Global Breast Cancer Prevention Strategies

Introduction

The history of breast cancer dates back at least 3000 years (Galgut 2013). According to Lizama et al. (2015), Facts and Statistics (2018), and Breast Cancer Statistics (2015), it is now the most commonly diagnosed cancer in women, comprising 28% of all female cancer case diagnoses, with all women having a lifetime risk of one in eight of developing breast cancer. Cancer Research UK (2015) also indicates there are at least 55,000 new breast cancers cases each year mainly in women aged over 50 years. Ideally, this translates to at least 150 new cases every day (Cancer Research UK, 2015). Nonetheless, on a global perspective, research evidence reveal that breast cancer incidences are still increasing, with a diagnosis of 1.4 million new cases every year (Laudisio et al, 2018). This rising trend highlights the need for ongoing research and healthcare dissertation help to explore effective prevention and treatment strategies.

A major breakthrough in the fight against cancer was experienced in 1988, based on the Forrest Report (Department of Health and Social Security 1986). This report recommended screening every three years for early detection of breast cancer. According to Stafford et al (2016), the implementation of this recommendation led to a 40% fall in cancer-related death rates. The idea of early screening is also supported by speculations that two-thirds of women with early diagnosis may survive another 20 years (Cancer Research UK, 2015). Besides, early screening is also supported by Mathers et al (2013) as the best way to detect early cancers and reduce mortality rates.

A need to prevent cancers worldwide is of primary importance to scientists and government policymakers and has been part of targets set by the World Health Organization (WHO) since 2014, as well as the World Cancer Research Fund (Wiseman 2008). Nonetheless, the prevention and reduction of breast cancer has been a subject of interest among academics and healthcare practitioners, with most of them recommending a change of lifestyle elements such obesity and diet, alcohol consumption, exercise, and smoking as an effective remedy. Hence, as recommended by Wise (2016), Del Valle (2014) Cadmus-Bertram et al. (2012) and Wiseman (2008), there needs to be public awareness on the idea of change of lifestyle. The main aim of the paper is to evaluate obesity and diet, alcoholism and physical exercise as lifestyle areas where changes can be initiated to reduce the risk of breast cancer.

Obesity and Diet

Much of the developed world has seen a massive increase in overweight and obese people, and this is becoming evident in the developing world as well (Goodwin 2016). Moreover, Arnold et al (2015) claim that at least 35% of adults worldwide are now overweight, with at least 12% within that percentage being obese. Obesity is particularly relevant to an increased risk of breast cancer as the extra adipose tissue is thought to produce higher levels of oestrogen, and higher levels of insulin in the body (Chan et al. 2014), and also lead to chronically low levels of inflammation within the body, all which are thought to be additional stimulus for tumour growth (Argolo et al.2018). In addition, research also links an imbalanced metabolism of cholesterol (a fat molecule in the body) to growth of breast cancer tumours (Kaiser 2013). Moreover, this metabolic imbalance is also linked to more aggressive strains of breast cancer (Obesity and Cancer 2017).

The relationship that exists between diet and breast cancer risk has been examined and documented for over the past 40 years (Key and Reeves 2016). For instance, current research by Breast Cancer Care (2017), Farvid et al (2016), Morris et al. (2014), Jung et al. (2013) and Wiseman (2008) indicates a beneficial effect of a diet high in fruit and vegetables. Similarly, a study by Farvid et al (2016) found that a frequent diet high in fruit intake during adolescence was associated with a lower risk of breast cancer; showing a need to educate the general public from an early age about the important role of proper diet in reducing breast cancer risks.

Other studies by Cancer Research UK (2016) and Olbrys (2013) have also evidenced that obese women have an increased risk of breast cancer. This is particularly relevant today, as recent decades have seen a large increase in obesity, with statistics showing that over 1.9 billion adults were overweight, with at least 600 million being obese (Picon-Ruiz et al. 2017). Noteworthy, evidence by Cancer Research UK (2016) supports findings by other studies that obese postmenopausal women have a higher chance of developing breast cancer. Moreover, an article by Laudisio et al (2018) backs this up further by indicating that worldwide obesity is increasing and is a preventable, leading cause of cancer, most notably breast cancer, and that obesity leads to a worse outcome for all the breast tumour types.

