Breasts (16 page)

A major challenge in developing a fake-pregnancy drug is finding the right dose. “When you’re pregnant, you have astronomical levels of steroids,” Pike continued. “Absolutely astronomical. Before pregnancy, you might have 100 units of estrogen in your blood, and when you’re pregnant, you’d have 10,000 units or more. If I gave you that by mouth, you’d die. So a number of us are fiddling with it. It will still be a long time in the future. It’s the early days yet of chemoprevention.”

THE PREGNANCY EFFECT SOUNDS LIKE A SLAM DUNK: YOU GET
high levels of hormones, you’re protected for life! Except that it’s not a slam dunk. There’s a lot of fine print. For example, the abortion exemption. You might think that if these pregnancy hormones are so great, then women who’ve had abortions are also protected,
because they too enjoyed the spiking hormones of early pregnancy. The evidence, though, seems to suggest that this does not happen. Some years ago, a distinguished researcher named Janet Daling published results of a study suggesting that women who got abortions before the age of eighteen were
more
likely to get breast cancer, not less. A few other studies found similar results. The right wing seized upon this data, gleeful to have another reason to condemn abortion. Pro-life groups even sought legal action requiring that abortion be mentioned
as a cause of breast cancer
to any woman seeking abortion. Early in the George W. Bush administration, the federal National Cancer Institute’s website proclaimed that abortion could increase a woman’s risk of breast cancer.

Then in 2003, the National Cancer Institute convened a panel to sort through the evidence. It concluded that abortion did not increase a woman’s risk, and that studies to the contrary were damaged by “recall bias,” one of the notorious bad sisters of scientific method. Here’s how these studies are typically conducted: You interview a bunch of women, say in their fifties, some of whom have had cancer and some of whom haven’t. The catch is that the ones with cancer are much more likely to come clean about past indiscretions. In other words, as Pike described it to me, “abortion gives you breast cancer if you’re Catholic, but doesn’t if you’re not.” It appears the non-cancer Catholics simply lied about past abortions. Ah, the joys of epidemiology! No wonder these things are hard to sort out.

In any case, no one can claim that abortion
protects
you from cancer, nor do natural miscarriages. It seems a full-term pregnancy is needed for the breasts to fully differentiate. Which renders the high-dose, short-term faux-pregnancy therapies a big question mark, to say the least.

…

AROUND ABOUT THE 1980S, SOME DOCTORS BEGAN NOTICING AN
unexpected pattern: young women who had been pregnant in recent years were
getting
breast cancer. Rather than being protected by pregnancy, some women were experiencing the opposite. These women tended to be relatively older when they had their first child, and they tended to suffer from premenopausal breast cancer. What if the protective effect of pregnancy was just a myth or, at best, a historical relict?

In the mid-1990s, Pepper Schedin was, like so many other researchers, studying the storied protection offered by pregnancy. Everyone knew the breast goes through massive changes in pregnancy, but Schedin thought it might be worth looking at the massive changes that occur
after
pregnancy (or for those women who breastfeed their babies, after lactation), when the breast regresses back to a “resting” state. This process is called involution, or the massive loss of cells and structures that were part of the dairy machinery. In fact, 80 percent of the glorious pregnant breast gland simply disappears. Its ability to practically vanish overnight is yet another unique and strange feature of breasts. Schedin thought perhaps this was why mothers might not get breast cancer; perhaps nascent tumors were zapped out during this epic house cleaning.

She ran some experiments and found that while normal cells were indeed killed during involution, breast cancer cells were, startlingly, promoted. “Oh man, was that a surprise,” she said. Just around that time, Schedin was contacted out of the blue by an old friend who had recently borne twins. The friend, who was in her thirties, had just been diagnosed with metastatic breast cancer. “I
thought, huh, that’s strange. It went against everything I’d ever heard. Pregnancy was supposed to be protective. Nobody ever mentioned it wasn’t. So I went back and looked in the literature, and there it was: a small body of work on pregnancy-associated breast cancer, and no one knew why it was happening.”

As far back as 1880, Samuel Gross, the surgeon subject of the celebrated Thomas Eakins painting
Gross Clinic,
noted that after pregnancy, breast cancer “was wonderfully rapid and its course excessively malignant.”

