1. Best Breast Health and State of the Art Diagnostics JAY H. MEAD MD, FASCP FOUNDER AND CHIEF MEDICAL DIRECTOR LABRIX CLINICAL SERVICES

2. Breast cancer Breast cancer is the most common cancer affecting women. Over 230,000 American women were diagnosed with invasive breast cancer this year and an estimated 40 thousand women died from it. American Cancer Society www.cancer.org Accessed 11/26/14 http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA#1 Accessed 11/26/14

3. Approximately 1 in 8 women will develop breast cancer in her lifetime.

4. Risk factors for breast cancer Gender – breast cancer is about 100x more common in women Age – 66% of invasive breast cancers are found in women over 55 Heredity – having a first degree relative with breast cancer approximately doubles the risk About 60% of women with BRCA 1 or 2 gene mutation will develop breast cancer (12% in the general population) American Cancer Society www.cancer.org Accessed 11/26/14 http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA#1 Accessed 11/26/14

5. Risk factors for breast cancer Estrogen exposure ◦Early menarche or late menopause ◦Nulliparity ◦First pregnancy over age 30 ◦Use of hormonal birth control or HRT ◦Exposure to xenoestrogens ◦Obesity ◦Vitamin D deficiency ◦Iodine deficiency American Cancer Society www.cancer.org Accessed 11/26/14

6. Xenoestrogens Artificial chemicals that, due to their chemical structure, act like estrogen in the human body ◦Plastics (BPA – recently found to be stronger than E2) ◦Pesticides ◦Synthetic hormones ◦Hormones in dairy, beef and poultry ◦Food additives ◦Cosmetics (paraben) Darbre PD. Environemental oestrogens, cosmetics and breast cancer. Best Pract Res Clin Endocr Metab. 2006; 20: 121-43. Chighizola C. Meroni PL. The role of environemental estrogens and autoimmunity. Autoimmun Rev. 2012;11: A493-501.

7. Patients on Premarin and oral estrogens… caution Gallstones Risk of breast cancer Insulin Estrone Liver enzymes Lower IGF-1 Oral estrogens can INCREASE: Cano A., et al. Effect of menopause and different combined estradiol-progestin regimens on basal and growth hormone, insulin-like growth factor-1, insulin-like growth factor binding protein (IGFBP)-1 and IGFBP-3 levels. Fertil Steril. 1999;71: 261-7. Goodman MP. Are all estrogens created equal? A review of oral vs. transdermal therapy. J Womens Health (Larchmt). 2012;21: 161-69. Blood pressure Triglycerides Inflammation CRP Carb cravings SHBG

8. Women’s Health Initiative In June 2002, the Conjugated Equine Estrogen + Medroxyprogesterone (PremPro) arm of Women’s Health Initiative was discontinued after 5.2 years instead of the planned 8.5 years due to increased risk of: Invasive breast cancer (+ 26%) MI/CAD (+29%) Stroke (+41%) Alzheimer's Dementia (+205 %) Pulmonary Embolism (+2,100%) Of note, there was evidence of decreased risk of: Colorectal cancer (-37%) Hip fractures (-24%) Editorial JAMA 7/17/2002 Vol 288, No 3.

9. Progesterone vs. Progestin

10. More Evidence JAMA 2000 – 15 year study, 46,000 women ◦The use of medroxyprogesterone along with estrogen increased the risk of breast cancer by 800% above that of patients using estrogen alone. JInst. 2. Natl Cancer 2000 – 1860 women studied ◦Estrogen alone had 7% increased risk of breast cancer. ◦The addition of medroxyprogesterone acetate caused a 400% increased risk over that of estrogen alone. Cancer Epidemiol. 2010 – 56,567 women studied ◦Estrogen alone, 15% increased risk of breast cancer. ◦Women who combined estrogen with progestin therapy for at least 15 years has an 83% increased risk of breast cancer.

11. Three estrogens EstriolEstradiolEstrone

12. Three estrogens are made by the body: Estrone (E1) ◦50-70% less active than E2 ◦Mainly produced in the fat cells via aromatization ◦Aromatase converts androstenedione to estrone, this is the predominant route of production after menopause ◦Estrone is the most prevalent estrogen in post- menopausal women ◦Women with PCOS have more circulating estrone ◦Premarin is approximately 50% estrone Speroff L. Clinical Gynecologic Endocrinology and Infertility. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.

