Young Women's Breast Cancer FAQs

All women have a 7 to 12 percent chance to develop breast cancer. This risk may be higher if a woman has a close family member(s) (sister, daughter, mother, aunt, or grandmother) with breast cancer. Risk for breast cancer also may be increased for women who have undergone breast biopsy and atypical cells have been identified.

BRCA1 and BRCA2 are genes that are present in both men and women and have a role in preventing breast and ovarian cancer.

A mutation is a harmful change in the gene that prevents the gene from working properly, leading to a higher risk of cancer. However, few women have breast or ovarian cancer as the result of a BRCA gene mutation.

Factors that increase the chance that a BRCA gene mutation is present include:

• A family history of breast cancer at or before age 45 in several closely related women on the same side of the family
• A generation-to-generation pattern of breast cancer
• A history of breast and ovarian cancer in the family
• A history of breast cancer in both breasts and male breast cancer
• Women of Ashkenazi Jewish (Eastern European) descent have a higher chance to carry a BRCA gene mutation

Women who have a lifetime risk of 20 percent or higher, based on family history, as well as women who have undergone chest irradiation for Hodgkin’s lymphoma, benefit from MRI yearly in addition to mammography.

The calculation of this risk profile should be made by a medical professional who specializes in risk assessment, as there are several methods to calculate a person’s risk of developing breast cancer.

Some women diagnosed with new breast cancer also benefit from MRI while others do not, based on particular factors for each patient.

Tomosynthesis is an advanced form of mammography where the x-ray tube moves through an arc and acquires a series of very-low dose images. These are converted into a set of thin slices through the breast, and so this technology allows the radiologist to evaluate the breast more clearly.

By FDA rules, tomosynthesis always is used along with standard mammography, because standard mammography is still the examination proven to improve outcomes when cancer is diagnosed. Tomosynthesis is a new test.

To date, tomosynthesis has been shown to reduce the number of patients recalled for screening mammograms and has been shown to be better than traditional diagnostic mammography views in the evaluation of masses.

Women with normal or mildly elevated risk of breast cancer should start screening mammography yearly, beginning at age 40 and continue annually until late in life.

Women with a mother or sister diagnosed with breast cancer before the age of 50 should start screening mammography 10 years prior to their relative’s cancer diagnosis.

Finally, women with a known BRCA mutation should start annual screening MRI at age 25 and annual mammography and MRI at age 30. This decision should be made in discussion with your physician.

The vast majority of women who have a breast biopsy do not have cancer.

At Magee, approximately 25 percent of biopsies performed by radiologists show cancer. However the chances of finding cancer in any one person may be higher or lower, depending on the specific appearance of the area under question.

If you are recommended to have a biopsy based on an imaging test, the radiologist will review your images with you and discuss with you the specific details of what has been found on your images.

The first step after a new cancer diagnosis is to consult with a surgeon. The radiology nurses and physicians will work directly with your referring physician to help you select a surgeon.

In some instances, a patient navigator may be involved to assist with this as well.

The two basic types of breast surgery we consider are:

1. A lumpectomy (also known as segmental mastectomy, partial mastectomy, and breast conservation.)
2. A mastectomy.

There is a negligible difference in the rate of reaccurence (cancer coming back) between lumpectomy and mastectomy and we consider the two surgeries to be equivalent. Overall survival (how likely you are to survive long-term) is exactly the same no matter what surgery you choose.

Many women consider this option, however very few get a big benefit from it.

Women with genetic mutations causing their cancer can have a risk of cancer in the opposite breast of 2 to 3 percent/year. Surgery can reduce that risk by about 95 percent.

Women with no genetic mutation have only a 0.5%/year risk of developing cancer in their opposite breast.

For these women, bilateral mastectomy doubles the risk of surgery without as big a benefit.

This is a personal decision that can be made between you and your surgeon.

Nipple-sparing mastectomy is a mastectomy that preserves all the breast skin, including the nipple and the areola, while removing the breast tissue below the skin. It is a great option for many women; specifically those with smaller tumors that do not involve or approach the nipple.

Women with smaller, less ptotic (droopy) breasts get the best cosmetic outcome with this operation.

Common complications of breast surgery include:

1. Infection — occurs in approximately 4 percent of patients and is usually treated with antibiotics. Risk factors for infection include smoking, obesity, diabetes, and older age.
2. Seroma — a collection of lymphatic fluid. After lumpectomy, seromas actually help preserve the normal breast shape as you heal. Sometimes these can be uncomfortable, and they can be drained in the office. After mastectomies, drains are used to manage seromas.
3. Bleeding — resulting in hematoma (a collection of blood) or bruising. Blood thinners, aspirin and nonsteroidal anti-inflammatory drugs like ibuprofen increase the risk of bleeding complications and should be avoided for one to two weeks before surgery.

