Breast Cancer: Do Non-Starchy Vegetables Lower Risk?

Limited evidence suggests that non-starchy vegetables may lower the risk for estrogen-receptor (ER) negative breast cancer, a less common but more challenging to treat type of tumor. Limited evidence also links dairy, diets high in calcium and foods containing carotenoids to lowering the risk of some breast cancers. Carrots, apricots, spinach and kale are all foods high in carotenoids, a group of phytonutrients studied for their health benefits.

The Study: Diet, Nutrition, Physical Activity and Breast Cancer evaluated the research worldwide on how diet, weight and exercise affect breast cancer risk in the first such review since 2010. The report analyzed 119 studies, including data on 12 million women and 260,000 cases of breast cancer.

Results: The report points to links between diet and breast cancer risk. There was some evidence — although limited — that non-starchy vegetables lowers risk for estrogen-receptor (ER) negative breast cancers, a less common but more challenging to treat type of tumor.

Limited evidence also links dairy, diets high in calcium and foods containing carotenoids to lowering risk of some breast cancers. Carrots, apricots, spinach and kale are all foods high in carotenoids, a group of phytonutrients studied for their health benefits.

These links are intriguing but more research is needed, says McTiernan. “The findings indicate that women may get some benefit from including more non-starchy vegetables with high variety, including foods that contain carotenoids,” she said. “That can also help avoid the common 1 to 2 pounds women are gaining every year, which is key for lowering cancer risk.”

Steps Women Can Take: Aside from these lifestyle risk factors, other established causes of breast cancer include being older, early menstrual period and having a family history of breast cancer.

While there are many factors that women cannot control, says Alice Bender, MS, RDN, AICR’s Head of Nutrition Programs, the good news from this report is that all women can take steps to lower their breast cancer risk.

“Wherever you are with physical activity, try to nudge it up a bit, either a little longer or a little harder. Make simple food shifts to boost protection — substitute veggies like carrots, bell peppers or green salad for chips and crackers and if you drink alcohol, stick to a single drink or less,” said Bender.

There are no guarantees when it comes to cancer, but it’s empowering to know you can do something to lower your risk.


The small print: The material presented herein is informational only, and is not designed to provide specific guidance for an individual. Please check with a valued health care provider with any questions or concerns. As for me, I am a Harvard- , Yale- and UPenn-educated radiation oncologist, and I practice in the Seattle, WA (USA) area. I feel genuinely privileged to be able to share with you. If you enjoyed today’s offering, please consider clicking the follow button at the bottom of this page.

And, one more thing: NEW free apps for Android and iOS (Apple): In apps, search My Breast Cancer by Michael Hunter.


Reference: S. J. Lowry, K. Kapphahn, R. Chlebowski, C. I. Li. Alcohol Use and Breast Cancer Survival among Participants in the Women’s Health Initiative. Cancer Epidemiology Biomarkers & Prevention, 2016; 25 (8): 1268 DOI: 10.1158/1055-9965.EPI-16-0151

Breast Cancer Local Recurrences Plummeting

This March, I had the pleasure of attending the European Breast Cancer Conference in Barcelona, Spain. While I would like to blog about tapas, the museums (Picasso; Miro; Catalan), the Gothic Quarter and the beach, I will focus today on more quotidian stuff. It is nice to share with you some remarkable progress in the management of early breast cancer. Here is what I heard about:

Women with small, low-grade and well-defined breast cancers that have a tumor gene (genomic) profile that is low have only a 1.4 percent risk of the cancer returning to the site of the original cancer or the nearby lymph nodes within five years, according to new results from a large randomized trial of nearly 7000 patients.

This low risk of locoregional recurrence was seen regardless of whether the women had a mastectomy (the whole breast removed) or breast conserving surgery, in which just the tumour and some surrounding tissue are removed, followed by radiotherapy of the whole breast.

Presenting the latest results from the MINDACT trial at the 11th European Breast Cancer Conference, Professor Emiel Rutgers, a surgeon at the Netherlands Cancer Institute in Amsterdam (The Netherlands), said the findings meant that it was possible to identify women who could safely avoid not only chemotherapy after surgery, but possibly also radiotherapy.

“These findings show that, for these selected women, breast conservation is as good as mastectomy, and the risk of relapse is so low that we should look for ways of giving them less aggressive treatment. For instance, even though radiotherapy reduces the risk of locoregional recurrence two-­ to three-­fold, can we do without it in some selected patients, such as these low risk women, and also in some women aged over 50 with small tumours, less than 2cms in diameter, who have a 1.4% risk of relapse within five years as well,” said Prof Rutgers.