13. Three estrogens are made by the body: Estradiol (E2) ◦The most potent and active estrogen ◦Made in the ovaries as well as in the peripheral tissues. ◦Estradiol acts as a growth hormone, stimulating growth and proliferation of tissue. ◦Aromatase converts testosterone into estradiol, especially in adipose tissue. ◦Estradiol yields the same family of estrogen metabolites as estrone as they are interconvertible. Speroff L. Clinical Gynecologic Endocrinology and Infertility. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.

14. Three estrogens are made by the body: Estriol (E3) ◦10% the activity of E2, the weakest of the three estrogens ◦Mainly produced by the ovaries (small amounts by adrenals) ◦Produced when converted from estrone and estradiol. (It does not convert back to E1 or E2) ◦Shortest binding time to Estrogen Receptor ◦Considered protective against over activity of E2 ◦High during pregnancy. ◦Estrogen receptors are more sensitive to estriol than either estrone or estradiol. Speroff L. Clinical Gynecologic Endocrinology and Infertility. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.

15. Estrone Estradiol Estriol

16. Estrone Estradiol Estriol 2 OH Estrone 16α OH Estrone 4 OH Estrone

17. 2-OH, 4-OH and 16-OH Estrone and estradiol are biochemically interconvertible and yield the same family of estrogen metabolites as shown for estrone The 2-OH metabolite confers very weak estrogenic activity, and is generally termed the "good" estrogen. In contrast, the 16a-OH and 4-OH metabolites show persistent estrogenic activity and promote tissue proliferation. 4-OH Estrone is readily converted to 3,4 hydroxyquinone ( a potent carcinogen) in the presence of free radicals Bradlow HL, et al. 2-hydroxyesteone: the ‘good’ estrogen. J Endocrinol. 1996 Sep;150 Suppl:S259-65.

18. Known Relationships Low 2/16a Hydroxyestrogen ratio (ie: less 2- OH more 16-OH) associated with: ◦Many cancers including breast, prostate, pancreas, gastric, osteosarcoma, ovarian Bradlow HL, et al. 2-hydroxyesteone: the ‘good’ estrogen. J Endocrinol. 1996 Sep;150 Suppl:S259-65. Fuhrman BJ, et al. Estrogen metabolism and risk of breast cancer in postmenopausal women. J Natl Cancer Inst. 2012 Feb 22;104(4):326-39.

19. The Estrogen Quotient In the 1960’s and 70’s Dr. Henry Lemon noted that women who developed breast cancer had a significantly reduced level of E3. He also found that rats that were treated with E3 prior to radiation and chemical exposure had a reduction in the development of mammary cancers. Since then research has shown that E3 blocks the estrogen receptor coupling receptor (GPR30) even in estrogen receptor negative breast cancer cells negating the proliferative actions of estradiol. Lemon, HM. Pathophysiologic considerations in the treatment of menopausal patients with oestrogens; the role of oestriol in the prevention of mammary carcinoma. Acta Endocrinol Suppl (Copenh). 1980; 233: 17-27.

20. Reduced Estriol Excretion in Patients With Breast Cancer Prior to Endocrine Therapy Lemon HM, Wotiz HH, Parsons L, Mozden PJ. Reduced estriol excretion in patients with breast cancer prior to endocrine therapy. JAMA. 1966 Jun 27;196(13):1128-36.

21. Estriol acts as a GPR30 antagonist in estrogen receptor-negative breast cancer cells Estrogens are structurally related steroids that regulate important physiological processes. 17beta-estradiol (E2) is reversibly oxidized to estrone (E1) and both E2 and E1 can be irreversibly converted to estriol (E3), which also originates directly from androstenedione. The action of E2 has been traditionally explained by the binding to the estrogen receptor (ER) alpha and ER beta, however the G protein-coupled receptor (GPR) 30 has been recently involved in the rapid signaling triggered by estrogens. Although the role of E2 in the development of breast cancer has been largely documented, the contribution of E3 still remains to be completely evaluated. Here, we demonstrate for the first time that E3 acts as a GPR30 antagonist since it was able to inhibit the GPR30-mediated responses such as the rapid ERK activation, the up-regulation of target genes like c-fos and connective tissue growth factor, the proliferative effects observed in ER- negative SkBr3 cells. Lappano R, et al. Estriol acts as a GPR30 antagonist in estrogen receptor-negative breast cancer cells. Mol Cell Endocrinol. 2010 May 14;320(1-2):162-70. doi: 10.1016/j.mce.2010.02.006. Epub 2010 Feb 6.

