KUALA LUMPUR, Oct 31 – About 13.6 per cent of women in Malaysia are diagnosed with breast cancer before the age of 40, according to a Universiti Putra Malaysia (UPM) study, in sharp contrast to the United States, where the rate is 5 per cent in the same age group.
Consultant breast and oncoplastic surgeon Dr Tan Gie Hooi, citing the UPM study published in 2020, said a similar trend of early-stage breast cancer diagnosis is evident in other Asian countries, with Singapore at 19.1 per cent and Indonesia at 11.4 per cent.
Contrary to Western nations, where breast cancer diagnoses often occur in women aged 60 to 70, Asian countries typically observe diagnoses in women in their 40s and 50s.
According to Dr Tan, a woman’s age plays a crucial role in the diagnosis and treatment of breast cancer, as diagnostic and screening methods differ significantly when compared to a woman who is 60 to 70 years old.
“It’s a different story. Because in this age group, we face special challenges. First, it’s difficult to diagnose. Achieving a diagnosis itself is already a challenge because young women tend to have very dense breasts. This means that when you go for a mammogram, you don’t see it very clearly. You will see a lot of white areas – we call it opacity – because of the density. This will make the sensitivity of the mammogram go down.
“Secondly, routine screening is typically advised to start at 50 years old. So, what happens to women before 50? They don’t go for routine screening. So, what do they depend on? Who’s going to check their breasts? Do you think they will religiously go and see a doctor every six months and get a checkup? No, it’s not in our health culture,” said Dr Tan at the Pink October Media Sharing Session held by Thomson Hospital last October 21.
Besides the reduced effectiveness of mammograms for younger women, Dr Tan said that younger patients often face more aggressive breast cancer subtypes, such as triple-negative breast cancer (TNBC), which is associated with a lower survival rate compared to older patients.
“When they diagnose, let’s say, a 70-year-old and a 35-year-old being diagnosed with stage two breast cancer, you’ll find that the 70-year-old typically has a better outcome. They (younger age group) also have a higher risk of metastasis and recurrence. These are the things that make managing patients with young breast cancer very challenging.”
The TNBC cancer subtype accounts for 10 to 15 per cent of all breast cancers and is relatively rare. The term triple-negative breast cancer refers to the fact that the cancer cells don’t have oestrogen or progesterone receptors, and do not make any or too much of a protein called HER2 — a protein that helps breast cancer cells grow quickly.
Despite the lack of HER2, TNBC tends to grow quickly and is more likely to have spread by the time of diagnosis, making patients more prone to relapse after treatment. Young women, particularly those under 40, are more commonly affected.
Dr Tan highlights that approximately 10 to 20 per cent of breast cancers in young women are attributed to genetic mutations, often inherited from either parent. Mutations in the BRCA1 and BRCA2 genes are among the most common causes of hereditary breast cancer.
Additionally, Dr Tan notes that many young women lack awareness of breast cancer symptoms and subscribe to common misconceptions.
Dr Zamzuri Zakaria, consultant breast, endocrine, and general surgeon, highlighted one such myth regarding lumps, saying some people believe that if the lump is painful, it is cancer, while others believe that if it is not painful, it is not cancer.
“Both are wrong. You need to go and see your doctor if there is any lump. Get it checked,” said Dr Zamzuri.
Unfortunately, many young women who discover a painless lump will often turn to the internet for information, Dr Tan said. After reading that painless lumps are less likely to be cancerous, they may choose to ignore the issue or attempt alternative remedies such as massages.
“Google says, ‘Okay, painless Nothing to worry about.’ So, they will just leave it alone, or some of them, they go for a massage and hope to massage away. All this happens,” said Dr Tan.
While patients bear some of the responsibility when it comes to a late diagnosis, doctors, said Dr Tan, too, can be responsible as they may not immediately consider cancer in young patients.
“Because in a young woman, 30 years old, we are less likely to be thinking of cancer rather than putting that diagnosis out front. If I’m 70-years-old with a breast lump, no doubt I will [do a] biopsy. If I’m 30-years-old, sometimes I think, ‘Is it cancer?’ I also don’t want to be over-diagnosed. Then you scare the woman out of health care.
“It is a balance. These are the things that we actually face sometimes when we have young patients with breast cancer,” Dr Tan said.
Dr Tan held that while early detection and treatment may not prevent 100 per cent of all breast cancers, it significantly increases survival chances. Patients diagnosed at stage one or two have a remarkable 95 per cent survival rate, according to Dr Tan.
Breast Cancer In Young Women Hits Differently
Early menopause is an added challenge for young women battling breast cancer, with some experiencing its onset as early as 40 or 42, a situation that can be distressing for many.
In addition to early menopause, breast cancer can lead to sexual dysfunction, a topic often left unspoken.
“Sexual dysfunction. A lot of people do not talk about it, but they face it then they don’t know who to talk to. Do they talk to the gynae? Do they talk to the breast surgeon? Do they talk to the oncologist? And where do they seek help from? And then whether their partners are understanding enough, that is also another problem.”
When it comes to supportive partners, Dr Zamzuri shared that some women conceal their breast lumps for up to two years, until the lumps become ulcerated, out of fear it may be cancer or due to a lack of support from their partners.
“Sometimes I have patients that keep the breast lump for about two years until it’s fungating, dah pecah (has broken). Okay. Kenapa? Takut. (Why? Scared) Or, sometimes, they don’t have a good spouse who doesn’t want to support them,” said Dr Zamzuri.
Socioeconomic factors also significantly impact the treatment and recovery of young women with breast cancer. Many in their 30s and 40s who are diagnosed with breast cancer also face anxiety and depression.
They must continue to fulfil their family roles, caring for their children and household, even while undergoing chemotherapy, which can be physically and emotionally taxing.
“Imagine they are lethargic, they are vomiting away, and yet they have to cook, they have to clean the house, and they have to shout at the children. So it is not easy. Anxiety and depression [will] definitely set in.”
In addition to these challenges, women in this group often must cope with the loss of one or both breasts, which can have a profound psychological impact. Dr Tan notes that not all women can easily accept the altered image they see in the mirror, with only one breast remaining.
Detecting And Treating Breast Cancer In Young Women
Mammograms are generally not recommended for women under 40, primarily due to the challenge of obtaining clear images from dense breast tissue in younger individuals. Performing a mammogram on a young patient may yield inconclusive results and prove to be a futile use of time and resources.
Thus, in cases of younger women, screening is done with breast magnetic resonance imaging (MRI). According to Dr Tan, if a patient has a family history of breast cancer, screening is done 10 years earlier at which the “first affected relative in the family” was diagnosed.
Dr Tan held that the MRI is a good screening method for young women as it gives doctors a better understanding of breast tissue structures and allows doctors to rule out suspicious lesions. She added that a woman’s first line of defence is her own understanding of her body and her breasts.
“I always tell my patients, you must be breast aware. You must get used to how your breasts feel. Because if one day when you examine, it feels different, then you know it’s time to see a doctor. A lot of times they say, ‘I don’t feel anything’. I say, ‘It’s okay, you don’t feel anything, but you get used to the feeling. You know how it feels. Once you get used to it, [when you] feel a bit more than you know that it’s time you go and see a doctor’.”
Treatment, said Dr Tan, is of two types: local and systemic. Local treatments involve surgery and radiation, and systemic treatments are hormone treatment, chemotherapy and targeted therapies.
Personalisation is key in treatment, as not every patient requires all these approaches. Doctors may even conduct gene testing to determine how a patient will respond to specific drugs. “These are things that we do to help them to get a better survival outcome.”