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Vol. 02 Issue 2, Spring 1997

Intergenerational Education: Starting Early to Reduce Breast Cancer Risk
The Ribbon 

Early on in the development of its educational program, BCERF recognized that there were important reasons to address not only women, for whom breast cancer is often already a matter of personal concern, but also young women and girls. Dr. Carol Devine, Education Project Leader for BCERF (see accompanying biographical sketch, page 5) designed a unique approach for doing so: "intergenerational education," or, reaching girls by working with their mothers and grandmothers, as well as teachers and youth leaders.

An important reason for prioritizing girls in BCERF's educational strategy is the biological reason. As with all cancers, there is a period of 3-35 years that it takes for breast cancer to develop. As research continues to provide information about the risk factors for breast cancer, scientists are also learning more about the time period that may be especially critical for reducing risk later in life. The research suggests that this time period may be as long as pre-adolescence, through menarche to first birth.

BCERF's purpose for taking an intergenerational educational approach involves the development of health behaviors. Carol's previous and current research on women's health- and nutrition-related attitudes and behaviors over the life course, provide background for this aspect of the intergenerational approach. Health-related behaviors, such as eating, exercise, smoking and alcohol consumption habits, and safe use of chemicals and pesticides, are influenced by a wide variety of circumstances in a girl's life, such as family environment, available choices, and positive opportunities for self-expression. Reducing exposure to environmental risk factors, such as certain chemicals, clearly relies on the knowledge and behavior of the adults around a girl.

A mother's feeling of responsibility for her daughter's health gives her a strong motive to set a good example. Alternately, a daughter pursuing positive health behaviors can influence a mother and others around her. Importantly, a girl's health behaviors may form the basis of behaviors throughout her life.

Carol is currently doing critical reviews of the existing research on diet and other lifestyle factors and breast cancer, and using what she finds to further develop BCERF's intergenerational risk reduction efforts.

The Pre- and Post-Puberty Years: Importance in Breast Cancer Risk

Age of menarche. One established risk factor for breast cancer is the age of menarche. Research studies have estimated that women who have their first menstrual period at or before age 14 have a 30% greater risk of developing breast cancer than women who reached menarche at age 15 or later. Early menarche means an early start to a girl's lifetime exposure to estrogen, and thus may increase breast cancer risk.

Although age at menarche may not be modifiable for individual women, there is evidence that age of menarche is, to some extent, related to social trends that have changed over time. We know this for several reasons:

The goal is clearly not to try to change the age of menarche in individual girls. Rather, the goal is to make use of existing knowledge about the many benefits of a healthy diet and physical activity for this age group, as described below. With these ideas put to work, an added benefit for the population may be an effect on the age of menarche, and a decreased risk of breast cancer for this or a future generation.

Sensitivity of rapidly growing cells. There is another indicator which points to the importance of the time of pre- and post-puberty, with regard to breast cancer risk. During this time, the cells in the breasts are growing and dividing rapidly. This rapid growth and division presents more opportunity for genetic mistakes to occur, and therefore greater 'sensitivity' to outside factors. The diagram below refers specifically to activity that takes place between the onset of puberty and first pregnancy.

Research after the bombings of Japan during World War II showed that the effect of the radiation on breast cancer risk was greatest among women in their teens and early twenties, and far less for older women. Starting smoking at an early age may present a higher risk of breast cancer. Likewise, it seems that exposure to any environmental risk factor may have a greater effect on girls and women in the period between menarche and first pregnancy.

In addition, protective factors, such as a diet rich in fruits and vegetables, may have an especially important role during this time. The antioxidant nutrients which can help repair damaged cells may be especially needed during a period of rapid cell growth and division.

Reducing Risk: Steps to Take With Girls and Young Women

There are many difficulties in studying the possible environmental risk factors for breast cancer, and understanding the exact significance of girls' and young womens' exposures. Carol points out that prospective, long-term studies are needed, but are complicated and expensive to carry out. Simply put, these are studies which would follow a large group of girls over time to adulthood, recording behaviors and measuring exposures, then observing the incidence of breast cancer. In the absence of these kinds of studies, there is still enough information to focus attention on girls and young women and encourage policies and behaviors that have many positive health benefits.

House and garden chemicals.For a variety of reasons, children may be more sensitive to environmental toxins than adults. Girls in the developmental period described above may be especially susceptible. BCERF's project of evaluating evidence of any links between exposure to certain pesticides and breast cancer risk also identifies the knowledge gaps in these areas, and has shown that there are many. Even in the absence of complete knowledge, it is sensible to protect this group from unnecessary exposure to pesticides and other environmental chemicals.

