Too young to have breast cancer

Prof Carol-Ann Benn educates us on breast cancer in the young (under 25 and 35 years).

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Dom (my oldest son) was sorting out the IT at HJH Breast Care Clinic and walked in after I had been counselling a 24-year-old with breast cancer. His comment was, “She is so young…it’s so different with us (youth)…to have this scary sh*t when we’re young.” He is a Type 1 diabetic. 

A different disease? Yes and no

Is breast cancer in the young (under 35yrs) a different disease? What about in the very young (under 25yrs)? The answer lies with a yes and no.

So, firstly young women don’t fit into the ‘screening age group’. They usually present with a symptom (a mass; nipple discharge; big lymph nodes).

The first important comment is: if you’re young with a breast problem, don’t receive it as nothing, or “wait till your next cycle”, or believe the doctors ‘who feel your breasts’ and tell you that you’re too young to have cancer. No doctor has eyes on their fingers! Ask for an ultrasound if there is a mass. 

If you’re told it is a fibroadenoma (non-cancerous tumour in the breast that’s commonly found in women under the age of 30), go for a three-month follow-up. Good radiology (ultrasound) can tell the difference between a fibroadenoma and a breast cancer. Though, sometimes triple-negative breast cancer can be mistaken for a fibroadenoma. If the lump grows, insist on a core needle biopsy.

The second comment is: don’t let your friendly surgeon cut anything out without knowing what it is. Has the radiology been reviewed in a multi-disciplinary meeting?

Diagnosis arrives  

Breast cancer – you either do or don’t have a family history of breast cancer. Most women with breast cancer (65-70%) have no risk factors and don’t have the BRCA gene (Angelina Jolie type genes); 10% have BRCA; and the other 20% have a combination of genetic events (I will write on this later).

Don’t rush

Don’t be hasty to start any treatment until you’ve followed the ABC. Even before the ABC….add an S….for safety – SABC. I am going to change this analogy to better the communication system. How about SMS:

Safety – don’t rush into treatment (surgery or chemotherapy) until there has been a discussion in the Multi-disciplinary team, and you’ve been given all options and opportunity for a Second opinion. Take time and listen. It’s very difficult, when faced with a frightening diagnosis, to know what to do.

So, once you know what ‘clothes the cancer is wearing’ i.e. 

• Luminal A (lazy and hormone sensitive)
•  Luminal B (not so lazy and hormone sensitive)
• HER2-enriched (that gene that drives the motor inside the cancer cell)
• Triple-negative (basal-like, not sensitive to hormones and HER2-negative)

You need to know the true size (MRI scans are a huge value in young women if their breast tissue is dense) and true spread (body scans, sometimes sentinels or good ultrasounds and cores of the lymph nodes). Once you know all of this, you’re almost ready to start your treatment journey.

Expert check: has the following been discussed with you?

Fertility

Many young women diagnosed with breast cancer have either not started families or have not finished completing their families. There needs to be a CATS discussion as to whether post treatment you’ll be able to: 

• Conceive
• Ability to breastfeed
• Timing of pregnancy
• Safety of pregnancy

The international guidelines for all young women and men diagnosed with cancer is that fertility treatment should be discussed prior to starting any treatment. Read Perserving fertility before cancer treatment 

Your jeans/genes

I think jeans look good on everyone. We all have our own outward traits no matter what our internal genetic structure is.

You have been born with your own genetic blueprint, though the denim looks different on everyone.

Some young women who get breast cancer may be BRCA positive; more will be BRCA negative and we may never find the genetic cause of that cancer. Is it useful to test genetics? Yes, there is power in knowledge.

Should your genetic status, if positive, dictate what surgery you have as a young breast cancer patient? No. Why? Once you have a cancer, that cancer determines outcome and survival. So, it’s not necessary to do a bilateral mastectomy (both breasts) just because post diagnosis the cancer is thought to be ‘genetic’ or you have a crazy family history. A bilateral mastectomy is a choice. Remember, surgery is for blondes…you just need to take the cancer out with a clear margin (the edge or border of the tissue removed in cancer surgery).

What we do know is that margins are crucial in young women with breast cancers. Studies show that wider margins from the cancer to normal tissue (i.e. a big garden from the house to the gate) is more likely to prevent cancer cells regrouping and growing. It’s also thought that good clear margins may prevent cancer coming back in other places (remember the terrorists escaping into the street).

Breast saving surgery is safe in young women and should you wish to have it, please do not be arm-wrestled into “You must have both your breasts removed because you’re young.”

Breast reconstruction

This is so essential in young women. All options – pros and cons –  should be discussed in detail. In my unit, there are four reconstructive surgeons (hopefully six by the end of the year); they each have different interests, styles and ideas.

All patients are discussed in onco-reconstructive combined meeting with the focus on the patient; her relationship with her breasts; short- and long-term potential problems; and last but not least the size and position of the cancer and the need for radiation therapy. This is discussed all before surgery happens. 

Don’t be caught with your pants (jeans) down. Once the breast is off or the surgery is done, it’s much harder to reconstruct an aesthetically acceptable breast mound.

Most women today choose immediate reconstruction and most mastectomies today are nipple- and skin-saving.

Not all young women need chemo; certain luminal A and B tumours that are node negative can be genetically profiled, which may result in no need for chemotherapy and the patient only requiring endocrine therapy.

Your genes look great on you

So, I know you don’t think your genes look great on you; but I think they do. Each one of us, particularly young women, need to learn to accept our bodies; love them in the jeans (genes) we are wearing. 

We all look different, are different and will have our own medical challenges. And as hard as it is to accept that you have been diagnosed with a breast cancer at a young age; most young women survive breast cancer. And, our job in the medical profession is to ensure that you feel beautiful in your genes. So, you can wear them with a sassy pride; and a kick ass attitudes cos “Girl, your ass does not look big in those jeans!”