By Dr Vanitha Budhavaram, Specialist Breast Surgeon, Joondalup, Midland and Subiaco
Breast cancer is often thought of as a disease associated with older women, however, recent studies indicate an increased incidence in women younger than 40.
Early onset of breast cancer poses unique challenges in terms of detection, treatment, psycho-social impact and long-term outcomes. This trend reflects a growing global concern, as the prognosis in these women is poorer when compared to their older counterparts.
In Australia, one in 10 women with a breast cancer diagnosis are under the age of 40.
The cause of breast cancer in young women is attributed to hormonal, environmental and lifestyle factors. A significant number of breast cancers in young women is linked to genetic mutations like BRCA1 and BRCA2 genes.
Women with these mutations have a high lifetime risk of developing second breast cancer and ovarian cancer. Family history, risk stratification and genetic counselling is important to devise treatment strategies for these women.
Younger women often present with advanced disease as detection of breast cancer is delayed. Often the lumps are overlooked or attributed to a benign lesion. Misinterpretation of symptoms or lack of awareness contributes to delayed diagnosis, especially in pregnant and lactating women.
Younger women fall outside the routine surveillance programs. Further complicating the scenario, conventional imaging may obscure findings due to dense breasts.
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Contrast mammogram and/or MRI Breast are required in addition to conventional imaging for diagnosis and staging. Breast lumps in any age group should be subjected to triple testing which includes clinical examination, imaging and biopsy.
Discordant lesions present a diagnostic challenge leading to missed malignancies. When imaging findings do not correlate with pathology results, it is important to revisit the diagnosis in a multidisciplinary team, perform additional investigations and surgical excision biopsy.
Younger women with breast cancer require specialised care and personalised treatment plans. They are likely to have aggressive sub types of breast cancer such as HER2 amplified or triple negative breast cancer.
They are also more likely to have chemotherapy which can adversely affect fertility. Collaboration with fertility specialists for egg harvest and preservation is imperative before commencement of treatment.
Recommended treatment may include double mastectomy in patients with genetic predisposition. This can affect body image, sexual life, breast feeding and timing for future conception.
Key messages
- Breast cancer in women younger than 40 is on the rise
- Triple assessment is mandatory for investigation of breast lump in any age group
- Early detection leads to better outcomes
Diagnosis of breast cancer at a younger age significantly impacts mental health, relationships and career plans. They are also at risk of long-term side effects of treatment such as early menopause, osteoporosis, cardiovascular disease and second cancers.
Management strategies for breast cancer in younger women require a tailored approach, multidisciplinary care, long term survivorship strategies and support. Advanced imaging, genetic testing and tumour genomic profiling are required for treatment planning.
Surgical management depends on tumour breast ratio, genetic results and patient preference. Breast conserving surgery requires adjuvant radiotherapy to achieve an optimal oncological outcome.
Several techniques such as level 1 or level 2 oncoplastic procedures using volume displacement and replacement techniques, therapeutic mammoplasty, and partial breast reconstruction using local perforator flaps can be used to achieve safe oncological outcomes with good cosmesis.
Neoadjuvant therapies have helped in shrinking the size of tumours to enable breast conservation in a certain sub-set of patients.
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Patients preferring mastectomy or those not suitable for breast conserving procedures can have immediate or delayed reconstruction using autologous free flap reconstruction or implant reconstruction. Alternatively, some patients prefer to “go flat”.
De-escalation strategies in breast and axillary surgery have shown improved outcomes with the concept of “less is more”. These strategies reduce the intensity of the treatment without compromising its effectiveness. Targeted axillary dissection is used in eligible patients with axillary nodal disease to assess response to neoadjuvant treatment, thereby reducing lymphoedema rates in young women.
Breast cancer in younger women presents a unique set of challenges that require a multidisciplinary and personalised approach. Diagnostic delays, biological aggressive tumours and genetic factors coupled with psycho-social and reproductive implications of the disease contribute to challenges in treatment.
Advances in imaging, surgery, targeted therapy, radiation techniques, lymphoedema interventions and supportive care have helped improve outcomes. GPs, multidisciplinary collaboration and allied health support are essential in providing the comprehensive care these young women deserve.
Author competing interests – nil
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