22. The Estrogen Quotient Application Use as a screening for women whom, due to past medical history, or your clinical intake are at higher risk for breast cancer Women who are on HRT – especially E2 only As part of Comprehensive Hormone Testing for evaluation of symptoms or prevention where you may be planning to use estrogen replacement Provides a broad brush stroke for quickly assessing estrogen status: “good vs. bad”

23. The Estrogen Quotient EQ = E3/(E1 + E2) The lower the Estrogen Quotient, the higher the risk of breast cancer. EQ <1.0 : higher risk EQ >1.5 : lower risk Lemon, HM. Pathophysiologic considerations in the treatment of menopausal patients with oestrogens; the role of oestriol in the prevention of mammary carcinoma. Acta Endocrinol Suppl (Copenh). 1980; 233: 17-27.

25. On Evamist 2 pumps daily after hysterectomy 6 years ago (1 spray = 1.53mg estradiol)

26. Is this better than the Pg/E2 ratio? Both ratios are highly useful and effective in helping define treatment The EQ is a measurement of all three estrogens in relationship to each other, and helps determine the risk status for each patient in development of cancers (reproductive cancers; breast, prostate, uterine etc) EQ is specific only to estrogens and will help clarify for clinicians when to focus more heavily on specific (anti-estrogen) therapies- it’s another very powerful tool which underscores our mission and our motto – test now and treat right Pg/E2 ratio is another parameter which will help provide assessment to further protect against reproductive cancers Clinical pearl: Pg/E2 Ratio used not only to address risk but most helpful for symptoms EQ – used mostly to address risk assessment

27. Prevention: Increase the EQ How to increase EQ ◦Lower E1, E2 ◦Support 2-OH metabolism ◦Raise E3

28. Support Liver and Detoxification The metabolism of estrogen takes place primarily in the liver through Phase I (hydroxylation) and Phase II (methylation, glucuronidation, and sulfation) pathways, with final excretion in the urine and feces. Fuhrman BJ, et al. Estrogen metabolism and risk of breast cancer in postmenopausal women. J Natl Cancer Inst. 2012 Feb 22;104(4):326-39. Speroff, L. (2005). Clinical Gynecologic Endocrinology and Infertility. Philadelphia, PA: Lippincott Williams & Wilkins. Raftogianis R, et al. Chapter 6: Estrogen Metabolism by Conjugation. Oxford Journals; JNCI Monographs. Vol 2000, Issue 27. Pg 113-124.

29. Nutrients which Support ‘Healthy’ Estrogen Metabolism Flax seeds Isoflavones Indole-3-carbinol DIM Omega 3 Fatty Acids Green tea B vitamins Magnesium Calcium Limonene D-glucarate Antioxidants

30. Benefits of ground flaxseeds Interrupts the enterohepatic circulation of estrogens in two ways: ◦Can bind unconjugated estrogens in the digestive tract, which are then excreted in the feces. ◦Beneficially affects the composition of intestinal bacteria and reduce intestinal b-glucuronidase activity, resulting in lowered estrogens via the conjugation of estrogen and reduced reabsorption. Dietary fiber intake also increases serum concentrations of SHBG, thus reducing levels of free estradiol. Flaxseed and its lignans inhibit estradiol-induced growth, angiogenesis, and secretion of vascular endothetial growth factor in human breast cancer xenografts in vivo. Toure A, Xueming X. Flaxseed lignans: source, biosynthesis, metabolism, antioxidant activity, bio-active components and health benefits. Compr Rev Food Sci Food Safety. 2010; 9: 261-69. Clin. Cancer Res. 2007; 13(3):1061

31. Fiber Lignans- are found in fiber-rich foods such flaxseed and other oil seeds, whole grains, legumes, and vegetables. Lignans stimulate the production of SHBG in the liver, and therefore reduce the levels of free estrogen insulation. They also inhibit aromatase activity, thus decreasing conversion of testosterone and androstenedione into estrogens in fat and breast cells. Women consuming 10g of flaxseed per day experienced longer menstrual cycle length, increased progesterone-to-estrogen ratios, and fewer anovulatory cycles, all of which were considered to reflect improved ovarian function. Tham DM, et al. Clinical review 97: Potential health benefits of dietary phytoestrogens: a review of the clinical, epidemiological and mechanistic evidence. J Clin Endocrinol Metab. 1998; 83: 2223-35.

32. Isoflavones Soy Legumes Alfalfa Clover Licorice Kudzu root Japanese diets, are associated with low rates of hormone dependent cancers. The average daily isoflavone intake of Japanese women is 20 mg, while that of American women is 1 to 3 mg. Wakai K, et al. Dietary intake and sources of isoflavones among Japanese. Nutr Cancer. 1999;33(2);139-45.

