Dr. Alison Jones: Breast Cancer in Young Women – Survival & Fertility Issues
Approximately 20% of breast cancer cases occur in women under 40 years of age. The principles of management are similar to older women, however the higher proportion of grade 3 tumours and the recognition that young age may in itself be an adverse prognostic factor. This means that treatment may be more intensive, with more young women receiving chemotherapy. This can have an impact on fertility, as the use of chemotherapy may cause temporary amenorrhoea or indeed an induced early menopause, depending on the age of the woman at the time of treatment and the choice of regimen. Moreover, young women with steroid hormone receptor positive disease (oestrogen and/or progesterone receptor positive) will need endocrine treatment. This treatment will comprise of Tamoxifen for 5 years. It is now recognised that ovarian suppression with a GnRH analogue such as Goserelin (Zoladex) may be recommended in addition to chemotherapy and Tamoxifen to offer the best chance of long-term disease-free control for younger women. This in itself will also impact on fertility and both surgery and the drug treatment necessary to treat breast cancer can also affect a woman’s sense of sexuality and femininity. The induction of an early menopause may pose other long-term side-effects, for example the risk of osteopenia and osteoporosis and the consequent health problems.
What can we offer these young women? Firstly, the principles of treatment must be focused to offer them the best long-term outlook for cancer. For those women who wish to preserve their fertility, or indeed consider a pregnancy after a diagnosis of breast cancer, it is important that we give them a clear as possible estimate of their own risk of relapse over a period of time so they can make an informed decision with their partners. The only proven method for preserving fertility is embryo cryopreservation using IVF with the partner’s sperm. This is not always available and the success rate is variable and may be age dependent. Also the technique is less applicable for women without a partner unless they are prepared to consider donor sperm. Oocyte cryopreservation or ovarian tissue cryopreservation is still regarded as experimental, although may be promising. The use of GnRH analogies to “rest” the ovaries during chemotherapy is of interest and remains the subject of clinical trials, but is not yet fully proven as a valuable technique.
For young women, an assessment of bone health is important in relation to the risk of induced osteopenia and osteoporosis. There are emerging data that calcium and vitamin D levels may be prognostic in their own right in relation to breast cancer and this is an area for future research. Emerging data on the use of bisphosphonates has been proven in the treatment of osteoporosis and may also be important in the treatment of breast cancer.
The incidence of BRCA-1 and 2 mutations is 5% in the general population and young women may often be concerned about this, particularly if there is a family history. Consideration of genetic counselling for individual women is of importance in this age group.
Overall, the management of young women with breast cancer poses particular challenges, both in terms of the correct selection of treatment for the individual woman and also in terms of her own health and future personal and family aspirations.