How to Reduce Your Risk of Breast Cancer with Tiffany Onger, MD

Podcast Transcript

John Horton:

Hello, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

Breast cancer is something that many women worry about, and it's easy to understand why. It's the most common cancer worldwide and a leading cause of death. But here's the statistic that really brings it home. One out of eight women will be diagnosed with breast cancer at some point during their life. That's 1 in 8 eight wives, mothers, daughters and sisters.

Today, we're going to talk with oncologist Tiffany Onger about breast health and things you can do to reduce your risk of developing breast cancer. Dr. Onger is one of the many experts at Cleveland Clinic who join our weekly podcast to help us learn more about our health. So, with that, let's see what we can do to lower those breast cancer numbers. Welcome to the podcast, Dr. Onger. Thanks for taking some time to come in and chat.

Dr. Tiffany Onger:

Thank you so much for inviting me to participate.

John Horton:

We usually try to stay pretty measured in how we talk about topics on this podcast, but I've got to be honest with you, breast cancer just feels scarier than so many other issues that we cover.

Dr. Tiffany Onger:

It can. I think part of that is that a lot of people have been impacted by breast cancer, so I think it gets a lot of attention.

John Horton:

Well, let's talk about just how common it is. And as I understand it, there are many things that go into determining someone's risk for getting breast cancer. Some of these factors, such as genetics, can't be controlled, but some factors can, right?

Dr. Tiffany Onger:

Absolutely. With breast cancer being one of the most common cancers, 1 in 8 women will experience breast cancer in their lives, so it's a significant portion of the population. And in terms of solid cancers, it's the most common one that affects women. It's important to know what the risk factors are, so we can try to minimize our risks as much as possible. As you mentioned, there are some risks that cannot be controlled for or reduced. We call those non-modifiable breast factors, which is just a fancy term to mean you're dealt the hand that you're dealt. That can include things like your genetics, your family history, even just, as we age, our risk for breast cancer goes up, or having dense breasts. But there certainly are some - what we call modifiable risk factors or things that we can each do to reduce our risk - some of those modifiable risk factors include being at a higher weight, physical inactivity and alcohol use.

John Horton:

Yeah, and let's dive into some of those kinds of controllable factors here. And you mentioned weight, which I know is always a sensitive topic. So why is that so important?

Dr. Tiffany Onger:

Most certainly. So, weight's a tough one. I think that it can be a sensitive topic to talk about because many people struggle with their weight. So, I'm going to talk about weight and physical activity together because we know that both of those together can affect your risk for breast cancer.

So, we know that, in particular for postmenopausal women, that being at a higher weight category - we call this either overweight or having obesity - can increase your risk for breast cancer. Part of it has to do with the fact that you're carrying more fat within the body, and that can affect the hormones that are circulating throughout your body. But we also know that physical inactivity can contribute to not only a higher weight but can also independently increase your risk for breast cancer. So, when it comes to physical activity, sometimes people ask me, like, "OK, how much do I really need to be doing? Do I need to become a gym rat?"

No, you do not have to become a gym rat. The recommendations are really, I think, pretty moderate. I recommend 30 minutes a day of physical activity, five days a week, so you can take off at the weekends, if you would like to, and preferably at a bit of a brisk pace. So, if you're walking with friends, you should be a little breathless as you're having the conversation. So not so slow that you could sing, but not so fast that you're not able to have a conversation at all.

John Horton:

Well, that's good. You don't have to be a marathon runner here. You just need to get out and move a little bit, and that'll help you. What does the physical activity do that helps your body ward off breast cancer?

Dr. Tiffany Onger:

A lot of things. One, it does decrease inflammation. We know that that's important for many different types of cancers and certainly, for breast cancer, that can contribute, but it also can reduce the size of the fat cells and, therefore, reduce the impact of the hormones on the body. The most common type of breast cancer is hormone-positive breast cancer. So, as we're thinking about some of these things that we can do to reduce our weight, we want to think about the things that can affect the hormones. It does contribute to other risk factors, such as a history of hormone replacement therapy, which you can view as a non-modifiable risk factor. If you had that five years ago, there's nothing you can do about it today, but moving your body is something that you can do today. So, I encourage people to do that.