33. Omega 3’s Have been shown to increase C-2 hydroxylation and decrease C-16a hydroxylation of estradiol in breast cancer cells. Functional Imaging. Nutritional Influences on Estrogen Metabolism. Available at: http://www.funimky.com/research_estrogen.htm Accessibility verified October 23, 2012. Schley PD, et al. Mechanisms of omega-3 fatty acid-induced growth inhibition in MDA-MB 231 human breast cancer cells. Breast Can Res Treat. 2005; 92: 187-95.

34. Green tea Cancer prevention is thought to be epigallocatechin-gallate (EGCG) Among women under the age of 50, those who consumed 3 or more cups of tea per day were 37% less likely to develop breast cancer compared to women who didn't drink tea Assisting in the prevention of breast cancer incidence Farabegoli F, et al. (-)-Epigallocatechin-3-gallate downregulates Pg-P and BCRP in a tamoxifen resistant MCF-7 cell line. Phytomedicine. 2010: 17: 356-62.

35. Resveratrol Has been shown to inhibit breast cancer cell growth in vitro. It has been classified as a phytoestrogen based on its ability to bind to and activate the ER, It exhibits estrogenic and anti-estrogenic activity and binds to ERa and ERb with comparable affinity. These estrogen modulatory effects may explain resveratrol's well- known anticancer and cardioprotective properties. Wang Y, et al. The red wine polyphenol resveratrol displays bilevel inhibition on aromatase in breast cancer cells. Toxicol Sci. 2006; 92: 71-7.

36. Indole-3-Carbinol (l3C) I3C derived from cruciferous vegetables such as broccoli, brussel sprouts, and cabbage Actively promotes the breakdown of estrogen to the beneficial metabolite, 2-OH Beneficial to those with health issues related to estrogen dominance Tham DM, et al. Clinical review 97: Potential health benefits of dietary phytoestrogens: a review of the clinical, epidemiological and mechanistic evidence. J Clin Endocrinol Metab. 1998; 83: 2223-35. Minich DM, Bland JS. A review of the clinical efficacy and safety of cruciferous vegetable phytochemicals. Nutr Rev. 2007; 65: 259-67. Hall DC. Nutritional influences on estrogen metabolism. App Nutr Sci Rep. 2001.

37. I3C Supplementation with 500 mg and 400 mg of I3C, respectively, resulted in significantly increased urinary excretion of 2-OH, while that of nearly all other metabolites including estradiol and l6a-OH was lower-indicative of their decreased formation. Through competitive inhibition, 13C has been shown to prevent the receptor binding of estradiol and estrone. Indole-3-carbinol. Monograph. Altern Med Rev. 2005; 10: 337-42. Minich DM, Bland JS. A review of the clinical efficacy and safety of cruciferous vegetable phytochemicals. Nutr Rev. 2007; 65: 259-67.

38. DIM 3,3′-Diindolylmethane Diindolylmethane is a metabolite of indole–3–carbinol Potent anti-cancer properties DIM can block estrogen receptors and inhibit growth of estrogen responsive breast cancer It has been shown to induce apoptosis in human cancer cells DIM inhibits the growth of both estrogen-dependent and estrogen- independent cancer cells by approximately 60 percent In a double blind, randomized clinical trial, DIM revealed potential support for maintaining the function of healthy breast cells Chang YC et al. Cytostatic and antiestrogenic effects of 2-(indol-3-ylmethyl)-3,3’-diindolylmethane, a major in vivo product of dietary. Biochem Pharmacol. 1999 Sep 1;58(5):825-34. Indole-3-carbinol. Monograph. Altern Med Rev. 2005; 10: 337-42. Minich DM, Bland JS. A review of the clinical efficacy and safety of cruciferous vegetable phytochemicals. Nutr Rev. 2007; 65: 259-67

39. What’s the difference? Studies of both compounds have shown significant benefit in promoting healthy metabolism of estrogen, however there is evidence that DIM may be more stable and have fewer byproducts and side effects. Diindolylmethane Indole 3 carbinol "Induction of cytochrome P4501A1 by 2,3,7,8-tetrachlorodibenzo-p-dioxin or indolo(3,2-b)carbazole is associated with oxidative DNA damage."Park JY, Shigenaga MK, Ames BN, Proc Natl Acad Sci U S A. 1996 Mar 19;93(6):2322-7. "Presence of 3,3’-Diindolylmethane in human plasma after oral administration of Indole-3-carbinol."Arneson, DW, Hurwitz, A, McMahon, LM, and Robaugh, D, Proceedings of the American Association for Cancer Research, 1999 Mar; (40): #2833.

