Breast Cancer

(Treatment and Prevention)

Breast cancer is the leading cause of death in women between the ages of 35 and 54. In 1960, a woman's lifetime risk for getting breast cancer was 1 in 20, now it is approaching 1 in 7. In 1971 President Richard Nixon declared the "War on Cancer", but despite the efforts of conventional medicine and research, this war is being miserably lost. Much of the blame for this trend can be placed with the misdirected efforts of the cancer establishment, the formidable lobby consisting of the National Cancer Institute (NCI), the American Cancer Society (ACS), and the NCI- and ACS-funded cancer clinics in universities, hospitals, and cancer centers. Rather than identify ways to prevent breast cancer, the cancer establishment instead allocates the majority of its resources on drug therapies to treat cancer. The problem with this approach is evident. It is better to prevent cancer, if possible, rather than be forced to treat it once it develops. In its 1998 Cancer Facts for Women, the ACS continues to imply that there are no known avoidable causes of breast cancer, and goes even further stating "the biggest risk factor for breast cancer is being a woman". Incredibly, the ACS recommends early detection as the "best defense" against breast cancer, giving women false confidence that mammography can somehow protect them against breast cancer. However, recent findings support alternative medicine's long-held belief that there are numerous effective and practical methods to prevent the development of breast cancer.

The human breast is a gland that contains milk ducts, fatty tissue, milk-producing glands, lobes, and a network of lymphatic vessels. Women with dense breasts, such as seen with fibrocystic breast disease, are at a higher risk for developing cancer. Cancer can arise in any part of the breast, and is often detected when a woman feels a lump. In fact, about 90 percent of breast cancers are found by women themselves. In general, cancerous lumps are firm, never go away, and are usually pain-free. They may cause dimpling of the skin, changes in the breast shape, or nipple discharge. Most breast lumps are not cancerous, but are instead cysts, dense glandular tissue, or fibroid masses. Usually an examination by a health professional can determine whether a diagnostic test, such as an ultrasound, thermogram, or mammogram is necessary.

Breast cancer is not a single entity. There are several different types of breast cancer that are defined by the specific type of breast tissue that is affected. Common to all cancer, however, is the uncontrolled growth of abnormal cells that is termed malignancy. With regard to the breast, malignancies can develop in the milk ducts, the nipples, and the glands. Infiltrating ductal carcinoma is a cancer that arises in the lining of the milk ducts and spreads to the surrounding breast tissue. About 80 percent of all cases of breast cancer are of this variety. Intraductal carcinoma in situ is a localized type of cancer that grows in the milk ducts. Conventional treatment may be unnecessary because it may never spread to the surrounding tissue. Paget's disease of the nipple is a form of cancer that occurs when cells from an underlying cancerous tumor migrate to the nipple. Symptoms include chronic nipple dryness, itching, redness, and discomfort. These same symptoms, however, can indicate a food allergy or contact dermatitis. Paget's disease always signals the presence of primary ductal carcinoma elsewhere in the breast tissue.

Cause

There is probably no singular cause of breast cancer. It is likely due to the combined effects of genetics, the use of hormones and other medications, environmental factors, diet, and stress. Even mammography, the test that is considered the gold standard to detect early breast cancer, may increase the risk of developing cancer. Despite conventional medicine's denial of these effects, recent research is providing evidence in support of this view.

Genetics

Most women are aware of the role heredity plays. However, this role has been exaggerated by the press and doctors themselves. The National Breast Center of Australia published a concise overview of genetic risks in the Spring 1995 issue of BreastNews, dividing these risks into three categories:

1. At or slightly above average risk: Women who have (a) no family history, or (b) a first- or second-degree relative diagnosed with breast cancer after the age of 50. Ninety-five percent of women fit into this category. Their lifetime risk is between 1 in 13 and 1 in 8.
   
    
2. Moderately increased risk: Women who have (a) one or more first- or second-degree relatives diagnosed with breast cancer before the age of 50; or (b) two first- or second-degree relatives on the same side of the family with breast cancer, especially those diagnosed before the age of 50. Less than 4 percent fit into this group. Their lifetime risk is between 1 in 8 and 1 in 4.
   
    
3. Potentially high risk: Women who have three or more first- of second-degree relatives on the same side of the family diagnosed with breast or ovarian cancer. Less than 1 percent of women fall into this group. Their lifetime risk is between 1 in 4 and 1 in 2.

