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Breast Cancer in Young Women

 

Dealing with breast cancer is difficult at any age, but a diagnosis of breast cancer at a young age can be particularly challenging because it is so unexpected and because of the unique issues facing young women with breast cancer. Although breast cancer risk increases with age, of women newly diagnosed with breast cancer in the United States, about 11% are under age 45 and 6% are under 40, according to the American Cancer Society. More than 13,000 women age 40 or under will be diagnosed this year.

 

At the Chevy Chase Breast Center, we provide state of the art treatment designed to meet the specific needs and challenges of each young woman with breast cancer. We create a multidisciplinary team of the most respected specialists with expertise in treating young women with breast cancer, tailored to each woman’s circumstances.

 

Unique challenges

 

Young women with breast cancer face unique challenges which must be recognized and addressed. At time in one’s life when priorities typically center on family and career, complex issues of breast cancer diagnosis, treatment, recovery and survivorship take precedence. Furthermore these issues can affect choices regarding one’s family and career. These issues include implications for fertility/ pregnancy, premature menopause, psychosocial issues, sexuality and body image, genetics and cancer risk, treatment specifics and prognosis for young women with breast cancer. Because most young women with breast cancer are treated successfully, issues of long term side effects are important. 

 

Fertility/ pregnancy

 

Breast cancer treatment can affect fertility, the ability to become pregnant, in a variety of ways. This is often a crucial issue when a woman of child-bearing age is diagnosed with breast cancer.

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Chemotherapy can affect the cells in the ovaries, making it harder to become pregnant. Ovaries that have stopped producing eggs during treatment may or may not start functioning again. Chemotherapy and hormone therapies such as tamoxifen can reduce fertility by making periods come less often or stop. Sometimes, the loss of fertility is temporary, and the ability to get pregnant returns after treatment is completed, but in other cases, it is permanent. In women whose periods return, treatment can shorten one’s child-bearing years. Tamoxifen is often taken for many years and during this time, women should not become pregnant because of the possibility of birth defects.

 

Chemotherapy has the potential to cause early menopause which can also prevent one from becoming pregnant. This is more likely for women who are older than 40 during treatment and also depends on the type of chemotherapy. Women younger than 40 at the time of treatment are more likely to have their periods return after chemotherapy. However, early menopause limits the number of years one is able to get pregnant.

 

Fortunately, there are steps to take before treatment begins which can help preserve the ability to have children. One option is to freeze ova (eggs) or fertilized embryos and store them until treatment is finished. The eggs are collected over a number of menstrual cycles. Fertilized or unfertilized eggs can be frozen and stored. After treatment, embryos can be implanted into the uterus with a good chance for a viable pregnancy.

 

Certain drugs like goserelin (Zoladex) and leuprolide (Lupron) can be used during chemotherapy to suppress the ovaries, which may protect the ovaries and reduce the risk of early menopause.

 

If you know you want to have a child, it is essential that the effects of breast cancer treatment on fertility are considered before starting treatment. We recommend reproductive endocrinologists, doctors who have expertise with fertility and pregnancy in women with breast cancer, who work with our patient’s obstetricians and gynecologists and medical oncologists, to preserve fertility in our patients who wish to have children after treatment. Consulting with a fertility specialist early increases the range of options available to preserve fertility.

 

Premature menopause

 

Treatment such as chemotherapy sometimes puts young women into premature menopause. This can cause symptoms such as hot flashes, vaginal dryness, urinary tract infections, painful sex, and/or alterations in mood.  Premature menopause and the inability to use hormone replacement therapy can increase one’s risk for osteopenia or osteoporosis.  We work closely with gynecologists to be sure that symptoms associated with premature menopause are managed in a way that it does not conflict with breast cancer recurrence risk or treatment.

 

Psychosocial issues/ sexuality

 

Younger women may not have support systems to help handle the physiological and psychological issues of treatments. Physical, emotional or sexual intimacy can be difficult. A breast cancer diagnosis, changes in body image, and treatment effects can lower one’s sex drive or make one feel too sick, tired or overwhelmed to be intimate.

We can recommend a psychologist or psychiatrist sensitive to psychological and emotional issues associated with breast cancer. We can provide access to support groups for young women with breast cancer.  

 

Body image

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We use of variety of surgical techniques to obtain the best possible cosmetic outcome in patients having lumpectomies.  For our patients who have mastectomies, we have access to the finest reconstructive surgeons who offer a full spectrum of options for breast reconstruction, from implant-based reconstructions to reconstructions which use one’s own tissues (flap reconstructions).  We can refer our patients to medical oncologists who use cold caps to minimize chemotherapy-related hair loss.  We provide our patients with contact information for organizations which assist with wigs, makeup and clothes during and after treatment.

 

Nutrition and exercise

 

Maintaining an optimal body weight, eating a healthy diet, and exercising regularly may reduce the risk of a breast cancer recurrence. We work with nutritionists who can help you with a healthy diet and/or weight-loss. We have information for exercise groups designed for women with breast cancer, with options as diverse as yoga or dragon boat racing for breast cancer survivors.