40. Calcium D-Glucarate Aids in detoxification and the regulation of estrogen (of increased estrogen and toxin elimination from the body) Inhibits b-glucuronidase Increases the activity of the glucuronidation Phase II pathway Has been found in animal models to lower estradiol levels and inhibit the initiation, promotion, and progression of cancer Hall DC. Nutritional influences on estrogen metabolism. App Nutr Sci Rep. 2001.

41. Curcumin A member of the ginger family. A combination of curcumin and the isoflavone genistein has shown synergy in reducing xenoestrogen-induced growth of breast cancer cells. Increases hepatic levels of glutathione and induces glutathione-S-transferase (GST) and glucuronyl transferase, important in the Phase II detoxification of quinones produced from the oxidation of catechol estrogens. Kidd PM. Bioavailability and activity of phytosome complexes from botanical polyphenols: the silymarin, curcumin, green tea and grape seed extracts. Alt Med Rev. 2009; 14: 226-46.

42. Chrysin Bioflavonoid that inhibits aromatase activity Reduces the conversion of androgens into estrogen Aromatase is found in breast tissue, and its inhibition may be useful in reducing the cell proliferative effects of estrogen Cass H. Herbs for the nervous system: gingko, kava, valerian, passionflower. Sem Int Med. 2004; 2: 82-88.

43. Link between estrogen metabolism pathway and breast cancer risk discovered ScienceDaily (Aug. 5, 2010) …“strengthens the utility of the well- established aromatase inhibitors as chemoprophylaxis agents for targeted subgroups of women identified to have an increased risk of breast cancer.” Low YL, et al. Multi-variant pathway association analysis reveals the importance of genetic determinants of estrogen metabolism in breast and endometrial cancer susceptibility. PLoS Genetics. 2010; 6. 10.1371/journal.pgen.100101210.1371/journal.pgen.1001012

44. Rosemary Promotes the 2-hydroxylation of estrogen in a similar fashion to 13C Inhibits 16a hydroxylation Rosemary may also enhance estrogen detoxification Al-Sereitia MR, et al. Pharmacology of rosemary (Rosmarinus officinalis Linn.) and its therapeutic potentials. Indian J Exp Biol. 1999; 37: 124-31.

45. Prevention: Reduce xenoestrogens Plastics: BPA, pthalates ◦Especially important to avoid heating or freezing foods in plastic containers and avoid foods/beverages that have been stored for long periods of time ◦Avoid hormone fed meat and dairy sources ◦Avoid pesticides and herbicides – they can mimic estrogens and interfere with hormone metabolism Wozniak AL, et al. Xenoestrogens at picomolar to nanomolar concentrations trigger membrane estrogen receptor-alpha- mediated Ca2+ fluxes and prolactin release in GH3/B6 pituitary tumor cells. Environ Health Perspect. 2005; 113: 431-39.

46. ESTROGEN DOMINANCE Insufficient Progesterone to balance against Estradiol and Xenoestrogens

47. Estrogen Dominance Stress Diet Other Nutritional Iatrogenic (Doctor-Caused) Environmental Phytoestrogen deficiency Sugars and refined starches Cortisol Anovulatory cycles Immune dysfunction Birth control pills Conventional ERT and HRT Excessive calorie intake Impaired liver function Deficiencies that impair either ovary or mitochondria Estrogen fed to cows and steers Xenoestrogen exposure during embryo phase of life Chronic exposure to xenoestrogens Potential Causes Of Estrogen Dominance

48. Prevention: Increase the Pg/E2 Ratio with progesterone Estradiol levels decline by approximately 40% during menopause, at the same time progesterone levels fall by as much as 90%! Progesterone ◦Opposes effects of estrogen in breast tissue ◦Promotes cell differentiation and inhibits growth of breast cells ◦Promotes normal cell death (apoptosis) by up regulation of p53 ◦Has been shown to protect against breast cancer and treat fibrocystic breast disease

49. Menstrual cycle

50. Dr. John R. Lee, M.D. John R. Lee, M.D. was internationally acknowledged as a pioneer and expert in the study and use of the hormone progesterone, and on the subject of hormone replacement therapy for women. He used transdermal progesterone extensively in his clinical practice for nearly a decade, doing research which showed that it can reverse osteoporosis. Dr. Lee also famously coined the term "estrogen dominance," meaning a relative lack of progesterone compared to estrogen, which causes a list of symptoms familiar to millions of women.

51. Osteoporosis Reversal: The Role of Progesterone. Lee JR. International Clinical Nutrition Review (1990) 10(3). Followed 100 women average age 65.2 for 3 years. All women were treated with 30mg of topical progesterone bid. “It was common to see a 10% increase in the first 6-12 months and an annual increase of 3-5 percent until stabilizing at the levels of healthy 35-year-olds”. The degree of rise was greatest in the patients with the lowest bone density. Concomitant estradiol therapy was not a factor. Patients often noted a return of normal libido.

