BREAST CANCER AND THE YOUNG PATIENT Dr Karin Baatjes, Specialist Surgeon and by Dr Justus Apffelstaedt, specialist surgeon with an interest in breast, thyroid and parathyroid health as well as soft tissue surgical oncology. We define breast cancer as being in a young patient when the woman is younger than 35 or 40 years of age. While in the western societies one in 16 of all women with breast cancer is under 40 years of age, in our practice one in 6 women with breast cancer is younger than 40. This could possibly be because of the younger age structure of the population in a developing country but there is also evidence that breast cancer in non-white populations occurs at an earlier age. While obesity, a sedentary lifestyle, drinking and environmental factors as well as commencing menstruation early, before age nine, and falling pregnant for the first time after 30 years have been linked to breast cancer, it is current thinking that for the young women a genetic component is more important and many of the young patients are found to have a mutation in the breast cancer genes. When a younger woman is diagnosed with breast cancer we have to take into consideration the impact of treatment on body image, sexuality, fertility, premature menopause, as well as pregnancy and long-term side-effects of treatment (like the impact on mental functioning and osteoporosis). In younger women, breasts are generally denser and combined with hormonal changes because of their cycles, the examination can be trickier. The accuracy of mammography is lower in younger than in older women due to the increased density. Screening mammography is not recommended for young women except for those with a significant family history of breast cancer. Therefore, young women tend to present more often with palpable disease, rather than with an abnormality that has been found via a mammogram. It is very important that any young woman with a lump should have it fully investigated. Clinical examination along with imaging of the lesion is essential. As mentioned, mammography can be more difficult to interpret in younger women as their breasts are more dense, which can, unfortunately, obscure small lesions. Full field digital mammography help though and the addition of a good ultrasound of the breast in conjunction with fine needle aspiration or core needle biopsy of the lump will ensure a complete examination. The biopsy sample needs to be microscopically examined to investigate the cells and tissue to determine whether or not there is a manifestation of the disease before the lump can be accepted as benign. Apart from the immediate management of the breast cancer which is likely to include a combination of surgery, radiotherapy, chemotherapy, hormonal therapy and biological treatment, the following issues also need to be considered. Fertility Current breast cancer drugs (e.g. chemotherapy) can make some women infertile. This may not be an issue for women who are beyond child-bearing age or who already have children but it’s definitely a problem for younger women, who had planned to have children. The impact of the treatment should be discussed before it is starts. Current guidelines for the treatment of breast cancer in the young recommend the use of chemotherapy for all but the earliest cancers and the vast majority of young breast cancer sufferers will have chemotherapy as part of their treatment. This is an important factor for women, as the chance of suffering premature ovarian failure is as high as around 50% of women who have chemotherapy before the age of 40. After that, the proportion rises rapidly to 95%+. Lack of age appropriate treatments Breast cancer in younger women can be more aggressive than in older women, and treatments are not designed for the younger population. Since young women have more aggressive tumours most guidelines recommend in addition to surgery, they also need chemotherapy. Hormonal therapy regimens also differ as ovarian function has to be taken into consideration. There has been success in fine-tuning the treatment so that it has less of an impact on fertility, but ovarian failure needs to be taken into account, along with an increased risk of miscarriage. Work and career paths Prolonged treatment regimens can affect work schedules and daily functioning which is likely to have more of an impact on younger women. If possible, younger patients should be treated in a dedicated breast unit, by a multi-disciplinary team that can deal with each case in an individualized fashion – fine tuning the treatment and taking all the challenges into consideration. So how old are you and how should you be looking after your breasts? Age 20-39: *Monthly breast self-examination *Clinical breast examination by a healthcare professional every 3 years Age 40 and over: *Monthly breast self-examination *Annual clinical breast examination by a healthcare professional *Annual mammography What can I do to reduce my risk of breast cancer? DON’T eat too many saturated fats. Avoid anything fried, including junk food. DO go green. Stock up on fresh fruit and vegetables. DO watch your weight. Increased body fat is linked to a raise in oestrogen levels. DON’T drink more than two alcoholic drinks per day. DO exercise more to decrease your breast cancer risk by 30%. 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