 

Genetics

 

Young women with breast cancer need genetic counseling and genetic testing. We work with a nationally-recognized lab which offers comprehensive genetic testing for cancer-associated genetic abnormalities. This lab provides high-quality results quickly and has options to minimize costs, especially if genetic testing isn’t covered by insurance. We refer our patients to geneticists with expertise in genetic counseling for cancer- associated mutations, such as BRCA mutations. Some genetic mutations have a significant impact on treatment decisions, and a genetic counselor can be helpful in navigating the impact of a genetic mutation on short- and long- term decisions about cancer monitoring and treatment.

 

Breast cancer risk 

 

Some woman younger than age 45 have a higher risk to develop breast cancer at an early age: If a woman has close relatives with breast or ovarian cancer who were diagnosed younger than age 50, multiple relatives with breast and/or ovarian cancer, male relatives with breast cancer, or relatives with bilateral breast cancer. Having a BRCA1 or BRCA2 gene mutation significantly increases risk for breast and other cancers. Being of Ashkenazi Jewish descent increases risk for a BRCA mutation, especially if there is a family history of breast, ovarian, pancreatic or colon cancer. A history of radiation therapy to the breast or chest in childhood or early adulthood, for example for lymphoma, can raise breast cancer risk, particularly 15 or more years after treatment. A breast biopsy showing LCIS, atypical ductal hyperplasia, or atypical lobular hyperplasia, increases breast cancer risk, particularly if there also is a family history of breast cancer. 

 

We use computer programs to assess breast cancer risk in young women as accurately as possible based on multiple breast cancer risk factors.  We offer comprehensive genetic testing and referrals to genetic counselors with expertise in hereditary breast cancer and other hereditary forms of cancer. We can develop a program of monitoring and discuss ways to reduce breast cancer risk, tailored to the level of risk.

 

Diagnosis

 

Screening mammography typically isn’t recommended until after age 40 to 45 years because of the lower breast cancer risk in younger women. However, this means that breast cancers are not diagnosed until a finding develops in the breast. Because young women’s breasts are denser, it can be harder to find abnormalities on exam or see them on a mammogram in women in their forties.  Often women and their doctors don’t suspect breast cancer in young women even when an abnormality is present because breast cancer is less common, and this can result in a delay in diagnosis.

 

Treatment

 

The principles of breast cancer treatment in young women are the same as in older women, based mainly on cancer stage, tumor grade and tumor characteristics, such as hormone receptor status and HER2 status, rather than age, per se. However, age may play a role in the choice of certain treatment options.

 

For many reasons, including body image and quality of life, breast-conserving treatment is preferable for many young women. Exceptions to this include large or advanced breast cancers or the presence of a BRCA mutation. The main considerations when deciding between breast-conserving surgery and mastectomy are the risk of local recurrence versus the cosmetic result.  Breast conserving treatment will typically consist of local excision (lumpectomy) followed by breast radiation.  A mastectomy, in which the entire breast is removed, can often be combined with breast reconstruction.  There are circumstances in which radiation therapy is needed after a mastectomy. If a mastectomy is necessary and breast reconstruction is performed at the same time it may be possible to preserve all of the breast skin except for the nipple areolar complex (skin-sparing mastectomy), or to preserve the nipple itself (nipple-sparing mastectomy).  These options enable the reconstructive surgeon to create a more natural- looking breast.

 

 Although younger women tend to have a higher chance of a local recurrence of breast cancer, this chance appears to be the same whether a young woman is treated with lumpectomy and radiation or a mastectomy with or without reconstruction.  More importantly, survival appears to be the same with either form of treatment.

 

Chemotherapy and/or endocrine therapy for early breast cancer in patients under 50 years of age significantly reduces the risk of a breast cancer recurrence and significantly increases the likelihood of surviving in the long-term.  Young women are more likely to have triple-negative breast cancers (estrogen receptor negative, progesterone receptor negative and HER-2/neu negative) which require chemotherapy. There is some evidence that premenopausal women whose periods stop because of chemotherapy have a better prognosis than those who continue to have menstrual cycles.  In other words some researchers think that one of the ways in which chemotherapy works is by stopping ovulation and menstrual cycles. 

 

Women with estrogen receptor positive breast cancers are typically treated with endocrine therapy.  For premenopausal women this typically is a drug called tamoxifen.  Other drugs called aromatase inhibitors are usually not used in premenopausal women unless ovarian suppression is used. 

 

In study of over 1000 women under 40 versus 9000 women over 40 with breast cancer treated in the US military health system, women under 40 were more likely to have breast cancers which were high-grade, estrogen receptor negative,.  There were more likely to undergo bilateral mastectomies and/or undergo chemotherapy, regardless of stage.  They had a similar overall survival rate to older women despite receiving more aggressive treatment.

 

Prognosis

 

In the United States and globally, the incidence of breast cancer in women ages 18 to 49, including pregnancy-associated breast cancer, is increasing; the reasons for this are unclear.  Although prognosis tends not to be as favorable in women under 40 as in older women, with appropriate treatment, many women live healthy, fulfilling lives after being diagnosed.

