Very young women (<35 years) with operable breast cancer: features of disease at presentation

Conditional Disease-Free and Overall Survival of 1,858 Young Women with Non-Metastatic Breast Cancer and with Participation in a Post-Therapeutic Rehab Programme according to Clinical Subtypes

Background

Breast cancer in young women is associated with unfavourable tumour biology and is the main cause of death in this group. Conditional survival analysis estimates survival rates under the pre-condition of already having survived a certain time.

Objectives

To describe conditional disease-free and overall survival of female breast cancer patients according to clinical subtypes and age.

Methods

This study analyses information from 1,858 breast cancer patients aged between 21 and 54 years, who were taking part in a post-therapeutic rehab programme (time between diagnosis and rehab start: maximum 24, median 11 months). Mean follow-up time was 3.6 years. We describe biological, clinical and pathological features in regard to different age groups (<40 and ≥40 years) and report conditional 5-year survival rates for overall and disease-free survival, and Cox proportional hazard models.

Results

Very young and young patients differed in regard to hormone receptor negativity, tumour grade, lymphovascular invasion, and molecular subtypes. Young women bore triple-negative and HER2-like disease more frequently. Conditional 5-year overall survival did not differ substantially between women <40 and 40-54 years of age (95 vs. 96%). It was highest for women with cancer of the luminal A subtype (98%) and lowest for the triple-negative subtype (91%). Lymphangiosis was a significant predictor of death. Results for disease-free survival were comparable.

Conclusions

Conditional 5-year overall survival after non-metastatic breast cancer was as high as 95.5%, and disease-free survival was 85.2%. When controlling for time between diagnosis and rehab start, molecular subtypes influenced overall and disease-free survival prospects. When additionally controlling for clinical characteristics, this effect only remained stable for disease-free survival.

Disparities in Risk Reduction Therapy Recommendations for Young Women With Lobular Carcinoma In-Situ

BACKGROUND

Endocrine therapy (ET) significantly reduces the risk of breast cancer development in high-risk patients diagnosed with lobular carcinoma in situ (LCIS). However, the variables impacting recommendation and use of ET in young adults (YAs) is not well-studied. We examined the role of provider recommendation and patient acceptance for ET for YAs with LCIS.

MATERIALS AND METHODS

The National Cancer Database was queried for women aged < 40 years with primary LCIS between 2000 and 2012. Socioeconomic, demographic, and treatment variables were examined to determine their impact on ET provider recommendation and initial patient acceptance of risk-reducing therapy.

RESULTS

Among 1650 YA patients with LCIS, only 749 (45.4%) were recommended ET. On multivariable analysis, women > 30 years of age were more likely recommended ET than women < 30 years (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.10-2.47), African Americans more than other ethnicities (OR, 1.48; 95% CI, 1.1-2.0), and YAs treated in New England were more likely than those in the rest of the country (OR, 3.26; 95% CI, 2.0-5.2). Among YA women recommended ET, only 20.2% had a documented refusal. Only geography appeared to independently impact the likelihood of refusal, with YAs in the Southeastern-Central United States being most likely to refuse ET (OR, 5.4; 95% CI, 1.2-24.0).

CONCLUSION

ET is underutilized for risk-reduction in YAs with LCIS. This underuse appears dependent on disparities in provider recommendation practices rather than non-acceptance of therapy. This may reflect regional practice patterns, community standards of care, or provider bias regarding the significance of LCIS as a risk factor for development of invasive cancer.

HDAC5 Inhibitors as a Potential Treatment in Breast Cancer Affecting Very Young Women

Background: Breast cancer in very young women (BCVY) defined as <35 years old, presents with different molecular biology than in older patients. High HDAC5 expression has been associated with poor prognosis in breast cancer (BC) tissue. We aimed to analyze HDAC5 expression in BCVY and older patients and their correlation with clinical features, also studying the potential of HDAC5 inhibition in BC cell lines. Methods: HDAC5 expression in 60 BCVY and 47 older cases were analyzed by qRT-PCR and correlated with clinical data. The effect of the HDAC5 inhibitor, LMK-235, was analyzed in BC cell lines from older and young patients. We performed time and dose dependence viability, migration, proliferation, and apoptosis assays. Results: Our results correlate higher HDAC5 expression with worse prognosis in BCVY. However, we observed no differences between HDAC5 expression and pathological features. Our results showed greatly reduced progression in BCVY cell lines and also in all triple negative subtypes when cell lines were treated with LMK-235. Conclusions: In BCVY, we found higher expression of HDAC5. Overexpression of HDAC5 in BCVY correlates with lower survival rates. LMK-235 could be a potential treatment in BCVY.

Breast cancer tumor histopathology, stage at presentation, and treatment in the extremes of age

BACKGROUND

Given presumed differences in disease severity between young (≤ 45 years) and elderly (≥ 75 years) women with breast cancer, we sought to compare tumor histopathology, stage at presentation, patterns of care, and survival at the extremes of age.

METHODS

Adults with stages 0-IV breast cancer in the National Cancer Database (2004-2015) were categorized by age (18-45 years, 46-74 years, ≥ 75 years) and compared. Kaplan-Meier curves were used to visualize unadjusted overall survival (OS). A Cox proportional-hazards model was used to estimate the effect of age group, including adjustment for tumor subtype [hormone receptor [HR]+/HER2-, HER2+, triple-negative (TN)].

RESULTS

Of the 1,201,252 patients identified, 13% were ≤ 45 years and 17.5% were ≥ 75 years. Women ≤ 45 years were more likely to have higher pT/N stages and grade 3 disease compared to older patients; however, rates of de novo cM1 disease were comparable (3.7% vs 3.5%). HER2+ and TN tumors were more common in those ≤ 45 years (HER2+ : 18.6% vs 9.2%; TN: 14.9% vs 8.2%), while HR+/HER2- tumors were more likely in women ≥ 75 years (69.3% vs 51.3%) (all p < 0.001). Younger patients were more likely to undergo mastectomy vs lumpectomy (56% vs 34%), and receive chemotherapy (65.8% vs 10.2%) and radiation (56.2% vs 39.5%). After adjustment, OS was worse in older patients (older HR 2.94, CI 2.86-3.03).