Complications specific to particular procedures:

1. Mastectomy
1. Excess skin (“dog-ears” or “angel wings”): especially in obese women, that can appear more prominent after mastectomy.
2. Numbness — can occur in the nipple if it is preserved and/or in the remaining skin of the breast.
2. Axillary staging procedures
1. Lymphedema — permanent arm swelling, which requires long-term treatment with physical therapy and compression sleeves, occurs in 5 percent of patients after sentinel lymph node biopsy and 25 percent of patients after axillary lymph node dissection. Risk factors include obesity and radiation therapy.
2. Inner arm numbness — due to removal of sensory nerves in the axilla (armpit), which course directly through the nodal tissue en route to the skin of the inner arm.

Candidacy for immediate breast reconstruction after mastectomy depends on many factors, including the following:

• Extent of disease
• Need for post-mastectomy radiation
• Anatomy
• Overall health
• Emotional state

Your breast surgeon and plastic surgeon will be able to examine these factors and advise you of your options.

There are two main categories of breast reconstruction, tissue-based and implant-based. Within these two broad categories are many potential options.

Tissue-based reconstructions may borrow tissue from your lower abdomen (most common), your back, your thighs, or your buttocks.

Implant-based reconstructions vary in the number of stages required for completion. Details about surgery, the hospital stay, and the recovery time depend on the type of reconstruction and vary widely between procedures.

Good resources to review the different procedures include EMMI, and the following UPMC websites:

• UPMC Hillman Cancer Center
• Aesthetic Plastic Surgery Center
• Watch the Knowledge is Power Breast Reconstruction video series located in the right column

The options for radiation are whole breast radiation therapy for about six to six ½ weeks or a short- and long-term course of radiation therapy with balloon catheter depending on the stage of disease.

Common side effects are:

• Skin irritation
• Pigmentation
• Fatigue
• Tiredness

They are common, but resolve once treatment is completed.

The options for radiation are whole breast radiation therapy that lasts for about six to six ½ weeks or a short course of radiation therapy with a balloon catheter (twice daily treatments for five days).

Which one is most appropriate will be determined by the stage of your disease and other factors you can discuss with your radiation oncologist.

Common side effects are:

• Skin irritation
• Pigmentation
• Fatigue
• Tiredness

They are common, but resolve once treatment is completed.

When one groups all breast cancer patients together, studies show that premenopausal women benefit more from chemotherapy than post-menopausal women. However, there are many caveats to this.

The major determinants to requiring chemotherapy are the type of breast cancer that a patient has and how many lymph nodes are involved. Patients who are hormone receptor positive estrogen receptor (ER) and progesterone receptor (PR) positive may not require chemotherapy, especially if lymph node negative.

However, patients who are “triple negative” (ER/PR and HER2 negative) or those who are HER2 over expressing (HER2 positive) frequently will be recommended for chemotherapy.

Hormonal Therapy is treatment directed at the estrogen-receptor and estrogen-mediated gene expression. This is a very important part of the therapy for patients who are estrogen-receptor and/or progesterone-receptor positive (ER/PR+). In premenopausal women, tamoxifen is a commonly prescribed drug for ER/PR+ tumors.

Tamoxifen works by physically blocking estrogen binding to the estrogen receptor on breast tissue. It is an oral medication that is taken daily for five to 10 years.

Sometimes, women also may be prescribed treatment to block the function of their ovaries, which is termed ovarian suppression.

This is frequently done in conjunction with tamoxifen or another type of hormonal therapy. The methods for ovarian suppression include medications (Zoladex or Lupron) or sometimes surgical removal of the ovaries.

The ability to tolerate chemotherapy varies from woman to woman. Some women are able to tolerate chemotherapy well with little side effects and can work. Other women are more sensitive to the fatigue that chemotherapy can create and need to take some time off work. This also will be determined by the physicality of someone’s job. Your medical oncologist will help you decide what is best for your particular situation.

Exercise is definitely encouraged. Exercise is one of the few things that has been shown in clinical trials to improve the fatigue that patients can have with chemotherapy. Even as little as a slow walk around one’s neighborhood for 15 minutes a day is enough to be helpful to combat tiredness.

Playing with children is good for the soul, and helps to alleviate the fears and worries that your children have too. Just be sure to keep some hand sanitizer and tissues close by for the inevitable germs.