As you can see, the majority of breast cancer cases are not genetically correlated. Many women unmistakably believe they are at higher risk, and often undergo hazardous mammograms at a young age (before the age of 45). Conventional doctors themselves often fall prey to this misconception and are recommending mammograms unnecessarily and unwisely.

Estrogen and Cancer

From the time a girl reaches menarche (her first period), until the time she reaches menopause, there are varying amounts of estrogen flowing throughout her body. Estrogen is the main female hormone that is responsible for the development of secondary sex characteristics, including breast development, increased height and weight, skin changes, and the growth of pubic and underarm hair.

With regard to the breast, estrogen causes cells to multiply and swell, in preparation for possible milk production. Estrogen levels are naturally highest in the first half of the menstrual cycle, or the two weeks after the cessation of menstruation. There are natural estrogens produced within the body, and synthetic estrogens that are used in birth control pills and hormone replacement therapy. Synthetic estrogens are much more potent than natural estrogen, and prolonged exposure to the synthetic variety significantly increases the risk for developing breast cancer.

• In 1991, a review that pooled the results from sixteen previous studies found that women who used estrogen replacement therapy for 15 years increased their risk of breast cancer by 30 percent.(1)
• A study published in 1995 by the National Cancer Institute found that just a few months' use of birth control pills could increase breast cancer risk by 30 percent. If a woman used oral contraceptives for 10 years, her risk for developing breast cancer increased by 100 percent.(2)
• The Harvard Nurses Study, released in 1995, demonstrated an increased risk of 30 to 70 percent for women taking estrogen replacement therapy.(3)
• In 1997, a study published in the New England Journal of Medicine showed that the use of estrogen replacement therapy for more than 10 years increased breast cancer deaths by 43 percent.(4)
   

Estrogen exposure clearly increases a woman's chance of getting breast cancer. The duration of estrogen exposure throughout life is termed "estrogen window". The estrogen window is lessened by late onset of menstruation, early menopause, pregnancy, and breastfeeding. Studies have demonstrated a decreased risk of breast cancer with pregnancy and breastfeeding. The less estrogen you are exposed to, the less your risk of breast cancer. Women who are contemplating the use of oral contraceptives or hormone replacement therapy should weigh the risks and benefits carefully. In the Dynamic Wellness index, when to use HRT and alternatives to coping with menopause are discussed.

Diet

Diet is the most fundamental relationship with we have with our environment. The foods we eat affect the immune system, and alter the fundamental chemical processes that support life. Certain foods can actually increase, or decrease inflammatory reactions in the body. There are two fundamental dietary issues that put a woman at risk for developing cancer of the breast: obesity, and food contaminants such as pesticides and industrial chemicals.

Numerous studies have linked obesity with breast cancer:

• A study in the Journal of the National Cancer Institute demonstrated that breast cancer risk increased progressively with weight.(5)
• In 1983, research in the American Journal of Epidemiology showed that any amount of obesity was associated with a 50 percent increase in breast cancer risk.(6)

At what age a woman is obese determines cancer risk. An obese premenopausal woman has about a 10 to 20 percent decrease in risk, largely because of lowered estrogen levels. However, obesity after menopause will have the opposite effect. Fat cells contain an enzyme that converts certain hormones into estrogen, thereby increasing overall estrogen levels and increasing breast cancer risk at the same time. Obesity also widens the estrogen window by hastening the onset of menstruation, delaying menopause, and increasing levels of "bad" estrogens postmenopausally.

The ubiquitous nature of pesticides poses an especially hazardous risk with regard to breast cancer. This widespread use of agricultural chemicals also makes quantifying exposure difficult. Evidence supports the role pesticides play in the evolution of cancer:

• In 1992, a study found that concentrations of PCBs and DDE (dichlorodiphenyldichloroethylene) were up to 60 percent higher in the tissues of women with breast cancer compared to those without cancer.(7)
• In 1993, a study was published in the Journal of the National Cancer Institute that demonstrated women with the highest blood levels of DDE were at four times greater risk for breast cancer compared to women with the lowest levels.(8)
• Research published in the December 5, 1998 issue of The Lancet found a dose-dependent relationship between dieldrin and breast cancer. This means the more dieldrin that gets into your tissues, the higher your risk for cancer. Dieldrin is a pesticide that was used in this country for many years.(9)

Many agricultural chemicals belong to a group of substances that can mimic estrogen within the body. They are termed xeno-estrogens. Xenoestrogens have potent estrogenic effects, binding to cells in the breast, where they can cause cancer. These chemicals are fat-soluble, and therefore do not like to leave the body once inside, significantly increasing the body's Total Toxic Load.

