Breasts: An Owner’s Manual: Every Woman’s Guide to Reducing Cancer Risk, Making Treatment Choices and Optimising Outcomes. Kristi Funk

protocol. Some patients choose prophylactic surgery. Others don’t want to go anywhere near the knife but take preventive medications. Still others decide to improve lifestyle factors combined with an aggressive screening regimen. If you’re struggling with medical choices, in part 4 I’ll help you find a path that leaves you feeling confident and comfortable with your decisions. I will review surgical options, explain the differences between lumpectomy and mastectomy, endocrine and immunotherapy, radiation and chemotherapy, and address specific questions I repeatedly hear at my center.

      It turns out acronyms abound in medicine, and in the interest of keeping you easily moving through our time together in this book, I use a number of them. To that end, please reference the appendix, a handy-dandy table that puts all those acronyms into a tidy little list. I’ve been sure to back up every claim I make with reference to a study, a paper, or a text. These endnotes are quite extensive, so I’ve placed them online for easy searching at pinklotus.com/drfunkendnotes. Long quotes from studies or articles, and the endnotes attached to data in tables, have been retained at the back of the book.

      So let’s get started! I firmly believe that knowledge is power, and power replaces fear with confidence and joy, which motivates you to implement changes—changes that I know could save your life, and in turn, make the lives of all those whom you love, and who love you in return, all the more joyful too.

PART 1

       BREAST HEALTH BASICS

CHAPTER 1

       Breast Care ABCs

      Take it from someone who’s around breasts all day, every day, and has been known to dream of them at night—women can have very emotional associations with their breasts. It takes a strong sense of self, which I hope we all strive to achieve, to say, “I am not my breasts,” because breasts connect in undeniable ways to femininity, sexuality, body image, and womanhood. Our feelings about our breasts run the gamut from pride in their shape and size, to awe over their milk-producing and life-affirming function, to trepidation and dread that someday they may give us cancer. To this last point, despite our fears, there have been few solid guidelines on how to improve your breast health, lower your risk of getting cancer, optimize your outcomes if you’re faced with a diagnosis, and make informed medical choices after treatment—until now.

      I’d like to start off here with a few basics about breast health: the parts and functions of your breasts, surprising facts about the “girls,” and how to take good care of them so you live a long, vibrant life. Understanding the breasts you’re caring for will ultimately go a long way to reducing their cancer risk. While you can’t control all your risk factors—some, like being a woman and getting older, are nonnegotiable—you can influence and reduce more than you may know by recognizing the factors that are under your control and then adjusting your life choices accordingly.

      BREASTS 101

      When it comes to your chest’s general anatomy, breasts remind me of a funky Jell-O fruit salad. Imagine one of your breasts as many bunches of grapes that you’re holding by the top of the largest stems (at the nipple). As you picture these bunches, see all the tiny connecting stems as the tubes that carry milk out of the nipple during lactation (they exist whether you ever get pregnant or not). The stems all connect to grapes, which represent the milk-producing lobules of your breast. The entire breast has fifteen to twenty lobes (grape bunches), and all the stems coalesce toward the nipple, with eight to twelve milk ducts opening on your nipple’s surface.

      Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist. https://commons.wikimedia.org/wiki/File:Breast_anatomy_normal.jpg.

      Now, push that entire bunch of grapes and stems, which together comprise what we call glandular tissue, into a mold of Jell-O that’s shaped like your breast and sits on top of your chest wall muscles. (By the way, imagine if Tupperware actually made breast molds. They’d make a killing at “bye-bye breast” parties—or as one of my patients called hers, “Ta-ta, ta-tas!”) The Jell-O represents the supportive structures that surround the breast gland, composed of stroma (a kind of connective tissue), adipose tissue (fat), ligaments, lymphatics, and blood vessels. The lobules and ducts, or grapes and stems, are usually what become cancerous (milk ducts alone are responsible for 75 percent of all breast cancers), but the Jell-O rarely does. For example, a Mayo Clinic review of all breast cancers in women over fifty-nine years old showed that a stromal-based breast cancer, called primary breast sarcoma, accounted for only 0.0006 percent of breast malignancies.¹

      Breasts range in size from absent, as seen in a rare disease called Poland Syndrome, to ones that swing down to your knees. Cups go from AAA to L—with the average American cup size being a D; Russia, Sweden, Norway, and Finland have cup sizes larger than D; Australia, France, Italy, the UK, Canada, and South America average a C; in Africa and Asia, women are A/B. Few women have a perfect match. In most, the left breast is up to 20 percent larger than the right (sudden one-sided changes in size are not normal, so if that happens, see your doctor). Your breast size and “perkiness” mostly come from a genetic patchwork of markers handed down from both of your parents to you, plus nutrition and the influence of estrogen, progesterone, insulin, and growth factors during your early years, puberty, pregnancy, lactation, and menopause. Fatness, exercise, aging, skin quality, and hormone use also influence size and shape. Since your breasts contain a genetically predetermined amount of fat, your breasts expand when you do. And contrary to what you may have heard, there’s no direct connection between the size of your breasts and your risk of getting breast cancer.

      Your actual breast takes up more space on your body than you probably realize—a point to keep in mind when you do your breast exam every month, as I’ll discuss next. The girls aren’t limited to the two fleshy mounds nestled into your bra. Each breast technically goes all the way up to your collarbone (the clavicle superiorly), centrally to your breastbone (the sternum medially), down to the curve you associate with being the bottom of your breast (the inframammary fold inferiorly), and off to the side of your chest wall (the anterior border of the latissimus dorsi muscle laterally). Another bit of breast tissue extends like the point of a teardrop toward the armpit, called the axillary tail, located just beneath the hair-bearing part of your axilla. Sometimes this tissue actually extends into the armpit itself, which is called axillary accessory breast tissue. When rather pronounced, it bulges out, covered by skin. Depending on whether this happens on one or both sides, you might feel as though you have three or four breasts. An axillary accessory nipple could even connect that breast tissue to your skin, and yes, this means you could actually breastfeed from your triple nipple one day.

      All breasts are lumpy, not just cancerous ones. Who in the world ever referred to breasts as melons? Did that person ever feel a breast before? Melons are uniformly firm, round, and very smooth—and they don’t budge when you poke them. The natural terrain of the breast is more like a mountain range with peaks and valleys covered in a blanket of snow (fat) and then wrapped in skin. When you run your fingers across that skin, the snow feels soft until you push deep enough to feel a mountain peak, and with a valley on both sides, that peak sure feels like a lump. The only way to trust that that’s a mountain and not a malignant intruder is to either see a doctor, or to know that it’s been there forever and it’s just your normal anatomy. All breasts have lumps, breasts are lumps, and they feel lumpy. The denser your tissue, the lumpier you feel. Genetics determine breast density, as do the estrogen levels in your body.

      Lastly, there’s the surface of the breast. Arteries and veins circulate blood flow to nourish the breast skin, and in lighter-skinned