Natural Health Journals

by Rosalie Bertell

Mammography performed yearly on asymptomatic women, or undertaken for screening purposes on a large number of women, raises medical and ethical questions.

The incidence of breast cancer has risen steadily since 1970. The American Cancer Society estimated in 1980 that based on rates reported over the previous decade, 1 in 11 North American women would have breast cancer at some point in life. The 1987 estimate was 1 in 10; and the 1991 estimate was 1 in 9. With the post-World War II baby boomers approaching the 50-to-64 age range, the group found to be at highest risk for breast cancer, a significant increase in the number of cases is expected during the 1990s.

According to current estimates, 70 to 75 percent of all women will survive five years after diagnosis. Ten-year survival rates are predicted for 60 to 63 percent of women – reflecting only a 2 to 3 percent improvement over the 1950 rates.(1)

Why the continuing increase? What factors play a part? What do we know about today’s diagnostic methods? What steps can women take to protect themselves?

The Biological Picture

The breast is designed for feeding a baby. Its most prominent structure, the nipple, is supplied with ducts that radiate to lobules deep in the breast tissue, where the milk is collected. Between these lobules are connective tissue, lymphatics, nerve cells, and other cells that give the breast its characteristic shape and texture. About 90 percent of breast cancers occur in the lobule or duct cells, and about 10 percent occur in other tissues of the breast.(2)

With a woman’s first pregnancy, the breast matures. The earlier this maturation occurs, the less likely the woman is to develop breast cancer. Women who birth their first babies in their early 20s have significantly lower rates of breast cancer than those who never give birth or who have their first child after age 35.(3)

Breastfeeding – nature’s system for transferring food and protective antibodies from mother to baby – is also presumed to protect women from breast cancer. While “failure of lactation” is known to be a high risk factor, the precise benefits of breastfeeding have been poorly researched until now. Current thinking is that the benefits are “measurable” among women who breastfeed for at least 25 months.(4) Women who breastfeed for shorter periods of time are likely to experience benefits too subtle to be picked up by clumsy measuring skills.

Another protective agent is the immune system. Whereas scientists previously thought of cancer as “one cell gone wild,” increasing evidence suggests that cells undergo malignant transformations continuously and that the body’s immune system perpetually searches out and destroys these cancerous cells. With advancing age, however, this protective process becomes less efficient. Other factors that reduce immune competence include stress, grief, and severe infections.

Whereas the transformation of a normal cell to a malignant cell may occur randomly, identifiable factors influence the development of that cancerous cell into a clinically detectable life-threatening disease. Biological influences include the following: * Age-related factors. Only 2 percent of breast cancers occur before age 34, while 50 percent develop between ages 55 and 74.(5) The incidence of breast cancer increases with age due not only to decreased immune competence, but also to hormonal changes that occur. According to one study, the incidence of breast tumors that were estrogen receptive negative rose 22 to 27 percent, while over the same period of time, the incidence of tumors very rich in estrogen receptors rose 131 percent.(6) * Delayed or reduced childbearing. Research shows a decreased incidence of breast cancer among women who first become pregnant early in their reproductive life and among women who have had multiple pregnancies.(7) * Early onset of menstruation (before age 12) and late menopause (after age 50).(8) * Endometrial, ovarian, or colon cancer.(9) * A family or personal history of breast cancer. A woman whose mother or sister has had premenopausal breast cancer is at increased risk of developing the disease. In addition, a woman who has had cancer in one breast is at increased risk of developing cancer in the other breast.(10) * Genetic and cultural factors. Slightly increased rates of breast cancer are found among white women and, with the exception of Japan, among women living in highly developed countries. The low rate in Japan – far lower than in North America – has sparked considerate interest. Some researches point to the link between breast cancer and hypothyroidism (underactivity of the thyroid gland), and speculate that iodine deficiency, which is known to cause poor thyroid functioning, may also contribute to the development of breast cancer.