Details, details

Among 6693 patients enrolled in the MINDACT trial, 5470 (82%) underwent breast conserving surgery and 1223 (18%) mastectomy. Decisions on how the women were treated were made  on the basis of the tumour characteristics (size, grade, hormonal and HER2 status, and whether or not the disease had spread to any lymph nodes). In addition, their genetic make-­up was investigated using the 70-­gene-­signature test (MammaPrint®). This analyses the activity of certain genes in early breast cancer and has been shown to accurately predict the risk of the cancer spreading (metastasising) to other parts of the body within five or ten years.

Women who were at low risk of a recurrence, based on these clinical and genomic factors, did not receive chemotherapy after surgery, while those who were at high risk, did. Women with a mixture of high and low risk factors were randomised to receive chemotherapy or not. Almost all women who had breast conserving surgery also had radiotherapy, but not all of the women who had a mastectomy.

In this latest part of the study, Prof Rutgers and his colleagues looked at the rate of locoregional recurrences five years after surgery and analysed them according to the clinical and genetic characteristics. They found that women who had breast conserving surgery had an overall 2.1% risk of recurrence by five years, but if they had a low 70-­gene signature score, the risk dropped to 1.4%, while if they had a high score the risk was 3.6%. Among women who had a mastectomy, the overall risk of recurrence was 2.5%, but this dropped to 0.7% in those with a low genetic score and went up to 4.9% in those with a high score. After full statistical analysis, tumour grade and size were the only factors significantly associated with the risk of locoregional recurrences.

Prof Rutgers said: “The importance of this MINDACT analysis is that local and regional control, in which breast cancer does not come back in the preserved breast, or in the skin after mastectomy, or in the surrounding lymph nodes, is extremely good. The odds of the cancer coming back are about 2% in five years after breast conservation and 2.5% after mastectomy. This includes relapses in the surrounding lymph nodes. This very low risk is determined by the biology of the primary cancer, such as grade, size and growth pattern, and to some extent also by age, with women over 50 years also having a lower overall risk. Among these women aged over 50, those with slow-­growing ‘lazy’ breast cancers have a 0.88% risk, and those with more aggressive ones have a 3.5% risk at five years. We should remember that some 10-­15 years ago a 10% recurrence rate at 10 years was considered the norm.

“Another important message from these findings is that well-­performed breast conserving surgery in women with good indications is as good as mastectomy. Doing a mastectomy when you could very well perform breast conservation will not add a day to the life of a breast cancer survivor. This is a wonderful trial that provides wonderful opportunities for further research.”

I’m Dr. Michael Hunter, and truth be told, immediately after the session’s close, I headed to the Gothic Quarter of Barcelona for churros to dip in rich, smooth and thick dark chocolate. Thanks for joining me today, and if you wish to follow me, please sign up below. Thank you in advance!

Oh, one more thing: Please take a look at my newer blog here: Wellness!

Abstract no: 2 (Best abstract), “Very low risk of locoregional breast cancer recurrence in the EORTC 10041/BIG 03-­04 MINDACT trial: analysis of risk factors including the 70-­gene signature”, closing plenary session, Friday, 15.05-­16.35 hrs, Picasso room.

Can Breast Radiation Therapy Cause Sarcoma?

Can radiation therapy for breast cancer cause cancer; more specifically, can it cause a soft tissue cancer known as a sarcoma? The answer is clearly yes.


Angiosarcoma is a type of rare, rapidly proliferating, soft tissue sarcoma (STS) derived from anaplastic endothelial cells lining the blood vessel walls. They make up 4.1% of soft tissue sarcomas, which comprise 1% of all malignant tumors. Angiosarcomas are becoming recognized as a complication following radiation therapy in women receiving conservative therapy for breast cancer treatment, as well as lymphedema following axillary node dissection.

Rare (0.9 per 1,000 treated)

As the incidence of breast cancer in the western world rises, so is the incidence of radiation induced angiosarcoma of the breast (RIASB), with a cumulative 15-year incidence of 0.9/1,000 breast cancer patients receiving radiation as a means of conservative therapy, with an average age of onset of 68 years. Overall survival for post-irradiation breast sarcomas are poor, with a mean 5-year survival of 27–35%.

