What Is Unique About Breast Cancer In Young Women?

Breast cancer affects around one in every seven women during their lifetime. Although it is common in women over 50, it can also occur in women as young as 35 and even adolescents. Notably, over 5% of invasive breast cancer cases are seen in women between 15 and 39. Different factors influence the type, management and outcome in adolescents and young women distinct from those experienced by women over 50.¹ 

Young women with breast cancer often face challenges when it comes to diagnosis, treatment and survival. Unfortunately, these issues are often overlooked and not given the attention they deserve.

This article explores the subject of breast cancer in young women, delving into crucial aspects such as risk factors, types of breast cancer and diagnostic difficulties outcomes. 

Salient features of early-onset breast cancer

Breast cancer among young women exhibits unique characteristics:^1,2

This includes: 

• Family history of breast or ovarian cancer  
• Common among women with BRCA mutation 
• Often associated with aggressive subtypes
• Poorer outcome
• Impact on reproductive health after therapy
• Survivorship issues due to complex long-term side-effects of treatment.

Addressing these key factors can help reduce the far-reaching implications of breast cancer on a young woman's overall well-being.

How common is breast cancer in young women?

If you are in your 30s, you may still be at risk for developing breast cancer. Around  6.6% of breast cancer cases are reported in women under 40 and 2.4% under 35.¹

In particular, black women under the age of 35 are more likely to develop invasive breast cancer and have a three times higher risk of breast cancer mortality compared to young white women.¹

What causes breast cancer at a young age?

Risk factors

Various risk factors may contribute to young-age breast cancer including:^1,3

• History of breast cancer in the family
• Harbouring mutated breast cancer genes, BRCA1, BRCA2 or TP53
• Using hormone replacement therapy and oral contraceptives
• Radiation therapy to the chest
• Early menarche (getting your first period early)
• Dense breast
• Pregnancy after you reach 30
• If you choose not to breastfeed
• Smoking and alcohol consumption
• Lack of physical activity and obesity
• High energy-rich food and low vitamin D intake

Can breast cancer in younger women be prevented?

By adopting underlying preventable measures, you can lower the likelihood of getting breast cancer at a young age by: ^4,5,6

• Dietary modifications, for example, increasing the intake of fruits and vegetables as well as limiting the use of processed food.
• Lifestyle changes include doing regular exercises, maintaining a healthy weight, avoiding smoking, and reducing alcohol intake.
• Promoting breastfeeding after childbirth
• Getting screened if you are in a high-risk group.Avoiding long-term use of hormonal contraceptives
• Examining breasts and underarms for abnormal swelling and lumps regardless of what age you may be.

Warning signs and associated symptoms

The presentations of breast cancer in women of any age group are similar:³ This includes: 

• Breast lumps
• Change in the size of the breast
• Dimpling of the breast skin
• Redness of the breast
• Nipple discharge with or without blood
• Nodes under armpit

Most likely, a lump in the breast is due to non-cancer conditions such as fibroadenoma and breast cysts. However, if you find any swelling in the breast, avoid self-diagnosis and discuss it with your GP (general practitioner) to rule out the possibility of breast cancer. The earlier you get a breast cancer diagnosis, the better the outcome is likely to be.  

Breast cancer types in young women

Breast cancer subtypes can vary significantly with age. If you are young, the likelihood of developing triple-negative breast cancer is more than any other type. This aggressive subtype accounts for around 26% of all invasive breast cancer in younger women. Other frequently identified breast cancer types are  Her-2/neu (HER2)-overexpressed, oestrogen receptors (ER) and progesterone receptors (PR) which are negative and basal-like.^1,2

How is young-age breast cancer different?

Breast cancer subtypes, stages and grades^1,2

Breast cancer in young women tends to be high grade with a late presentation. Usually, the tumour size tends to be large, with the lymph nodes often being involved. A greater extent of spread is to the surrounding areas, and there usually is poor survival under 40 compared to older age. Family history

If your close relatives have had breast cancer, then there is a possibility of having breast cancer at a younger age. Also, you are more likely to get breast cancer if there is a family history of ovarian cancer or both breast and ovarian cancer.¹

Genetic mutations

Notably, half of all young female breast cancer patients carry mutations in genes such as BRCA1, BRCA2, or TP53. Also, if you possess the PALB 2 mutation, your chances of developing breast cancer at a young age increase by eight times. Molecular markers are essential in subtyping, treatment and outcome of early-onset breast cancer.^1,2

Risk of cancer after the treatment

If you are under 35 years old and have undergone conservative surgery, your risk of recurrence may be nine times higher. When compared to women with late-onset breast cancer, a young woman there is a significant risk of:¹

• Breast cancer in the opposite breast
• Radiation-induced cancer
• Cancer at other sites such as bone, thyroid, ovary, colon, etc

Post-treatment outcome

After breast cancer therapy, it is normal for young women to have concerns related to breast conservation and reproductive health. Cancer therapy can potentially result in long-term ovarian failure, infertility, or even breast cancer recurrence during pregnancy.^1,2

Diagnosis of breast cancer

In the UK, your GP will refer you to a breast clinic if you present with symptoms suggestive of breast cancer. In the breast clinic, the healthcare professionals will do physical examinations and all the tests required to diagnose breast cancer. This is known as the triple assessment which is described below. 

