March 27, 2008
Jewish women change their destinies by testing for genetic mutation
Combating breast cancer -- before it hits
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In Los Angeles in particular, the numbers seem to be especially high.Gordon estimates that 65 percent to 70 percent of BRCA-positive women in Cedars' cancer programs opt for the surgery, some immediately, some after a few years of surveillance. The quantity and quality of medical options makes the surgery more attractive in big cities, and Los Angeles has a high tolerance for breast surgery, Gordon said. She is spearheading a study about decision-making among BRCA-positive women at Cedars' Gilda Radner early detection program, which screens genetically high-risk women for ovarian cancer.
Gordon understands that a woman's decision about treatment is intertwined with her relationship status, her self-image and how many family members she saw battle or succumb to cancer.
Surgery or Surveillance?
"The decision to take off your breasts is really hard. It's a part of your body that is associated with your outward appearance, and it's a part of who you are. It's a part of your sex life," said Joi Morris, who was 41 when she learned she carried the same genetic mutation that gave her mother and grandmother breast cancer at a young age.
Morris remembers a day, not long after she found out, when she really confronted the issue as her sons, then 7 and 10, played at the beach.
"My kids were in the water and jumping and playing and having a fabulous time, and I looked down at my breasts in my swimming suit and thought, 'Oh my God, what would it be like to not have these?'" It's a seesaw of emotions, she said, because at the same time, "you wake up every morning, and you know you are at risk, and you wonder if there is something in there you can't find."
Morris initially opted for close surveillance -- a regimen of regular mammograms, manual exams, ultrasounds and breast MRIs -- the most sensitive, noninvasive screening available, used only for high-risk patients. Her first MRI revealed a lump close to her chest wall.
"I panicked. There is no other way to put it. That lump turned out to be benign, but the whole process was so stressful for me and hard on my family. I just decided if this lump is not cancer, the next one could be," Morris said.
She had a prophylactic bilateral mastectomy, with immediate reconstruction. As it turned out, her surgery wasn't prophylactic at all -- pathology revealed pre-cancerous cells scattered throughout both breasts.
Early in the process, Morris turned for support and information to FORCE: Facing Our Risk for Cancer Empowered, an organization that advocates for people at high genetic risk for breast and ovarian cancer.
Today, she is an outreach coordinator for FORCE, helping link women through face-to-face groups and one-on-one pairings as they face life-altering decisions.
"It was very hard getting those results," said Lisa Stein, a 43-year-old mother of two, who found out she has the gene last year. "I was trying to prepare for being positive, but I don't think you ever can. After I got the results, I really struggled. I was feeling raw for a while, crying easily knowing that it was going to be life-changing."
Stein's mother died of breast cancer at 57, and her grandmother died of ovarian cancer, but she didn't test until her older sister, Lauren Rothman, tested positive.
Rothman opted for a mastectomy, but Stein chose to keep her breasts.
"I think I knew instinctively that I was not going to have a double mastectomy. That felt too radical to me," Stein said. "I didn't feel psychologically prepared or that it was necessary. I don't feel like cancer is imminent; I feel like I have a few years to take it in and think about it and prepare, so I've put that decision on hold."
She goes in for screening every few months, and she said the anxiety of waiting for those results has been manageable.
Both Rothman and Stein had their ovaries removed, however, which doctors are now recommending for women who test positive and who are finished having children or who are over age 35. Removing ovaries not only reduces the risk of ovarian cancer -- which is notoriously hard to catch early and thus has a high mortality rate -- but it reduces the risk of breast cancer by 50 percent. Stein also went on Tamoxifen, a drug taken by breast cancer survivors to reduce the risk of recurrence and which reduces risk by 50 percent in BRCA-positive women. The birth control pill, which stops the ovaries from cycling, can also reduce the risk of ovarian cancer but requires more vigilant screening for breast cancer.
Both ovary removal and Tamoxifen push women into menopause, with all its emotional, sexual and physiological ramifications.