How it Presents

RIASB typically presents with non-specific clinical findings, such as skin thickening and discoloration, scarring, a series of little red dots, and nodularity. Under the microscope findings include a poorly defined bleeding mass, and there may be connecting blood vessel channels within the breast tissue that are lined by cancerous cells containing small and pale nuclei. Treatment generally consists of surgical resection with mastectomy, and chemotherapy to reduce the risk of recurrence.

But Radiation Has Been Recommended

For selected patients with breast cancer, the omission of radiation therapy has not only been associated by a much higher risk of local (chest wall after mastectomy, or breast after lumpectomy) and regional (lymph nodes) recurrence, but a lower survival as well (by up to 10 percent). So, on balance, the vast majority of patients who are recommended to receive radiation therapy, particularly for invasive disease, should commit to radiation therapy.

Explore my new blog more here: Wellness


I received an undergraduate degree from Harvard, a medical degree from Yale, and completed a residency in radiation oncology at the University of Pennsylvania. I have been blessed to be named a “top doctor” in Seattle Magazine, US News & World Report, Seattle Metropolitan Magazine, 425 Magazine, and WA magazine. Readers of the Kirkland Advertiser have voted me the top doctor (in any field) in the region. I help individuals with cancer at Evergreen Hospital, outside Seattle.

Any information provided herein is not to serve as a substitute for the good judgment of your valued health care provider.

Breast Cancer: Endocrine Therapy and Hair Loss

I recently blogged about male pattern baldness (Click here to learn more: Male Pattern Baldness). Today, we turn to hair loss among women. Many of my patients who have had chemotherapy for breast cancer experience hair loss. But what about endocrine therapy such as tamoxifen or aromatase inhibitor pills? There is relatively little data looking at this issue. Now comes a retrospective study from a single cancer hospital in the USA, published in JAMA Dermatol 2018 April 11.

Scope of the Problem: Alopecia (hair loss) resulted from aromatase inhibitors and tamoxifen in 67 percent and 33 percent of patients. The pattern of hair loss resembles androgenic (“male hormone”) alopecia, including increased shedding and shorter, finer, sparse hairs.

Researchers identified 112 a women with alopecia who had received endocrine therapy in the form of tamoxifen or the so-called aromatase inhibitors (anastrazole, letrozole, and exemestane are examples), but not chemotherapy for breast cancer. The investigators asked whether 5% minoxidil applied to the scalp could help with hair loss from endocrine therapy. Here are the authors’ findings:

1) Alopecia negatively affected quality of life; and 2) Topical minoxidil resulted in moderate or significant improvement in 80 percent of those who tried it.

My Take: This study confirms the emotional impact of hair loss on patients with breast cancer who received endocrine therapy. It also provides genuine hope (in the form of the topical drug minoxidil) in the management of this condition. Affected patients may wish to discuss this option with their doctor. I’m Dr. Michael Hunter, and I thank you for joining me today.


I received an undergraduate degree from Harvard, a medical degree from Yale, and completed a residency in radiation oncology at the University of Pennsylvania. I have been blessed to be named a “top doctor” in Seattle Magazine, US News & World Report, Seattle Metropolitan Magazine, 425 Magazine, and WA magazine. Readers of the Kirkland Advertiser have voted me the top doctor (in any field) in the region. I help individuals with cancer at Evergreen Hospital, outside Seattle.

Any information provided herein is not to serve as a substitute for the good judgment of your valued health care provider.

Rare Breast Implant-Associated Lymphoma

The US Food and Drug Administration (FDA) has provided an update on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). First, a bit of background: The FDA has been closely tracking the relationship between breast implants and ALCL since the agency first identified a possible association in 2011. Here’s what they have found:

As of 20 September 2017, the FDA has received a total of 414 medical device reposts of BIA-ALCL, including nine deaths.

  • Of the 414 reports, 272 included information about the surface of the implant. There were 242 reports of implants with textured surfaces, and 30 implants with smooth surfaces. Of the 413 that reported implant fill types, 234 were silicone gel, and 179 saline.
  • BIA-ALCL has been identified most often in patients undergoing implant revision operations for late-onset, persistent sermon. Half of the reported cases of BIA-ALCL were found within 7 to 8 years of implantation.
  • Based on the clinical literature, the FDA estimates that the lifetime risk of developing BIA-ALCL for patients with textured breast Jim plants ranges from 1 in 3817 to 1 in 30,000.

