Shoshana M. Rosenberg

Perceptions, Knowledge, and Satisfaction With Contralateral Prophylactic Mastectomy Among Young Women With Breast Cancer: A Cross-sectional Survey

UNLABELLED Chinese translation BACKGROUND Rates of contralateral prophylactic mastectomy (CPM) have increased dramatically, particularly among younger women with breast cancer, but little is known about how women approach the decision to have CPM. OBJECTIVE To examine preferences, knowledge, decision making, and experiences of young women with breast cancer who choose CPM. DESIGN Cross-sectional survey. SETTING 8 academic and community medical centers that enrolled 550 women diagnosed with breast cancer at age 40 years or younger between November 2006 and November 2010. PATIENTS 123 women without known bilateral breast cancer who reported having bilateral mastectomy. MEASUREMENTS A 1-time, 23-item survey that included items related to decision making, knowledge, risk perception, and breast cancer worry. RESULTS Most women indicated that desires to decrease their risk for contralateral breast cancer (98%) and improve survival (94%) were extremely or very important factors in their decision to have CPM. However, only 18% indicated that women with breast cancer who undergo CPM live longer than those who do not. BRCA1 or BRCA2 mutation carriers more accurately perceived their risk for contralateral breast cancer, whereas women without a known mutation substantially overestimated this risk. LIMITATIONS The survey, which was administered a median of 2 years after surgery, was not validated, and some questions might have been misinterpreted by respondents or subject to recall bias. Generalizability of the findings might be limited. CONCLUSION Despite knowing that CPM does not clearly improve survival, women who have the procedure do so, in part, to extend their lives. Many women overestimate their actual risk for cancer in the unaffected breast. Interventions aimed at improving risk communication in an effort to promote evidence-based decision making are warranted. PRIMARY FUNDING SOURCE Susan G. Komen for the Cure.

Body image in recently diagnosed young women with early breast cancer

To assess body image concerns among young women following a breast cancer diagnosis.

Treatment-related amenorrhea and sexual functioning in young breast cancer survivors

Sexual dysfunction is a known complication of adjuvant therapy for breast cancer and an important determinant of quality of life. However, few studies have explored how treatment and other factors affect sexual functioning in young breast cancer survivors.

Contralateral prophylactic mastectomy in women with breast cancer: trends, predictors, and areas for future research.

Recent studies have revealed increasing rates of contralateral prophylactic mastectomy (CPM) among women with unilateral early stage breast cancer. This trend has raised concerns, given the lack of evidence for a survival benefit from CPM and the relatively low risk of contralateral breast cancer for most women in this setting. In this article, we review available data regarding the value of CPM, predictors, and outcomes related to CPM, and areas for future research and potential intervention.

Management of breast cancer in very young women

Breast cancer is the leading cause of cancer-related deaths in women age 40 and younger in developed countries, and although generally improving, survival rates for young women with breast cancer remain lower than for older women. Young women are more likely to develop more aggressive subtypes of breast cancer (more triple negative and more Human Epidermal Growth Factor Receptor 2 [HER2]-positive disease) and present with more advanced stage disease. Previous research has demonstrated that young age is an independent risk factor for disease recurrence and death, although recent data suggest this may not be the case in certain tumor molecular subtypes. Recent preliminary evidence suggests potential unique biologic features of breast cancer that occurs in young women although this has yet to have been translated into treatment differences. There are clearly host differences that affect the management of breast cancer for young patients including generally being premenopausal at diagnosis, and fertility, genetics, and social/emotional issues in particular should be considered early in the course of their care. Despite an increased risk of local recurrence, young age alone is not a contraindication to breast conserving therapy given the equivalent survival seen in this population with either mastectomy or breast conservation. However, many young women in recent years are choosing bilateral mastectomy, even without a known hereditary predisposition to the disease. For those who need chemotherapy, multi-agent chemotherapy and biologic therapy targeting the tumor similar to the treatment in older women is the standard approach. Select young women will do well with hormone therapy only. Recent data from the TEXT and SOFT trials evaluating the optimal endocrine therapy for the first 5 years, and the ATTom and ATLAS trials demonstrating benefit from extended duration of tamoxifen (10 vs. 5 years), have further defined options for adjuvant endocrine therapy for young women with early breast cancer. Attention to adherence with endocrine therapy may be particularly important to improve outcomes in this population who are at increased risk of non-adherence compared to older women.