If this proves true, then the underlying agent is not biological, but dietary. And indeed, while the Japanese diet includes iodine-rich foods such as seaweed, the North American diet does not; much of the soil in the United States and Canada is in fact lacking in natural iodine.(11) Moreover, the annual consumption of fish in North America is about 40 pounds per person, whereas consumption rates in Japan stand at 190 pounds per person.(12) The impact of these large dietary differences remains unknown.

External Influences

Several external factors are associated with the development of breast cancer. One is exposure to estrogenic compounds, chemicals that imitate the female hormone estrogen. Some studies suggest increased rates of breast cancer among women who have taken birth control pills for more than six years or in higher than usual doses. Estrogen hormones given to postmenopausal women may also be implicated.(13) Excess fatty tissue, which produces estrogen naturally in the body, is likewise thought to be a contributing factor.

Pregnant women who took the estrogenic drug diethylstilbestrol (DES), popular from in the late 1940s until the early 1970s, showed a definite hike in breast cancer 20 years later. Other synthetically produced estrogenic compounds in wide use today, say environmental scientists, may also promote illness. Synthetic preparations containing DDT, kapone, lindane, certain PCB congeners, dioxins, furans, cadmium, lead, mercury, styrene dimers and trimers, as well as nonbiodegradable detergents currently pollute the food chain and water supplies, and are known to disrupt the endocrine system. Their role in promoting breast cancer remains unknown.(14)

A second concern is exposure to electromagnetic fields (EMFS). In 1987, University of Colorado Medical School researcher Nancy Wertheimer reported an association between EMF exposure and breast cancer.(15) Some degree of exposure may occur while operating a video display terminal (VDT) or sitting behind and to the left of one in operation, while lying under an electric blanket, or while using certain other electrical appliances.

EMF emissions have also been documented around high-tension electrical transmission wires. In 1989, Genevieve Matanoski of Johns Hopkins University discovered six cases of male breast cancer among 50,000 New York telephone workers.(16) Soon afterward, the Fred Hutchinson Cancer Research Center in Seattle, Washington, reported six times the expected rate of male breast cancer among electricians, power station operators, and telephone linemen.(17) In December 1990, Norwegian researchers found a doubling of male breast cancer among workers exposed to EMFS, with four times the expected incidence among railroad and tram drivers.(18)

A third major concern is exposure to ionizing radiation – radiant energy emitted in the use of X rays, fluoroscopy, mammography, and additional forms of radiography, as well as from other radioactive sources. In 1961, Nova Scotia physician Ian MacKenzie noted an increase in breast cancer among women exposed to ionizing radiation in the course o treatment for tuberculosis (TB). Of 271 female TB victims receiving numerous X rays between 1940 and 1949, 13 (4.8 percent) developed breast cancer; of 510 females victims receiving no such treatment, only 1 (0.2 percent) developed breast cancer. These highly significant findings led MacKenzie and his colleagues to conclude that X-ray damage accumulates in the body over time.(19)

The MacKenzie study stimulated research into breast cancer among atomic bomb survivors in Hiroshima and Nagasaki. The first report, compiled by C. K. Wanebo, appeared in 1968.(20) This data, along with MacKenzie’s, formed the first epidemiological picture of radiation-related breast cancer. For different populations (North American and Japanese) receiving radiation in a different manner (a series of fluoroscopic X-ray examinations versus one atomic bomb) over a different period of time (several months or years versus one brief moment), the rise in breast cancer showed certain similarities. In both instances, the percent increased could not be recognized and measured until approximately 10 years had elapsed from the time of exposure to ionizing radiation. Also in both instances, the peak percent increase occurred about 40 years after exposure.

It is important to note that the women studied by both MacKenzie and Wanebo averaged between 24 and 28 years of age, indicating peak percent increases at 64 to 68 years of age. The progression of breast cancer among populations exposed at earlier or later stages of life remained unknown.