However, patients getting chemotherapy are more likely to get sick from the bacteria that normally live on our bodies, than by catching germs from others. So while good hand hygiene and common sense is needed, there is no need to sequester yourself during chemotherapy.

So far, data suggests that becoming pregnant after being treated for breast cancer does not increase the risk of breast cancer recurrence or death.

Some oncologists may prefer for you to wait for two years after finishing treatment for breast cancer before you try to get pregnant because this is the time period with the highest risk of recurrence.

When it is okay for you to try to get pregnant after being treated for breast cancer is an issue you should discuss with your oncologist. The risk of having a baby with a birth defect does not appear to be increased if you get pregnant after completion of your breast cancer treatment.

Whether your periods return after chemotherapy is largely dependent on your age when you start chemotherapy.

Most women under the age of 35 will resume having their periods after chemotherapy and/or tamoxifen. For women who are over 40 when they receive chemotherapy, there is a higher chance that your periods will not return.

If you are diagnosed with breast cancer and wish to have a baby in the future, freezing your eggs or embryos prior to being treated with chemotherapy may be a good idea to help protect your chance of having children in the future.

Chemotherapeutic agents can cause damage to the eggs in the ovaries and may result in infertility, or difficulty achieving pregnancy.

If you freeze eggs or embryos prior to undergoing chemotherapy and then have trouble getting pregnant in the future, you can use those frozen eggs or embryos to help you achieve pregnancy.

Although it is difficult to predict who may have trouble getting pregnant after treatment for breast cancer, women over the age of 35 are at greater risk.

Additionally, fertility declines in the 30s, and in addition to chemotherapy, you may experience an age-related decline in your fertility as you undergo treatment for breast cancer and surveillance after you complete your treatment.

If you don’t have a partner yet, you have the option of freezing your eggs.

Although freezing eggs is a newer technology than freezing embryos (eggs that have already been fertilized by sperm), recent studies of egg freezing are very encouraging, and egg freezing for the purpose of protecting your fertility prior to chemotherapy is no longer considered to be experimental by the American Society of Reproductive Medicine (ASRM).

The process to freeze either your eggs or embryos is the same, and requires taking hormone injections for about 10 days followed two days later by a procedure to remove the eggs vaginally.

The whole process generally takes about two weeks from the time you start your hormone injections. Once the eggs are removed, they can either be frozen unfertilized that same day, or, for women with a male partner, the eggs can be fertilized with his sperm, and the embryos that develop can be frozen three to five days later.

If you do not have health care coverage, or if you are underinsured, you may be eligible for coverage through the Healthy Woman program in Pennsylvania, also known as the Breast and Cervical Cancer Treatment Program.

If you are not eligible, you may apply for UPMC Financial Assistance to cover the cost of your treatment. One of the patient navigators can assist you with reviewing these options.

To contact an oncology patient navigator for assistance, call 412-641-1926 or email mwhbcnavigators@upmc.edu.

Transportation issues can be addressed with the patient navigator. There are volunteer driver services available with Road to Recovery through the American Cancer Society at 1-800-227-2345, as well as the Medical Assistance Transportation Program.

Other resources, such as cab vouchers, bus tickets, and gas cards also are available through the patient care fund. One of the patient navigators can assist you with reviewing these options.

Family and community resources are the best option to be explored for child care and elder care. Solution-finding can be explored through peer websites such as:

• Sharsheret
• Young Survival Coalition

To contact an oncology patient navigator for assistance, call 412-641-1926or email mwhbcnavigators@upmc.edu.

Once treatment is completed, you will be asked to return once a year for follow up in the wellness clinic, unless your surgeon advises otherwise.

You will be asked to have a screening mammogram prior to your yearly checkup, unless otherwise ordered by your surgeon. You may also follow up with a medical oncologist more frequently for the first five years after treatment.

Our LiveWell Survivorship program offers a range of services if you choose to participate.

The program includes:

• Cancer surveillance
• Long-term effects of treatment
• Coordination of other medical care, and adjusting to life after cancer

You may call to schedule an appointment at 412-641-4530, ext. 1.

To contact an oncology patient navigator for assistance, call 412-641-1926 or email mwhbcnavigators@upmc.edu.

The yearly mammogram serves as the standard screening along with a yearly visit to the wellness clinic. If the mammogram or exam indicate a concern, an MRI or ultrasound may be ordered.

Screening with ultrasound and/or MRI can lead to unnecessary biopsies and rarely detect recurrence not found on mammogram and/or physical exam.

To contact an oncology patient navigator for assistance, call 412-641-1926, or email mwhbcnavigators@upmc.edu.