52. Progesterone modulates the proliferation and differentiation of human periodontal ligament cells Hormone deficiency has been recognized as a risk factor for periodontal disease in postmenopausal women. The anabolic effects of progesterone on human periodontal ligament cells (hPDLCs) needs validating. Our results demonstrated that the PgR is expressed in hPDLCs at the gene and protein level, and that progesterone can stimulate the proliferation and differentiation of the hPDLCs. These findings suggest that progesterone may play a significant role in osteoblastic function of hPDLCs and may influence the maintenance of alveolar bone mass. Yuan et al. CalcifTissueInt. 2010 Aug;87(2):158-67. doi: 10.1007/s00223-010-9377-9. Epub 2010 Jun 9.

53. Progesterone receptor modulates ERa action in breast cancer Progesterone receptor (PR) expression is used as a biomarker of oestrogen receptor-a (ERa) function and breast cancer prognosis. Here we show that PR is not merely an ERa-induced gene target, but is also an ERa-associated protein that modulates its behavior. In the presence of agonist ligands, PR associates with ERa to direct ERa chromatin binding events within breast cancer cells, resulting in a unique gene expression program that is associated with good clinical outcome. Progesterone inhibited oestrogen-mediated growth of ERa1 cell line xenografts and primary ERa1 breast tumour explants and had increased anti-proliferative effects when coupled with an ERa antagonist. Our findings indicate that PR functions as a molecular rheostat to control ERa chromatin binding and transcriptional activity, which has important implications for prognosis and therapeutic interventions. Mohammed H et al. Nature. Published online 08 July 2015, doi:10.1038/nature14583.

54. PR positive research Progesterone is “antiproliferative via a PgR-mediated mechanism in breast cancer cells.” ◦Progestins Inhibit the Growth of MDA-MB-231 Cells Transfected with Progesterone Receptor Complementary DNA Lin VC, Ng EH, et al. Clin Cancer Res (1999) Feb; 5(2):395-403. Progesterone “exhibited a strong antiproliferative effect on at least two breast cancer cell lines. Apoptosis was induced in the progesterone receptor expressing T47-D breast cancer cells.” ◦Progesterone Inhibits Growth and Induces Apoptosis in Breast Cancer Cells: Inverse Effects on Bcl-2 and p53. Formby B, Wiley TS, et al. Ann Clin Lab Sci (1998) Nov-Dec; 28(6):360-9.

55. Pg/E2 Ratio empirically determined Progesterone/Estradiol = Pg/E2 ratio Female reference range: 200-600 Male reference range: 200-300

56. Hormonal decline with menopause Lee J. What Your Doctor May Not Tell You About Menopause

57. CHANG KJ Study Randomized placebo controlled study 40 Premenopausal women scheduled for excisional biopsy (B9) Study groups given either Pg 25mg or E2 1.5mg or both topically qd to the surgical breast (10-13 days before surgery) Fertil Steril 1995 Apr; 63(4):785-91

58. Effect of Transdermal Progesterone and Estradiol on Breast Cell Hormone Concentration

59. Effect of Progesterone and Estradiol on Breast Cell PCNA

60. Another Hormone imbalance Vitamin D ◦Insufficiency is literally an epidemic. New statistics extracted from the National Health and Nutrition Examination Survey (NHANES) found that more than 90% of the population with pigmented skin and 75% of the white population have insufficient levels of vitamin D. 85,000 cases of breast cancer could be prevented in North America alone with sufficient vitamin D levels! ◦A study out of San Diego compiled data on breast and colon cancer and vitamin D levels and found that dosages of 3500 IU/day would reduce breast cancer by 50% ◦Current median adult intake of vitamin D in the US is 230 IU/day Adams JS, Hewison M. Update in vitamin D. J Clin Endocrinol Metab. 2010; 95: 471-8 Garland, Cedric F. et al. What is the dose-response relationship between vitamin D and cancer risk? Nutr Rev. 2007; 65: 91-95. Garland, et al. Vitamin D and prevention of breast cancer: pooled analysis. J Steroid Biochem Mol Biol. 2007; 102: 708-11.