John Horton:

Yeah. When you mention weight, what do you guys use as kind of the bar there? Like you said, it is a sensitive topic, but I know there's ways to kind of measure it, where you go, "Here's where you might have a little bit of concern and here's where you might be OK."

Dr. Tiffany Onger:

Yeah, so John, you might not have known it, this is a little bit of a loaded question.

John Horton:

It is. I know. It's always sensitive when you talk about weight.

Dr. Tiffany Onger:

It is, and as women, we don't always like to talk about our weight, but it is important. So, we usually look at the BMI [body mass index]. The BMI has quite a little bit of flack in the media recently, knowing that it's not always inclusive of a person's full health status. And so, I really view it as just one measurement, just one measurement of an assessment of potential risk and health. And so, we're looking at the number 25. Twenty-five and above, you're really moving into the heavier weight category. And so, ideally, you'll keep your BMI lower than that. That being said, I'm not perfect, and I have a little extra weight myself. But that doesn't stop me from doing physical activity. I know that, even if my weight is something that's challenging for me to change, and I am saying this, because I'm talking to real people and I'm a real person myself, I know that physical activity can offset some of that. So even if the weight moves slowly, the fact that I'm exercising on a regular basis really helps reduce my risk.

John Horton:

Well, and the next thing we're going to talk about fits into the weight discussion, too, and that's mealtime choices and the foods that you choose to eat. How does that fit into somebody's breast cancer risk?

Dr. Tiffany Onger:

I'm so glad that you asked about this. So, there's a couple of things when it comes to mealtime choices. One, I want to mention that the best diet for overall health and for cancer health is a diet that's balanced with plenty of fruits and vegetables, low in saturated fat and sugar. And I'll come back to the sugar in a little bit. But it doesn't have to be like a strict Mediterranean diet. You can have some meat there, some red meat, some pork, if you enjoy that. Sometimes, people think that they need to be on a very strict diet, and they need to be just juicing all the time and kale salads for breakfast, lunch and dinner.

And the studies do not show that it has to be that strict. Having a balanced diet with plenty of fresh fruits and vegetables and kind of limiting those added fats and sugars is really the best diet for both before, during treatment, and in survivorship.

I also mentioned sugar. And so, sugar has been a hot topic. My patients will ask me, "Doc, do I need to avoid sugar? My sister is slapping cookies out of my hand left and right, and I just want one bite of cookie."

John Horton:

We all have our sweet tooth. I know.

Dr. Tiffany Onger:

We most certainly do. And so, I say, "Enjoy the cookie." Sugar in moderation is just fine. There have been questions about, "Well, doesn't sugar feed cancer? So should I be keto?" High-quality studies have not shown that you need to be keto to improve your overall survival with breast cancer. The ketogenic diet — it had its heyday — and for some other conditions, it can be effective. Breast cancer is not one of those conditions. So, I say be balanced and enjoy your cookie if you'd like to.

And to the question about whether the sugar feeds the cancer, cancer is made up of cells, and all cells need sugar as a form of energy, including the heart and the brain. And so, I want to make sure that you're giving your body the energy that it needs while you're going through cancer treatment, and that can include sugar in moderation, best from natural sources. But if you want to have a warm cookie every now and again, be my guest.

John Horton:

I have to say, if people are going to take anything away from this podcast, it's going to be, have the cookie. It's the advice you usually don't get, but have it in moderation, but enjoy it every once in a while.

Dr. Tiffany Onger:

That's right.

John Horton:

And since we're talking about moderation, too, I think that would also apply, I'm guessing, to alcoholic beverages. We all kind of enjoy maybe a little glass here and there. Is that OK in this whole thing?

Dr. Tiffany Onger:

Very good question, John. So, I do say that, during treatment, and that is specifically when I'm really referring to chemotherapy, I would recommend that we really limit the alcohol during that time. And when I mean limit, I mean abstaining during that short amount of time. I just don't want there to be interactions with the alcohol and the side effects of the chemotherapy kind of compounding the picture. We also do know — and this is bad news for my brunch bunch — that there has not been a level of alcohol that has been shown not to increase the risk for cancers.

And so, even one drink a day, that can mildly increase the risk for cancers. That being said, when we talk about overall health, alcohol is a big part of a lot of people's culture. With the holidays coming up, there's going to be toast. If there's going to be brunches, there's going to be different activities where that's a part of the culture. And so, I really encourage, again, moderation. I want to make sure I bring factual information, and so, unfortunately, that we do know that all drinks, alcoholic drinks, can increase the risk, but I still encourage moderation, even when it comes to alcohol.

