ó Katherine Warrick was 31 when she was blindsided by an
aggressive form of breast cancer. Like many young adults, she
simply had no time for it: She was a newlywed, finishing her
first year of graduate school and working full time as a
treatment forced Warrick to take two semesters off from her
graduate program. Though newly promoted at work, she worried
she wasnít pulling her weight. Now she wonders whether sheíll
be able to have children. And if she does, will she live long
enough to see them grow up?
cancer steals something from everyone, regardless of age. But
when youíre younger than 40, the disease threatens key
milestones and independence during the prime of life, adding
to the burden of the illness.
thought treatment would be a phase; once it was done I could
go back to the way it was," said Warrick, who went
through 18 rounds of chemo, four surgeries and will now take a
daily maintenance drug for the next five years. "But
cancer takes your old Ďnormalí and gives you this new one.
Thanks, but no thanks. I liked my old Ďnormalí just
cancer is relatively rare in young women: In the U.S., about 7
percent of women with breast cancer are diagnosed before theyíve
hit their 40th birthday.
it does strike, young women often grapple with distinct
concerns and have lower survival rates than their older
counterparts, due to differences in the tumors, biology and
stage of life.
we look at why the incidence of advanced late-stage breast
cancer may be on the rise among younger women and at the
unique challenges these women face ó everything from
treatments that can compromise fertility to an increased risk
of secondary cancers.
breast cancer risk increases with age, the prognosis tends to
be worse for younger patients, says pediatric oncologist
Rebecca Johnson, medical director of the Adolescent and Young
Adult oncology program at Seattle Childrenís Hospital.
her 40th year of life, a woman has a 1 in 173 chance of being
diagnosed with breast cancer, Johnson said, though the
incidence varies with race and ethnicity. Black women younger
than 35 have more than twice the incidence of invasive breast
cancer and three times the breast cancer mortality of young
white women, several studies show.
latest research, meanwhile, shows another disturbing trend: a
small but statistically significant increase in the incidence
of advanced breast cancer for women 25 to 38 without a
corresponding increase in older women. (The researchers did
not find a rise in earlier-stage breast cancer in young
study, published in the February issue of The Journal of the
American Medical Association, showed the number of young adult
women getting metastatic breast cancer has nearly doubled
since the 1970ís.
used to be 4 percent, now itís 7 percent," she said.
"Itís still thankfully a small increase but we didnít
find a single risk factor to explain it."
cancers appear to make up the bulk of the increase, which is
"comparatively fortunate," the Journal authors note,
because those cancers are somewhat more responsive to
treatment and have longer average survival rates.
still, less than one-third of women with advanced or
metastatic disease survive at least five years after
diagnosis. Women with early stage disease ó where the cancer
hasnít spread ó have a more than 80 percent chance of
survival if they are older. If they are younger than 40
however, they have a 60 percent chance, Johnson said.
odds hit close to home for Johnson, who was 27 and beginning
the second year of her medical residency when she was
diagnosed with breast cancer. Treatment included chemotherapy
and a mastectomy. This August, at age 44, doctors detected a
slightly different type of cancer in her other breast. In
September she underwent a second mastectomy.
first time,) my doctor said ĎWe donít know why, but young
women with breast cancer donít do as well,í" said
Johnson. "Seventeen years later, we still donít really
know why young women have a greater chance of dying of early
stage breast cancer than older women."
while Johnsonís study is "provocative" and
warrants further work, one expert said it could also be more
of a reflection of how doctors are looking at advanced disease
and less that things are getting worse for young women.
not completely clear is whether itís a true new problem or
whether itís a result of better imaging or screening for
metastasis and newer technologies," said Dr. Ann
Partridge, founder and director of the Program for Young Women
with Breast Cancer and director of the Adult Survivorship
Program at the Dana-Farber Cancer Institute. "Are weíre
looking harder in young women or is there some biological
phenomenon going on?
women still have lower survival rates than older women ó
those in their 40s have the best survival ó so something is
going on with the very young that weíre trying to sort
the discrepancy in survival between younger and older women
has become worse over the past 25 years, according to federal
data. One possible explanation is that most of therapeutic
efforts have targeted middle-aged and older women, and not
young women whose cancers may require a different treatment
news, said Partridge, is that overall survival is improving
among young women.
disagree on when screening should begin; some guidelines say
at age 40. The U.S. Preventive Services Task Force recommends
that women between age 50 and 74 get a mammogram every other
year, with the option to start earlier if a woman desires.
women younger than 40 arenít routinely screened, their
cancer can be missed for months or even years. But, Johnson
said, thereís also no evidence showing that screening before
age 40 would help younger women who are not at high risk and
have no symptoms.
she said, women shouldnít just assume they are "too
young" to get cancer. If they notice a lump, pain or
other change, they should see a doctor.
Lamont, a New York City writer and blogger, was diagnosed in
December at age 25, four months after another doctor waved off
her concern, calling it a cyst.
was totally at ease while this cancer was growing inside of
me," she said. "But those four months could have
been the difference between life and death."