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Eating for cancer prevention, even at Jewish tables
by Tamar Sofer Eat less. Exercise more. Avoid refined foods. Are these the latest recommendations of yet another medical study? Yes and no. In fact, the great Jewish thinker and physician, Maimonides, wrote these same prescriptions for preventing disease more than 800 years ago in his compilation of Judaic texts called the Mishneh Torah. Writing in the Book of Knowledge, Maimonides (also known as Rambam) advises not to eat freely "fine meal so completely sifted that not a trace of bran remained....." He also wrote that a person should "take active exercise" and eat "about one-third less" before feeling full. Now, two new reports agree with Maimonides. A five-year study published by the World Cancer Research Fund International and the American Institute for Cancer Research concluded that diet and exercise can prevent six different types of cancer and slow its spread and prevent recurrence in those who have been diagnosed. Another study just published in the Journal of the National Cancer Institute concluded that women who reduced their dietary fat to 20 percent of their calories lowered their risk of developing ovarian cancer by as much as 40 percent. It didn't matter what age these women began the low-fat diet, as long as they stuck to it for eight years. Given that one person in 40 among Ashkenazi Jews carries mutations in the genes that raise the risk of developing breast, ovarian, prostate, pancreatic and skin cancers (one in 500 carries this risk in the general population), a low-fat diet may well be the doctor's prescription for the entire Jewish community. Yet how is it possible to eat less, given the staggering amount of food at every banquet, synagogue Kiddush and Shabbat table? Here are some tips from the experts on how to manage at Jewish communal events. At the Bar Mitzvah "Carbohydrates are sweet and taste good," said Dr. Michel Mazouz, a weight-loss specialist in private practice in Los Angeles. But alcohol and carbohydrates -- the ubiquitous bagel -- just make you hungrier. Carbohydrates release hormones that make you eat more, while protein and vegetables decrease appetite. "Most eating at social events is due to boredom, so taste the food and walk away," Mazouz said. Other strategies include eating before the event or chewing slowly. "As you chew, receptors in the mouth signal the brain to release hormones that tell you to stop eating," Mazouz said. The slower you eat, the more signals are able to reach the brain. At the Synagogue Kiddush Rachel Beller, a registered dietitian and president of the Beller Nutritional Institute, suggests filling your plate halfway with vegetables and the other half with protein, fruit and something you love. "That way, you've cut the damage by 80 percent," Beller said. "Focus on what you need. When you eat vegetables, you're gaining nutrients. Protein [such as sliced turkey] is necessary for strength." One of her patients became so desperate for fresh vegetables at a Kiddush that he ate the decorations -- cherry tomatoes and carrots. A spokesperson for the American Cancer Society, Beller considers food a preventative medicine. "Unfortunately, people come to me for nutritional counseling when they've been hit by cancer or other diseases. People need to think prevention and make a commitment" to eating healthfully, Beller said. At the Shabbat Table Guests at Shabbat tables often feel doomed when they see the salad drenched in oil and filled with sugar-coated items. Beller suggests that if you know the family well, make a modest request to address your dietary needs. It's just another of many dietary issues people face, such as limiting sodium, diabetes and cardiac problems. Ask the host for some undressed salad on a side plate and then mix in one scoop of dressed salad. You won't feel out of place -- important to the dieter. "You've cut 500 calories right there," she said. Still, Beller believes the strongest way to help is through the host's side: "Make everybody happy. Serve two bowls of salad, one 'naked' and one with goodies. Offer two types of chicken, with and without sauce." Olivia Schwartz, co-director of the Chai Center, has learned to replace fat and salt with fresh herbs and spices. She feeds dozens of guests at her Shabbat table and at women's retreats. "I find that if healthy food is cooked well, it's more interesting to people. It's also an area of creativity for me." We Are All at Risk "There is no golden path to losing weight," Mazouz said. "There are several ways to do it, but the common denominator with all these paths is being motivated and responsible." Schwartz, who only bakes whole-wheat challah, even considers it a Jewish responsibility. "The Jewish community must change our way of eating," she said. "We are all at risk." Schwartz suggests more symposiums on health, like the Bikur Cholim: Jewish Healthcare Foundation event on breast cancer awareness last fall or cooking demonstrations on how to incorporate eating well into daily life. But it's daunting to face the carving station or dessert tiers. Even Maimonides acknowledged that it is hard to stay the course. "A man who is wise and exercises self-control, who does not yield to his appetite ... is indeed a hero!" Maimonides wrote. Tamar Sofer lives in Los Angeles and writes about nutrition and disease prevention. |
