Laparoscopic surgery

Breast Cancer in Young Women

BREAST CANCER IN YOUNG WOMEN

 

Michael McFarlane, Contributor

 

Cancer is generally considered a disease of the elderly, but clearly it affects people at all ages. In spite of screening recommendations that now begin at 50 years of age, breast cancer is often diagnosed in women under the age of 40, and there are specific challenges to the management of the disease in this younger population.

In a special session at the American Society of Clinical Oncology Breast Cancer Symposium in San Francisco last week, several clinicians and researchers discussed some of the specific issues that come with cancer diagnoses in younger women.

 

 

Breast cancer rarely affects young women and has been considered a disease of the elderly. It nevertheless involves all ages. Age can be considered to the most significant risk factor. The risk of developing a breast cancer from age 30 – 39 is 0.43 percent, whereas the risk from age 50 – 59 is about 2.3 percent. This risk increases by a factor of 2 times if a first-degree relative (mother, sister or daughter) had a breast cancer.

 

There are certain issues that affect younger women particularly those that relate to psychological concerns and the fertility of the woman. One significant concern that arises with a diagnosis of breast cancer in young women is that of genetic testing and counseling. It is certainly reasonable to investigate all women diagnosed with breast cancer before age 50 for genetic mutations particularly the BRCA 1 and 2 genes. Further testing may also make use of risk scoring systems such as the Gail model which may be important in counseling and planning of future treatment approaches. The BRCA genes are the best-known genetic mutations are associated with a 28% risk of contralateral breast cancer at 10 years and 63% at 25 years. Genetic testing is costly and at nearly US $3,000.00 may be prohibitive for most people. The testing may also be less applicable in some families and in some ethnic groups. More extensive testing is also available but may not be practical for many women.

 

The role of surgery in the young patient has to be carefully considered. Many patients are concerned about a satisfactory cosmetic outcome. Concerns relating to body image, sexuality and fertility are uppermost in the mind of most young patients. The role of mastectomy vs. breast conserving surgery should be carefully discussed. Current research has shown that there is no survival advantage to a more extensive operation. Breast conserving surgery has the same long-term survival as mastectomy with a marginally increased risk of local recurrence. This does not affect the overall survival though.

 

Recent research has also shown that younger women do not have a significantly poorer outcome than older women despite having tumours with higher grade and adverse characteristics such as a higher rate of ER negative tumours and a higher rate of HER2 positive tumours.

Other concerns relate to restoring a pleasing cosmetic contour after mastectomy. Many women request immediate rather than delayed reconstruction. Breast reconstruction has traditionally been performed with the woman’s own tissues e.g. the latissimus dorsi flap or with the use of an implant.  The use of implants is becoming a more practical method of performing breast reconstruction and has made immediate reconstruction a favourable option for most women.

 

Another concern of young women following treatment for breast cancer is the question of future pregnancy. This question is quite apt though the evidence that could provide an unequivocal answer is still not available. Nevertheless most studies available have not shown any survival disadvantage for women who become pregnant post-treatment for breast cancer. Large case reviews comparing women who have become pregnant and those who have not become pregnant have not shown any statistical difference in survival to date.

 

Fertility can also be affected by the type of treatment that is the standard of care for most premenopausal women. Chemotherapy which is almost routine for all women during the reproductive years, is associated with significant impairment of fertility. The effects of chemotherapy vary with the age of the woman and the type of agent used. Women who are less than 30 years of age have the best chance of future fertility while those closer to the menopause are more likely to be adversely affected. Some of the agents with the lowest risk include vincristine and methotrexate, while some including the common combination of cyclophosphamide and adriamycin carry the highest risk of permanent amenorrhoea. The taxanes which are now being used more frequently have not been shown to have a significant risk. Women who are most concerned about fertility should be advised of the risk and informed of the possible options for future pregnancy including in vitro fertilization with the use of frozen embryos, ovarian stimulation, oocyte freezing and other newer experimental methods that are in the process of investigation.
Cryopreservation is a process of freezing and storing frozen embryos (fertilized eggs) for use at a later date. The eggs can be implanted in the woman after completing chemotherapy at a later date or into a surrogate mother.

Other means of achieving parenthood including adoption, surrogacy and the use of donor eggs may have to be considered.

Young patients with breast cancer pose a significant challenge to all concerned including the woman and physicians involved in her care. Not all the evidence is available to answer every one of the questions relating to the biological behaviour of the tumour, the response to treatment, fertility and psychosocial issues. The woman should be advised that age is not an adverse factor and that a suitable standard of care can be provided with a multidisciplinary approach.

 

Dr. Michael McFarlane is a senior lecturer and consultant surgeon at the University Hospital of the West Indies


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