Food contamination does not end with pesticides. Growth-stimulating sex hormones are used to fatten livestock before slaughter. The danger the FDA and the cancer establishment for decades have known these drugs pose, and yet little has been done in the way of change. A random survey conducted in 1986 found that up to half of the cattle sampled in Texas, Colorado, Kansas, Oklahoma, and Nebraska had hormone pellets illegally placed in the muscle tissue of the cattle.(10) Other reports by the FDA offer additional evidence:

• In 1983, an FDA report showed that Synovex-S, a cattle supplement containing progestin and estradiol, increases estradiol concentrations in cattle liver by six times, in muscle by 12 times, and in fat by 23 times. Levels can be much higher depending on when the animal is implanted with a hormone pellet, and in what part of the body.(11)
• A November 1991 report by the FDA found the revalor caused weight gain in the uterus and ovaries, and significantly stimulated the division of breast cells in implanted cows. Revalor contains synthetic estradiol and testosterone, and residues in beef tissue can be as high as 50 parts per billion.(12)

The United States Department of Agriculture (USDA) stamps on meat and poultry that proclaim safety, refer only to the cleanliness and general health of the meat. The USDA does not test for levels of hormones.

Although hormones are not typically used in pork, poultry, and lamb production, feed that is given to these animals contains pesticides and other agricultural chemicals that are stored in the animal tissues. Fish, depending on where it is caught, can also be highly contaminated with pesticides and other pollutants known to cause breast cancer.

Mammography

Mammography consists of the compression of the breasts between two plates, followed by shooting radiation through the breast tissue. Dense material allows less x-rays to pass through to the film, so cancerous masses should be distinguishable from normal tissue. Screening mammography is performed on otherwise healthy breasts for the purpose of identifying cancer earlier than with palpation alone. The question becomes whether or not mammograms are effective, and safe, at early breast cancer detection.

• All mammograms rely on the focusing of x-rays (electromagnetic radiation that is able to penetrate solid material) on the breasts. X-ray radiation itself, however, is known to cause breast cancer. Much of the evidence identifying this hazard has been obtained by the analysis of persons who have undergone a variety of radiation for medical purposes.
• In the past radiation was used in an attempt to reverse scoliosis in children. A 1989 study published in the Journal of the National Cancer Institute found excess breast cancer in women who had undergone this procedure at an average age of 13.(13)
  In 1989, The Lancet published a study that also found excess breast cancer in women who were treated with x-rays for fungal infections.(14)

Dr. John Gofman, an international authority on the effects of radiation on biologic tissue, published the book Preventing Breast Cancer.(15) In it Dr. Gofman claims that medical radiation is probably the single most important cause of the breast cancer epidemic.

The American Cancer Society recommends that women over the age of 40 have yearly screening mammograms, however, the effectiveness and safety of mammography in premenopausal women is to be questioned. A Swedish study published in 1993 found that women under the age of 55 who had regular mammograms experienced a 29 percent greater risk of dying from breast cancer.(16) Other studies have found similar results.

One of the main problems with performing screening mammograms in younger women is that their breasts are naturally more dense than in older women, due to higher levels of estrogen. The increased density produces poorer mammograms that are more difficult to read. As a result, many women with healthy breasts are receiving unnecessary biopsies to rule out suspicious findings on mammography. According to Samuel Epstein, MD, a leading expert on the environmental causes of cancer, women between the ages of 40 and 49 who have mammograms every year run as much as a 50 percent chance of being told that an abnormality has been found, even though their breasts are normal.(17)

There are safer, and perhaps more effective tools to indicate breast problems, and to diagnose cancer. These include the self-breast examination, clinical examination (performed by a doctor), thermography, ultrasound, and the AMAS (antimalignin antibody in serum) test.

Mammography Alternatives

Breast self-examination: Examining your breasts every month has been shown to result in as high as 90 percent detection of malignancies. Examine your breasts in the first week after your period. This is the time when the breasts are normally the least lumpy and dense, making palpation easier and more accurate. Self-exams should be performed each month.