The phone call changed Schedin’s life. She now works in the young woman’s breast cancer program at the University of Colorado’s Anschutz Medical Center in Denver. Her office was decorated with framed photos of mammary gland cells and a giant poster of the well-known U.S. Postal Service breast cancer stamp. On a corner of her desk sat a 1915 microscope that her brother found in a junk shop.

Over the years she has made some interesting discoveries, most having to do with how the molecules of the breast talk to one another during involution. Remember, the breast gland doesn’t just perch in an empty vacuum. It’s a resident in a busy neighborhood filled with fat, collagen, and extracellular matrix, a rainstorm of proteins, hormones, and other material. Schedin has found that during involution, this matrix orchestrates a type of inflammation. Most of us are familiar with inflammation—it’s what happens when a paper cut gets red and swollen or when we bump into the table and get a bruise. Immune cells rush to the injury and help repair it and battle infection. A similar thing happens to the retreating breast gland after lactation: macrophage immune cells swarm in to help clean the old gland and remodel the remaining tissue.

The problem is that sometimes our milk ducts have weird little
not-quite-normal growths in them. Usually it’s not a big deal, but sometimes these growths, or lesions, break free of the duct for reasons nobody entirely understands, tap into blood veins for nutrients and oxygen, and grow like bananas. Hello, cancer. This jailbreak appears able to happen during involution, promoted by the inflammatory environment. Schedin calls this the “involution hypothesis.” It’s just a theory, one of several, but she likes it. Older women are more likely to have these precancerous lesions in their ducts (perhaps thanks to their long years of environmental exposures); hence they’re more likely to unleash cancer after their pregnancies.

So while young mothers may indeed be protected by pregnancy, old mothers are not. In fact, mothers who give birth after thirty have a slightly higher risk of breast cancer than women who never have children. That’s right: if you heard nuns had it bad, older moms have it worse. And the types of cancers these moms get are more aggressive. A study in 2011 found that the more times a woman gives birth, the higher her risk of “triple negative” breast cancer. A cancer subtype making up about 10 to 20 percent of all breast cancers, these tumors do not express receptors for estrogen or progesterone, meaning they are more resistant to treatment and more deadly. (By contrast, postmenopausal breast cancers tend to be slower growing and can often be treated with hormonal therapies.) Women who have never given birth have a 40 percent lower risk of this type of breast cancer.

For the legion of us who had kids late in the game: bummer. Fortunately, pregnancy-associated breast cancer, called PABC, is still quite rare. In the United States, about 3,500 cases are reported per year, but under the standard definition a cancer has to be diagnosed within one year of pregnancy. Schedin fiercely disputes this definition and says pregnancy-related factors are still very much at
work for many years after delivery. She thinks the risk goes up for five and maybe even ten years after pregnancy. “It’s far more common than the stats let on,” she said.

Sturdy and fit, with shoulder-length brown hair and glasses, she walked me through the eighth-floor lab overlooking east Denver. We passed a bank of freezers calibrated to –80 degrees Celsius (–112 Fahrenheit), the magic temperature for preserving the code of life, the RNA, in tissue samples. The tissue culture room smelled vaguely of cough syrup and sported a photo on the wall of a goofylooking baby wearing a pink hat, below which exhort the words “Find a Cure before I Grow Boobs.” The scientists here know they’re working to help real people, thanks to their partnership with the university hospital and the young women (generally under forty) who proffer their cancer cells for research. In return, the lab tries to come up with therapies that will help these women before another forty years go by in the war against cancer. Schedin called this mission “Bench-to-Bedside.”

If she’s right and inflammation is causing trouble, Schedin wants to know what happens if you reduce it by taking ibuprofen, or fish oil, or other anti-inflammation substances. She’s setting up a trial to find out. Another translation to the real world Schedin is willing to bet on: new mothers should get screened for breast cancer. Right now. They make up another high-risk group, she said, just like women over fifty or women with a family history of the disease.

She finds it unfortunate that the pregnancy-as-protective camp dominates much of the field. A street-tough Chicago girl who litters her words with expletives, Pepper is aptly named. “Not everyone agrees with me, but we need to let the science speak for itself,” she said. “Pregnancy-associated breast cancer is too devastating to
ignore.” She’s grateful that her work has led her to think of the breast in a whole new way, as a highly responsive organ whose signals get easily crossed. “I consider the gland plastic and poised to respond to signals because it needs to be quick to respond to pregnancy,” she said.