By the mid-1970s, radiation-related breast cancer had become an acknowledged reality and researchers had begun trying to quantify the increase. In 1977, J. D. Boice, Jr., and R. R. Monson reviewed the medical records of a large number of women in Massachusetts who had received fluoroscopic X-ray examinations for TB. These researchers, unlike earlier ones, were able to determine the cancer induction rate per unit dose of radiation (per 1 rad or 10 mSv).(21) Women who were exposed to radiation under the age of 30 had a peak percent yearly increase in breast cancer of about 2.30 percent per unit dose. That is, women given doses of 5 rads had an increase of 11.50 percent in the peak year. For women over 30, the peak percent increase was about 0.49 per unit dose. Women in this age group receiving 5 rad doses showed an increased of 2.45 percent in the peak year. The women in this study averaged 38 years of age at the time of exposure.(22)

In the late 1970s, further studies were undertaken at Hiroshima and Nagasaki. The most startling discovery was that girls exposed to atomic radiation between the ages of 10 and 19 showed a peak percent yearly increase in breast cancer of 6.2 percent per unit dose of radiation – a far higher induction rate than had ever before been reported. Girls exposed prior to 10 years of age reflected an increase of 39 percent per unit dose. This population of 0 to 10 year olds turned 46 to 56 years old in 1991, and thus the data is still coming in [see table below].

Although the estimated percent increases in breast cancer may change as new studies come to light, a remarkably consistent picture has emerged. Exposure to ionizing radiation increases the risk of breast cancer. The increase is greatest among girls exposed before the age of 20, and drops off considerably for those exposed in later stages of life. X-ray and nuclear exposures are cumulative in effect, and spreading them over time tends not to reduce the risk of developing breast cancer in later years.

Diagnosis and Prognosis

Currently, about 90 percent of breast cancers are detected by women themselves. A tumor can be felt manually when it reaches about 1 centimeter (1/2 inch) in diameter. With training in self-examination,a woman can detect even smaller tumors.(23) Mammography can detect tumors of about 1/2 centimeter (1/4 inch) in diameter. It takes two “doublings” of a 1/2 centimeter tumor to produce a tumor measuring 1 centimeter; the first doubling increases the cell count from about 1 billion to about 2 billion, and the second doubling increases the cell count from about 2 billion to about 4 billion.

At first glance, it may seem marvelous to be able to detect a tumor only 1/2 centimeter in diameter through the use of mammography. There are difficulties, however. One is that about 80 percent of breast tumors grow slowly – taking a year or two to enlarge from 1/2 to 1 centimeter in diameter – and early detection of slow-growing tumors has not proven advantageous for survival. Very small tumors may in fact be in a dormant state and best left alone. The discovery of such tumors, which may never pose a medical problem, is often called “overdiagnosis.” A Swedish study estimates that small tumors are subjected to overdiagnosis at a rate of 30 to 40 percent.(24)

In addition, the 20 percent of breast tumors that are fast growing can double in size within 21 days, and thus become manually detectable only three weeks to six weeks after they can be picked up by a mammogram. About 3 percent of these tumors produce inflammatory carcinoma, a rarely curable form of cancer. Very clearly detection of an inflammatory carcinoma is unlikely to improve the outcome. Overall, mammograms taken every two years have a 10 percent probability of picking up a fast-growing tumor of any sort within six weeks prior to the manually detectable 1 centimeter stage of growth.

Early detection of most types of tumors can change the prognosis. The prognosis is best when a cancer is small, encapsulated, and confined to its primary site. With metastases to the lymph nodes and bloodstream, the outlook becomes less favorable.

Early detection through manual examination seems to provide the best all-around results. This method, however, has not been well researched because the timing and quality of self-exams do not lend themselves to scientific scrutiny. “Unproven” as it may be, breast self-examination [see sidebar] on a monthly basis remains the safest, least expensive, and least invasive preventive action available to women. It enables women to become familiar with their breast tissue, natural lumps and all, and to report early on any noticeable changes.

Another diagnostic tool is thermography, which measures small changes in breast temperature. This method has proven unreliable, and is not in general use today. Trans-illumination, which involves shining low-intensity red or near-infrared light through the breast, is much more promising – especially for young women with dense breasts, older women with lumpy breasts, and pregnant women – and has no known side effects. Of all diagnostic methods, mammography has sparked the most controversy.

