Breast cancer in the young

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Breast cancer is the second most common cancer among women in India. As per the population based cancer registry data, it is the commonest cancer among women in urban registries of Delhi, Mumbai, Ahmedabad, Kolkata, and Trivandrum where it accounts for  30% of all cancers in females. Over 100,000 new breast cancer patients are estimated to be diagnosed annually in India. Breast cancer though a disease of the older age group can rarely occur in the younger woman. In the western countries about 10% of the breast cancers occur in women less than 45 years. However in India, data from the national cancer registry programs shows that approximately 20% of breast cancer is occurring in women below the age of 45yrs. The overall rate of breast cancer in young women remains almost the same world over. The number of cases has increased because of the increase of the population in that age group.

The special issues among the young are  the higher likelihood of a genetic predisposition, premature menopause, fertility and sexuality issues, education and career concerns, and role functions that may be threatened including partnering and caring for young children. Distress about these issues may contribute to younger women experiencing higher levels of psychosocial problems following diagnosis as compared with older women.The diagnosis of breast cancer is often delayed in young women, and they present with more advanced disease. These delays are mainly because younger women are less concerned about and aware of breast cancer, and by physicians, who have less suspicion of this disease in younger women. Diagnosis is also complicated by the various physiological changes that occur during periods of pregnancy and lactation.

Prognosis for young women

Breast cancer is the leading cause of cancer related deaths in this age group, with survival rates for women younger than 40 years at diagnosis lower than for older women with the disease. Generally prognosis is worse in younger women than in older women. This is because breast cancers in younger women are usually aggressive in nature and early detection through  population screening is not effective in this age group.The tumors occurring in younger age group are more likely to be rapidly growing, high grade and hormone receptor negative ( most often triple negative) and Her-2 positive tumors than older women.

Psychosocial issues

Diagnosis of breast cancer brings in anxiety and depression. 40-50% of our patients are either anxious or depressed. There are concerns about the future, fertility and early  menopause related issues. Issues of infertility, body image, and the impact of the disease on family life, relationships, career and finances are different for younger women. Unless these issues are sorted out in the beginning it can affect the quality of life, adherence to treatment and follow up.

Psychological support

Counseling and talking to survivors of breast cancer of similar age group can help them cope with the special problems they face, like hair loss and other issues.

Treatment

Basics of breast cancer treatment – surgery, radiation, chemotherapy, hormone therapy and targeted therapy are the same for patients of all ages. Selection of a particular treatment depends upon the clinical findings, stage of breast cancer, tumor grade and tumor characteristics, such as hormone receptor status (estrogen and progesterone) and HER2 status

Being young, most patients prefer breast conservation surgery (lumpectomy) as opposed to mastectomy. Even if they need mastectomy breast reconstruction is possible. This can be done with implants made of silicon or reconstruction using muscles from other parts of the body. Radiotherapy is needed for all those who opt for breast conservation surgery or for those with higher stages of disease. As the disease is usually of aggressive nature, majority will need chemotherapy in addition. Special issues with chemotherapy are hair loss, fall in the blood counts, mouth ulcers, menstrual irregularities and in some cases permanent menopause. Hormone receptor positive patients are offered tamoxifen tablets to prevent recurrence of cancer. A monoclonal antibody called traztuzumab is used when their tumor is Her-2 positive. Aromatase inhibitors (Eg.letrozole, anastrozole or exemestane) are used, only if they have attained menopause or in premenopausal women after suppression ovarian function by surgical or non surgical means.

Breast cancer during pregnancy

Chemotherapy is safe after the first trimester. There is no added risk to the fetus. Breast cancer treatment and fertility A main concern for young women being treated for breast cancer is loss of fertility. Chemotherapy can damage the ovaries, and both chemotherapy and tamoxifen can cause irregular periods or in some cases permanent menopause. Women younger than 40 at the time of treatment are more likely than older women to have their periods return after chemotherapy. The risk of permanent menopause increases with age. So, young breast cancer patients who are yet to have a family or want to have more children should look for fertility preservation options before starting the treatment. Once the treatment is over, those who are desirous of having children can do so after a period of 2 years. Because of the risk of birth defects, women should not conceive while they are on tamoxifen.

Fertility Preservation options

Options for preserving fertility are

a).Storing the embryo- In this procedure, eggs are collected, fertilized and frozen prior to initiation of therapy. After treatment, the embryos can be thawed and implanted into the uterus. Breast cancer treatment may be delayed while eggs are collected. Here a sperm donor is needed to fertilize the eggs before they are stored.

b) Collecting and freezing of unfertilized eggs for later fertilization in cases where a sperm donor is not available or acceptable

c) Using hormones to temporarily shut down and protect the ovaries during chemotherapy.  Chemotherapy attacks rapidly dividing cells. These include not only cancer cells but other rapidly dividing cells like those in the bone marrow, hair follicles and gonads. Drugs like leuprolide can shut down the ovaries during chemotherapy.

Many studies have shown that these drugs may protect the ovaries from damage and lower the chances of early menopause.

Early detection

Screening mammograms are not useful in young women ( 40yrs ) because of the higher density of breast tissue. For women in the high  risk group (eg family history of breast cancer) MRI (magnetic resonance imaging) mammogram is advised.  Monthly breast self-exams and annual breast exams by a doctor is important to improve early detection. Medical help should be sought at the earliest if there is a lump in the breast or discharge from the nipples.

Genetic counselling

Breast cancer can be familial in about 5% of cases. This is usually due to inheritance of defective genes – called BRCA1 and BRCA2.  Normal BRCA1 and BRCA2 genes are DNA repair genes that prevent the development of tumors. If a woman inherits a defective BRCA1 or BRCA2 gene, her chance of developing breast and/or ovarian cancer is much higher than that of women in the general population. Inherited defects in several other genes are also associated with higher risk of developing breast and/or ovarian cancer. If so, they are offered prophylactic mastectomy and or  oophorectomy as in the case of Hollywood actress- Angelina Jolie.

Even though rare, breast cancer can also occur in young women. So in doubtful cases patient should be investigated further to exclude the possibility of breast cancer. As screening measures are not effective in this age group, breast self examination and an annual checkup by a health care provider is very important.  High risk women should have screening with MRI mammogram.

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