CONCLUSIONS

High-risk tumor subtypes and comprehensive multimodal treatment remain significantly more common among younger women (≤ 45 years) with breast cancer, yet, elderly women are similarly diagnosed with incurable de novo metastatic disease. Tailored screening and treatment strategies are critical to prevent age-related disparities in breast cancer care.

Pediatric Malignant Phyllodes Tumors of the Breast: Characteristics and Outcomes Based on the Surveillance Epidemiology and End Results Database

BACKGROUND

Malignant phyllodes tumors of the breast are uncommon in women and rare in children. This study aimed to assess the differences in survival among five specific pathologic groups of breast malignancies and the differences between pediatric and adult breast phyllodes malignancy.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results database, we collected data on 270 pediatric (aged ≤21 y) female breast malignant tumor patients and 2773 female malignant phyllodes tumor patients between 1976 and 2015. We evaluated survival differences among younger patients with breast malignancy and compared the pediatric and adult groups based on characteristics, treatment patterns, and survival months. Finally, we identified the risk and protective factors for breast phyllodes cases using a multivariable Cox analysis.

RESULTS

We collected and analyzed 270 malignant breast cancer patients aged ≤21 y and 2773 malignant phyllodes tumor patients. Pediatric patients with malignant phyllodes tumors (22.2%, n = 60) exhibited better overall survival (OS; log-rank, P = 0.012) and cancer-specific survival (CSS; log-rank, P = 0.005) among the younger patients with malignant breast tumors. Furthermore, pediatric patients with malignant phyllodes tumors showed better OS (log-rank, P = 0.004), and similar CSS (log-rank, P = 0.105), compared with older patients. After adjustments for potential confounding factors, age >21 y, Black race, tumor size of >100 mm, high grade, wider invasion, positive nodal status, larger scope surgery, and no surgery were found to be associated with worse OS. All these factors, except for race, were found to be independent risk factors for CSS.

CONCLUSIONS

The prognosis of malignant phyllodes tumors in children is better than that of adults. Appropriate surgical scope and risk of overtreatment should be considered when treating pediatric malignant phyllodes tumor patients.

Hormone Therapy and Factors Affecting Fertility of Women Under 50-Year-Old with Breast Cancer

BACKGROUND

Although the use of contraceptive hormones is a risk factor for development of breast cancer, level of risk is unknown; thus the current research was conducted to investigate the effect of factors related to fertility and hormone use on risk of breast cancer in women aged under 50 years old in the west of Iran.

METHODS

In this case-control study, all incidence cases of breast cancer aged between 25-49 years old (n=212) were selected. Twice as many as the case group, the individuals referred to other outpatient sections of the same hospital at the time of study and up to 2 years after the follow-up not diagnosed with breast or other cancers were selected as a control group. The data were collected using healthy fertility program and middle-aged periodical care forms developed by Iran's Ministry of Health (MOH).

RESULTS

After controlling for confounding variables, history of hormonal use for contraception (OR=2.02, 95% CI=1.2-3.3) and hormone therapies (OR=1.9, 95% CI=1.2-3.04) were identified as factors increasing the risk of breast cancer. Dose-response relationships between breast cancer and the use of hormones for contraception and hormone therapy indicated that these factors increased the risk of breast cancer. The risk was found to be higher in women who had been under hormone therapy for more than 120 months. With an increase in the age of the first menstruation, risk of breast cancer increased linearly, but with an increase in the age of the first pregnancy, risk of breast cancer increased exponentially. After 20 years of age, the risk increased with a steeper slope.

CONCLUSION

Considering the effect of hormone therapy and fertility factors on breast cancer and changeability of listed risk factors, the researchers suggest planning for sensitizing, increasing the awareness, and educating women and professionals regarding the influence of fertility and hormonal factors including pregnancy at lower ages, minimizing the use of hormones for contraception, and hormone therapy.

Prognostic Values Of Preoperative Serum CEA And CA125 Levels And Nomograms For Young Breast Cancer Patients

Background

Young breast cancer patients have poor prognosis compared to older patients in both overall survival (OS) and loco-regional failure-free survival. Carcinoembryonic antigen (CEA) and Cancer antigen 125 (CA125) have been widely used, but their prognostic value in young breast cancer patients remains unknown. The objectives of this study were to evaluate the prognostic value of preoperative CEA and CA125 serum levels and to build nomograms for better prognostic prediction of young Chinese breast cancer patients using both tumor markers.

Methods

We included 576 young breast cancer patients (≤40 years at diagnosis) and collected their preoperative information. The best cut-off values of the CEA and CA125 were identified with receiver operating characteristic (ROC) curves. Univariate and multivariate analyses were used to identify the relative risks of factors for the overall survival (OS), and disease-free survival (DFS), and nomograms were constructed based on these identified factors.

Results

The best cut-off values for CEA and CA125 in young breast cancer patients was 3.38 ng/mL and 19.38 U/mL, respectively. Kaplan-Meier analysis showed that young patients with low levels of CEA and/or CA125, had longer OS and DFS. Multivariate analysis suggested that both CEA and CA125 levels were independent predictive elements for OS. Nomograms were built and showed a better predictive ability for OS (AUC = 0.856) and DFS (AUC = 0.702) in young breast cancer patients.

Conclusion

Preoperative serum CEA and CA125 levels could be the independent prognostic factors for OS, and the nomograms including these two variables provide more personal forecasts information to help physicians optimize treatment for young breast cancer patients better.

Effects of Age and Immune Landscape on Outcome in HER2-Positive Breast Cancer in the NCCTG N9831 (Alliance) and NSABP B-31 (NRG) Trials

PURPOSE

Young age has been shown to be an independent predictor of poor outcome in breast cancer. In HER2-positive breast cancer, the effects of aging remain largely unknown.

EXPERIMENTAL DESIGN

A total of 4,547 patients were included [3,132 from North Central Cancer Treatment Group (NCCTG) N9831 and 1,415 from National Surgical Adjuvant Breast and Bowel Project (NSABP) B-31]. Pathologic stromal tumor-infiltrating lymphocyte (sTIL) and molecular tumor infiltrating lymphocyte (mTIL) signatures were evaluated.