The Trouble with Mammography

The use of mammography, in conjunction with other diagnostic methods, is not controversial. It is universally recommended. However, mammography performed yearly on asymptomatic women, or undertaken for screening purposes on large numbers of women, raises medical and ethical questions.(25)

One problem is accuracy. Mammography provides 5 to 10 false reports of tumors to every correct report.(26) Many false-positive results lead to reexamination, exposing women to additional X rays and further stress. Some lead to unnecessary surgery.

Mammography also fails to detect advanced tumors measuring more than 2 centimeters in diameter. While the North American rate of false-negative results is unknown, one major Canadian study reports a failure rate of 15 percent.(27) In some instances, mammograms have missed lumps that were easily recognized manually. Even repeat mammograms have been known to provide a clean bill of health to women with advanced cancers spreading through both breasts. In essence, failure to detect a cancer can encourage a false sense of well-being and lead ultimately to extensive surgery and chemotherapy.

Responding to a growing number of false-negative reports, Senator Brock Adams of Washington proposed a Breast Cancer Screening Safety Act in 1991 for the regulation of mammography units and the establishment of personnel training centers. Four years prior to these hearings, in 1987, the American College of Radiology had set up a voluntary mammography accreditation program; however, only 40 percent of the 11,000 mammography centers across the nation had been granted certification.

A second problem with mammography is efficiency. Proponents of mammograms hope to reduce breast cancer deaths through early detection; at the same time, they admit that in the process of reducing deaths, mammography programs may increase breast cancer rates through cumulative X-ray exposures.

Considerable debate has revolved around exactly how many women will experience a prolonged life span compared with how many will develop iatrogenically induced breast cancer. Advocates say each breast cancer cure attributed to mammography is worth it. Critics argue that the resulting number of breast cancers and unnecessary surgeries is too great a trade-off. Critics also note that physicians intent on “preventing death” often fail to inform women of the known and suspected risks of mammography screening.

The public relations effort behind mammography conveys a false sense of benefit, security, and control, and it does so by glibly overlooking the core question: How much X-ray exposure is too much? Part of the answer can be found in the epidemiological studies, which reveal that breast tissue becomes cancerous over a wide range of doses. Each of the women in the Nova Scotia study received about 7.50 rads (75.0 mSv) per fluoroscopic X-ray examination, and had several such exams over a long period of time. Each of the Nagasaki and Hiroshima women received a total dose of 35.00 rads (350.00 mSv). The Massachusetts women received about 1.50 rads (15.0 mSv) each per fluoroscopic examination and had several such exams over a 10-year period, resulting in an average overall dose of about 150.00 rads (1500.0 mSv).

While the most up-to-date mammographic equipment delivers only 0.14 rads (1.4 mSv) to breast tissue, the total dose measurement of such exposures may not be the critical factor. Indeed, once a breast tumor overrides the body’s defense system and becomes established, any further dose of radiation is not cancer inductive. What counts, according to an updated report on the Hiroshima and Nagasaki data, is a percentage increase per exposure over a person’s base risk (or relative risk), and not an absolute increase per unit of exposure. Also, say the authors, the radiation-related risk of breast cancer death appears to lessen among women exposed after menopause, specifically after 55 years of age.(28) The reason may be that these women die of other causes before breast cancer has had a chance to develop.

Variables affecting a woman’s base risk include the following: known risk factors, such as those mentioned above; prior exposures to radiation, in the form of chest X rays, unshielded dental X rays, and X rays of the thoracic spine; and unknown risk factors, such as genetic composition. For example, about 1.4 percent of North Americans carry a gene for ataxia-telangiectasia (a disease which, if inherited from both parents, impairs coordination and the ability to repair DNA). Research shows that people with one such gene will, upon exposure to radiation, exhibit a higher than usual susceptibility to breast cancer. At exposures ranging from 0.1 to 0.9 rads (1 to 9 mSv), men with this gene are 3.8 times more likely to develop breast cancer than men without the gene. For women, the increase is 3.5 times. Dr. Michael Swift, author of the study, calls for protection of women’s breasts when X rays of any sort are taken, and for substituting other medical tests for X-rays exams whenever possible.(29)

As yet unknown risk factors may also exist, and this possibility must be taken into account whenever mammography is under consideration. More importantly, women with known risk factors need to be told that a mammogram will increase their risk of developing breast cancer. Unfortunately, because these women are considered “high risk,” routine mammography is often recommended, and the consequences of repeated exposures are seldom explained.

