Elsevier

Seminars in Oncology

Volume 36, Issue 3, June 2009, Pages 237-249
Seminars in Oncology

Impact of malignant disease on young adults
Breast Cancer Before Age 40 Years

https://doi.org/10.1053/j.seminoncol.2009.03.001Get rights and content

Approximately 7% of women with breast cancer are diagnosed before the age of 40 years, and this disease accounts for more than 40% of all cancer in women in this age group. Survival rates are worse when compared to those in older women, and multivariate analysis has shown younger age to be an independent predictor of adverse outcome. Inherited syndromes, specifically BRCA1 and BRCA2, must be considered when developing treatment algorithms for younger women. Chemotherapy, endocrine, and local therapies have the potential to significantly impact both the physiologic health—including future fertility, premature menopause, and bone health—and the psychological health of young women as they face a diagnosis of breast cancer.

Section snippets

Epidemiology

The American Cancer Society (ACS) estimates that 182,460 women in the United States were diagnosed with breast cancer in 2008 and that 40,480 women died of the disease during the year.2 The incidence of breast cancer appears to have a sigmoid function in women less than 55 years of age (Figure 1, lower panel), with 6.6% of all cases diagnosed before age 40, 2.4% diagnosed before age 35, and 1% diagnosed before age 30 (Figure 2, inset). The individual average risk of a woman developing breast

Clinicopathologic Features, Biology, and Prognosis

The comparison of clinicopathologic and prognostic features of breast cancer arising in younger women with those in their older counterparts has been the subject of published studies for decades.27, 28, 29 Traditionally, breast cancer arising in a younger host is characterized by a more aggressive phenotype. Among 185 premenopausal women carrying a diagnosis of invasive breast cancer, referred for surgery at the European Institute of Oncology from April 1997 to August 2000, those aged less than

Treatment and Management

Although the principles of managing invasive breast cancer in adolescent girls and young women are the same as in older women, there are a number of management and therapeutic issues requiring special consideration. Adolescents and young women are at particular risk of emotional and psychosocial problems, and require appropriate support from age- and disease-specific psychosocial and medical multidisciplinary teams.39

For many reasons, including development, function, body image, and quality of

Outcomes

Across all histologic subtypes and stages, breast cancer survival rates are comparatively lower for women <40 years of age than for older women.13 The lowest overall rate of cancer survival for females diagnosed during 2000-2005 was in those aged 25-29 years (72% 5-year relative survival), followed by 20- to 24-year-olds and 30- to 34-year-olds (75% and 76%, respectively) and 35- to 39-year-olds (80%) (Figure 5). In contrast, relative survival for women between age 45 and 80 years was 84%-86% (

Fertility and Pregnancy

Young women undergoing chemotherapy for breast cancer may struggle with fertility and pregnancy issues. To that end, the American Society of Clinical Oncology has published guidelines to address infertility.68 Unfortunately, there is no way to measure fertility other than to follow patients for subsequent pregnancies and the use of amenorrhea as a surrogate marker for infertility, which is imperfect. Also, many women may continue or resume menses months after the administration of chemotherapy.

Pregnancy and Breast Cancer

Current estimates of breast cancer during pregnancy are 1.3 cases per 10,000 births73 and, when cancer is diagnosed in women 30 years old or younger, an estimated 10%-20% of cancers are detected either during pregnancy or within the first year postpartum.74, 75

Bone Health

As a majority of young women diagnosed with early-stage breast cancer will survive many years following diagnosis and treatment, bone loss associated with both adjuvant endocrine and cytotoxic chemotherapeutics must be taken into consideration to prevent long-term complications including osteopenia, osteoporosis, and potentially disabling fractures. Traditionally, the postmenopausal breast cancer population had been the focus of bone health research, given the success of aromatase inhibitors,

Inherited Breast Cancer and Risk Reduction

Family history is a known risk factor for breast cancer, with elevated risk due to both increasing number and decreasing age of first-degree relatives affected. For example, in a large, population-based study, risk of breast cancer was increased 2.9-fold among women whose relative was diagnosed prior to age 30, but the increase was only 1.5-fold if the affected relative was diagnosed after age 60 years.90 While twin studies indicate familial aggregation among women diagnosed with breast cancer,

Psychosocial Issues

Although a diagnosis of breast cancer can be distressing to patients across all age groups, diagnosis at a younger age presents a variety of unique psychosocial and emotional challenges, including, but not limited to, interactions with spouse/children, body image, sexuality, and loss of fertility/premature menopause.69, 100 A retrospective study evaluating more than 500 breast cancer survivors aged 25-50 years illustrated that emotional and social functioning, vitality, and depression 6 years

Conclusions

Although thought to be a relatively uncommon condition, potentially one third of all breast cancers are diagnosed among premenopausal women. Breast cancers diagnosed at a younger age harbor aggressive clinicopathologic features and, more recently, have been recognized as a unique biologic entity. Special considerations, including infertility, pregnancy, bone health, genetic syndromes, and psychosocial issues must be addressed when developing treatment algorithms, including local therapies and

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