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Breast Cancer in Young Women

Breast cancer is the most common malignancy in women after non-melanoma skin cancer.. It is estimated that 192,370 women were diagnosed with breast cancer in 2009. When we talk about breast cancer in young women, we usually refer to those younger than 50 years of age. Recently, the focus has turned to women younger than 45 year of age who have unique issues. Breast cancer is the leading cause of cancer related deaths in women under 40 years of age. This is despite the fact that breast cancer is relatively rare in young women and they usually receive more aggressive therapy than older women. Most cases of breast cancer in young women are spontaneous and are not associated with a specific carcinogen, environmental factor, or a known genetic mutation.

Screening Guidelines from the American Cancer Society

  Beginning in the 20's women should be told about the benefits and limitations of breast self-examination (BSE). If she chooses to do a BSE the technique should be reviewed with a health care professional. Self-awareness has been shown to be beneficial in detecting breast cancer
  For women in there 20's and 30' s, a clinical breast examination should be a part of a periodic health examination
  Asymptomatic women aged 40 and older should continue to receive breast clinical exams, preferably annually
  Begin annual mammography at the age of 40
  Women who have a lifetime risk of 20% to 25% of developing the disease should undergo annual screening with breast MRI in addition to mammography and breast ultrasound. The risk can be calculated by a health professional using one of the various models of breast cancer risk analysis

Epidemiology

Although breast cancer is infrequent in young woman, it does happen. There are often signs and symptoms, however women tend to ignore them.. More recently, greater efforts have been made to help women at a younger age understand the importance of being aware of the possibility of breast cancer.

According to the most recent statistics from the American Cancer Society (2009- 2010), the estimated new female breast cancer cases in women younger than 45 years of age is 18,640/ year. The estimated new breast cancer annual death rate in this same age group of young women is 2,820. If the current age of a woman is 20 her probability of developing breast cancer in the next 10 years is 0.06% or 1 in 1,760. This figure goes up to 0.44% or 1 in 229 if the age is 30 and 1.44% or 1 in 69 if the age is 40 years.

  "You Are Too Young To Get Breast Cancer"
SIMPLY NOT TRUE.....

 

Risk Factors

Family history is a primary risk factor for developing breast cancer at a young age. A history of chest radiation therapy during childhood or adolescence poses an absolute lifetime risk for developing breast cancer of 15% to 25%. Several rare genetic disorders may predispose young women to develop breast cancer.

  BRCA1 or BRCA2 Gene Deleterious Mutation
  The Cowden Syndrome
  Hereditary Diffuse Gastric Cancer
  Ataxia-Telangiectasia
  The Li Fraumeni Syndrome
  The Peutz-Jeghers Syndrome

Tumor Characteristics in Young Women

Younger patients are at an increased risk of dying from breast cancer than older patients. The 5-year relative survival rate is lower among women diagnosed with breast cancer before the age of 40 (83%) as compared to women who are diagnosed at the age of 40 or older (90%). We know that younger women have more aggressive disease, but we do not know if being "young" is in itself a risk factor for more aggressive tumors. The difference in outcome may reflect:

  More aggressive disease in younger women
  The tumors are more likely to be high grade, hormone receptor negative, HER2neu positive, and to have more lymphovascular invasion
  Young women are more likely to be diagnosed with larger tumors and greater lymph node involvement. A possible explanation is that they are at a lower risk to develop breast cancer and are not screened as regularly as older women. They have denser breast tissue that make mammography less reliable and may miss the tumor
  In general, breast cancer in young women may be less responsive to conventional therapy than in postmenopausal women

This potentially life-threatening disease is difficult for anyone who may be faced with this diagnosis. A diagnosis of breast cancer is fraught with special challenges for young women, which include physical, psychological, and financial challenges. These will be issues that must be faced for the rest of their life.

  Young women are less likely to have completed their education
  Young women may be starting a new career
  Young women may have a new relationship or may not have started one yet
  Young women are less likely to have children or have completed their families prior to diagnosis
  Young women may have young children for whom they are responsible
  Young women may wish to have biological children and breast cancer treatment may cause infertility

Surgical Treatment

Generally, young women with breast cancer have the option to either preserve their breast or opt for a mastectomy. Although young age is a risk factor for local recurrence for both invasive and non-invasive disease, it is not a contraindication to breast conservation. The same principles of breast conservation as in older women apply: the margins of resection must be free of tumor, while preserving adequate cosmesis of the breast. Margin status is particularly important in young woman undergoing breast conservation. A positive margin is associated with a higher incidence of both local recurrence and distant disease. Overall, the results in terms of survival are the same as in the treatment group of mastectomy and lumpectomy. Not every patient, including older and younger women, is a candidate for breast conservation. Each case is unique and must be evaluated by the breast cancer team prior to making a final decision.

Fertility

A young woman with breast cancer faces the risk of infertility following therapy. The risk of menopause is related to the age of the patient and the treatment received. The older the patient the higher risk of permanent infertility. This fact could have devastating effects for some women. The cancer specialist should have an open discussion with the patient prior to commencing her systemic therapy. Cancer patients should be informed of options for fertility preservation and future reproduction prior to cancer treatment. The patients interested in future childbearing should be referred to a fertility specialist, who can offer further counseling and management. Some patients may wish to have children in the future and elect to preserve their fertility. Embryo cryopreservation is the most efficacious and well-studied fertility preservation strategy. Options for fertility, some of which are experimental, may include:

  Embryo cryopreservation
  Sperm cryopreservation in men
  Oocyte cryopreservation
  Ovarian tissue cryopreservation
  Gonadotropin-releasing hormone (GnRH) agonist

Definition of Menopause in Breast Cancer Patients

Reasonable criteria for determining menopause:

  Prior bilateral oophorectomy
  Age > 60 years of age
  Age < 60 years of age and
  Amenorrhea for 12 months in the absence of chemotherapy, tamoxifen... or ovarian suppression with FSH and estradiol levels in post menopausal range
  If taking tamoxifen and age < 60 the FSH and estradiol levels in post menopausal range

Caveats:

  Not possible to assign menopausal status in those taking an LHRH antagonist or agonist
  Amenorrhea after chemotherapy does not guarantee postmenopausal state
  For women with therapy-induced amenorrhea and in who aromatase inhibitor therapy is considered, serial FSH and estradiol levels should be obtained to assure postmenopausal status