A 1991 report on a Canadian study investigating the risks and benefits of mammography analyzed the study group of 50,000 women. Of those between the ages of 40 and 49 who received mammograms, 44 developed breast cancer; of those in a comparable control group not receiving mammograms, 29 developed the disease. The entire report has not yet been released; however, the findings have been verified and the outcomes are statistically significant.(30)

How much is too much? Quite simply, no level of mammography exposure can be presumed safe, particularly for females under 55 years of age.

One last question overlooked by many of mammography’s ardent champions: What might lie at the root of today’s breast cancer epidemic? Percent increases in breast cancer throughout North America began appearing in the mid-1980s among women approaching 60-plus years of age. These women were just over 20 years old at the time the first nuclear bomb was set off in Alamagordo, New Mexico, in July 1945. Then, after the second and third nuclear bombs were dropped on Hiroshima and Nagasaki, this cohort of women was exposed to repeated fallout from nuclear weapons testing, the debris of which was deposited from west to east throughout the entire North Temperate Zone.

Between 1946 and 1958, about 109 nuclear weapons were detonated over the Pacific Islands; and between 1951 and 1963, about 214 were detonated over Nevada. Radioactive debris from these more than 300 above-ground tests drifted eastward over the continent – so much so that measurable amounts of radioactive particles were found in milk, vegetables, meat, and fish throughout the United States and Canada.(31) Women who were in their 20s at the time comprise the largest group of today’s breast cancer victims. And women who were born in 1951, when the Nevada Test Site first opened, are just now turning 40 years old and thus approaching the time interval after which peak percent increases tend to occur.

If the root of today’s breast cancer epidemic lies in above-ground nuclear testing, mammography – a source of further exposure to radiation – may only intensify the problem. Certainly, since babies born in the 1940s and 1950s have become a generation of men and women at risk for may diseases such as AIDS, toxic shock syndrome, and chronic fatigue, the password ought to be caution. And caution in terms of breast cancer prevention means special protection against mammography and sound information and self-care.

Self-Care Measures

* If you have fibrous, or lumpy, breast tissue that is painful at certain times in the menstrual cycle, eliminate coffee, tea, chocolate, cola, and red wine. Also give up cigarette smoking. Most often, palpable lumps in the breast are due to normal structural changes and respond rapidly to these measure. About 26 percent of all women with fibrous breast tissue have a slight chance of developing breast cancer, and only 4 percent have a substantially higher risk, identifiable upon biopsy.[32] * See a physician immediately if you notice breast pain (although most breast cancer are painless, vague discomfort has been reported(, a retracted nipple, bleeding from the nipple, distortion of the area around the nipple or of the breast contour, dimpling of the skin over an apparent lesion, edema, of the breast, a change in breast color, or enlarged or painful lymph nodes under the arm. * Do not join a breast screening program or a request a mammogram without giving serious thought to your overall risk of breast cancer. Discuss your history, including all known X-ray exposures, with your physician, and decide on a approach that meets your needs. * If you decide to have a mammogram, go to a center that specializes in mammography, that performs 20 to 30 exams a day, and that is accredited by the American College of Radiology. Request a technician and a radiologist who specialize in mammograms (preferably to the exclusion of other X rays ), as these exams are difficult to do well, require practice, and are hard to interpret. Make sure the laboratory has new, high-quality equipment and quality-control measures in effect. Anticipate maximum compression of the breast – it should hurt! * If you are over age 55, decide whether or not the recommended mammogram every two years is right for you. A baseline mammogram for reference may be a good idea; the frequency of any subsequent exams should depend on your personal risk factors. * Perform high-quality monthly breast self-exams. Mothers, teach your daughters. Physicians, teach your patients. * I you are at high risk for breast cancer, reduce your intake of animal fats and dairy products. The National Cancer Institute is now conducting a large-scale study on diet and breast cancer in the United States, with a special focus on the role of fatty foods. Results are expected sometime between 1995 and 1997. * If you use a VDT, have it checked for EMF emissions. If the electrical field is high, invest in a shield. In any case, sit 26 inches form the screen and avoid sitting behind and to the left of another person’s terminal. * Eat plenty of fresh fruit and vegetables, whole grains, fish, and poultry. Avoid sugar, excess fat, full-fat dairy products, and red meat. * Don’t put off childbearing in favor of a career that can wait; and when your babies are born, breastfeed them. * Enjoy life, reduce stress, and think positive!