RESULTS

In NCCTG N9831, comparable benefit of trastuzumab was observed in all patients [age ≤ 40; HR, 0.43; 95% confidence interval (CI), 0.28-0.66; P < 0.001; and age > 40; HR, 0.56; 95% CI, 0.45-0.69; P < 0.001]. Similar results were observed in NSABP B-31 (age ≤ 40; HR, 0.45; 95% CI, 0.29-0.68; P < 0.001; and age > 40; HR, 0.42; 95% CI, 0.33-0.54; P < 0.001). Among patients who received chemotherapy alone, younger age was associated with poor outcome in the hormone receptor-positive subset, but not the hormone receptor-negative subset, in both trials. Although there was no association between sTILs and age, a small, but significant increase in mTIL CD45 and some immune subset signatures were observed. Among patients who received chemotherapy alone, patients over 40 years of age with lymphocyte-predominant breast cancer had excellent outcome, with 95% remaining recurrence free at 15 years.

CONCLUSIONS

Among patients treated with trastuzumab, there was no significant difference in outcome related to age. Our study suggests that trastuzumab can negate the poor prognosis associated with young age.

Prognostic Impact of Pregnancy in Korean Patients with Breast Cancer

BACKGROUND

Pregnancy concurrent with, shortly before, or after breast cancer poses unique challenges because hormonal changes in pregnancy potentially interact with breast cancer outcomes.

MATERIALS AND METHODS

We studied a cohort of 3,687 female patients of reproductive age (<50 years) with breast cancer, linking a large institutional database and the nationwide claims database to comprehensively capture exposure status and tumor characteristics. Exposures included breast cancer during pregnancy, postpartum breast cancer (<12 months after delivery), and pregnancy after breast cancer.

RESULTS

Forty-five patients with postpartum breast cancer were significantly more likely to have advanced stage, hormone receptor-negative tumor and to be younger than 35 years at diagnosis than those without postpartum breast cancer. This trend was not observed with 18 patients with breast cancer during pregnancy. The unadjusted 5-year survival rates were 77% versus 96% for patients with postpartum breast cancer versus their counterparts, 89% versus 96% for patients with breast cancer during pregnancy versus their counterparts, and 98% versus 96% for patients with pregnancy after breast cancer versus their counterparts, respectively. In the multivariable analyses, postpartum breast cancer exhibited hazard ratios for death of 1.57 (95% confidence interval [CI], 0.82-2.99), whereas those for breast cancer during pregnancy and pregnancy after breast cancer were 1.09 (95% CI, 0.15-7.91) and 0.86 (95% CI, 0.26-2.83), respectively.

CONCLUSION

Postpartum breast cancer, but not breast cancer during pregnancy, was associated with advanced stage, younger age at diagnosis (<35 years), hormone receptor-negative disease, and poorer survival. Pregnancy after breast cancer did not compromise overall survival.

IMPLICATIONS FOR PRACTICE

Although pregnancy around the time of diagnosis of breast cancer is expected to become increasingly common with maternal age at first childbirth on the rise, data on the prognostic impact of pregnancy have been inconsistent and rare from Asian populations. In this investigation of a Korean patient cohort with breast cancer, pregnancy-associated breast cancer was associated with advanced stage, younger age at diagnosis (<35 years), hormone receptor-negative disease, and poorer survival. This adverse impact of pregnancy on the prognosis was apparent with postpartum breast cancer but not observed with breast cancer during pregnancy. Pregnancy after breast cancer did not compromise overall survival.

Imaging Findings and Clinicopathological Correlation of Breast Cancer in Women under 40 Years Old

Objective

The aim of this study was to evaluate the clinical, imaging and histopathological features of breast cancer in patients aged under 40 years of age. The relationship between radiological characteristics and histopathological features was also investigated.

Materials and Methods

The study included 131 patients aged under 40 years, diagnosed pathologically with breast cancer. A retrospective evaluation was made of the imaging and clinicopathological findings and the relationship between pathological and imaging findings was investigated.

Results

Most of the cancers were detected from clinical symptoms, especially a palpable mass (76.3%). The most common histological type of tumor was invasive ductal carcinoma and 64.8% of the tumors were high grade tumors. The predominant features were irregular borders (92.4%), microlobulated-angulated contours (43.5%), hypo-homogeneous internal echogenicity (80.9%) on ultrasonography, and the presence of a mass (41.2%) and suspicious microcalcifications (40.2%) on mammography. Magnetic resonance imaging commonly showed mass enhancement (66.7%) with type 2 or 3 dynamic curve (92.6%). High-grade tumors were associated with posterior acoustic enhancement (p: 0.03) while low-grade tumors presented with spiculated margins more than high grade tumors (p: 0.04).

Conclusion

Breast cancer in women aged under 40 years usually presents with a self-detected palpable mass and can show different imaging findings according to the histological grade. Ultrasonography is the main modality for the diagnosis of breast cancer in young women, but mammography and magnetic resonance imaging can help in both diagnosis and evaluation of the extent of disease.

Mortality after breast cancer as a function of time since diagnosis by estrogen receptor status and age at diagnosis

Our aim was to estimate how long-term mortality following breast cancer diagnosis depends on age at diagnosis, tumor estrogen receptor (ER) status, and the time already survived. We used the population-based Australian Breast Cancer Family Study which followed-up 1,196 women enrolled during 1992-1999 when aged <60 years at diagnosis with a first primary invasive breast cancer, over-sampled for younger ages at diagnosis, for whom tumor pathology features and ER status were measured. There were 375 deaths (median follow-up = 15.7; range = 0.8-21.4, years). We estimated the mortality hazard as a function of time since diagnosis using a flexible parametric survival analysis with ER status a time-dependent covariate. For women with ER-negative tumors compared with those with ER-positive tumors, 5-year mortality was initially higher (p < 0.001), similar if they survived to 5 years (p = 0.4), and lower if they survived to 10 years (p = 0.02). The estimated mortality hazard for ER-negative disease peaked at ~3 years post-diagnosis, thereafter declined with time, and at 7 years post-diagnosis became lower than that for ER-positive disease. This pattern was more pronounced for women diagnosed at younger ages. Mortality was also associated with lymph node count (hazard ratio (HR) per 10 nodes = 2.52 [95% CI:2.11-3.01]) and tumor grade (HR per grade = 1.62 [95% CI:1.34-1.96]). The risk of death following a breast cancer diagnosis differs substantially and qualitatively with diagnosis age, ER status and time survived. For women who survive >7 years, those with ER-negative disease will on average live longer, and more so if younger at diagnosis.

