatement to say it has been life changing in an extremely positive way.
Many experts tell us we can take HRT even if BC runs in the family. Other experts tell us an absolute no, going so far as to say, “Do you know how bad BC can be? You’re a mother. Do you want to put yourself and your children through that?” That is what I was told by a very well regarded female OBGYN in Singapore, where I currently live, a few years ago when I told her I was on HRT and considered high risk.
Just because you are a doctor or a medical specialist does not automatically make you an expert in everything. Medicine is vast, and BC and HRT sit in a particularly complex and evolving space. When it comes to BC and HRT the views and opinions can be downright confusing at best and incorrect at worst. You will get plenty of podcasts leaving their lane and giving their opinions.
That confusion is part of why I started listening more widely. We have so much information available to us now and different platforms to access it. During Covid I started listening to podcasts mostly in the midlife, health and wellness space. I listen to well regarded, evidence based, measured podcast hosts and their guests, but I realised early on that even amongst the experts I trusted there were contradictions, bias, uncertainty and too many absolutes. I would listen to one expert and think that makes sense, then listen to another and think that makes sense too. My point is you have to make up your own mind.
What about only focusing on evidence based information? That should make things simpler. Not necessarily. It can all be evidence based, just different evidence. Add to the mix different interpretations of the data and you can be left more confused than you were before you started your own research. When Avrum Bluming said on a podcast, “I don’t know all the answers. I don’t know why Tamoxifen works in some women,” I pretty much gave up trying to understand it all, given that he wrote the book Oestrogen Matters and, to me and many others, has been the voice of reason in all this confusion.
I go for my yearly recommended mammogram followed by an ultrasound. I have been doing this for the last 15 years or so. I follow my mammogram with an ultrasound for two reasons. One because I have dense breasts, more of that later, and two because it gives me a better sense of reassurance that everything is ok. Note I said better, not absolute.
The usual questions are asked before your mammogram, invariably after you have taken your bra off and in Singapore with the harsh aircon I am usually freezing and super nervous by this point.
When was your last mammogram?
Are you pregnant?
When was your last period?
Does anyone in your family have BC?
Have you had a biopsy in the past?
Are you on HRT?
When I answer yes to the last question I have seen a look of surprise on the nurses’ faces, especially as I had answered yes to having had a previous biopsy and yes to anyone in the family with BC.
On an episode of her podcast Dr Streicher talks about when she goes for her mammogram and is asked if she takes oestrogen. She writes down what a ridiculous question and that it is irrelevant. Wouldn’t a better question be what do I weigh and how much alcohol do I drink as those are actual risk factors. Her guest Dr Mindy Goldman chimes in saying it is also important to ask how much exercise are you doing as that is another important factor when considering risk factors for BC. Both Dr Streicher and Dr Goldman are well renowned experts in the fields of menopause and HRT with Dr Goldman also being a BC expert.
So what are the risk factors of getting BC?
Well firstly being a woman and secondly getting older. After that the main risk factors that most experts agree on are:
Having a gene mutation that makes BC more likely, for example BRCA1 and BRCA2. There are also others.
Having BC in the family but without a gene mutation.
Having been previously diagnosed with BC including DCIS.
Having had a breast biopsy in the past.
Having ADH, ALH, LCIS. These are usually discovered on a biopsy, often incidental when you are having a biopsy for other reasons. They are atypical cells that are growing in an unusual fashion.
Drinking more than one glass of alcohol a night. Some experts would say any alcohol is a risk factor.
Being obese.
Having dense breasts. However 50 percent of women have dense breasts so in the past this wasn’t something that seemed to have much attention paid to it. Now in the US a new federal mandate requires that all women undergoing a mammogram be told about the density of their breasts.
I also have extremely dense breasts and that is a medical term. I had no idea in the past that we should know if we have dense breasts and if we do we should ask what classification we have. This is for two main reasons. One, having dense breasts makes it harder to read a mammogram. Sometimes the imaging just looks like a snowstorm and hard to see any cancerous growths as they are also white, so it’s like finding a snowflake in a snowstorm. Most important to note is that there is also an increased risk of BC if you have dense breasts.
Something I did not know is that HRT can cause an increase in breast density. Whether that is true only of the old HRT and not the newer transdermal HRT is still being debated and needs to be further researched, like so many things related to women’s health. Further research needed.
The different classifications of breast density:
A almost entirely fatty
B scattered areas of fibroglandular density
C heterogeneously dense
D extremely dense
Fifty percent of women have dense breasts, so either C or D on the classification.
It’s important to be aware of your risk factors. You can then take the necessary steps to minimise your risk of ever getting cancer. Knowledge is not about fear. It is about clarity. It is about making informed decisions rather than reactive ones.
Most of the experts I follow and respect do not consider HRT to be a significant independent risk factor for BC. Where risk is seen, it is small and comparable to everyday risks like regular alcohol consumption, being overweight or a sedentary lifestyle. That perspective shifts the conversation from fear to proportion.
So have your yearly mammogram. Know your breast density. Ask what classification you are. And understand your personal risk factors.
You don’t have to have relatives in your family with BC for you yourself to get BC. Most women who get BC don’t have a family history of it. Most women who get BC don’t take HRT. And most women who take HRT won’t get BC.
References
Streicher, L. (Host). (2024, October 17). S3Ep150: Managing menopause when cancer is a concern with Dr. Mindy Goldman [Audio podcast episode]. In Dr. Streicher’s Inside Information: Menopause, Midlife.
https://podcasts.apple.com/ca/podcast/managing-menopause-when-cancer-is-a-concern-with/id1615785832?i=1000673379360
Newson, L. (Host). (2023, November 21). 231: Getting to the truth around HRT and breast cancer with Dr Avrum Bluming [Audio podcast episode]. In The Dr. Louise Newson Podcast.
https://podcasts.apple.com/gb/podcast/231-getting-to-the-truth-around-hrt-and-breast-cancer/id1459614845?i=1000635503765
Huberman, A. (Host). (2022). What alcohol does to your body, brain and health [Audio podcast episode]. In Huberman Lab.
https://hubermanlab.com/what-alcohol-does-to-your-body-brain-health/
OMG: The Women's Health Brief 
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