61. Vitamin D Mechanism How does vitamin D prevent breast cancer? ◦Vitamin D binds to a nuclear transcription factor that is also known as a vitamin D receptor (VDR). This complex modulates the transcription of more than 50 genes that promote differentiation and apoptosis and prevents proliferation. Vitamin D: Importance in the Prevention of Cancers, Type 1 Diabetes, Heart Disease and Osteoporosis. Holick MF. Am J Clin Nutr 2004;79:362-71. Vitamin D and vitamin D analogs as cancer chemopreventive agents. Guyton KZ, Kensler TW, Posner GH. Nutr Rev. 2003;61(7):227-238.

62. Vitamin D In addition to being anti-proliferative and pro-apoptotic, vitamin D also exerts action as an aromatase inhibitor and down regulates the expression of estrogen receptors. Vitamin D and breast cancer: Inhibition of estrogen synthesis and signaling. Krishnan AV, Swami S, Feldman D. J Steroid Biochem Mol Biol. 2010 Feb 13. [Epub ahead of print]

63. Vitamin D ◦Insufficiency is literally an epidemic. New statistics extracted from the National Health and Nutrition Examination Survey (NHANES) found that more than 90% of the population with pigmented skin and 75% of the white population have insufficient levels of vitamin D. 85,000 cases of breast cancer could be prevented in North America alone with sufficient vitamin D levels! ◦A study out of San Diego compiled data on breast and colon cancer and vitamin D levels and found that dosages of 3500 IU/day would reduce breast cancer by 50% ◦Current median adult intake of vitamin D in the US is 230 IU/day Adams JS, Hewison M. Update in vitamin D. J Clin Endocrinol Metab. 2010; 95: 471-8 Garland, Cedric F. et al. What is the dose-response relationship between vitamin D and cancer risk? Nutr Rev. 2007; 65: 91-95. Garland, et al. Vitamin D and prevention of breast cancer: pooled analysis. J Steroid Biochem Mol Biol. 2007; 102: 708-11.

64. Iodine It’s not just for your thyroid Breast tissue is the second most concentrated place we find iodine in the body. Japanese women who ingest an average of 13.8 mg iodine/day have one of the lowest breast cancer rates in the world. Rat studies confirm link to iodine deficiency and dysplastic changes in mammary glands. Iodine and mammary cancer. Eskin, BA, Adv Exp Med Biol. 1977, 91:293-304.

65. Deficiency 70% of the world population is estimated to be iodine deficient and Dr. Brownstein found that out of 3,000 patients tested, 95% of them were iodine deficient! Iodine is not in our food! It’s not in our soil and most American’s do not (and shouldn’t) consume enough salt to achieve sufficient iodine levels. There is only 77 mcg of iodine in 1 gram of iodized salt Nutrition Research, vol 24, Issue 12: 1005-1010, S. Elahi, Z. Syed, S Nagra

66. Adding insult to injury… In addition to a lack of dietary iodine, other halogens (chlorine, fluorine and bromine) compete for absorption with iodine symporter. Bromine is more prevalent in environment and is used as a dough softener in bread, found in some soft drinks, toothpastes, cleaning products and more. Fluoride is found in drinking water and tooth care products.

67. Iodine and Breast Cancer Iodine has been shown responsible for altering gene expression that regulates hormone metabolism as well as regulation of cellular growth and differentiation. Stoddard FR et al. Iodine alters gene expression in the MCF7 breast cancer cell line: evidence for an anti-estrogen effect of iodine. Int. J. Med Sci. 2008, 5(4):189-196 Iodine forms iodinated lipids called iodolactones that induce apoptosis and disrupt proliferation. Aceves C, Anguiano B, Delagado G. Is Iodine a gatekeeper of the integrity of the mammary gland? J Mammary Gland Biol Neoplasia 2005 Apr;10(2):189- 96 A study of 108 women showed a 98% reduction in breast pain when treated with iodine for 9 months. Ghent WR, et al. Iodine replacement in fibrocystic disease of the breast. Can J Surg 1993;36:453-460.

68. Screening tests Pros May detect malignancy 1.7 years before breast exam Can detect lesions as small as 12mm Cons Radiation exposure Compromised by dense breast tissue False positives (3-6%) may lead to unnecessary biopsy Mammography Ultrasound is generally performed if palpable breast lump or abnormality found on screening test Thermography Pros No radiation May show early changes up to 8 years before mammography would detect Painless – even in women with FBC Inexpensive Cons May not be covered by insurance Not available in all areas May lead to unnecessary biopsy

