IN CASE YOU MISSED IT

The young do get breast cancer

This story was first published in The Straits Times on Jan 9, 2014

A typical 20-year-old, Amelia adored K-pop and fast food. The undergraduate at a university in Australia was looking forward to celebrating her 21st birthday abroad.

But one day, she felt a "bony" lump in her left breast while trying on a new bra.

She dismissed it and waited three months before telling her parents.

Term break brought her back to Singapore, where, several tests later, she was diagnosed with locally advanced, high-grade breast cancer.

Her mother, 49, broke down.

She wanted to know how it could happen when she was in perfect health and there was no family history of cancer.

"Did fast food or fried chicken cause this?" she asked, her voice breaking.

Amelia was more concerned about completing her economics course and whether she could go on to do her Masters course during her treatment.

She was standing at the cusp of adulthood with so much potential; so much to look forward to in life.

Fortunately, she responded well to neoadjuvant chemotherapy, which is anti-cancer drug treatment given before surgery.

After she completed it and underwent breast surgery, there were no discernable cancer cells in her breast tissue.

I did not have all the answers to her mother's questions.

But I knew that the grey cloud of Amelia's early encounter with cancer had a silver lining - her excellent response to treatment, fuelled by the determination and vigour of her youth.

A MOTHER'S LOVE

Irena, 34, a breastfeeding mother, was referred to me by her lactation nurse for repeated instances of blocked ducts in her right breast.

"My six-month-old baby has been refusing to nurse from this breast for the past two weeks. My breast has gone all hard quite quickly over the last few days," she said.

I examined her swollen right breast and retracted nipple.

The overlying skin was red and thickened with an orange-peel appearance.

An ultrasound scan of her breast revealed a mass behind the nipple.

Its outline was ill-defined, but its danger was dreadfully imminent - cancer.

Irena had inflammatory breast cancer, a rare but aggressive form of breast cancer afflicting younger women.

Fortunately, further tests did not show that the cancer had spread.

While shaken by the diagnosis, Irena was mainly concerned about her baby.

"Would I have passed on the cancer cells to my baby in the milk?" she asked, horrified at the thought that she could have "infected" her child in her bid to give him the best.

"No, you can't pass on cancer this way," I reassured her. "But you have to stop nursing because it will no longer be safe once you start chemotherapy."

She dutifully completed her rigorous regimen of chemotherapy and returned for surgery on her son's first birthday.

The tenacity of her maternal spirit kept her going.

"I will endure anything for one more day with him," she said.

Singing a birthday song for her son, she resolved to prevail over her adversary.

That day, Irena celebrated life - both her son's as well as her own.

SYMPTOMS OFTEN DISMISSED

While it is true that the risk of breast cancer increases with age, younger women are not spared.

In fact, 10 to 13 per cent of breast cancer patients here are below 40 years old. These young women are not recommended for routine breast cancer screening, because mammograms are less sensitive in picking up cancer in dense, young breast tissue than in older breasts.

For young women, breast self-examination with the aim of detecting symptoms, such as breast lumps or unusual nipple discharge, is typically the key to early diagnosis.

However, many young women and doctors tend to dismiss these early warning signs, because they believe the women are too young to contract breast cancer.

Hence, delays in diagnosis are all too common.

In addition, breast cancer in young women is more likely to be aggressive, high grade and unresponsive to hormonal treatment.

A combination of these factors result in poorer survival rates for young women with breast cancer than those for older women.

Doctors are typically confronted with otherwise healthy patients facing a life-threatening disease.

Treating them poses unique challenges and considerations pertaining to possible hereditary cancer, future fertility, premature menopause, bone health and psychological health.

Hence, doctors are more inclined to offer therapies with maximal benefit and minimal long-term toxicity, in the face of frequently inadequate or evolving data on how to achieve these aims, as young women are usually under-represented in major breast cancer trials.

Neoadjuvant chemotherapy is a common strategy, due to the advanced stage of the disease when the patient seeks help and the general non-responsiveness of such cancer to other forms of treatment.

This strategy provides a better chance of sparing the young breast from the finality of a mastectomy. It also provides a window during which the doctor can determine the efficacy of the treatment and to choose an alternative treatment if needed.

This also offers an excellent opportunity for clinical trials that can efficiently test new strategies.

Young women can, and do, get breast cancer. Although they form a small percentage of all breast cancer patients, the impact of the disease is significant on their young lives.

drestherchuwa@gmail.com

Dr Esther Chuwa is a consultant breast surgeon at Gleneagles Hospital. She sub-specialises in oncoplastic breast surgery.

This story was first published in The Straits Times on Jan 9, 2014

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