BRCA1 and BRCA2 Mutation Testing in Young Women With Breast Cancer

IMPORTANCE BRCA testing is recommended for young women diagnosed as having breast cancer, but little is known about decisions surrounding testing and how results may influence treatment decisions in young patients. OBJECTIVES To describe the use of BRCA testing and to evaluate how concerns about genetic risk and use of genetic information affect subsequent treatment decisions in young women with breast cancer. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis of data collected following the opening of the study to accrual from October 10, 2006, through December 31, 2014, as part of the Helping Ourselves, Helping Others: Young Womens Breast Cancer Study, an ongoing prospective cohort study. Study participants included 897 women aged 40 years and younger at breast cancer diagnosis from 11 academic and community medical centers. MAIN OUTCOMES AND MEASURES Frequency and trends in the use of BRCA testing and how genetic information is used to make treatment decisions among women who test positive vs negative for a BRCA mutation. RESULTS A total of 780 (87.0%) of 897 women reported BRCA testing by 1 year after breast cancer diagnosis (mean age at diagnosis, 35.3 vs 36.9 years for untested women; P < .001), with the frequency of testing increasing among women diagnosed from August 1, 2006, through December 31, 2013. Of 39 women who were diagnosed as having breast cancer in 2006, 30 (76.9%) reported testing. In 2007, a slightly lower percentage of women (87 of 124 [70.2%]) reported testing; however, the proportion tested increased each subsequent year, with 141 (96.6%) of 146 and 123 (95.3%) of 129 women diagnosed as having breast cancer in 2012 and 2013, respectively, reporting BRCA testing (P < .001). Among untested women, 37 (31.6%) of 117 did not report discussion of the possibility that they might have a mutation with a physician and/or genetic counselor, and 43 (36.8%) of 117 were thinking of testing in the future. A total of 248 (29.8%) of 831 women said that knowledge or concern about genetic risk influenced treatment decisions; among these women, 76 (86.4%) of 88 mutation carriers and 82 (51.2%) of 160 noncarriers chose bilateral mastectomy (P < .001). Fewer women reported that systemic treatment decisions were influenced by genetic risk concern. CONCLUSIONS AND RELEVANCE Rates of BRCA1 and BRCA2 mutation testing are increasing in young women with breast cancer. Given that knowledge and concern about genetic risk influence surgical decisions and may affect systemic therapy trial eligibility, all young women with breast cancer should be counseled and offered genetic testing, consistent with the National Comprehensive Cancer Network guidelines.

Premature menopause in young breast cancer: effects on quality of life and treatment interventions

Many young women are at increased risk for premature menopause following adjuvant treatment for breast cancer. These women must deal with consequences of menopause, including loss of fertility and physiologic symptoms such as night sweats, hot flashes, vaginal dryness, and weight gain. These symptoms can be particularly distressing for young women and can adversely affect both health-related and psychosocial quality of life (QOL). While there are a wide range of pharmacologic and non-pharmacologic interventions available to help with these symptoms and in turn, improve QOL, there is little data available about the use and efficacy of these interventions in younger women who become menopausal as a result of their breast cancer treatment. Future studies should focus on this vulnerable population, with the goal of identifying effective strategies to relieve symptoms and improve quality of life in young breast cancer survivors.

Partner support and anxiety in young women with breast cancer

Using a large prospective cohort of women age 40 or younger diagnosed with breast cancer, we examined the relationship between perceived partner support and anxiety.

New Insights Into Nonadherence With Adjuvant Endocrine Therapy Among Young Women With Breast Cancer

Despite the well-established survival benefit associated with adjuvant endocrine treatment (ET), ensuring that breast cancer survivors adhere to the prescribed duration of therapy remains challenging. Studies have found young age to be a risk factor for nonadherence and nonpersistence to ET (1). However, little is known about the reasons why young women are less likely to take ET as prescribed, including noninitiation and early discontinua-tion. In this issue of the Journal, Llarena et al. focus on the potential predictors and reasons for nonadherence in this particularly high-risk population. Their findings not only shed new light on the role of side effects and concern about side effects on nonadher-ence in young women, but also draw attention to the impact of fertility concerns on adjuvant ET decision-making (2). While patients of all ages may contend with myriad decisions surrounding their treatment, the youngest women with early-stage hormone receptor–positive breast cancer who are interested in having biological children after treatment face added complexity. Not only are these women at risk of premature menopause and infertility following chemotherapy, if needed, (3), but this issue is compounded by the time it takes to adhere to a regimen of adjuvant hormonal therapy. Because of the increased risk of infertility with age alone, even if a woman remains premenopausal, achieving pregnancy after completion of even five years of adjuvant ET may be particularly challenging for older premenopausal women with hormone receptor–positive breast cancer. Thus strategies to preserve fertility have been increasingly incorporated into the care of these young patients (4). According to the American Society for Clinical Oncology fertility preservation clinical practice guidelines , prior to beginning adjuvant treatment, premenopausal women should be informed of the potential risk of experiencing premature ovarian failure as well as counseled regarding fertility preservation options available to them (5). However, the literature suggests that issues related to impaired fertility and fertility preservation have been underaddressed historically in young breast cancer patients (6–8). It is therefore encouraging that among the women interviewed by Llarena et al. who did not take tamoxifen or who stopped treatment early, most indicated that they had been adequately informed about fertility preservation, with only 9% reporting that they had not (2). However, the generalizability of these findings is limited by the very nature of how this study was conducted, using the information provided after an electronic medical record prompt flagged providers to ask young patients about interest …

Preadolescent and Adolescent Risk Factors for Benign Breast Disease

PURPOSE It is well established that exposures during childhood and adolescence affect breast cancer risk much later in life. Recently, studies have begun to evaluate whether early life exposures might also impact the risk of developing benign breast disease (BBD). A diagnosis of proliferative BBD independent of other breast cancer risk factors also increases the subsequent risk of breast cancer; therefore, understanding how to decrease the incidence of BBD may have important implications for primary breast cancer prevention. METHODS We reviewed several studies from prospective cohort studies that have investigated the relationship between risk factors during childhood and adolescence, such as anthropometric and reproductive characteristics as well as diet and other behaviors, and subsequent risk of BBD. RESULTS Higher intake of vegetable oils, nuts, vitamin E, and fiber and lower consumption of animal fat, red meat, and alcohol are associated with reduced risk of BBD. Childhood weight and adolescent body mass index are inversely associated with BBD risk, whereas a greater peak height velocity during adolescence is associated with a higher risk of BBD. There was no association between age of menarche and risk of BBD. CONCLUSION Early life exposures and behaviors appear to impact BBD risk. The current body of evidence further supports the importance of a life-course approach to breast cancer prevention.