If the breast needs to be responsive in pregnancy, it’s because it’s preparing for its big-night out, its very
raison d’être:
breast-feeding. All its 200 million years of evolution and all its individual months and years of construction and signaling and wiring are for this event. Nowhere is the breast more responsive and more conversant and more mind-blowingly intelligent than where there’s an actual baby on tap.

First we nursed our babies; then science told us not to. Now it tells us we were right in the first place. Or were we wrong then but would be right now?

— MARY MCCARTHY,
The Group

I
DIDN’T BOTHER TO READ THE SECTIONS IN THE PREGNANCY
books about breast-feeding. I was much more concerned about the pain and blood and gore of childbirth. I got stuck on the terrifying bit about pushing a head the size of a bowling ball through what was now bluntly called “the birth canal.” I found that part so colossally distracting that I waved off what the books call the fourth stage of childbirth: lactation. I was a mammal. How hard could it be? I would flip through those sweetly illustrated sections later if I made it through the delivery alive.

How wrong I was.

What I didn’t know, what I couldn’t know, was that childbirth ended up being the easy part. It turns out I was a bit of a champ at it. Nurses filed into my room to watch my breathing technique. In between contractions, they talked about real estate. I didn’t
need drugs; I didn’t even accept an Advil when it was over. “You’re tough,” said my doctor, shaking his head. My son was beautiful, if a little orange looking. My pride swelled.

But then came the pain and the blood, and it came from breast-feeding, the part of the deal that was supposed to be all saccharine and drenched with love hormones. The first time Ben latched on was wonderful, a little strange, but the fact that he knew what to do seemed a miracle. His strong little mouth created a vacuum like a particle accelerator. The second time he latched on, it hurt, and the third time, it hurt more. My nipples grew inflamed, then formed canyons of fissures, then bled. They looked mangled. I couldn’t wear a shirt, much less a bra. My mother-inlaw came to visit, and I staggered around the house looking like a crazy bleeding topless person who’d had an unfortunate accident with farm equipment.

I was doing it all wrong. What I learned the hard way is that neither women nor babies “know” how to breast-feed, despite this enterprise being a fundamental part of our humanity. (To be fair, the babies know more than the mothers. Studies have shown that right after birth they are capable of a heroic “crawl” to the nipple, which might be colored extra dark for their blurry-eyed benefit.) If we human mothers once instinctually knew how to nurse babies, we lost it along with things like the ability to make vitamin C. Through our evolving social context, we learned from each other how to eat foods with vitamin C and how to tickle an infant’s chin so his mouth will open bigger for breast-feeding. Now, though, we have lost the social transmission that came from living in kin groups. We are replacing it with the paid profession known as “lactation consultant.”

Mine was named Faylene, and she made house calls. Friendly but no-nonsense, she showed me the football hold, the lying-down hold, even the upside-down hold (the baby, not me). She helped me open my son’s mouth wider and stuff more of my areola in it, and she showed me how to gently break the force-of-nature suction with my pinky when it was time to stop. It was bewildering, but I was getting the knack. Then a relative noticed my son was now even more orange hued. He was diagnosed with a condition called breast-milk jaundice, in which some unknown component of my milk was temporarily interfering with the ability of his liver to break down bilirubin. A pediatrician told us that if this weren’t corrected by a twenty-four-hour break from breast milk and immediate application of artificial light to his skin, he would suffer brain damage.

We fed him formula from a bottle for a day and a night while I tried to pump my engorged breasts. When it was time for our reunion, Ben looked at my nipple like it was a foreign metal object. Faylene told me this is called “nipple confusion.” I called her back for more body contortions and face stuffing to reacquaint Ben with the real deal. We were finally getting everything sorted out on day 10 when I suddenly felt like I was going to die. My temperature spiked to 104 and my right breast turned to red, hot cement. I went to the emergency room. I had mastitis, a blockage or inflammation of a milk duct that triggers a systemic infection. I needed antibiotics, and I needed them fast. I couldn’t help but wonder how humanity had made it this far. What happened to cave women with yellow babies and clogged ducts and no ER? Breast-feeding may have helped the species evolve, but not before killing off a good percentage of its mothers with what used to be called “milk fever.”