This begins in the home, where, for example, adults may not recognize the exposures they may create for their families when they use or have someone else use pesticides when dealing with weed, insect, or rodent problems. A 1992 EPA study showed that people often do not recognize that pesticides pose health and safety threats if not managed properly. Other household chemicals, such as cleaning products, can also be harmful if they are used without appropriate precautions.

With pest control, it is critical to understand the problem, look for the least toxic alternative to dealing with it, and use a range of precautions if choosing pesticide use. The question of pesticide use in schools and other places where children spend time has increasingly been addressed by the Environmental Protection Agency, the New York State Attorney General's Office, municipalities, and others. The New York State Integrated Pest Management (IPM) Program is helping to reduce pesticide use in these places. Parents can get involved in reducing their children's pesticide exposure in the schools by such efforts as: asking about the school's pest management policy; requesting notification of pesticide use; and observing posted warnings on school grounds and parks, and encouraging their children to do the same.

Diet. Many of the studies analyzing diet and breast cancer risk have been inconclusive. One of the reasons may be that these studies typically do not address lifelong diet, but rather a limited period in adulthood. Currently scientists are discovering more and more aspects of whole vegetables, fruits and grains which contribute to the protective effect of certain foods in the diet against cancer. Other ways that a plant-based diet may contribute to a reduced risk of breast cancer include the possibilities that this kind of diet is associated with a later age of menarche, and lower levels of circulating estrogens. These are both possibilities that have been suggested by research studies, such as the several cross-sectional studies which found a later age of menarche in vegetarian girls. Providing a range of vegetables, fruits and whole grains for developing girls is a good strategy for a whole range of health reasons. Parents may need to make the extra effort of ensuring that these foods are available in their children's schools.

Exercise. There is evidence that exercise is related to reduced breast cancer risk among women. Studies suggest that teens who are physically active may have a reduced risk for breast cancer later in life. The biological mechanisms may be related to levels of circulating estrogens, body weight and fat distribution, and increasing the number of anovulatory menstrual cycles (menstrual periods without ovulation.) There are no prospective, longitudinal studies that have measured exercise and subsequent breast cancer risk. However, because exercise appears to reduce the risk of breast cancer among women, and because we know that physical activity tends to decline around adolescence, this is another area in which starting early may be a good idea for many reasons.

Alcohol and smoking. An increase in the risk of breast cancer has been found among women who drink even moderate amounts of alcohol for their lifetime. There is much evidence suggesting that alcohol increases a woman's estrogen levels. One of the more specific questions that remain about the association between alcohol and breast cancer is whether the timing of alcohol consumption matters; for example, whether alcohol use in adolescence is especially significant, or whether it is the total lifetime exposure to alcohol. One study from the National Cancer Institute showed that alcohol consumption increased the risk of breast cancer only in those who had started drinking before age 30. Although the research overall is not clear on this question of timing, it may be that stage of life is an important aspect of this risk factor also.

Beginning to smoke at an early age presents a greater risk of several cancers, including breast cancer. Several studies showed that it is the age a woman begins to smoke, rather than the duration of smoking years, that is related to increased breast cancer risk. One recent study showed that, among heavy smokers, there was an 80% increased risk of breast cancer among those who began smoking before age 16, and a 140% increased risk for those who began before age 14. This suggests that there is a period when the breasts are more susceptible to the carcinogens from cigarette smoke.

An Intergenerational Educational Strategy

There are changes that can be made to address many of the possible risk factors for breast cancer. However, Carol emphasizes that many of these practices cannot be expected from girls on their own. Some involve changes in family habits, including what is served at meals and available for snacks, opportunities for exercise, and home chemical safety. Others involve policy changes; for example, menu options in school lunches, physical education programs, and chemical-use practices in public places.

Additionally, parents and educators would not want girls to be too worried about breast cancer at too young an age. Fortunately, many of the ways that are being identified to reduce the risk of breast cancer are health practices that are recommended for a variety of reasons, and can be 'packaged' with positive messages for girls and young women.

For example, together with Cornell Cooperative Extension of Nassau County, BCERF is developing a new initiative that, if funded, intends to contribute to the reduced risk of breast cancer in its target population by working with mother-daughter teams. A variety of activities will have objectives that are primarily positive and immediately meaningful to girls in this age group, such as involvement in sports. In addition, in BCERF's upcoming inservice training in June, there will be a session on lifestyle changes for mothers and daughters, which will include a discussion of successful models for working with this population. BCERF is putting to work what is known about the development of breast cancer, risk factors for breast cancer, and health-related attitudes and behaviors of girls and women, in order to promote risk reduction when it may matter the most.

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Last Update 06.19.00