Going for a Mammogram

Preparation: Dress so you can easily strip to the waist. Do not apply body powder, creams, or underarm deodorant. Do not wear a necklase. While undressing for the exam, remove all clothing above the waist, remove any jewelry, and put on a front-opening gown. If you have had a breast biopsy, wait two weeks before having a mammogram, as the blood that collects around the needle site may otherwise interfere with the X ray.

The test: You will be asked to sit in from of the X-ray machine and rest one breast on the table above the X-ray cassette. A plastic compressor will be placed over your breast and pressed down. (This will hurt.) You will then be told to hold your breath to avoid moving while the picture is being taken. Most often, two pictures – a frontal and a lateral image – are taken of each breast.

After the test: You may be asked to wait a short while until the films are developed and the technician is assured that the pictures are of good quality. In the event of a suspected tumor, you will be notified by phone.

Breast Self-Examination (BSE)

BSE should be practiced once a month. If you menstruate, practice BSE two or three days after the end of your period, when your breast are least likely to be tender or swollen. If your are nonmenstruating, due to lactation or menopause, choose a day such as the first of the monthly, and practice BSE each month on that day.

Notes

(1) National Cancer Institute, 1987 Annual Cancer Statistics Review Including Cancer National Cancer Institute, 1987). (2) G.V. Dalrymple and M.L. Baker, “X-ray Examination for Breast Cancer: Benefit vs. Risk”, in Health Effects of Low Level Radiation, William R. Hendee, ed. (Norwalk, CT: Appleton Century Crofts, 1984), pp. 119-125. (3) D. Mant and M. Vessey,” Epidemiology and Primary Prevention of Breast Cancer,” in The Breast, K. I. Bland and E. M. Copeland III, eds. (Philadephia: W.B. Sauders, 1991). (4) T. Byers et al., “Lactation and Breast Cancer,” American Journal of Epidemiology 121, no. 5(1985):664-674; and Mothering, no. 63(Spring 1992):29. (5.) See Note 2,p.120. (6.) A. Glass and R. N. Hoover, “Rising Incidence of Breast Cancer,” Journal of the National Cancer Institute 82,no. 8 (18 April 1990):603-696. (7.) I. Rosenfeld, Modern Prevention: The New Medicine (New York: Simon & Schuster, 1986), pp. 316-321. (8.) Ibid.,p 318. (9.) Ibid., p.319. (10.) Ibid., p. 318. (11.) Carolyn DeMarco,”The Great Debate over Breast Screening,” Today’s Health (June-July 1990). (12.) John Feltman, ed., Prevention’s Giant Book of Healthy Facts (Emmaus, PA: Rodale Press, 1991). (13.) S. M. Wolfe, “Estrogen, Breast Cancer, Heart Disease,” A Friend Indeed for Women in the Prime of Life 8 (8 Jan 1992). (14.) Consensus statement from “Chemically Induced Alterations in Sexual Development: Wildlife and Humans,” to be published in an environmental book series edited by J. Cairns and R. M. Harrison (London, UK: Alsevier Applied Science). (15.) Nancy WErtheimer and Ed Leeper, “Magnetic Field Exposure Related to Cancer Subtypes,” Annals of New York Academy of Science 502 (2 July 1987): 43-54; see also Mothering, no. 37 (Fall 1985):81, no. 39 (Spring 1986): 10, no. 44 (Summer 1987): 82-83, and no 45 (Fall 1987):10. (16.) G. Matanoski, E. Elliot, and P. Brysse, “Cancer Incidence in New York Telephone