Breast Cancer in Very Young Patients in a Spanish Cohort: Age as an Independent Bad Prognostic Indicator

Purpose:

Breast cancer (BC) in very young women (BCVY) is more aggressive than in older women. The purpose of this study was to evaluate the relevance of a range of clinico-pathological factors in the prognosis of BCVY patients.

Methods:

We retrospectively analyzed 258 patients diagnosed with BCVY at our hospital from 1998 to 2014; the control group comprised 101 older patients with BC. We correlated clinicopathological factors, treatments, relapse and exitus with age and with previously published miRNA expression data.

Results:

We identified some significant differences in risk factors between BCVY and older patients. The age at menarche, number of pregnancies, and age at first pregnancy were lower in the BCVY group and had a greater probability of recurrence and death in all cases. Lymph node-positive patients in the BCVY group are associated with a worse prognosis (P = .02), an immunohistochemical HER2⁺ subtype, and disease relapse (P = .03). Moreover, there was a shorter time between diagnosis and first relapse in BCVY patients compared with controls, and they were more likely to die from the disease (P = .002). Finally, from our panel of miRNAs deregulated in BC, reduced miR-30c expression was associated with more aggressive BC in very young patients, lower overall survival, and with axillary lymph node metastases.

Conclusions:

Patient age and axillary lymph node status post-surgery are independent and significant predictors of distant disease-free survival, local recurrence-free survival, and overall survival. The HER2⁺ subtype and lower miR-30c expression are related to poor prognosis in lymph node-positive young BC patients.

Dietary patterns, nutrition, and risk of breast cancer: a case-control study in the west of Iran

OBJECTIVES

Unhealthy dietary patterns are the most important changeable risk factors for breast cancer. The aim of this study was to assess the relationship between dietary patterns and the risk of breast cancer among under-50 year women in the west of Iran.

METHODS

All women under 50 years old with pathologically confirmed breast cancer between 2013 and 2015 who were referred to oncology clinics in the west of Iran, and 408 under-50 women referred to other outpatient clinics who were without breast or other cancers at the time of the study and 2 years later were selected as the control group. The data were collected using the middle-aged periodical care form of the Iranian Ministry of Health and analyzed using univariate and multivariate logistic regression in Stata.

RESULTS

The most powerful risk factor for breast cancer was fried foods; the odds ratio of consuming fried foods more than once a month for breast cancer was 4.5 (95% confidence interval, 2.1 to 9.4). A dose-response model indicated that increasing vegetable and fruit consumption up to 90 servings per month decreased the odds of breast cancer, but consuming more than 90 servings per month increased the risk.

CONCLUSIONS

Inadequate consumption of vegetables and consumption of soft drinks, industrially produced juices, fried foods, and sweets were identified as risk factors for breast cancer. In response to these findings, it is necessary to raise awareness and to provide education about healthy diets and the need to change unhealthy dietary patterns.

Overview of the genetic basis toward early detection of breast cancer

Cancer is a socioeconomical burden in any nation. Out of that, breast cancer is identified as the most common malignancy worldwide among women irrespective of age. As women are an important segment in a community, the weakening of their strength toward the development of a nation is a critical problem in each nation. In this review, it was aimed to discuss the characteristics of cancer genome, cancer genetics, and cancer epigenetics in general and then focus on discussing both genetic and nongenetic factors responsible for the predisposition of breast cancer in humans. More emphasis was placed on genes responsible for the early onset of the disease and which can be used as genetic tools in the identification of the disease at an early stage. Then the context of genetic involvement toward the breast cancer occurrence before age of 40 years was highlighted accordingly. In addition to genetic testing, the review paid adequate attention to mention novel liquid biopsy techniques and other clinical, laboratory, and radiologic assessments. These techniques can be used in early detection and recurrence as well as the surveillance of the patients after primary therapies.

Prognostic Value of BCL2 in Women Patients with Invasive Breast Cancer

Background: Breast cancers are heterogeneous, making it essential to recognize several biomarkers for cancer outcome predictions especially in young women where the classical prediction parameters are not suitable. The goal from this study is to evaluate the impact of B cell lymphoma 2 (BCL2), P53 and Ki-67 proteins expression on survival in young women patients with invasive ductal carcinoma. Patients and methods: Samples and clinical data from 238 patients were collected between 2003 and 2017. They were selected according to 2 criteria: age ≤40 years old and most of them are affected by an Invasive Ductal Carcinoma. We evaluated BCL2, P53 and ki-67 expression by immunochemistry test, and then we assessed correlations of these biomarkers expression with patient’s clinicopathological characteristics and survival. Results: Triple negative breast cancer group showed a high frequency among our cohort but we emphasize an almost equitable distribution among all molecular groups. Contrary to other studies which reported that luminal A was correlated with better prognosis, our analysis demonstrated that luminal A is correlated with the Scarff, Bloom and Richardson (SBR) grading 2 or SBR grading 3. To better investigate the prognosis, we analyze three biomarkers known by their impact on physiopathology behavior on breast cancer BCL2, ki-67and P53. BCL2 is the more relevant one, it was correlated with molecular subtypes (p=0.0012) and SBR grading (p=0.0016). BCL2 seems to be the good prognostic biomarker related to survival (p=0.004) with a protective role among patients when endocrine therapy is not provided and Lymph Node (LN) involvement is positive (p=0.021, p=0.000 respectively). Conclusions: The classical prognostic parameters based mainly on the molecular classification in breast cancer seem insufficient in the case of young women. BCL2 protein expression analysis provides a better prognostic value. BCL2 should be clinically associated in current practice when young women specimens are diagnosticated.

[Expert centre Cancer du sein et Grossesse (CALG): Concordance between the proposed therapeutics and those finally received]

OBJECTIVE

Breast cancer associated with pregnancy (CSAG) is a rare condition whose management justifies the use of expert center. The Pregnancy-Associated Cancer Network (CALG) was created in France to optimize therapeutic management. The objective of our study was to evaluate its impact on the therapeutic management of CSAGs and the discrepancy rate between the CALG proposal and the treatment performed.

METHOD

A retrospective study including 58 CSAGs for which the opinion of the CALG network was solicited between January 2015 and November 2017. A questionnaire was addressed to the practitioner requesting the network. These practitioners were contacted to know the treatments received by the patient to assess the discrepancy rate.