Johnsonís study didnít look at the reasons for the
potential increase, one theory to explore looks at whether
overeating and lack of exercise are driving up early-life
metastatic breast cancer rates, Johnson said. The use of
hormonal birth control could play a role, but the risk level
goes back to normal about a decade after going off the drugs,
according to the National Cancer Institute.
the change has been so marked over just a few decades,
"We think itís likely related to something external, a
modifiable lifestyle-related risk factor or perhaps an
environmental toxic exposure, but we donít know what,"
half of breast cancer cases in all age groups combined are due
to known risk factors ó genes, reproductive patterns and
socioeconomic status ó which means environmental factors are
likely also related, according to the Centers for Disease
Control and Prevention.
radiation or X-rays have been clearly linked to breast cancer.
Since medical diagnostic X-rays are an increasingly common
source of radiation they should only be given when medically
necessary, according to an Institute of Medicine committee on
breast cancer and the environment.
widescale use of carcinogenic chemicals tracks tightly with
the incidence of breast and other cancers, but so far thereís
no solid causal evidence in human studies, said sociologist
and filmmaker Sabrina McCormick, the author of "No Family
History: The Environmental Links to Breast Cancer."
growing area of research looks at whether the timing of
environmental exposure influences breast cancer risk later in
time periods are particularly important: in utero, puberty,
pregnancy and post-menopausal stages of life ó when women
are particularly vulnerable to environmental causes, according
to the National Institute of Environmental Health Sciences.
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early childhood and adolescence, the breast tissue is
developing and maturing. Recent studies suggest environmental
exposures such as certain chemicals, diet and social factors,
during these critical stages of development may affect breast
cancer risk later in life, the institute said.
aromatic hydrocarbons, found in air pollution, have been tied
to an increase in breast cancer tumors, said McCormick, an
associate professor at School of Public Health and Health
Services at The George Washington University. Once cancer
treatment is over, "itís always good to reduce exposure
to carcinogenic chemicals," she said. "Many
accumulate in the body."
can also absorb chemicals found in pesticides, food packaging
and consumer products that can act as endocrine disrupters.
These disrupters concern researchers because they are commonly
found in the environment and can mimic or block hormones and
disrupt the bodyís normal functions.
have repeatedly shown that younger women have more difficulty
adjusting to a diagnosis of breast cancer, in part because the
disease and treatment impacts nearly every aspect of their
lives, including their evolving identity.
stole my independence, my youth, my fun, my fertility, my
body, my beauty and my ignorance of death and mortality,"
said Lamont. "I used to feel invincible; now I am more
aware than ever that my life will end one day."
STORY CAN END HERE)
also have a higher risk of developing cancer that spreads
throughout the body when they are diagnosed at a younger age
and subsequently receive more aggressive therapy, Johnsonís
research has shown.
under 40-crowd is less likely to comply with treatment due to
side effects, which can be more severe for younger women than
older ones, some research, including Partridgeís, suggests.
The treatments, often harsher out of necessity, also can
potentially impact a womanís menstrual cycle and thus her
fertility and dreams of having children.
community can also be difficult, due to the general lack of
information about the risks and the issues facing younger
cancer patients and a shortage of peer group support and
resources, said Partridge, an associate professor of medicine
at Harvard Medical School.
milestones people go through in adolescence and young
adulthood are brightly defined, added Johnson, an assistant
professor of pediatrics at the University of Washington School
of Medicine. Failing to meet these traditional markers
"can cause tremendous anxiety and grief; they feel they
arenít doing the things they are supposed to and this sets
them back from their peer group," she said.
STORY CAN END HERE)
cancer diagnosis is distressing at any age, itís
particularly challenging for young women. Hereís a look at
some of the quandaries they face:
INDUCED INFERTILITY: Fertility preservation is one of the most
pressing issues for young adults, according to Partridgeís
than half of the women in a web-based survey said they had
"substantial concern" at diagnosis about fertility
after treatment; 29 percent reported that fertility worries
influenced their treatment decisions.
women lack information about options. In a separate study
published in the journal Cancer, researchers found only 61
percent of women received counseling on the fertility risks of
cancer treatment from their doctors or other providers.
Overall, only 4 percent of women in the study pursued
which is used to reduce the risk of cancer recurrence in young
women, often triggers menopause.
though women younger than 40 are more likely to have their
periods continue after chemotherapy compared with older women,
their ovaries are often damaged at least to some degree,"
the drug tamoxifen as part of treatment or follow-up treatment
has a price. It doesnít damage the ovaries directly like
chemotherapy, but it is generally recommended for five to 10
years. During that time, women shouldnít become pregnant
because tamoxifen can cause birth defects, hence
"shortening or closing the childbearing window for many
women," said Partridge.
women choose to take less than the standard recommended course
of tamoxifen in order to get pregnant earlier, and this may
compromise their cancer outcomes. Itís a difficult dilemma.
