by Dr. Suleiman Alfred Massarweh
Although the risk of breast cancer increases with age, a significant number of women will get the disease earlier in life.
About 77 percent of women with breast cancer are over 50, the postmenopausal age. That means nearly a quarter of all cases will fall into the premenopausal, or reproductive, age group.
Breast cancer in younger women carries significant implications for young and growing families. Typically, the prognosis for young women with breast cancer is worse than it is for older patients, because the disease is more difficult to detect early and is more likely to behave aggressively.
Some of the difficulty in early detection arises from the fact that younger women do not benefit from screening mammography, since that does not start until age 40. In addition, because of high breast density, breast cancer may be more difficult to find on a mammogram in younger patients. In menstruating women, breast tissue often feels “lumpy” and it may be difficult to identify a true lump that may represent
Particularly problematic is the tendency to dismiss the possibility of breast cancer just because a woman is young, and this bias may contribute to delayed presentation and delayed consideration of the diagnosis by primary medical providers in younger women with breast symptoms.
Every woman, regardless of age, should exercise “breast awareness” and be familiar with the way her breasts feel during different times of the menstrual cycle. Any new lump, rash, or change in size of breast or shape of nipple should prompt immediate medical attention.
An even more dangerous situation is when breast cancer presents during or right after pregnancy. Breast cancer may be especially hard to detect during pregnancy because of the changes in the breast related to pregnancy itself such as engorgement and more “lumpiness.” A delay in breast cancer diagnosis during pregnancy could potentially be catastrophic. For this reason, pregnant women should report any unusual breast symptom to their obstetrician or primary care provider.
If breast cancer is diagnosed during pregnancy, this high-risk situation is best managed by an experienced breast cancer group with a true multidisciplinary nature and a close collaboration with high-risk obstetrics.
Treatment decisions for breast cancer during pregnancy are often complex and have to take into account both patients involved — the mother and her fetus. Surgery for breast cancer in pregnancy is often limited to mastectomy. Often, extensive radiologic testing is not possible because of the risk of radiation exposure.
The choice of medical therapy is complex and it depends on the stage of the pregnancy and the stage of the cancer itself. Chemotherapy options are limited to very few approved drugs. Anti-estrogen or other biologic therapies cannot be given until after delivery. Radiation therapy is contraindicated.
Treatment is particularly risky during pregnancy, and patient treatment must be carefully planned and thoroughly explained to the patient and her husband or a supportive family member.
Despite the difficulties and complexity, excellent outcomes for both the patient with breast cancer and her baby can be achieved. The rewards, for both patients and for the doctors who treats them, are priceless.
Dr. Suleiman Alfred Massarweh is a professor of medicine in the University of Kentucky College of Medicine and a breast oncologist at the Markey Cancer Center.