I would get mastitis three more times that first year. I’m not sure what propelled me to stick it out. Faylene, probably, and a dogged sense of granola-girl duty. But then, once the agony ceased, I found I really liked breast-feeding. In fact, I loved it. Ben and I would settle into our bright-yellow glider at all hours of the day and night. I learned about things that went on along my street at four in the morning that I never imagined. Sometimes I flipped through a magazine or just marveled at my son’s now-porcelain skin. I loved the surges of prolactin, a gentle stoner hormone, and of oxytocin, which, as one writer describes it, produces “slight sleepiness, euphoria, a higher pain threshold, and increased love for the infant.” I loved the lazy intimacy with my son, and the way he panted and flapped his arms with joy when it was time for dinner.

We were a team. After that first mastitis episode, I gave up pumping. My ducts seemed to clog up too easily, and my son would never take a bottle again anyway. Put in the cold terms of economics, pumping allows women and babies to decouple supply and demand. At the same time, they can decouple themselves, which can be very convenient. If you pump and freeze (as opposed to pump and dump), there’s enough for a dry day or an extended absence from your baby, or a chance for your partner to bottlefeed in the middle of the night. Since such arrangements were not to be in our household, we had to be in perfect sync. There was an urgent, immediate need for my breasts to be in good working order. What my breasts cooked up, my baby ate on the spot. When the baby had a growth spurt and fed more frequently, my breasts magically responded by stepping up production. My husband, well rested every night, was just fine with this arrangement.

“Lactation is a father’s best friend,” he said, heading happily off to work. It’s yet another reason for men to like breasts. It’s yet another reason for new mothers to want to throttle their husbands.

My pediatrician wore red Converse high-tops and a graying ponytail. When I complained to him in the early months that my son woke up every two or three hours for a feed, he looked at the baby and said, “You little shit.” Then he explained that’s the way it’s supposed to work. Too many parents expect their babies to sleep through the night; it’s probably one of the factors driving the use of formula, which takes the baby longer to digest.

I always knew I would breast-feed, and most of my peers would consider it a near felony not to, even though few of us were breastfed as babies. My mother nursed me for all of four weeks. I know this because I’ve inherited her journals. There’s one labeled, “F Feeds.” It was the late 1960s, when only 20 to 25 percent of all American women tried nursing. This era represented the formula companies’ strongest headlock on mothers and pediatricians, a time when the science (and profits) of nutritive molecules trumped the fumbling art of breast-feeding. My mother, normally an intuitive spirit with a high disregard for paperwork of any kind, must have been influenced by the men in lab coats. Her journal reads a bit like a high school science log:
Mar 20, 1:15pm: L breast
—
15 mins. R breast
—
12 mins.
No wonder she gave it up.

By then, breast-feeding rates had been declining steadily since the postwar baby boom, falling by half from 1946 to 1956 as mothers readily turned to the science of the bottle. Today, some breast-feeding advocates—the lactivists or nutricionistas, as they’re sometimes called—make you out to be a freak of nature if you don’t breast-feed. Historically, though, this is inaccurate. As “natural”
as breast-feeding is, there has always been a cadre of women who couldn’t or wouldn’t do it, for either physiological or cultural reasons. Humans are the only mammal for whom not lactating is occasionally an option (although elephants, foxes, and primates have been known to nurse each other’s young). Archaeologists have found four-thousand-year-old graves of infants buried beside ancient feeding vessels lined with residue of cow’s milk. (It’s no wonder the infants died; for most of our history, not being nursed by someone usually meant a death sentence.) Sometimes mothers couldn’t nurse because they had died in childbirth, or their milk dried up after a breast infection, or they were ill. Syphilis, which could be transferred to the baby from the mother during breastfeeding, deterred many in Europe after the Middle Ages. Even fashion posed a problem; the tight corsets of the Restoration were known to flatten or even invert women’s nipples. And once the industrial revolution started, many working-class women took jobs away from their homes and babies.

Into these voids marched professional men with their half-witted and highly politicized ideas. Pliny and Plutarch were opposed to the practice of hiring wet nurses, but Plato loved the idea, “while taking every precaution that no mother shall know her own child.” Good thing he stuck to philosophy. Many ancient pundits and doctors offered suggestions for finding the best nurse: she should be cheerful and not deranged, and she should have a strong neck and moderately sized breasts, according to Avicenna in the eleventh century. Babylonia’s Code of Hammurabi, circa 1750 BC, was specific about laws and punishments for errant wet nurses: “If a man has given his son to a wet-nurse to suckle, and that son has died in the hands of the nurse, and the nurse, without
consent of the child’s father or mother, has nursed another child, they shall prosecute her; because she has nursed another child, without consent of the father or mother, her breasts shall be cut off.”