Workers,” The Lancet 337 (23 March 1991): 737. (17.) Paul Demers et al. in a presentation at the 23rd Annual Meeting of the Society for Epidemiologic Research, in Utah (12-15 June 1990). (18.) Tore Tynes and A. Andersen, “Electromagnetic Fields and Male Breast Cancer,” The Lancet 336 (22 Dec 1990): 1596; see also Matthew Connelly and Louis Slesin, “EMFs: The Darker Side of Electricity,” Mothering, no. 61 (Fall 1991): 48-53. (19.) Ian MacKenzie, “Breast Cancer following Multiple Fluoroscopies,” British Journal of Cancer 19 (1965): 1-8. (20.) C. K. Wanebo et al., “Breast Cancer after Exposure to the Atomic Bombings of Hiroshima and Nagasaki,” New England Journal of Medicine 279 (1968):667-671. (21.) Rad, an acronym for “radiation absorbed dose,” is the unit of measurement used in the United States. The milliSievert unit (mSv) is the measurement used in Canada. (22.) J. D. Boice, Jr., and R. R. Monson, “Breast Cancer in Women after Repeated Fluoroscopic Examinations of the Chest,” Journal of the National Cancer Institute 59 (1977):823-832. (23.) A. new kit containing a lifelike simulated Breast with five basic types of lumps, a 45-minute videotape on breast self-examination, and a 32-page manual is available from Mamma Care, Box 15748. Gainesville FL 32602 (800-626-2273); see Geeta Dardick, “Breast Self-Exam: A New Program Makes Early Detection Easier,” East-West (July/Aug 1991): 32-36. (24.) L. Tabar et al., “Reduction in Mortality from Breast Cancer after Mass Screening with Mammography,” The Lancet (1985):829-832. (25.) M. Maureen Roberts, MD, “Breast Screening: Time for a Rethink?” British Medical Journal 299 (1989): 1153-1155. (26.) A. C. Upton, “Risks of Mammography,” a report by the National Cancer Institute (8 July 1976). Some researchers claim that with improved equipment and techniques, this figure is now approaching 5 percent; however, Dr. Anthony Miller, director of a Canadian breast cancer study, reports a false-positive figure of 10 percent in the Toronto Star (11 Aug 1991): A1 and A13. (27.) A. B. Miller, “Moore on Breast Cancer Screening” (letter) Cancer Forum 1, no. 3 (March 1988). (28.) U. S. National Academy of Science Report on the Biological Effects of Ionizing Radiation (BEIR V) (Washington, DC: U. S. National Academy of Science, 1990). (29.) Michael Swift et al., “Incidence of Cancer in 161 Families Affected by Axtaxia-Telangiectasia,” New England Journal of Medicine 325, no.26 (26 Dec 1991):1835. (30.) Dr. Anthony Miller, a presentation of the findings of the Canadian National Breast Screening Study, in Cambridge, UK (April 1991). (31.) Rosalie Bertell, No Immediate Danger: Prognosis for a Radioactive Earth (Summertown, TN: The Book Publishing Company, 1987). (32.) See Notes 7, p. 318.

Rosalie Bertell, PhD, GNSH, (63) has worked in the cancer prevention and environmental health fields for the past 25 years, and is currently president of the International Institute of Concern for Public Health in Toronto, Ontario, Canada. In addition to serving as a Grey Nun of the Sacred Heart with North American native people in India, Malaysia, and the Marshall Islands, she has written for 97 publications and is the author of the book No Immediate Danger: Prognosis for a Radioactive Earth (The Book Publishing Company, 1987).

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