Women under 40 years of age account for one in six cases of breast cancer diagnosed annually, yet diagnosis is often delayed impairing survival outcomes. General practitioners can play a crucial role including raising awareness, early detection, and referral to shared care with the oncology team to manage patients during systemic treatment.
INTRODUCTION
Breast cancer is the most commonly diagnosed cancer
in Singaporean women with nearly six new cases
diagnosed each day. It is a lethal disease, being the
leading cause of cancer deaths among Singaporean
women and accounting for one in six of all-cause
mortality.
RISK FACTORS OF BREAST CANCER
Typical risk factors associated with breast cancer
include:
-
Personal history of breast cancer or non-cancerous
breast conditions
- Family history of breast cancers
- Radiation exposure
- Increasing age
However, the vast majority of four in five women
diagnosed with breast cancer do not have any identifiable
risk factors.
The incidence of breast cancer rises with age, with the
peak incidence in the fifth to sixth decades of life.
It is important to remember that breast cancer can also affect younger women, with one out of six cases
of breast cancer diagnosed in those under 40 years
old, though this is often overlooked.
BREAST CANCER IN YOUNG WOMEN
More aggressive cancer biology
Breast cancer in young women is associated with more aggressive biology being enriched for triple-negative,
HER2-positive and luminal B subtypes. They are of a
higher grade and tend to present at a later stage. The
reasons for late stage of presentation are complex
and multifactorial.
Lack of awareness and regular self-examination
Two in five young women do not do regular breast self-examinations
(BSE), and a general lack of awareness
about breast cancer results in delayed presentation
to healthcare providers, delayed investigations and
diagnosis, and hence delayed treatment.
Limitations of screening modalities
The current screening modalities such as mammograms
are not always ideal for younger women due
to differences in breast tissue density. Younger women
tend to have denser breast tissue, resulting in lower
sensitivity of mammography in detecting breast cancer.
HOW GPs CAN HELP IMPROVE SURVIVAL OUTCOMES
Early diagnosis is associated with improved survival
outcomes.
Primary care physicians play a key role in raising
awareness, early detection and referral of breast
cancer in young women.
They must work closely with the oncology team
throughout the patient journey by helping to manage:
Patient background
Ms L is a 31-year-old single lady with no past
medical history nor significant family history. She
noticed a painful breast nodule in July 2022, and
was then referred by her company doctor to see a
breast surgeon in October 2022. Investigations
A breast ultrasound detected a solid nodule,
reported as probably benign. After consultation
with the surgeon, she underwent an excision
biopsy in late November 2022 which unfortunately revealed an aggressive invasive carcinoma. Staging investigations done subsequently yielded
extensive regional nodal involvement on PET CT.
There was no evidence of distant metastasis.
Diagnosis
A lymph node biopsy confirmed the presence of
nodal spread, hence a diagnosis of locally advanced,
clinical T2N3M0 invasive breast carcinoma
was confirmed. Treatment
Due to the advanced nature of her breast cancer, she
was recommended neoadjuvant chemotherapy
with plans for subsequent surgery. |
NEOADJUVANT CHEMOTHERAPY
Increasingly, there is a move towards neoadjuvant
chemotherapy prior to surgery for patients with
breast cancer. This is especially the case for young
women with locally advanced and aggressive
tumours.
Benefits of neoadjuvant chemotherapy
Downstaging of the tumour
- Increases rates of breast conservation
surgery, in contrast with mastectomy Early treatment of micrometastatic disease Permits evaluation of effectiveness of systemic
therapy in in situ tumour
- Pathological complete response is a strong
surrogate endpoint for event-free survival
(EFS) Allows tailoring of further adjuvant treatment
by risk-stratifying higher-risk patients who
have residual disease, to receive additional
therapies or a change in therapies
- E.g., capecitabine as per CREATE-X or
T-DM1 as per KATHERINE Allows time for genetic testing Allows time to plan reconstruction (if desired)
|
WHY EARLY GP REFERRAL IS CRUCIAL
Identifying symptoms
Breast cancer is often perceived as a disease that
primarily affects older women, leading to a lower
suspicion of breast cancer in young patients. This
could potentially result in missing its early signs and
symptoms.
Younger women may develop other breast lumps
including fibroadenomas or have cyclical fibrocystic
change. However, should symptoms persist, these
patients should still receive an expedited referral
for specialist breast evaluation including further
imaging.
Importance of early referral
In Ms L’s case, five months had passed from her
initial presentation to when she was able to start
treatment for her breast cancer. With aggressive
locally advanced breast cancers, treatment delays
are associated with poorer overall survival rates.
Hence, it is imperative to commence treatment as
soon as possible, and early referral to a breast
surgeon is key if there is any clinical suspicion.
SYMPTOMS AND SIGNS AMONG
YOUNG WOMEN
Self-examination
Screening mammograms do not start till age 40, hence
most young patients only present after they exhibit
symptoms.
Regular monthly BSE is also often neglected in the
young and should be emphasised. In a 2017 survey
commissioned by the Breast Cancer Foundation (BCF),
though the majority of Singaporeans regard breast
cancer as dangerous, only 62% of females reported
ever doing a BSE.
Symptoms
Young patients may present with symptoms similar to older patients, including:
- Breast or axillary lumps
- Skin changes such as thickening or swelling
(including peau d’orange)
- Persistent uniductal bloody or brownish nipple
discharge, including bloody discharge
These symptoms may occur with other benign conditions,
however having a low index of suspicion should
prompt earlier evaluation, imaging and specialist
consultation.
