Breast cancer in women under 40

One and 68 women will develop breast cancer by age 40, and one in 220 before the age of 30.

Breast cancer incidence has slowly increased about 0.2% per year among women under age 50.

More likely associated with high risk factors than in older women.

Patients younger than 40 years have a significantly inferior overall and breast cancer specific survival.

Breast cancers are rising in young women, as compared to their older counterparts are characterized by a greater percentage of patients with grade 3, triple negative, HER2 overexpression, lymphovascular invasion, lymphocytic infiltration and higher proportion of basal like an HER2 enriched tumors.

Young women have less favorable outcomes than older women, particularly for luminal-A like tumors and irrespective of the stage at diagnosis.

Premenopausal women, particularly in the very young, less than 40 years of age, have higher rates of endocrine therapy nonadherence or early discontinuation than those persons age 50 to 65 years, likely because of side effects and negative impact on the quality of life.

Young women may be at risk for being over treated based solely on their age.

Most cases of unknown etiology.

Testing for BRCA should be considered in all younger women with breast cancer.

Premenopausal women with breast cancer experience inferior long-term outcomes, particularly in the setting of hormone receptor positive, human epidermal growth factor receptor 2 negative disease.

These patients present with more advanced disease and or less favorable disease biology, and suboptimal adjuvant endocrine therapy.

Lesions more likely to be estrogen receptor negative and of higher grade than older women with breast cancer.

Suggested that HER 2 positive disease more common in younger women.

Young African-American women have a higher incidence of triple negative breast cancer than do Caucasians under the age of 40 years, or black elderly females.

Studies show a greater proportion of luminal B and estrogen receptor negative tumors in young patients, increased risk of early relapse and a more unfavorable longer-term outcome for young women with estrogen receptor positive tumors in particular compared with older women.

Treatment for young women with breast cancer should be driven not by their age, but rather by the biology of their disease to ensure appropriate anti-tumor treatment and to avoid over treatment.

Hereditary breast cancer predisposition is more common among younger women and may influence decisions based on local and systemic disease management.

Women with germline mutations are challenged by the additional future cancer risk, risk reducing surgeries, family risk assessment, and pre-implantation gestational testing.

Treatment in younger women may be associated with premature menopause, impaired fertility with medical and psychosocial implications.

Ovarian function suppression in addition to tamoxifen and aromatase inhibitors have demonstrated significantly improved disease free survival for hormone positive early breast cancer: for 5 and possibly 10 years: in this setting aromatase inhibitors and ovarian function suppression confer clinically relevant improvements over the use of tamoxifen.

The RxPONDER trial evaluated node positive, hormone positive, pre-menopausal women with breast cancer and recurrent score of 0 to 25 and found they benefited from the addition of chemotherapy to standard endocrine therapy.

The rationale for the improvement with the addition of chemotherapy suggest its direct side of toxic effect and its indirect endocrine effect on ovarian function.

It is suggested that ovarian suppressor agents (lutenizing hormone receptor  agonists) be added to oral endocrine therapy for all pre-menopausal women with intermediate and higher risk early breast cancer.