1. Start in front of a mirror, noticing the shape, contour, and nipple position of each breast. Masses within the breast can distort the shape, causing dimpling, nipple retraction, and changes in the overall contour. Nipples pointing in a different general direction can also be an ominous sign. Next, raise your arms over your head, again looking for changes in shape. Then place your hand against your outer waist, pushing inward to contract the chest muscles beneath the breasts. This can also bring out changes in the contour of the breasts or position of the nipples. Chronic dryness, redness, and itching of the nipples can indicate Paget's disease (cancer of the nipple), or may simply indicate a contact dermatitis, or food allergy.
   
    
2. While standing, explore each armpit with the opposite hand. The armpit is the home to numerous lymph nodes that are not typically palpable. If a lump is felt, it should be reported to your doctor. Then explore each breast with the opposite hand, starting in the upper portion of the breast, and working in a circular fashion, gradually working toward the nipple. Do not use the fingertips, but rather keep the fingers flat, using the entire pads of the fingers. A rolling motion will help distinguish normal glandular lumpiness from larger, abnormal masses. Benign (non-cancerous) lumps are usually tender, and freely movable with the fingers. Malignant (cancerous) tumors tend to be hard, non-tender, and attached to the adjacent breast tissue. Pinch each nipple between your thumb and index finger, and roll it back and forth. Feel for small "beads" that can indicate an intraductal carcinoma. Finally, attempt to express fluid.
   
    
3. Perform step 2 while lying on your back with the arm of the side being examined up over your head. Laying down puts the breasts in a different position that maximizes the ability to detect abnormalities.

If you detect anything suspicious, contact your doctor.

• Clinical Examination: Examination of the breasts by a physician who is adequately trained and takes the time to perform a thorough exam is an important means to identify breast abnormalities. Many doctors are too rushed and fail at this task. A thorough examination includes visualization and palpation of the breasts while seated, including checking the lymph nodes starting at the elbow, working up to the armpit, and ending with the nodes above the collar bone. Palpation should also be performed while lying down. The nipples should always be checked for discharge. This examination should be completed at least every other year for women between 20 and 30, and every year thereafter.
• Thermography: Breast thermography is based on findings that breast tumors have abnormal blood vessel patterns that give off more heat than the surrounding tissue. This blood vessel growth that accompanies tumor formation is termed neovascularization. Neovascularization is the earliest sign of a rapidly growing tumor, and can be identified with infrared technology.(18,19)

Infrared thermography analyzes the heat that is given off by the breasts and allows for immediate display onto a computer monitor. The images obtained provide an indirect measurement of the metabolic rate of breast tissue. The "hotter" the image, the faster the rate of the tissue growth, and the greater the degree of neovascularization. In other words, cancer is identified on a thermogram is focal "hot spots" and abnormal blood vessel patterns.

Thermography research has demonstrated that about 40% of women with fibrocystic breasts and an abnormal thermogram develop cancer within five years. The rate of cancer for fibrocystic patients without thermal abnormalities is less than 3%. (19, 20, 21, 22) These findings are significant because there is difficulty in assessing such women with mammography due to the high proportion of breast lumps and general breast density. Frequently, mammograms result in unnecessary biopsies, and associated anxiety.

Thermography is useful because its interpretation is not dependent upon the density of suspected masses. This fact is important because many women have dense tissue in their breasts that make mammographic interpretation difficult. This characteristic of thermography makes it an ideal choice for screening women under the age of fifty. If abnormalities are identified, an ultrasound, mammogram, or AMAS test should be performed. For women over 50, thermography can provide useful information to be used in conjunction with mammograms.

• Ultrasound: Ultrasound uses high-frequency sound waves that are reflected off of tissue within the breasts. The echo patterns are then converted into electronic images. Although this tool has drawbacks that make it an inferior choice for screening purposes, it can be useful as an alternative to biopsy when abnormalities are detected with other tests.
• AMAS Test: Unveiled in the 1990's by the Harvard-trained biochemist and physician Sam Bogoch, the AMAS (anti-malignin antibody in serum) test measures the level of antibodies in the blood to malignin, a protein in the wall of cancer cells. Dr. Bogoch found that the AMAS serves as a reliable marker for all types of cancer.