69. Thermal imaging Metabolic activity and vascular circulation in both pre-cancerous tissue and the area surrounding a developing breast cancer is almost always higher than in normal breast tissue. In an ever-increasing need for nutrients, cancerous tumors increase circulation to their cells by holding open existing blood vessels, opening dormant vessels, and creating new ones (neoangiogenesis).neoangiogenesis This process frequently results in an increase in regional surface temperatures of the breast. DITI uses ultra-sensitive medical infrared cameras and sophisticated computers to detect, analyze, and produce high-resolution images of these temperature variations. Because of DITI’s extreme sensitivity, these temperature variations may be among the earliest signs of breast cancer and/or a pre-cancerous state of the breast. Gautherie M. Thermobiological assessment of benign and malignant breast diseases. Am J Obstet Gynecol. 1983; 147: 861-69. Gamigami P. Atlas of Mammography: New Early Signs in Breast Cancer. Blackwell Science. 1996. Keyserlingk J. Time to reassess the value of infrared breast imaging? Oncology News Int. 1997; 6. Ahlgren P, et al. Is it time to reassess the value of infrared breast imaging? Primary Care & Cancer (NCI). 1998:18. Belliveau N, et al. Infrared imaging of the breast: initial reappraisal using high-resolution digital technology in 100 successive cases of state I and II breast cancer. Breast J. 1998; 4.

70. Thermography follow-up Estrogen dominance Before and after Kajarin progesterone cream x 3 months

71. 49yo Caucasian female. MRI December 2015 WNL History of DCIS. Treatment: Topical progesterone 20mg bid, Vit D3 5000iu, Iodine 12.5mg and vascular

72. 61yo female. Only VitD3 3000iu/day

73. THE BIG SQUEEZE A SOCIAL AND POLITICAL HISTORY OF THE CONTROVERSIAL MAMMOGRAM By Handel Reynolds, MD Cornell University press, Copyright 2012 “One fifth of the 2.5 million breast cancer survivors in the US carry a diagnosis of ductal carcinoma in situ (DCIS). 50,000 woman each year receive this diagnosis” “DCIS has 10 year survival rate of 98%”

74. Growing Use of Contralateral Prophylactic Mastectomy Despite no Improvement in Long-term Survival for Invasive Breast Cancer. We identified women diagnosed with unilateral stage I to III breast cancer between 1998 and 2012 within the Surveillance, Epidemiology, and End Results registry. Of 496,488 women diagnosed with unilateral invasive breast cancer, 59.6% underwent breast-conserving surgery, 33.4% underwent unilateral mastectomy, and 7.0% underwent CPM. Overall, the proportion of women undergoing CPM increased from 3.9% in 2002 to 12.7% in 2012 (P < 0.001). The use of CPM more than tripled during the study period despite evidence suggesting no survival benefit over breast conservation. Further examination on how to optimally counsel women about surgical options is warranted. Wong, SM, et al. Growing Use of Contralateral Prophylactic Mastectomy Despite no Improvement in Long-term Survival for Invasive Breast Cancer. Annals of Surgery. 2016 March 8 (Epub ahead of print.)

75. Substantial contribution of extrinsic risk factors to cancer development Recent research has highlighted a strong correlation between tissue- specific cancer risk and the lifetime number of tissue-specific stem-cell divisions. Whether such correlation implies a high unavoidable intrinsic cancer risk has become a key public health debate with the dissemination of the ‘bad luck’ hypothesis. Here we provide evidence that intrinsic risk factors contribute only modestly (less than ~10–30% of lifetime risk) to cancer development. First, we demonstrate that the correlation between stem-cell division and cancer risk does not distinguish between the effects of intrinsic and extrinsic factors. We then show that intrinsic risk is better estimated by the lower bound risk controlling for total stem-cell divisions.= Finally, we show that the rates of endogenous mutation accumulation by intrinsic processes are not sufficient to account for the observed cancer risks. Collectively, we conclude that cancer risk is heavily influenced by extrinsic factors. These results are important for strategizing cancer prevention, research and public health. Wu S, Powers S, Zhu W, Hannun Y. Substantial contribution of extrinsic factors to cancer development. Nature 2016 Jan 7;529(7584):43-7 doi:10.1038/nature16166

76. Test, Treat, Retest Comprehensive Plus Panel EQ is highly useful for determining when to employ additional anti- estrogenic therapies, anti-aromatase and E1 and E2 detoxification aiding therapeutics as well as assessing the need for E3 therapy PG/E2 ratio is first line look and evaluation for assessing estrogen dominance and progesterone deficiency Labs Vitamin D, Lipids, CMP, Thyroid Thermography Use this information to guide additional screening, treatment

77. What does all of this mean? Women don’t have to live in fear of breast cancer. There is much that can be done to optimize breast health and PREVENT breast cancer. Even for women with genetic susceptibility (BRCA mutations, positive family history), prophylactic mastectomy is NOT the answer.