John Horton:

So be smart and be responsible with it, which is good advice always, when it comes to alcohol.

Dr. Tiffany Onger:

Yes.

John Horton:

I've seen a lot of questions, too, asking if eating soy-based foods increases breast cancer risk — is there any truth to that?

Dr. Tiffany Onger:

So yes and no. It depends on the organism that we're looking at. So, when I'm treating breast cancer patients, they're people, and thankfully, the studies in humans have not shown that soy-based products necessarily increase their risk for cancer. The concern about soy is whether they can act like phytoestrogens or plant-based estrogens in the body when they are consumed. So, studies have looked both at animal models and at people, and their studies are a little bit conflicting. And so, at this time, it's reasonable to suggest moderation — this has been kind of our theme today, moderation — and I really encourage folks to get their soy through the diet, as opposed to taking supplements. When it comes to overall nutrition, it's definitely best to have a variety of fruits and vegetables, and you can use tofu or soy milk in dietary quantities. But I would probably avoid the supplements, just because we don't know as well what effect that might have.

John Horton:

Well, Dr. Onger, you set me up perfectly for every question I'm going to ask because we are going to move right from that into taking vitamins and supplements. Is that something that people can do to maybe to limit their risk?

Dr. Tiffany Onger:

So, studies have shown that up to 80, sometimes 90 percent, of patients, and especially breast cancer patients will include supplements in some part of their care. We know that those supplements can be natural. That doesn't mean that they won't interact with the medicines that we're using to treat cancer. It's important to understand that relationship that supplements can have on the treatments because sometimes, they can increase the side effects; sometimes, they can decrease the efficacy or how effective the treatment is; sometimes, it can have no effect at all; and sometimes, the supplements themselves can have side effects.

And so, I really encourage people to communicate with their doctors the supplements that they're taking or that they're interested in taking during the cancer treatment journey, just so that we can all know what's going into your body and how those things might interact together. The supplements can come in the form of many different types. They can be pills. Sometimes, people go to other clinics, sometimes, natural clinics, and are getting IVs. They can come through a number of different ways into the body, but I really want people to know how to talk to their doctor about what they're taking. It's important just to have that conversation, so ultimately, you and your doctor can make the best decision for your cancer care.

John Horton:

Is there any evidence that taking vitamins and supplements can cause cancer, looking at it ahead of a diagnosis?

Dr. Tiffany Onger:

Very good question. So, we know that there are some substances that can be what we call carcinogenic or increase the risk for cancer. Generally, those are things that we were testing initially in animal models. Studies will kind of let the media know, "Hey, this is kind of what we're seeing." Generally, those things have been kind of curtailed in the general population use, but sometimes, when you're buying things off the internet, for example — which, let's be honest, a lot of us do buy things off of the internet — you don't always know what's in those supplements. Sometimes, they can be contaminated with heavy metals, and we know that heavy metals can increase the risk for cancers. And so, that's one of the reasons why the supplement companies, especially the reputable ones, the ones that you can find in the stores, they'll specifically say, "This supplement has not been proven to prevent, cure or treat any medical condition."

And sometimes, I've read these labels, and there can be literally conflicting with the front of the label, where maybe it says, "Healthy for this" or "Healthy that," but on the back, it clearly says, "This has not been proven to treat any conditions." So, I encourage people to read the labels, understand what they're bringing into their bodies, and be thoughtful and judicious about where you buy your supplements from. If there's a pharmacist there that you can talk to, that's usually a good sign.

John Horton:

Well, and I know you had mentioned earlier, too, the importance of diet, and I know a lot of those vitamins and nutrients that you're trying to get through pills, you can also get just through eating a little better and mixing in some leafy greens here and there.

Dr. Tiffany Onger:

Most certainly. As a matter of fact, one of the studies that we did here at the Cleveland Clinic looked to try to understand what number of supplements are most helpful for patients as they're going through cancer care. And we found that the fewer supplements that you're using during cancer care, the better. And this study didn't look at every single supplement that someone was taking. As you can imagine, there are hundreds, if not thousands, of things that people can take. But we did find that, and likely due to the potential interactions with the cancer treatment, that those patients who had fewer supplements tended to do better. So, I would say, keep it really to the bare minimum, but certainly have a conversation with your doctor.