RESULTS

In 70% of the cases, the CALG network was solicited before any therapeutic treatment. When the opinion was requested after initiation of therapy, the discrepancy rate between the CALG proposal and the one practiced was 47%. Of the 46 physicians contacted, the response rate was 62.5% (30/46). In 90% of cases, the therapy proposed by the CALG network was the one received by the patient.

CONCLUSION

This study emphasizes the need to refer to an expert center before treatment of a CSAG and the need for the contribution of doctors requesting the expert center to inform them of the follow-up of patients and children.

Invasive breast cancers in adolescent and young adult women show more aggressive immunohistochemical and clinical features than those in women aged 40-44 years

BACKGROUND

Limited knowledge exists concerning the clinicopathological features of breast cancers (BCs) occurring in adolescent and young adult (AYA) women. We evaluated tumor characteristics in AYA women in comparison with those in middle-aged premenopausal women.

METHODS

From consecutive AYA patients (< 35-year-old) with invasive BC in a single institute, 82 patients first treated with surgery were examined. As the control group, 82 tumors from middle-aged premenopausal patients (40-44 years) were selected by matching pathological T and N factors. We compared habitual factors, immunohistochemical parameters, and patient outcome between the two groups.

RESULTS

Most of the study population (148 of 164, 90.2%) were in the early clinical stages (stage I or II). In the AYA group, the number of childbirths was smaller (p < 0.0001), while the volume of alcohol consumption was larger (p < 0.0001), and palpable primary tumors were more frequent (p < 0.01) than in the control group. The positivities of estrogen receptor, progesterone receptor, and androgen receptor were lower (p < 0.001, p = 0.03, and p < 0.001, respectively), and the triple-negative (TN) BCs rates were higher (p < 0.01) in the AYA group. Distant recurrence-free survival (DRFS) curves were different in the whole population (p = 0.02) and in hormone receptor-positive cases (p = 0.01).

CONCLUSIONS

We confirmed that BCs occurring in AYA women had more aggressive features than those of the older premenopausal women in terms of a high proportion of TN subtypes and a lower DRFS.

Breast cancer in adolescents and young adults

Breast cancer is the most common cancer of adolescents and young adult (AYA) women aged 15 to 39 years, accounting for 5.6% of all invasive breast cancer in women. In comparison with older women, AYAs are more likely to have familial cancer predisposition genes, larger breast tumors, unfavorable biological characteristics, distant metastatic disease at diagnosis, and adverse outcome. Endocrine therapy and some chemotherapy recommendations differ between young and older women. AYAs require coordinated multidisciplinary care, treatment regimens that minimize late effects such as premature menopause and osteoporosis, and proactive management of psychological and sexual health during and after cancer treatment.

Young age is an independent adverse prognostic factor in early stage breast cancer: a population-based study

Objective

To compare the prognosis of young breast cancer patients with the older ones.

Patients and methods

Utilizing the Surveillance, Epidemiology, and End Results database, we identified 150,588 female breast cancer patients diagnosed during 2003–2014, including 6,668 patients younger than 35 years and 143,920 patients aged between 35 and 60 years. Kaplan– Meier analysis was performed to compare the prognosis of these two groups. Univariate and multivariate Cox proportional hazard models were utilized to identify independent prognostic factors and calculate the HR and 95% CI. Subgroup analysis was performed stratified according to the lymph node status and estrogen receptor (ER) status.

Results

The young patients presented with more aggressive clinicopathological characteristics, including larger tumor size (P<0.001), more lymph node metastasis (P<0.001), higher grade (grades III and IV, P<0.001), more ER/progesterone receptor absence (P<0.001), and more human epidermal growth factor receptor 2 overexpression (P<0.001). The patients younger than 35 years presented with inferior breast cancer-specific survival (BCSS) and overall survival (OS) (log-rank, P<0.001) in comparison with the older ones. In the multivariable Cox proportional hazard regression analysis, young age remained to be an independent adverse prognostic factor in operable breast cancer in terms of BCSS (HR, 1.200; 95% CI, 1.110–1.297; P<0.001) and OS (HR, 1.111; 95% CI, 1.032–1.196; P=0.005). In the subgroup analysis, young age remained a significant adverse prognostic factor in N0 (BCSS), N1, and ER-positive subgroups (P<0.05).

Conclusion

Young age is an independent adverse prognostic factor in operable breast cancer. Young patients may receive more intensive treatment than older ones.

Methylation deregulation of miRNA promoters identifies miR124-2 as a survival biomarker in Breast Cancer in very young women

MiRNAs are part of the epigenetic machinery, and are also epigenetically modified by DNA methylation. MiRNAs regulate expression of different genes, so any alteration in their methylation status may affect their expression. We aimed to identify methylation differences in miRNA encoding genes in breast cancer affecting women under 35 years old (BCVY), in order to identify potential biomarkers in these patients. In Illumina Infinium MethylationEPIC BeadChip samples (metEPICVal), we analysed the methylation of 9,961 CpG site regulators of miRNA-encoding genes present in the array. We identified 193 differentially methylated CpG sites in BCVY (p-value < 0.05 and methylation differences ±0.1) that regulated 83 unique miRNA encoding genes. We validated 10 CpG sites using two independent datasets based on Infinium Human Methylation 450k array. We tested gene expression of miRNAs with differential methylation in BCVY in a meta-analysis using The Cancer Genome Atlas (TCGA), Clariom D and Affymetrix datasets. Five miRNAs (miR-9, miR-124-2, miR-184, miR-551b and miR-196a-1) were differently expressed (FDR p-value < 0.01). Finally, only miR-124-2 shows a significantly different gene expression by quantitative real-time PCR. MiR-124-hypomethylation presents significantly better survival rates for older patients as opposed to the worse prognosis observed in BCVY, identifying it as a potential specific survival biomarker in BCVY.