Giannobile was 28 when she was diagnosed with Stage 3 breast
cancer. She had her embryos frozen a week before she started
chemotherapy. She had hoped to carry the baby after treatment,
but her cancer quickly spread to her back, ribs and hip. She
and her husband, Tony, were able to find a surrogate, and
their son Rocco is now 5 months old.
has definitely given us another push and reason to
fight," said Tony.
many new moms diagnosed with cancer, Giannobile worries she
may not live to see Rocco, grow up. Though it was difficult to
start, she now keeps a memory book filled with photos and
writing for him.
and are also taking a lot of videos," she said. "I
always think if Iím not here, Iíd like Rocco to see the
way I light up when heís around," she said.
CANCER RISK: Women diagnosed with breast cancer before age 40
have triple the risk of developing a second primary cancer and
a 41/2-fold increased risk of a subsequent breast cancer,
according to the American Cancer Society. Much depends on a
personís genetic background, said Johnson.
certain families, cancer runs very strong," she said.
"Thereís also a chance of a second cancer from
chemotherapy, radiation; chemo in particular can predispose
someone to cancer, but itís a small risk," said
a genetic component, itís more likely that a woman will
develop a new breast cancer in her other breast in her
lifetime, compared to women who donít have susceptible
genes, said Partridge. If heredity is a factor, the risk of a
new primary cancer in the opposite breast is 20 percent over
the next five years, she said.
those without a genetic component, the average risk of a new
primary breast cancer in the other breast is 0.5 percent to 1
percent a year; taking tamoxifen can cut that risk in half.
why as a rule we donít counsel women to take the other side
off," said Partridge.
tamoxifen also poses a risk of uterine cancer, so itís
critical for young adults to see a gynecologist to catch any
potential early signs.
support: Within the breast cancer community, some young women
feel like outliers.
very mom and family focused," said Lamont, who is
unmarried. "Most of the breast cancer survivors are
literally 30, 40 years older than I am," she said. Though
they can be maternal and comforting, "they just have an
entirely different set of concerns; their kids, husband,
menopause. Iím like, ĎHow many dates do I wait before I
tell a guy my boobs are fake?í Iím just in a completely
nonprofits and hospitals are developing programs to meet the
unique needs of young adults, especially as evidence mounts
that this group suffers higher levels of social, emotional and
physical stress with a cancer diagnosis, said Johnson.
OR SCHOOL ISSUES: Young adults are usually in less stable jobs
earlier in their career and therefore more at risk of being
laid off, said Johnson. Or they are forced to drop out of
whole issue of balancing of family, work and cancer treatment
is a huge issue for people with families. Even very sick moms
do a lot of work." Warrick, who had to postpone graduate
school, had been promoted to a new position three weeks before
she started chemotherapy.
the time off that I needed for treatment and recovery
alongside still trying to feel like a valuable, productive
contributing member of my team was a struggle," she said.
vulnerability: People diagnosed with all types of cancer are
more than 21/2 times more likely to declare bankruptcy than
those without cancer, according to a study from the Fred
Hutchinson Cancer Research Center. The youngest people in the
study had up to 10 times the bankruptcy rates as the oldest,
perhaps because they are often diagnosed at a time when they
are still paying off student loans, purchasing a home or
starting a business. Older patients with cancer, conversely,
typically have Medicare, Social Security benefits and more
Many cancer patients say itís easier to be the one battling
the disease than it is to watch a loved one go through it. For
Lamont, the guilt of putting her parents through the cancer
diagnosis and treatment was "unexpected and
overwhelming," she said.
couldnít take any of the pain away ó they just had to feel
it too. More than anything, I would have liked to spare them
that." Patients who are parents also feel tremendous
guilt if they canít care for their children in the same way
as before the diagnosis. One 38-year-old mother of two
children ages 6 and 3 summed up a common sentiment in a forum
for young survivors: "Itís hard to explain why Iím
home but canít do certain things: why I canít take her to
the bus, go shopping or let them sit on my lap," she
IMAGE AND RELATIONSHIPS: For Lamont, an avid runner, treatment
ushered in a complicated new relationship with her body, which
had more or less always done what she wanted. Now, "My
body is like a cheating lover I decided to give a second
chance to," she said. "I love it ó I want to love
it ó but I canít trust it."
experienced "crazy changes" in her skin and estrogen
a younger woman, itís a lot harder to go through a
mastectomy and potentially losing your hair," she said.
"If you donít already have a companion or spouse, it
might seem overwhelming to try to meet someone on top of all
the treatments and surgeries. There are a lot of
caused by illness is perhaps more damaging for young adults
because of their reliance on their peer group, said Johnson.
older adult can spend more time with their spouse or nuclear
family; being sidelined due to an illness while the rest of
the peer group moves forward can be really hard for
also very hard on intimate relationships. Johnson was 27 and
engaged at the time of diagnosis but the couple broke up.
serious illness is always hard on a marital relationship, but
with teens and young adults, itís the rule, not the
exception." She was treated in 1996; four years later she
met her husband. But during the experience, "I had no one
my age I could talk to," she said. "Even finding
women 10 years close to my age was tremendously helpful, just
to have a couple of peers I could laugh about this with."