Background There is reason to be concerned about breast cancer. It is the No. 1 cancer in American women, with more than 180,000 new cases reported every year. It is second only to lung cancer as a cause of cancer death in U.S. women (about 45,000 deaths per year). For reasons that are not clear, breast cancer has also become somewhat more common. Between 1950 and 1987, new cases rose by an average of about 1% per year in the U.S. Improved detection only partly explains this increase. There is good news, however. Better detection and better treatment have greatly improved the chances of surviving breast cancer. Today, the 5-year survival rate for women whose breast cancer is found before it spreads is better than 90%. As screening mammography and earlier diagnosis have become more common, deaths from breast cancer have started to decline. Table 1 Breast cancer risk in women according to age. By age 25 By age 30 By age 35 By age 40 By age 45 By age 50 By age 55 By age 60 By age 65 By age 70 By age 75 By age 80 By age 85 Lifetime 1 in 19,608 1 in 2,525 1 in 622 1 in 217 1 in 93 1 in 50 1 in 33 1 in 24 1 in 17 1 in 14 1 in 11 1 in 10 1 in 9 1 in 8 What is a woman's individual breast cancer risk? You may have been told that your lifetime chances of developing breast cancer are about 1 in 8. This statement is true but assumes you will live to the age of 90! In fact, risk varies widely according to age and is small in younger women. The chance you will develop breast cancer by age 35 is only 1 in 622; the chance you will develop it by age 60 is 1 in 24. Even at age 50, a woman who is cancer free has only a 5.7% chance of developing the disease by age 70. Are there factors that can increase your risk? Increasing age and being female are the main risk factors for breast cancer (99% of cases are in women). Breast cancer in a close relative (mother, sister, daughter) also raises your likelihood of developing the disease, though not of dying from it. Greater than moderate alcohol intake is another probable risk factor. High-fat diet is no longer thought to influence risk. Some have suggested risk is also slightly higher for women who have never been pregnant, women who started menstruating early, and women who had menopause late. These risks are not proven, but if you fall into any of these groups you may want to discuss it with your doctor. Bottom line: Most women do not have specific risk factors for breast cancer, but all women are at risk. Will taking estrogens after menopause increase your risk? Results of more than 40 studies strongly suggest that taking estrogens to relieve symptoms of menopause such as hot flashes and night sweats does not increase breast cancer risk. The evidence is less certain for longer-term use of estrogen for other reasons, such as protection against osteoporosis. Most recent studies show no extra risk of breast cancer from more extended use of estrogen. A study of 120,000 nurses concluded risk was 30% higher, but only for current users of estrogen who had been taking it for 5 years or more. If the studies don't agree, how do I decide what to do? It's important that you discuss this issue with your doctor. Taken together, the evidence of many studies is that estrogen's influence on development of breast cancer, if it exists, is not large. By contrast, similar studies of estrogen's role in cancer of the endometrium (lining of the uterus) all showed a clear and strong impact. As a result, women with a uterus who take estrogen after menopause now also are given hormones called progestins that protect them fully against uterine cancer. Will adding a progestin also protect against breast cancer? Unfortunately, recent studies all agree that progestins have no effect on breast cancer risk. When taken with estrogen after menopause, progestins neither increase nor reduce the chance of developing breast cancer. Table2 Breast Cancer Risk by Decades Current age risk of developing breast cancer by age   50 60 70 80 40 1.6% 3.9% 7.1% 10.3% 50   2.4% 5.7% 9.0% 60     3.6% 7.1% 70       4.1% What other risks and benefits do I need to consider in deciding whether or not to undertake postmenopausal hormone therapy? In some women, estrogen may cause breast tenderness, headaches, dizziness, nausea, or abnormal bleeding, and it can increase the risk of gallbladder disease. On the positive side, besides relieving hot flashes and restoring vaginal lubrication, postmenopausal use of estrogen has been shown to promote bone strength and protect against osteoporosis as well as to retard deterioration of urinary tissue and incontinence. Most important, a major recent study has shown that long-term estrogen use may protect powerfully against heart disease, by far the leading cause of death in women. In that study, women taking estrogens reduced by 50% their risk of dying of heart disease. It is only when estrogen production drops at menopause that women's risk of heart disease rises to equal that of men. Evidence is also beginning to accumulate that estrogen may reduce the risk of Alzheimer's disease in women. If I take estrogen, should I have mammography more often? No extra precautions are needed just because you're taking estrogen. If you have no history or signs of breast cancer, all you need to do is follow this simple guideline: Starting at age 40, you should have a breast exam and mammography done every year. Monthly breast self-exam is also a good idea, but by no means a substitute for clinical exams or mammography. Women with breast cancer history or signs should discuss their screening needs with their doctors.

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