John Horton:

Moderation again. It seems it is our word of the day. Why don't we talk about prevention? I know there's a lot of talk about whether personal care items, such as deodorant or hair dye, can cause breast cancer. What do the studies actually say?

Dr. Tiffany Onger:

So the studies are, again, as we're thinking about animal models theory and then, moving into people, good thing is, for people, it has been shown that things like hair dye minimally, if at all, increase the risk for breast cancer, and deodorants, in particular, have not been shown to increase the risk for cancers. A lot of times, people are concerned about the aluminum. They say, "Boy, when I'm going to get my mammogram, they always say, ‘Don't wear deodorant. Don't wear deodorant.’" It's not because of a concern for cancer. It's really just because the aluminum can look like something called microcalcifications, which can be seen when there's cancer.

And so, they just want to prevent the interaction. The studies have also looked to try to understand, "OK, is there an amount of aluminum that's absorbed into the body?" And it's a tiny, minuscule amount that is absorbed into the body, and there's no evidence that it behaves as an estrogen to help the cancers grow. Sometimes, people wonder, "Well, we're applying deodorant to our underarms, and that's where the lymph nodes are." That's correct. That is where the lymph nodes are, but there's no evidence that the deodorant, aluminum or otherwise, is contributing to increased cancer risk. So even as you're going out and about, as you're exercising, as I hope you do, to reduce your cancer risk, please feel comfortable using whatever deodorant you like to use to feel most like yourself.

John Horton:

Well, that is good news, especially if we're going to be exercising a little bit more. We had also mentioned hair dye, so what are the specifics of that? It sounds like it's a little bit mixed.

Dr. Tiffany Onger:

It is a little bit mixed. There have been investigations into hair dyes. There have been investigations into relaxers in particular for the African American community. It hasn't been shown to be as impactful into the risk for breast cancer as we expected, and I think some of the concern is we're applying hair dyes to the scalp, and these are chemicals. And so, there have not been really strong studies to show that, "Hey, we should really be eliminating hair dyes throughout the cancer journey." I do have patients who ask me, "Can I get my hair dyed during my cancer treatment?" Especially those women who aren't going to be getting chemotherapy and losing their hair, they want to make sure that they still look the way that they're used to looking. And so, I just let them know that your hair might be a little bit more fragile during treatment and that can affect how the processing times are used during that time. But there's not necessarily a strong risk where I would say you categorically have to avoid using hair dyes.

John Horton:

And we should probably emphasize here, too, that there is nothing wrong with gray hair, right?

Dr. Tiffany Onger:

That's absolutely right. There's nothing wrong with gray hair. Embrace it. A lot of people have in the past years, and I think it's a fabulous trend.

John Horton:

Well, me, too. So, I'm a big fan.

Dr. Onger, we've covered a lot of ground here, and you've given us just fabulous information. Before we wrap things up, do you have anything else to add on what women can do to minimize their chance of getting breast cancer?

Dr. Tiffany Onger:

Yes, a couple things are, one, to maintain a healthy lifestyle with fruits and vegetables and with physical exercise. Two is to know that there are some risks that you can't change, and that's OK. Just because we're out living in the world, we're getting some natural sunlight, which is good for the body in all types of ways, but anything that we do can affect — increase or decrease — our risk for cancer.

But I also want to encourage people to know their family history. I really want people to know their family history because that can not only impact your risk for cancer, but it can also give you information that might be important in knowing when to start screening. We are recommending screening with mammograms for breast cancer once a year, starting at age 40 — starting at age 40, but that's really the latest that you would want to consider getting screened. Based upon your family history, your personal history, you might meet qualifications for screening earlier than that. So, it's really important to know your family history and your personal history as well.

John Horton:

Dr. Onger, thank you so much for coming in. I feel like we're all in a better spot now because of the information that you've given us.

Dr. Tiffany Onger:

Thank you so much for having me on the show.

John Horton:

Can you 100 percent protect yourself against breast cancer? The answer is no. But you can lower your risk of getting the disease by eating nutritious meals, regularly exercising and maintaining a healthy weight. Consider it as a way to turn the odds in your favor. Till next time, be well.

Speaker 3:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit ClevelandClinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.