The FDA approved the AMAS in 1977, but it wasn't until 1994 that a published study identified the tests predictive accuracy. According to Dr. Bogoch, the test is 95% accurate on the first test, and 99% with a second confirmation. This makes the AMAS the most sensitive early marker for the identification of cancer to date.

But the AMAS is more than just a screening tool. When cancer cells no longer exist, anti-malignin antibodies quickly diminish to normal levels. In other words, the AMAS is an effective yardstick with which to measure the success of therapy-and the test relies on a simple blood draw.

The AMAS has its greatest application in ruling-out cancer when presented with suspicious findings. For example, a 35 year-old woman with a small palpable lesion in her breast-normally a reasonable candidate for mammography-can forego the pain, and the increased risk of cancer associated with a mammogram by instead having an AMAS performed.

The AMAS is safe, and more sensitive than mammography. Additionally, a negative AMAS will avoid the need of a breast biopsy, a frequent occurrence subsequent to a suspicious mammogram. With mammograms, false positive results are frequent in premenopausal women due to the high density of breast tissue. It is for this reason that there are no reliable studies to date that have demonstrated benefit to screening mammography in women under the age of fifty.

Dr. Nicholas LeRoy, a holistic women's physician, recommends that if you suspect you have cancer, or you have had abnormal findings that failed to be resolved with conventional tests, obtain an AMAS. If it is negative, you have pretty much put the issue to rest, and avoided unnecessary anxiety. If the test is positive, you have given yourself a valuable head start in the healing process.

Natural Therapy

The cited recommendations below are intended for women with breast cancer, as well as for preventing cancer. Remember that it is your immune system that prevents cancer as well as aids in cancer destruction. Any treatment that facilitates immunity is a useful approach to breast cancer.

• Eat a whole foods diet, high in diverse vegetables such as in Dr. Nick's Vegetable Mix. Diet is the single most important therapy in treatment and prevention.
• Avoid animal products that usually contain high amounts of hormones as well as other agricultural chemicals. If you are going to eat meat, including turkey, chicken, and pork, try to purchase certified free-ranged meats that are not fed hormones, antibiotics, or pesticide-tainted feed.
• Do not consume alcohol that can elevate estrogen levels.
• Do not take iron supplements unless you have documented iron deficiency. Evidence has demonstrated iron may aid in tumor growth.
• Take a well-balanced multivitamin/multimineral supplement.
• Supplement with antioxidants. The Dynamic Wellness Super Antioxidant contains vitamin and mineral free-radical scavengers. The Herbal Antioxidant Support contains 13 plant-derived antioxidants that include ginkgo biloba, green tea extract, and grapeseed extract.
• Essential Fatty Acids are important in cell membrane integrity and immune system function. Three to five grams should be taken daily with food.
• Garlic enhances immunity. Increase its use in the diet, and/or supplement with garlic capsules.
• Shark cartilage may interfere with neovascularization, starving rapidly growing cancer cells. One gram per 2 pounds of body weight can be taken daily in three divided dosages. Reterna Labs makes a highly purified liquid extract that can be taken under the tongue. Research has demonstrated that this extract does inhibit neovascularization. This product must be ordered by a licensed health care professional by calling Douglas Laboratories at 800-245-4440. If you suffer from coronary artery disease, or have had a recent heart attack, you may not want to supplement with shark cartilage because it may impair new blood vessel growth into the heart muscle.
• Maitake mushroom consumption may prevent the growth and spread of cancer. It also increases immune system function.
• A plant-based digestive enzyme supplement can increase the absorption of vitamins, minerals, and essential fatty acids, as well as improve digestion to decrease total toxic load.
• For treating cancer, thymus, mesenchyme, and liver glandulars may significantly improve immunity. These products can be obtained by Reterna Labs in a purified extract form. This product must be ordered by a licensed health care professional by calling Douglas Laboratories at 800-245-4440.
• The herbs astragalus and echinacea are immune system stimulators.
• Regular exercise supports immunity. Exercise that is too intense may adversely affect the immune system.
• Practice meditation and visualization.
• Fasting and detoxification boost immunity, and can greatly diminish total toxic load.
• Self-breast massage is a simple and effective means of increasing tissue oxygenation and stimulating lymphatic drainage from the breast. The lymphatic system is important in removing fluid from the breast that may contain toxins such as pesticides. This is especially important in women who choose to wear bras, because the garment restricts lymph flow. This restriction is amplified with underwire bras. The authors of the book entitled Dressed to Kill that claim that there is a correlation between wearing of bras and breast cancer.(23) Lymphatic drainage requires a specific amount of pressure and technique to obtain the most benefit. The method involves stimulating lymph nodes in the neck, then the axilla (armpit), and finishing with the massaging of the breast tissue itself in a midline to axillary fashion. Massage in this fashion follows the normal flow of lymph from the breasts. This technique is best performed every day. Holistic doctors, or massage therapists that are trained in lymphatic drainage can demonstrate how to properly perform this technique. Self-breast massage is only for cancer prevention. It is critical to rule-out cancer prior to the initiation of this technique to avoid stimulating an already present cancer.
• Do not use underarm antiperspirants that may impede the natural elimination of toxins in sweat.