Engaging the services of a wet nurse wasn’t always the result of dire necessity. The practice was very fashionable in the upper classes of many societies across much of recorded history, probably because it was known to increase the fertility rate of the mother. Prolactin, one of the key hormones triggered by breast-feeding, suppresses ovulation. Nature was wise in this birth-spacing design. Even today, a child born in a developing country less than two years after an older sibling is almost twice as likely to die as a child born after a longer spread. Wet-nursing not only allowed mothers to dodge nature’s duties but also resulted in some serious social engineering. While the rich procreated annually, poor women—the wet nurses—often “dry-fed” gruel to their own babies, resulting in huge mortality rates; meanwhile, their own fertility was squelched by their line of work. (This contraception, though, came in handy as some wet nurses moonlighted as prostitutes.)

The natural functioning of breasts has been upended by culture for a long time. While some mothers ducked out of breastfeeding, others were transformed into virtual dairy cows. In Dickensian foundling hospitals established for abandoned babies, wet nurses fed dozens of infants, nursing as often as thirty-four times a day. Sometimes the babies were fed a supplement of rancid cow’s milk and flour. The results were grim; death rates in foundling hospitals in the eighteenth and nineteenth centuries ran as high as 90 percent. Even for the urban middle and working classes, who farmed their babies out to wet nurses in the country,
mortality rates reached 50 percent. Jane Austen’s story was typical. Three months after she was born in 1775, her parents sent her off to the nurse’s house, as they had her siblings before her. “When they approached the age of reason and became socially acceptable, they were moved again, back to their original home,” wrote Austen’s biographer Claire Tomalin. For harried parents, it was a rather appealing if appalling arrangement: pop the children out, send them off packing, and bring them back when they’re big enough to do some chores. Some sources claim this is where the term
farmed out
derived.

Dry-feeding, despite its disastrous results, was also rather common because it was cheaper than hiring a wet nurse. Many mothers throughout the ages suffered either real or perceived bouts of insufficient milk, and so they would resort to feeding babies some sort of mash as a milk supplement or total replacement. (Breast-feeding is an ingeniously calibrated feedback loop, and it’s not always forgiving. Once you embark on the slippery slope of supplemental feeding, milk production can taper precipitously.) Many recipes were handed down the generations for the ideal food, usually involving some sort of milk, water, grain, and sugar. Occasionally wine or spirits, cod liver oil, and opium were added. Before the days of refrigeration and pasteurization, such cocktails were at best a dicey proposition for infants, who have immature immune systems. Of the dry-fed kids who survived, many had scurvy, rickets, and iron or other mineral deficiencies.

It’s not surprising that by the end of the nineteenth century, medical professionals, who had increasingly elbowed their way into the realm of midwives, would also turn their attention to infant food. Motivated by high mortality rates due to malnutrition and
intestinal disease (and seeking to cement their own job security), leaders in the field actively recommended that doctors replace “old women” and “uneducated nurses” when it came to overseeing the infant diet. In fact, the growth of the pediatrics field at the turn of the twentieth century was predicated on infant nutrition. In 1893, the medical lecturer John Keating called it “the bread and butter” of the profession. These doctors tinkered with their own formulations for milk substitutes and readily experimented with offerings in the growing marketplace. Mothers had to visit the doctors regularly to get access to the food, which was available only by prescription. Together, the formula companies and the doctors reinforced each other’s businesses.

Two major developments around this time nudged the creep away from breast-feeding. One was the rise of manufacturing, which allowed formula companies to produce large amounts of relatively consistent product. Henri Nestlé was a young chemist and merchant surrounded by dairy cows in Vevey, Switzerland. In 1867, he concocted his Farine Lactée Nestlé. He described his Milk Food as “good Swiss milk and bread, cooked after a new method of my invention, mixed in proportion, scientifically correct, so as to form a food which leaves nothing to be desired.” By the 1870s, the product had gone global. (Now, 140-plus years later, formula has propelled Nestlé to being the largest food company in the world.)