Breast cancer in young women in Australia is rare. Only 6% of all women will be diagnosed with breast cancer in Australia under the age of 40. In women aged 35 to 39 years, 65 women per 100,000 will develop breast cancer compared to 337 women per 100,000 in the age bracket of 65 to 69.
The treatment for breast cancer in young women is generally the same as it is in older women. However, there are a few concerns which need to be considered in treating young women with breast cancer.
Genetic Testing and Type of Surgery
A detailed family history is required to determine which women need to be referred for genetic testing. Women who are less than 30 years of age or women that are less than 35 years of age with HER-2 positive breast cancer and women that have a triple-negative breast cancer of less than 45 years of age and any women of Ashkenazi Jewish background presenting with breast cancer will be eligible for a genetic test. This will help to determine if they have a genetic abnormality that caused their cancer. These women may be eligible to undergo a rapid gene test (10 business days) at the time of diagnosis.
If a gene is detected, a young women may decide to consider a bilateral mastectomy with an immediate reconstruction at the time of initial breast cancer diagnosis or after they have finished their further adjuvant treatment (chemotherapy). Alternatively the breast cancer may be excised using a special incision that would ensure an excellent cosmetic result was achieved if a patient decided to return to theatre at a later date to undertake a completion mastectomy with an immediate reconstruction. A detailed discussion with the surgeon regarding incision placement is required pre operatively.
The effect of breast cancer therapy on fertility will be determined by the age at which a woman is given chemotherapy and it also varies from one type of chemotherapy to another. Women in their 20’s and early 30’s tend to recover their fertility after chemotherapy while women in their late 30’s and early 40’s may be unlikely to recover their fertility and may go into an early menopause. Therefore, it is very important that if a woman wishes to have a family after their breast cancer treatment, they are referred to an IVF specialist immediately at the time of the breast cancer diagnosis. This needs to be performed before the chemotherapy is commenced.
Significant attention needs to be paid to a woman’s fertility. In women that have not had children or those that seek to have more children, an urgent consultation with an IVF physician is required in order for the patient to undergo a rapid cycle of IVF to freeze eggs or embryos before embarking on chemotherapy.
The prognosis of breast cancer in young women is worse than in older women with the same grade and stage of cancer. Consideration should be given to how breast cancer will affect a young woman, in particular to her working career, her family, her sexuality, and her future with her partner. Contraception also needs to be considered.
Making a diagnosis of breast cancer diagnosis in a young woman can be difficult as women with young breasts will often have extremely dense breast tissue. This makes it difficult to examine the breasts and also harder to see breast cancers on imaging. It is also much harder to diagnose a breast cancer in patients who are breastfeeding or pregnant.
The treatment options for breast cancer in young women are the same for women of all age groups. These can include surgery such as breast conservation or wide local excision with removal of the cancer and a sentinel lymph node biopsy or an axillary lymph node clearance if the lymph nodes are shown to be involved with cancer cells preoperatively. This may be followed by radiotherapy. Some women may opt for a mastectomy or may not be suitable for breast conservation [e.g. multifocal breast cancer, a large area of cancer or large area of precancerous change (DCIS) in small breasts].
Mastectomy may or may not be followed by post mastectomy radiotherapy.
Mastectomy in young women usually involves an immediate reconstruction if oncologically safe to do so. In young women, breast reconstruction is usually offered if it is oncologically safe to do so and the options for the reconstructive procedures are the same as in older women; however, young women who have not had children may not be suitable for a reconstruction using natural body tissue such as the abdomen. Thus, they are more likely to be offered an expanders/implant style reconstruction.
Chemotherapy is often recommended in young women. This can be offered pre
(neoadjuvant ) or post (adjuvant) surgery.
Neoadjuvant chemotherapy: Some women will be offered chemotherapy before undergoing surgery. This is termed neoadjuvant chemotherapy. The benefit of neoadjuvant chemotherapy is that it may assist in shrinking a large cancer such that a mastectomy would not be required post chemotherapy.
Hormonal therapies or endocrine treatment to turn off the ovaries is usually required for minimum of 5 years. Other treatment such as Zoladex to protect the ovaries may be given and in some women, there is a recommendation to also remove the ovaries and fallopian tubes. This is particularly relevant in BRCA 1/2 gene carriers who also have a risk of ovarian cancer.
Pregnancy after breast cancer treatment
Most medical oncologists will recommend that patient wait at least 2 years after completion of their cancer treatment before embarking on pregnancy. Patients who are being treated with tamoxifen are advised not to fall pregnant during treatment with tamoxifen. It is also important to know that patients may not be able to normally breastfeed from breast that had been previously irradiated.