 

Younger women are more likely to have tumors are high grade, hormone receptor-negative, triple negative and/or associated with axillary node involvement.  Although these types of tumors tend to grow faster, require chemotherapy, and have lower survival rates, these characteristics can be taken into account in order to select the most effective forms of treatment.  In addition, because younger women tend to be healthier, they may tolerate treatment better.

 

Young women diagnosed with luminal A (hormone receptor positive, Her-2/neu negative, low Ki-67) breast cancer may have lower survival compared to older women with the same subtype. This may be because this type of breast cancer is not as favorable in younger women. However one study found that younger women are more likely to stop taking hormonal therapy early or not take it at all.  It can be difficult for young woman to complete 5-10 years of tamoxifen, during which time one cannot try to become pregnant, or may have symptoms secondary to the medication.

 

We try to assist our patients in completing the recommended courses of treatment.  This may be by considering a different medication to see if symptoms are less, or using medications or therapy to reduce side effects. We make sure our patients get appropriate medication to alleviate hot flashes or vaginal dryness. If the cost of hormonal therapy is an issue, there are organizations that can help, such as the National Cancer Institute. Information about this is available on the Breastcancer.org website on its Staying on Track with Treatment page.

 

Clinical trials for young women with breast cancer

 

The outlook for young women with breast cancer has improved significantly in the last few decades, in great part because of information obtained from clinical trials. Clinical trials research ways to make treatments more effective and better tolerated.  The most important information we know about breast cancer treatment is based on information gained from clinical trials.  Current research is assessing ways to improve breast cancer treatment and fertility preservation for young women. Many women with breast cancer enroll in clinical trials to participate in the advancement of our knowledge of breast cancer treatment.

 

There are number of resources regarding clinical trials for breast cancer. The National Institutes of Health's website can help one find a clinical trial. BreastCancerTrials.org  can help identify clinical trials for young women with breast cancer or a clinical trial for fertility preservation.  Another resource is the Susan G. Komen Clinical Trial Information Helpline at 1-877 GO KOMEN (1-877- 465- 6636) or at clinicaltrialinfo@komen.org.

 

Services & treatments we provide

 

If you are a young woman with breast cancer, we will help you navigate its challenges while you receive state- of- the art care.  We provide:

 

  • Comprehensive Consultations

  • Second Opinions

  • Breast Cancer Risk Assessment

  • Computer Models for Assessing Breast Cancer Risk, Prognosis and More

  • Genetic Testing for Cancer-Associated Genes

  • Coordination of Multidisciplinary Breast Cancer Care

  • Breast Ultrasound

  • Minimally Invasive Breast Biopsies

  • Ultrasound- Guided Breast Biopsies

  • Breast Surgery 

  • Intraoperative Breast Ultrasound

  • Oncoplastic Breast Surgery

  • Breast Conserving Surgery/ Lumpectomies

  • Nipple- Sparing  and Skin-Sparing Mastectomies

  • Prophylactic (Preventative) Mastectomies

  • Ultrasound- guided Lymph Node Biopsies

  • Sentinel Node Biopsies

  • Axillary Node Dissections

  • Implantable Port Placement and Removal

  • Advanced Post-Operative Pain Management

  • Genomic Breast Cancer Profiling

  • Nurse Practitioner Case Manager/Nurse Navigator

 

Resources for young women with breast cancer

 

  • The Young Survival Coalition “strengthens the community, addresses the unique needs, amplifies the voice and improves the quality of life of young adults affected by breast cancer, locally, nationally and internationally”. https://www.youngsurvival.org/

 

 

  • Partners This list includes selected national organizations that have collaborated with CDC on Breast Cancer in Young Women activities.

 

 

 

  • Living Beyond Breast Cancer’s page for young women with breast cancer:

       https://www.lbbc.org/young-woman-breast-cancer  “This section of LBBC.ORG, a program of our Young Women's              Initiative, provides tailored information and resources to help you face your diagnosis, understand the treatment               options, manage side effects, talk with your family and friends, and communicate with your employer”.

 

Take steps to help yourself

 

  • Learn about your cancer and don’t be afraid to ask questions so you can make informed choices about your treatment. Ask your breast surgeon, medical and radiation oncologists, and/or reconstructive surgeon how your age might affect your treatment options.

 

  • Look at the resources for young women with breast cancer listed above.

 

  • Ask us about seeing a psychologist or counselor to discuss the emotional impact of your diagnosis, a fertility specialist to investigate your reproductive options, a nutritionist to develop healthy eating habits.

 

  • Take time for yourself to do something you enjoy to relieve stress, whether it is yoga, a long walk, talking with loved ones…

 

  • Many women who have faced a breast cancer diagnosis use this experience as an opportunity to re-assess their goals and priorities. Others decide do something helpful or creative to give back to others. This could be artwork which reflects your thoughts and feelings or an act of service to someone in need. This can be a way to take something negative and turn it into an opportunity for positive change.

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