BREAST CANCER IN YOUNG WOMEN: PATHOLOGIC AND IMMUNOHISTOCHEMICAL FEATURES

SUMMARY – A young woman with breast cancer is considered to be a woman younger than 40. According to the literature, breast cancer in the population of young women usually is of a higher histologic grade, unfavorable hormonal status, and overall higher mortality rate when compared with breast cancer occurring in older population. We compared pathologic and immunohistochemical features of breast carcinoma in women under 40 years of age with the respective features in women over 60 years of age. The following parameters were observed in these two groups: tumor size, lymph node status, histologic grade, hormonal receptor status, Ki-67 prognostic index, Her2/neu status, and histologic type of the tumor. Early onset breast carcinoma was found to have a higher frequency of tumor grade 3 (29% vs. 17%) and estrogen receptor negativity (45% vs. 23%). In the group of young women, breast carcinoma was mostly multicentric (23% vs. 5%), triple-negative (32% vs. 10%), and was found to have higher proliferation index Ki-67 (25% vs. 10%). Our results confirmed differences between the young and older groups of patients. In the group of young women, we found predominantly unfavorable prognostic parameters of the disease.

Breast cancer in an 18-year-old female: A fatal case report and literature review

Breast cancer (BC) is the most frequent malignancy in both pre- and postmenopausal women. However, it is exceedingly rare in very young patients, and especially in adolescents. Herein, we report a case of an 18-year-old female diagnosed with invasive BC. The proband had been found to be negative for BC in close family members. A common BC genetic screening test for the Polish population did not detect any known founder mutations in the BRCA1 gene. Further evaluation identified a p.Ile157Thr (I157T) mutation in the CHEK2 gene, a p.Ala1991Val (A1991V) variant of unknown significance in the BRCA2 gene, p.Lys751Gln (K751Q) variant in the XPD (ERCC2) gene, and a homozygous p.Glu1008Ter (E1008*) mutation in the NOD2 gene. No other mutation had been found by next generation sequencing in major BC high-risk susceptibility genes BRCA1, BRCA2, as well as 92 other genes. To date, all these found alterations have been considered as low to moderate risk factors in the general population and moderate risk factors in younger women (<35 years of age). There are no previous articles relating low and moderate risk gene mutations to very young onset (below 20 years) BC with a fatal outcome. In our patient, a possible cumulative or synergistic risk effect for these 4 alterations, and a mutation in the NOD2 gene in particular, of which both presumably healthy parents were found to be carriers, is suggested.

Clinicopathologic Factors Related to the Histological Tumor Grade of Breast Cancer in Western China: An Epidemiological Multicenter Study of 8619 Female Patients

BACKGROUND AND PURPOSE

Breast cancer is now recognized as a clinically heterogeneous disease with a wide spectrum of epidemiological and clinicopathologic features. We aimed to evaluate whether epidemiological and clinicopathologic features are associated with the histological tumor grade of breast carcinomas in Western China.

METHODS

We retrospectively collected data from the Western China Clinical Cooperation Group and assessed associations between clinicopathologic factors and histological tumor grade in 8619 female breast cancer patients. Patients were divided into two groups: Group I (tumor grade I/II) and Group II (tumor grade III). Univariable analysis and multivariable logistic regression models were used to analyze the relationships between clinicopathologic factors and tumor grade.

RESULTS

Patients presenting with positive axillary lymph nodes, large tumor size (>2 cm), lymphovascular invasion, hormone receptor negativity, human epidermal growth factor receptor 2 (HER-2) positivity, and triple negativity tended to have an increased risk of a high tumor grade. However, the number of pregnancies or births was inversely correlated with the risk of a high tumor grade. In addition, patients presenting with grade III tumors were more likely to receive aggressive treatment, such as adjuvant chemotherapy, anti-HER-2 therapy, and level III axillary lymph node dissection.

CONCLUSIONS

Our results suggested that several clinicopathologic factors were associated with high tumor grade of breast cancer patients in Western China.

Oncologic safety of skin-sparing mastectomy followed by immediate reconstruction in young patients with breast cancer

BACKGROUNDS

This study aimed to compare the oncologic outcomes of nipple-sparing mastectomy (NSM)/skin-sparing mastectomy (SSM) followed by immediate reconstruction with those of conventional mastectomy (CM) in young patients aged under 35 years old with breast cancer.

METHODS

We analyzed retrospectively 2889 patients who underwent mastectomy for breast cancer at Asan Medical Center from January 2003 to December 2008. We compared NSM/SSM followed by immediate reconstruction with CM in patients under 35 years old by analyzing clinicopathologic features, breast cancer specific survival rate (BCSS), distant metastasis free survival rate (DMFS), and local recurrence rate (LRR).

RESULTS

Out of a total of 2889 patients, we performed NSM/SSM in 118 patients and CM in 141 patients aged less than 35 years old. DMFS were 85.3% and 73.4% in NSM/SSM and CM, respectively (p = 0.001). BCSS were 90.7% and 73.0% in NSM/SSM and CM, respectively (p = 0.001). After adjusting for stage, there were no statistically significant differences between the two groups with respect to DMFS and BCSS. The type of surgery was not a prognostic factor in multivariate analysis for DMFS and BCSS (CM vs. NSM/SSM: DMFS HR = 0.67, p = 0.215; BCSS: HR = 0.66, p = 0.265).

CONCLUSIONS

Compared to CM, NSM/SSM followed by immediate breast reconstruction is oncologically safe and could be a viable surgical treatment in young patients under 35 years old with breast cancer.

Oncological safety of nipple-sparing mastectomy in young patients with breast cancer compared with conventional mastectomy

Although nipple-sparing mastectomy (NSM) is being used more frequently, the oncological safety of NSM remains unclear, particularly in young patients (<35 years). The aim of the present study was to compare the rates of local recurrence (LR), disease-free survival (DFS) and overall survival (OS) in young patients with breast cancer who had undergone NSM or conventional mastectomy (CM). The clinicopathological data of young patients with stage 0-IIB breast cancer who had undergone NSM (163 cases) or CM (194 cases) between 2007 and 2016 were retrospectively analyzed. The log-rank test was used to analyze the differences in the LR, DFS and OS rates between the two groups and multivariate analysis was used to analyze the patient prognostic factors for DFS. The median follow-up time was 49 months. Patients who had undergone CM were more likely to exhibit stage II disease (68.4 vs. 58.3%; P=0.015) and positive lymph nodes (45.9 vs. 33.1%; P=0.014). In the NSM group, LR occurred in 7 (4.3%) cases, systemic recurrence in 15 (9.2%) cases and mortality in 9 (5.5%) cases. In the CM group, LR occurred in 6 (3.1%) cases, systemic recurrence in 27 (13.9%) cases and mortality in 15 (7.7%) cases. There were no statistical differences in the LR, DFS and OS rates between the two groups (P>0.05). Following adjustment for clinical stage, the LR and DFS rates between the two groups exhibited no significant differences. Analysis of the prognostic factors demonstrated that clinical stage, lymph node status, estrogen and progesterone receptor status and human epidermal growth factor receptor 2 status were associated with DFS (P<0.05). NSM is safe for young patients with early-stage breast cancer and provides patients with an improved cosmetic outcome. Furthermore, nipple-areola complex preservation does not increase the risk of recurrence.

