By Samantha Peia

Many questions have been raised. New roads have been charted for future progress in the continuing fight against breast cancer. Much remains to be done by physicians and much remains to be done by you. Let us consider first what more could be done by the medical profession.

Our greatest efforts must be directed to learning more about what causes breast cancer. Are there factors that can be controlled? One school of thought believes that two different sets of factors may be operating—one that starts the process and another that promotes its growth. Some think that diet (particularly fats) has an effect in promoting cancer growth. A project has been started in the Netherlands to see if weight reduction may have a beneficial effect in reducing the risk of developing breast cancer.

Is there a virus involved—a submicroscopic living substance that changes the programming in a cell and turns it into an enemy of its neighbors? If so—and there is evidence that this occurs in some animals, such as mice—can this substance be isolated and a vaccine produced against it? Someday, perhaps, girl babies may be immunized against breast cancer. Such a concept would take much time and effort to substantiate. Even if a successful vaccine were produced, a whole generation of women would still be at risk and would still require all our efforts at earlier detection and treatment. Until the time we learn to prevent the disease from developing at all, we must continue to try to prevent disability and death.

When we have found the remedy that will eradicate the disease regardless of the stage in which it is detected, the pressure for earlier detection will be lessened. The probability is that such a remedy will lie in a still unknown chemical or a still unknown ability to manipulate the hormonal or immunological defense mechanism of the body. In the meantime we must use our surgical, radio-therapeutic, and chemotherapeutic tools to the best of our ability. Today this means finding breast cancer when it is confined to the breast or has only minimal spread. The earlier in its development the cancer is detected and the smaller its size, the greater our success with our present remedies. With our improved devices, we can find breast cancer when we can cure the woman, which is more than can be said of many other forms of cancer. We must continue to take advantage of this fact.

In the meantime we must continue to develop methods of diagnosis that are more accurate, more economical, and less time-consuming. We must find ways of tracking down the enemy when he is even smaller than we now find him. We must develop ever finer sieves so that he will not slip by as he now does too often.

Of great interest, too, would be improved methods of identifying high-risk populations. We have made only little progress in this direction. If we could find those women who are substantially more likely to develop breast cancer, we could concentrate on them and examine them more frequently. At the same time, we could conserve our time and energy and examine the low-risk women less frequently.

For many years, oncologists (cancer specialists) have believed that hormones, particularly estrogens, produced by the ovaries or adrenal glands were in some way closely associated with breast cancer. It has been known for some time that estrogens in substantial amounts could produce breast cancer in susceptible mice. The relationship to breast cancer in humans, however, has been much less clear. For instance, it is known that during many months of pregnancy the amounts of estrogen in the body increase to very high levels—up to ten times the usual amount—yet breast cancer seldom develops during pregnancy. Estrogen has been used for years to treat changeof-life symptoms such as flushes, dizziness, and depression. Tons of these hormones have been taken by thousands of women for long periods of time. Yet the incidence of breast cancer has not increased.

An explanation of much of the paradox has been offered by Dr. Henry Lemon, a cancer specialist from Nebraska; Dr. Brian MacMahon, an epidemiologist from Boston; and Dr. Herbert Wotiz, a biochemist from Boston, that may offer a true advance in identifying a high-risk group. It also may be a step in the direction of decreasing the risk of developing the disease.

Drs. Lemon and Wotiz have demonstrated that estrogen can be divided into three closely related fractions named estradiol, estrone, and estriol. They found that all three have similar effects as female hormones. However, they made the interesting observation that whereas estradiol and estrone promote the development of breast cancer in a mouse, estriol can actually prevent its onset. These scientists with Dr. MacMahon then asked this question: Could the ratio of this anti-cancer estrogen (estriol) to the pro-cancer estrogens (estrone and estradiol) play a part in the initiation or development of human breast cancer?

The answer is not yet available. However, several facts suggest this is true. It has been found that most estrogen in pregnant women is actually estriol, which may partly account for the reduced incidence of breast cancer in pregnancy. The ratio of estriol to the other estrogens is higher in young Oriental women than in Caucasians, although the total amount of estrogen is about the same. This may account for the fewer breast cancers in the Orient. The estrogens given orally to menopausal women contain substantial amounts of estriol and may account for the fact that there is no apparent increase in breast cancer among women taking hormones.

Even more striking has been the observation by Dr. MacMahon that full-term pregnancy in a woman under 20 confers considerable protection against developing breast cancer subsequently. This, too, may be related to the large proportion of estriol produced during pregnancy at a time when breast tissue may be particularly sensitive to the female hormones.

This leads to the exciting thought that measurement of the three estrogen fractions and their ratio may lead to a true high-risk marker. Furthermore, in those women who have a diminished ratio of estriol to the other estrogens and may be at higher risk of getting breast cancer, perhaps estriol administration could be used to lower their risk.

Much investigation is going on in this area of female hormone production and its involvement in breast conditions. The whole field is exciting and may offer biochemical clues to a better understanding of the cause of breast cancer.

An intriguing area for determining high-risk factors is evaluation of the emotional life of a woman. It is well known that psychological factors have a powerful effect on the endocrine system. Could such factors play a part in the hormone development of the young female and make her more or less likely to develop a subsequent breast cancer? Could a psychological questionnaire be constructed that would detect such factors? There are experts in the breast field who think such a possibility exists and should be investigated.

A most important problem that needs to be studied is motivation. How does one stimulate women to accept, if not demand the complete breast examination? Motivation is more easily developed in higher-income groups. But how about the minority groups or those at lower-income levels? How can they be made aware of the breast-cancer problem and how can they be brought in for examination? Such an effort requires education and dissemination of information at the community level, perhaps even on a personal level. Perhaps it will be necessary to keep screening centers open at night or on weekends to accommodate working mothers. Subcenters may need to be established in the communities where low-income women live. Other communities should follow the lead of the Guttman Institute, which operates a twenty-six-foot mobile unit that contains all the advanced equipment necessary for a complete examination, and that moves from one neighborhood to another. Special mobile equipment for mammography and thermography is also available which can be transported to locations for health fairs and community screening sessions. More emphasis must be placed on the use of trained paramedical personnel to examine large numbers of women.

In short, until we learn how to protect ourselves against the onset and development of breast cancer, we must continue to use improved methods of detection and treatment to cure the disease more often. We must also tell more women that much of their protection lies in their own hands. And the American Cancer Society must be supported in their continuing programs of education and information.