Obesity as major cause of breast cancer has also made news headlines and therefore the relationship between obesity and breast cancer is a public knowledge (NHS Choices 2011). In addition, a study by Chan et al (2014) indicates that obesity in post-menopausal women also increases a chance of breast cancer recurrence and gives poorer survival chances. These findings corroborate with those of Wiseman (2008) which included 67,142 women. Moreover, similar results were obtained by Copson et al (2014) who indicate that obese patients have a much worse prognosis than non-obese patients. Furthermore, evidence by Goodwin (2017) also indicates that obesity is associated with an increased risk of breast cancer and a much worse prognosis. Worryingly, studies by Morris et al (2014) also show a clear link between a high BMI and breast cancer incidence.

Alcohol

The links between alcohol and some types of cancer have been widely researched and documented by several scholars (e.g. Simapivapan et al. 2017; Cao and Giovannucci 2016; Dam et al. 2016; Hoffman and Gerber 2016). As alcohol seems to be a widely accepted and visible part of many cultures, this may obscure its scientifically proven link many health problems, especially breast cancer (Cao and Giovannucci 2016), yet this link appears to exist even in cases of light or moderate drinking (Simapivapan et al. 2017; Rehm 2015). Worryingly, according to Wise (2016) and Wiseman (2008), there appears to be no “safe” level of alcohol intake that is not associated with an increased breast cancer risk. Interestingly, the alcohol industry has more often than not tried to block media campaigns showing an association between alcohol and cancer as “scaremongering” to the public. According to Gornall (2014), such actions are meant to cover up the link, as was once the case with smoking. On the same note, Simapivapan et al (2017) assert that large amounts of alcohol intake is strongly linked to breast cancer, and strongly considered as a cause of primary breast cancer.

There appears to be an urgent need to educate the public, and to decide who will implement these programmes of education (Wise 2016). However, urgent as it may be, Anderson et al (2013), Cao & Giovanucci (2016), and Hall-Alston (2015) claim that addressing this urgency may only be possible with an effective reach out to those who participate in screening programs such as nurses and practitioners who are key figures with the ability to introduce public awareness of healthy lifestyle choices.

A study by Simapivapan et al (2017) reveals inconsistencies in clinicians’ knowledge on appropriate standards of drinking. This highlights a need to train clinicians in the knowledge of national drinking standards, and how to communicate them. This training is especially important because Del Valle et al (2014) indicate that nurses have a vital role in implementing lifestyle changes to reduce breast cancer risks, whereas Anderson et al (2014) believe that there seems to be very little evidence that lifestyle factors are even discussed in cancer screening sessions. Furthermore, an article by Hall-Alston (2015) cited by Olbrys (2013) believes that nurse practitioners in cancer care setting have a key role in educating patients to set new goals in their post-cancer care and to spot patients at high risk of hereditary breast cancer who may be open to suggestions to decrease alcohol consumption.

In their literature “Are you worried about breast cancer?” Macmillan Cancer Support (2016) unequivocally state that alcohol consumption increases the risk of developing breast cancer, and the more an individual drinks, the higher the risk. Dam et al (2016) also backs this up with their research, stating that women who drink a lot of are at a higher risk of breast cancer. Other ways of educating the public are highlighted in another booklet “Diet and Breast Cancer” by Breast Cancer Care (2017), stating that there is an association between breast cancer and imbibing alcohol, and that women should drink no more than 14 units of alcohol per week. Interestingly, when lifestyle factors were discussed in a young screening setting of a family history pre-disposition to breast cancer, participants in the study by Prichard et al. (2015) did report a desire to decrease alcohol intake.

Exercise

Exercise can be defined as any body movement using skeletal muscles that result in an expenditure of energy. Macmillan Cancer Support (2016) recommends performing at least two and a half hours of exercise a week, which can be divided into ten to thirty minutes during the week. Exercising at least five times a week for at least 30 minutes is also endorsed by Bruno et al (2016) and Lahart et al (2014). Cadmus-Bertram et al. (2012) also recommend building up to 150 minutes of exercise per week. Nonetheless, it is important to note that exercises such as walking, swimming, and cycling are considered sufficient.