So what does this all mean if you already have implants? You should continue to have routine care and support. As BIA-ALCL has generally only been identified among patients with late onset of symptoms (pain, lumps, swelling, breast asymmetry), removal of the implants if you do not have signs or symptoms is generally not recommended. And be aware that most confirmed cases of BIA-ALCL have occurred in women with textured breast implants. As clinicians, we should consider the possibility of BIA-ALCL in a patient with late-onset, persistent seroma (a pocket of clear fluid) around the implant.

I’m Dr. Michael Hunter, and I encourage you to follow me on this blog, or on my wellness blog: Wellness!


I am a graduate of Harvard and Yale. I completed a radiation oncology training program at University of Pennsylvania, and practice in the Seattle area. Thank you for joining me today. (21 March 2018)

Breast Cancer: Why I Prescribe Exercise

This is increasing evidence to support the use of physical activity as a part of the management of breast cancer. Potential benefits in cancer risk reduction, less fatigue with treatments such as chemotherapy or radiation therapy, improvements in the risk of at least 15 types of cancer and in cardiovascular disease, and better psychological well-being, and improved quality and length of life all come to mind. A lot of potential benefits. But today, I want to show you the results of a study published in the Journal of Clinical Oncology this week.

A condition known as metabolic syndrome is associated with an increased risk of heart disease and stroke, diabetes, and breast cancer recurrence among survivors of the disease. Researchers conducted a randomized clinical trial, examining the effects of a 16-week combined aerobic and resistance exercise intervention on metabolic syndrome, obesity, and blood markers among ethnically diverse, sedentary, overweight, or obese survivors of breast cancer.

Here’s what the researchers discovered at the 3 month follow-up mark:

Combined resistance and aerobic exercise effectively attenuated metabolic syndrome, obesity, and relevant biomarkers (such as insulin, insulin-like growth factor-1 (IGF-1), leptin, and adiponectin) in an ethnically diverse sample of sedentary, overweight, or obese survivors of breast cancer, as compared to usual care. Our findings suggest a targeted exercise prescription for improving metabolic syndrome in survivors of breast cancer and support the incorporation of supervised clinical exercise programs into breast cancer treatment and survivorship care plans.

I’m Dr. Michael Hunter, and I invite you to follow this blog by signing up below. Explore more here: Wellness! Thank you, and I hope you have a joy-filled day.


I am a radiation oncologist who serves patients in the Seattle area, and hold degrees from Harvard, Yale, and the University of Pennsylvania.

Breast Cancer: Do We Have a New Target?

Currently, chemotherapy is the only standard drug therapy for those with “triple negative” breast cancer. By triple negative, we mean that the cancer does not have estrogen receptors (it is ER negative), progesterone receptors (PR negative), or HER2 receptors (HER2 negative). Of the major groups of breast cancer, triple negative has the worst survival overall.

However, when we interrogate triple negative breast cancer cells with molecular assays, we find that there are distinct subjects of the entity. One subset expresses a receptor for “male hormone”; cancer cells that have these androgen receptors (AR-positive) have been shown to have a modest response to drugs that block androgen receptors. Examples of these AR-inhibitors include a abiaterone acetate and bicalutamide, drugs that we sometimes use to help manage prostate cancer in men.

Now researchers have conducted a study looking at enzalutamide, another androgen receptor inhibitor (that is sometimes used for prostate cancer that has spread to distant sites). How well did the drug work for patients with metastatic (spread to distant sites) androgen receptor positive, triple negative breast cancer? Certainly not extraordinary results, but at the 16 week mark the drug led to clinical benefit for 25 percent of patients; for the subgroup with androgen receptor over 10 percent, the clinical benefit was 33 percent. The most common severe side effect was treatment-related fatigue.

My take: The study did achieve its primary endpoint. Subsets of triple negative breast cancer may benefit from strategies targeting the androgen receptor in the future.

I am Dr. Michael Hunter, and I invite you to follow me (below) and to learn more here: Wellness!

My background? I have degrees from Harvard, Yale, and the University of Pennsylvania. I help folks with cancer in the Seattle area, serving as a radiation oncologist. Thank you for joining me today.


* above is the human androgen receptor ligand binding domain

Reference: J Clinical Oncology 2018 Jan 26; or try the web by clicking here: Targeting the Androgen Receptor in Triple-Negative Breast Cancer