Triple assessment 

This assessment includes a combination of three different modalities. here's an overview of how a suspected case of breast cancer is assessed:⁷

Physical examination

• A thorough examination of the breast lump to assess the size, shape, firmness and tenderness
• Examination of the overlying skin and nipple for skin changes and discharge
• Detailed examination of the opposite breast and armpits 

Imaging

X-rays of the breast, also known as a mammogram and breast ultrasound, are used to diagnose breast cancer.

Procedures

The standard procedures to check the presence of cancer cells in breast tissue for suspected cases are:

• Fine-needle aspiration cytology (FNAC)
• Core biopsy

The triple assessment is positive when one of the three methods shows positive results. If all three are negative, it is considered negative.⁷

For additional tests confirming breast cancer in young women, the doctor and the multidisciplinary team will advise molecular tests. These tests will help in molecular typing, grading, predicting the outcome and making treatment decisions. This involves genetic testing for mutations in breast cancer genes (such as BRCA and TP53) and testing for hormone receptors such as ER, PR and HER2.

Diagnostic difficulties

Diagnosing breast cancer in young women can be a challenging task. Firstly, breast cancer in young women is uncommon. There is a low level of suspicion by women as well as by physicians.

Secondly, screening services are unavailable for young women, and there is a possibility of missing cases that need interventions. Lastly, there is a lack of awareness regarding the importance of breast self-examination.³ These factors may delay the diagnosis of breast cancer in young women.

Staging of breast cancer

The most commonly used is the TNM staging system. This is made up of:

• Tumour  (T)- Size of the primary tumour
• Lymph node (N)- Whether cancer has involved the lymph nodes
• Metastasis (M)- Spread of the tumour to the other parts of the body

Treatment of breast cancer in young women

Choosing the right treatment

There are a range of options available, and decisions on what treatment suits you best are influenced by underlying factors including:⁸

• Your age
• Your general health
• The stage and grade of a tumour
• Status of molecular biomarkers such as ER, PR, and HER2 status

Treatment available

Surgery

• It is the treatment of choice which the majority of patients choose.
• Surgery can be breast-conserving,non-breast-conserving or mastectomy
• It also involves the removal of lymph nodes from the armpit to check for tumour deposits

Chemotherapy

• The cancerous cells are killed using anticancer drugs
• Ideally, it is done after a surgical procedure
• In some cases with large tumours, chemotherapy is used before surgery to shrink the tumour size ⁸

Radiotherapy

• A controlled dose of radiation is used to kill cancerous cells
• A month later, after the surgery or chemotherapy, your doctor will start the  radiation therapy depending upon your condition

Additional treatment

This includes endocrine therapy, neoadjuvant therapy and treatment of metastatic diseases based specifically on the status of hormone receptors, size, staging, etc.⁸

Survival outcomes

Prognosis

There are salient points related to the prognosis of breast cancer in young women. For example: ⁵

• There is 5-year overall survival of around 82%
• Women younger than 40 years have a higher death rate than those above 40
• Younger women are more likely to die from breast cancer at stage 1 and stage 2  compared to women who present at later age
• Irrespective of age, the prognosis is poor at an advanced stage

Impact of breast cancer therapy on young women

Breast cancer treatment can affect young people's physical, reproductive, psychological and emotional well-being. Here are the potential after-effects of breast cancer treatment:¹

• Prone to fracture and osteoporosis due to lowering of bone density
• Higher rate of depression, anxiety and sleep deprivation
• Young survivors often face occupational and financial hardships
• Concerns about body image and sexuality are higher in younger women
• Early menopause and infertility-related issues
• Strained relationships and social interaction

Advocacy and awareness

Achieving early diagnosis and reducing long-term survivorship issues are all possible by implementing the following strategies:

• Raising awareness about early-onset breast cancer risks
• Empowering young women to be proactive about self-examination of breast and armpit
• Support from the mental health group and breast cancer group
• Regular follow-up and monitoring for suspected recurrence in treated cases

FAQs

Can I get breast screening before 30?

In the UK, you will be invited for breast cancer screening once you reach the age of 50.  You can still discuss this with your GP for screening tests if you are in a high-risk group. After risk assessment, your GP will send you to the breast clinic for further evaluation.

What does a suspicious lump feel like?

A cancerous breast lump is usually hard and painless, with an irregular shape that has suddenly appeared and increased in size. Regardless of the feel, size or shape of the swelling, it is essential to get it checked by your GP.

Which breast cancer imaging method is best for young women?

If you are under 35, the doctor may suggest a breast scan instead of a mammogram. The dense breast tissue in younger women makes it difficult for a mammogram to pick up the abnormal areas.

Sometimes, doctors suggest MRI for younger patients with genetic mutations, multiple lesions or unclear ultrasound results.⁸

Do I need to undergo a mastectomy for breast cancer?

Not all women with breast cancer necessarily undergo a mastectomy procedure. It is performed in cases of a large tumour in a small breast, extensive calcification or multifocal cancer in the breast.⁸

Summary

• Breast cancer in young women, though uncommon, possesses unique challenges
• There is a delay in the diagnosis of breast cancer in young women
•  Frequent breast self-examination can help in early detection
• Triple assessment is a simple approach to diagnosing breast cancer
• Molecular testing plays a vital role in sub-typing, treatment and prognosis
• Early-onset breast cancer is often linked to genetic mutations and a family history of breast or ovarian cancer
• Standard treatment involves surgery, chemotherapy and radiation therapy
• Breast cancer and its treatment in young women can have long-term consequences on physical, reproductive and sexual health
• High grades and delays in diagnosis contribute to  poor outcomes in young women
• Management of long-term side effects of breast cancer therapy in young women needs a multidisciplinary approach