Breast Cancer Prognosis for Young Patients

BACKGROUND/AIMS

Breast cancer (BCa) prognostication is a vital element for providing effective treatment for patients with BCa. Studies suggest that ethnicity plays a greater role in the incidence and poor prognosis of BCa in younger women than in their older counterparts. Therefore, the goal of this study was to assess the association between age and ethnicity on the overall final prognosis.

MATERIALS AND METHODS

Nottingham Prognostic Index (NPI) was used to analyze BCa prognosis using Howard University Cancer Center Tumor Registry and the National Cancer Institute's Surveillance, Epidemiology, and End Results BCa datasets. Patients were grouped according to their predicted prognosis based on NPI scheme.

RESULTS

There was no correlation between the younger patients compared to their older counterparts for any of the prognostic clusters. The significance of ethnicity in poorer prognosis for younger age is not conclusive either.

CONCLUSION

An extended prognostic tool/system needs to be evaluated for its usefulness in a clinical practice environment.

Analysis of breast cancer in young women in the Department of Defense (DOD) database

PURPOSE

Breast tumors from young women under the age of 40 account for approximately 7% of cases and have a poor prognosis independent of established prognostic factors. We evaluated the patient population served by the Military Health System, where a disproportionate number of breast cancer cases in young women are seen and treated in a single universal coverage healthcare system.

METHODS

The Military Health System Repository and the DoD Central Registration databases were used to identify female breast cancer patients diagnosed or treated at military treatment facilities from 1998 to 2007.

RESULTS

10,066 women were diagnosed with invasive breast cancer at DoD facilities from 1998 to 2007, of which 11.3% (1139), 23.4% (2355) and 65.2% (6572) were < 40, 40-49 and > 50 years old (yo), respectively, at diagnosis. 53% in the < 40 yo cohort were white, 25% were African American (AA) and 8% were Hispanic, with 14% undisclosed. Breast cancer in women diagnosed < 40 yo was more high grade (p < 0.0001), Stage II (p < 0.0001) and ER negative (p < 0.0001). There was a higher rate of bilateral mastectomies among the women < 40 compared to those 40-49 and > 50 (18.4% vs. 9.1% and 5.0%, respectively). Independent of disease stage, chemotherapy was given more frequently to < 40 yo (90.43%) and 40-49 yo (81.44%) than ≥ 50 yo (53.71%). The 10-year overall survival of younger women was similar to the ≥ 50 yo cohort. Outcomes in the African American and Hispanic subpopulations were comparable to the overall cohort.

CONCLUSION

Younger women had a similar overall survival rate to older women despite receiving more aggressive treatment.

Breast cancer in young women and prognosis: How important are proliferation markers?

AIM

Compared to middle-aged women, young women with breast cancer have a higher risk of systemic disease. We studied expression of proliferation markers in relation to age and subtype and their association with long-term prognosis.

METHODS

Distant disease-free survival (DDFS) was studied in 504 women aged <40 years and 383 women aged ≥40 years from a population-based cohort. Information on patient characteristics, treatment and follow-up was collected from medical records. Tissue microarrays were produced for analysis of oestrogen receptor, progesterone receptor (PR), Her2, Ki-67 and cyclins.

RESULTS

Young women with luminal tumours had significantly higher expression of Ki-67 and cyclins. Proliferation markers were prognostic only within this subtype. Ki-67 was a prognostic indicator only in young women with luminal PR+ tumours. The optimal cut-off for Ki-67 varied by age. High expression of cyclin E1 conferred a better DDFS in women aged <40 years with luminal PR- tumours (hazard ratio [HR] 0.47 [0.24-0.92]). Age <40 years was an independent risk factor of DDFS exclusively in women with luminal B PR+ tumours (HR 2.35 [1.22-4.50]). Young women with luminal B PR- tumours expressing low cyclin E1 had a six-fold risk of distant disease compared with luminal A (HR 6.21 [2.17-17.6]).

CONCLUSIONS

The higher expression of proliferation markers in young women does not have a strong impact on prognosis. Ki-67 is only prognostic in the subgroup of young women with luminal PR+ tumours. The only cyclin adding prognostic value beyond subtype is cyclin E1. Age is an independent prognostic factor only in women with luminal B PR+ tumours.

Improved prognosis of young patients with breast cancer undergoing breast-conserving surgery

BACKGROUND

The aim of the present study was to evaluate how breast cancer prognosis has evolved over time in young women treated with breast-conserving surgery (BCS).

METHODS

Data from patients younger than 40 years who had BCS and whole-breast radiotherapy in a single cancer centre between 1997 and 2010 were analysed. The patients were followed until 2016. Endpoints were local recurrence, any breast cancer-related event and death from any cause.

RESULTS

A total of 1331 patients were included in the study. After a median follow-up of 9·3 years, 114 local recurrences, 289 breast cancer-related events and 138 deaths had occurred. Women were divided into three groups of similar size based on tertiles of the date of diagnosis: 1997-2002 (524 patients), 2003-2005 (350) and 2006-2010 (457). The risk of local recurrence was 1·42 per 100 person-years in women diagnosed in the first interval, 0·85 per 100 person-years in the second and 0·48 per 100 person-years in the third (P for trend = 0·028). The respective values were 3·01, 2·52 and 2·07 per 100 person-years for any breast cancer-related event (P = 0·004), and 1·59, 1·22 and 0·64 per 100 person-years for death (P = 0·003). Each passing year was associated with a decreasing risk of local recurrence (hazard ratio (HR) 0·93, 95 per cent c.i. 0·87 to 1·00), any breast cancer-related event (HR 0·94, 0·91 to 0·98) and death (HR 0·89, 0·83 to 0·94). A major improvement in prognosis was observed after 2005, when the classification of breast cancer molecular subtypes and use of trastuzumab were implemented in routine clinical practice.