The above recommendations are not intended to replace conventional treatment of cancer. They are best used adjunctively to maximize the ability of your body to cope with cancer.


References

1. Steinberg, KK, et al. "A metaanalysis of the effect of estrogen replacement therapy on the risk of breast cancer." Journal of the American Medical Association, 1991;265:1985-1990.
2. Brinton, LA. "Oral contraceptives and breast cancer risk among young women." Journal of the National Cancer Institute, 1995;87(11):827-835.
3. Colditz, GA, et al. "The use of estrogens and progestins and the risk of breast cancer in postmenopausal women." New England Journal of Medicine, 1995;332(24):1589-1593.
4. Brody, JE, "Hormone use helps women." The New York Times, June 19, 1997:A1.
5. Brinton, LA, et al. "Breast cancer risk factors among screening program participants." Journal of the National Cancer Institute, 1979;62:37-44.
6. Helmrich, SP, et al. "Risk factors for breast cancer." American Journal of Epidemiology, 1983;117:35-45.
7. Falck, A., et al. "Pesticides and polychlorinated biphenyl residues in human breast lipids and their relation to breast cancer." Archives of Environmental Health, 1992;47:143-146.
8. Wolff, M., et al. "Blood levels of organochlorine residues and risk of breast cancer." Journal of the National Cancer Institute, 1993;85(8)648-652.
9. Hoyer AP, et al. "Organochlorine Exposure and Risk of Breast Cancer," The Lancet, December 5, 1998;352:1816-1820.
10. Herrin, A. "FDA investigates 17 feedlots for improper hormone use." Food Chemical News, July 28, 1986:37-38.
11. Freedom of Information Summary for Synovex-S. US Food and Drug Administration, Washington, DC: October 5, 1983:2-3.
12. Freedom of Information Summary for REVALOR-S. US Food and Drug Administration, Washington, DC: November 27, 1991:5-6.
13. Hoffman, et al. Journal of the National Cancer Institute, 1989;81(17):1307-1312.
14. Modan, B., et al. "Increased risk of breast cancer after low-dose radiation." The Lancet, 1989;629-631.
15. Gofman, JW. Preventing Breast Cancer: The Story of a Major, Proven, Preventable Cause of This Disease. San Francisco: Committee for Nuclear Responsibility, 1995.
16. Elwood, JM, et al. "The effectiveness of breast cancer screening by mammography in younger women." Online Journal of Current Clinical Trials, 1993;(2)32.
17. Epstein S., et al. The Breast Cancer Prevention Program, Macmillan,1997;118.
18. Gautherie M. "Thermobiological assessment of benign and malignant breast diseases." Am J Obstet Gynecol, December, 1983.
19. Gautherie M. et al. "Thermovascular changes associated with in-situ and minimal breast cancers." Journal of Reproductive Medicine, 1987;32(11).
20. Gautherie M., Gros, "Breast thermography and cancer risk prediction," Cancer 1980;45(51).
21. Gautherie M, et al. "Long-term assessment of breast cancer risk by liquid crystal thermal imaging," Biomedical Thermology, New York, 1982.
22. Amalric R, Spitalier JM, "Follow-up of benign mastopathies by infrared thermography," Benign Mastopathies: Precancerous Conditions, Paris, 1982.
23. Singer S, Grismaijer S, Dressed to Kill: The Link Between Breast Cancer and Bras, Avery Publications.