CHALLENGES FACED BY YOUNG WOMEN
WITH BREAST CANCER
Breast cancer in young women presents multiple
challenges and should be managed by a dedicated
multidisciplinary team with special focus on their
specific needs.
Unique issues faced by young women with breast
cancer include:
- Diagnostic delays
- More aggressive disease biology –
chemotherapy is more often indicated
- Higher risk for inheritable genetic mutations –
commonly BRCA1 and BRCA2, among others
- Fertility and pregnancy concerns –
chemotherapy and hormonal therapy in the
treatment of breast cancer may result in
premature ovarian failure or affect fertility
- Social functioning – relationships, young families
with dependents
- Work and financial stability
- Psychological distress – anxiety, depression
- Body image concerns after breast surgery
- Sexuality and sexual dysfunction – this is
a sensitive topic in Asian culture, and may
stem from multiple factors (e.g., side effects
of treatment, body image issues, mood and
confidence issues)
- Survivorship – life, relationships and work after
cancer; getting back to a new normal; dealing
with the side effects of the treatment administered
Facing the often unexpected diagnosis of cancer,
together with the barrage of attendant issues above,
can often be overwhelming and isolating. The care
of a young woman with breast cancer requires a
dedicated, specialised team trained to actively look
out for and manage all the medical and non-medical
aspects of treatment (Figure 3).
While patients undergo treatment, most will
experience some side effects. Some of these
patients may present to primary care, especially if
after-hours. Conditions that require attention during systemic
treatment include: Uncontrolled vomiting
Patients are given antiemetics. However, despite
this, some patients continue to have significant
vomiting and should be referred back to
hospital if they exhibit signs of dehydration. Fever
Patients with ongoing chemotherapy are at
risk for myelosuppression and neutropaenia. If
they present with a high fever of 38 degrees
or above, they should be assessed for risk
of febrile neutropaenia and referred back to hospital for further management. Mucositis
Patients may consult their GP for pain relating
to oral ulcers and mucositis.
After treatment is complete, the oncology team
will work closely with the primary care team to: |
KEY TAKEAWAYS FOR GPs
Young women do get breast cancer, and these
women have unique needs and issues.
A strong support system is essential to
management, which requires a dedicated and
specialised multidisciplinary team working hand-in-hand with the patient, family and primary
healthcare team.
Early detection and treatment of breast cancer
improves survival greatly.
Increased awareness of the importance of
regular monthly BSE, even in young women,
should be emphasised with early referral for
assessment and treatment if required.
THE YOUNG WOMEN WITH BREAST CANCER PROGRAMME
The Young Women with Breast Cancer programme (also known as YoWo) was
set up to help support and guide these young women through all the emotions,
decisions and challenges unique to their stage in life.
Encompassing a multidisciplinary team of medical oncologists, breast surgical
oncologists, radiation oncologists, genetics specialists, fertility specialists,
supportive care physicians, psychologists and social workers, and featuring
our dedicated and experienced breast care nurses (BCNs) at the centre of
the programme, we provide a comprehensive support programme for young
women throughout their journey battling breast cancer.
YoWo specially curates resources for them – relating to the aforementioned
unique issues and other common questions they may have.
RESOURCES
Your Breast Health: Making Informed Choices
(SingHealth)
www.singhealth.com.sg/patient-care/patienteducation/breast-health
A specially curated booklet with a summary of
the common breast conditions, breast cancer,
screening recommendations, etc. Available in
English and Mandarin.
Guiding Young Women with Breast Cancer
(National Cancer Centre Singapore)
www.nccs.com.sg/patient-care/Pages/Guiding-young-women-with-breast-cancer-.aspx
An introduction to SingHealth YoWo.
Breast Self-examination Video
(Singapore Cancer Society)
www.youtube.com/watch?v=JV0WdDKExEs
Also available in Mandarin, Malay and Tamil.
REFERENCES
-
Singapore Cancer Registry Annual Report 2019. National Registry of Diseases Office 28 Jan 2022.
- Cohort profile: The Singapore Breast Cancer Cohort (SGBCC), a multi-center breast cancer cohort for evaluation of phenotypic risk factors and
genetic markers. Ho PJ, Yeoh YS, Miao H et al. PLoS One 2021, 26(16):4. doi: 10.1371/journal.pone.0250102.
Dr Tan Si Ying is an Associate Consultant at the SingHealth Duke-NUS Breast Centre. She
graduated on the dean’s list at the Yong Loo Lin School of Medicine, National University
of Singapore in 2009. She became a Fellow of the Royal College of Surgeons (Edinburgh)
and registered as a specialist in general surgery in 2018. She has a keen interest in bettering multidisciplinary and holistic care for young women
with breast cancer. Her current research interests are in mucinous breast carcinoma, patient-reported
outcome measures in breast cancer patients and exercise and breast cancer.
Dr Ma Jun graduated from Monash University, Australia with MBBS (Hons) and completed
her specialty training in medical oncology at the National Cancer Centre Singapore. She
currently specialises in breast cancer. Her key areas of interest include breast cancer in
young women and supportive care needs in breast cancer.
GPs can call the SingHealth Duke-NUS Breast Centre for appointments at the following hotlines or click here to visit the website:
Singapore General Hospital: 6326 6060
Changi General Hospital: 6788 3003
Sengkang General Hospital: 6930 6000
KK Women’s and Children’s Hospital: 6692 2984
National Cancer Centre Singapore: 6436 8288