A study by Lahart et al (2014) showed that at least 75% of women in a study of 188 women believed that physical exercise does decrease a risk of breast cancer. This same study showed that a family history of breast cancer increased an individual’s knowledge of the links between exercise and breast cancer risks. Hence, exercises are recognized as effective remedies to breast cancer risks.

Research currently indicates that exercise can help reduce the risk of developing breast cancer, and even after a diagnosis, it can enhance quality of life and future prognosis (Bruno et al. 2016; Lahart et al.2014; Knobf and Winters-Stone 2013; Anderson et al. 2013 and Chung et al. 2013). There is a documented need now to rehabilitate survivors, and this includes engaging them in physical exercise (Knobf and Winters-Stone 2013). Exercise can relieve fatigue, depression, sleep deprivation, pain and improve weight maintenance and base metabolic rate. It has also been proven that women who do physical exercise after a breast cancer diagnosis have reduced chances of dying from the disease by at least 34% (Ibrahim and Al-Homaidh 2010), although it is not yet clear how the protective mechanisms work. However, some scholars (e.g. Ferioli et al. 2018) hypothetically suggest that exercise reduces inflammation, reduces blood lipid levels, and improved insulin sensitivity, all of which help prevent cardio-metabolic cancer comorbidities. Bruno et al (2016) back this up in their research where they concluded that exercise can reduce insulin levels in obese breast cancer survivors, although more research may be needed to establish what type of exercise, and at what time in the cancer pathway is most effective for a positive breast cancer survival rate.

Because exercise is a relatively safe and cost-effective type of therapy that does not require any medication, it is argued by Ferioli et al (2018) that exercise is prescribed alongside more traditional breast cancer treatments. However, Hall-Alston et al (2015) hypothesize that nurse practitioners should play an important role in developing motivating programmes for patients to include exercise in their post breast cancer treatments. Other means of delivering exercise promotion could be via the telephone, group sessions, supervision within an exercise setting, or the more recent web-based delivery (Cadmus-Bertram 2012). To explain further, web-based self-monitoring has advantages when encouraging women to exercise, because the websites have the latest information and technology, and can provide electronic, motivational “rewards”. Moreover, the resultant websites are also useful tools for research.

In conclusion, the importance of lifestyle choices relating to the prevention and management of breast cancer is recognized globally. However, there is also recognition that lifestyle choices are not always discussed within a breast cancer setting. Family history clinics may also provide a setting in which lifestyle choices could be discussed, as people with family history of breast cancer are also sometimes more aware of lifestyle links and are more open to implementing change.

Whereas there are various public health campaigns to promote healthy choices, initiating changes in the public health should be addressed within breast cancer clinics, especially to visibly obese patients. However, this strategy may encounter a problem in terms of acceptability to people, and the question of who should deliver the appropriate health behaviour modifications may arise. Nonetheless, more education needs to be provided as to how to deliver health education programmes in a way that will be acceptable to the public and should be included at all routine screening appointments. But, this would only target the population that attend clinics for screening but would not address perhaps the most vulnerable population that do not attend routine screening programmes or those who may be at most risk for unhealthy lifestyle choices. Against this background, a way of reaching this percentage of the population may include media campaigns through television. Nonetheless, the following recommendations are considered appropriate:

Recommendations: -

• Physicians/Nurse practitioners should advice patients on the links between lifestyle choices and breast cancer risks. In the event of obesity, a free “weight -watchers” weekly attendance programme could be incorporated into the NHS services.

• Nationwide television advertisement of proven links between alcohol consumption and cancer-especially breast cancer.

• Promotion of public awareness that the “five a day” promotion of healthy consumption of fruit and vegetables is also a cancer preventative and needs to start in early life/adolescence.

• Education in secondary schools of links between lifestyle choices and cancer risks.

• That a coherent national surveillance system is set up to act as an early warning system for disease trends and patterns.