CONCLUSION

In the past two decades, both local control and overall prognosis have improved significantly in young women (aged less than 40 years) with breast cancer who undergo BCS.

Association of the Timing of Pregnancy With Survival in Women With Breast Cancer

Importance

Increasing numbers of women experience pregnancy around the time of, or after, a diagnosis of breast cancer. Understanding the effect of pregnancy on survival in women with breast cancer will help in the counseling and treatment of these women.

Objective

To compare the overall survival of women diagnosed with breast cancer during pregnancy or in the postpartum period with that of women who had breast cancer but did not become pregnant.

Design, Setting, and Participants

This population-based, retrospective cohort study linked health administrative databases in Ontario, Canada, comprising 7553 women aged 20 to 45 years at the time of diagnosis with invasive breast cancer, from January 1, 2003, to December 31, 2014.

Exposures

Any pregnancy in the period from 5 years before, until 5 years after, the index date of the diagnosis of breast cancer. Women were classified into the following 4 exposure groups: no pregnancy (the referent), pregnancy before breast cancer, pregnancy-associated breast cancer, and pregnancy following breast cancer.

Main Outcomes and Measures

Five-year actuarial survival rates for all exposure groups, age-adjusted and multivariable hazard ratios [HRs] of pregnancy for overall survival for all exposure groups, and time-dependent hazard ratios for women with pregnancy following breast cancer.

Results

Among the 7553 women in the study (mean age at diagnosis, 39.1 years; median, 40 years; range, 20-44 years) the 5-year actuarial survival rate was 87.5% (95% CI, 86.5%-88.4%) for women with no pregnancy, 85.3% (95% CI, 82.8%-87.8%) for women with pregnancy before breast cancer (age-adjusted hazard ratio, 1.03; 95% CI, 0.85-1.27; P = .73), and 82.1% (95% CI, 78.3%-85.9%) for women with pregnancy-associated breast cancer (age-adjusted hazard ratio, 1.18; 95% CI, 0.91-1.53; P = .20). The 5-year actuarial survival rate was 96.7% (95% CI, 94.1%-99.3%) for women who had pregnancy 6 months or more after diagnosis of breast cancer, vs 87.5% (95% CI, 86.5%-88.4%) for women with no pregnancy) (age-adjusted HR, 0.22; 95% CI, 0.10-0.49; P < .001).

Conclusions and Relevance

Pregnancy did not adversely affect survival in women with breast cancer. For breast cancer survivors who wish to conceive, the risk of death is lowest if pregnancy occurs 6 months or more after diagnosis.

Breast Cancer Epidemiology in Gulf Cooperation Council Countries: A Regional and International Comparison

Breast cancer is the most frequently diagnosed noncutaneous malignancy in women living in Gulf Cooperation Council countries. The present report aimed to highlight the similarities and variations in breast cancer incidence, age at diagnosis, clinicopathologic features, molecular characteristics, and lifestyle factors that contribute to an increasing incidence of breast cancer compared with neighboring Arab and westernized countries. The data presented, although having important implications for policy makers, also highlights the need for further research. Such research would ensure that effective prevention and detection strategies are tailored to the specific needs of the Gulf women such that the management of breast cancer is optimized.

Treatment Efficacy, Adherence, and Quality of Life Among Women Younger Than 35 Years in the International Breast Cancer Study Group TEXT and SOFT Adjuvant Endocrine Therapy Trials

Purpose To describe benefits and toxicities of adjuvant endocrine therapies in women younger than 35 years with breast cancer (n = 582) enrolled in the Suppression of Ovarian Function Trial (SOFT) and Tamoxifen and Exemestane Trial (TEXT). Methods In SOFT, women still premenopausal after surgery with or without chemotherapy were randomly assigned to tamoxifen alone, tamoxifen plus ovarian function suppression (OFS), or exemestane plus OFS. In TEXT, all received OFS with or without concomitant chemotherapy and were randomly assigned to exemestane plus OFS or tamoxifen plus OFS. We summarize treatment efficacy, quality of life, and adherence of the cohort of women younger than 35 years in SOFT and TEXT, alongside data from the cohort of older premenopausal women. Results For 240 human epidermal growth factor receptor 2-negative patients younger than 35 years enrolled in SOFT after receiving chemotherapy, the 5-year breast cancer-free interval (BCFI) was 67.1% (95% CI, 54.6% to 76.9%) with tamoxifen alone, 75.9% with tamoxifen plus OFS (95% CI, 64.0% to 84.4%), and 83.2% with exemestane plus OFS (95% CI, 72.7% to 90.0%). For 145 human epidermal growth factor receptor 2-negative patients younger than 35 years in TEXT, 5-year BCFI was 79.2% (95% CI, 66.2% to 87.7%) with tamoxifen plus OFS and 81.6% (95% CI, 69.8% to 89.2%) with exemestane plus OFS. The most prominent quality of life symptom for patients younger than 35 years receiving OFS was vasomotor symptoms, with the greatest worsening from baseline at 6 months (on the order of 30 to 40 points), but loss of sexual interest and difficulties in becoming aroused were also clinically meaningful (≥ 8-point change). The level of symptom burden was similar in older premenopausal women. A total of 19.8% of women younger than 35 years stopped all protocol-assigned endocrine therapy early. Conclusion In women younger than 35 years with hormone receptor-positive breast cancer, adjuvant OFS combined with tamoxifen or exemestane produces large improvements in BCFI compared with tamoxifen alone. Menopausal symptoms are significant but are not worse than those seen in older premenopausal women.

Younger age is an independent predictor of worse prognosis among Lebanese nonmetastatic breast cancer patients: analysis of a prospective cohort

Background

Several retrospective studies have reported that younger age at presentation is associated with a worse prognosis for nonmetastatic breast cancer patients. In this study, we prospectively assessed the association between different baseline characteristics (age, tumor characteristics, mode of treatment, etc) and outcomes among newly diagnosed nonmetastatic Lebanese breast cancer patients.

Methods

We recruited a sample of 123 women newly diagnosed with nonmetastatic breast cancer presenting to American University of Beirut Medical Center. Immunohistochemical, molecular (vitamin D receptor, methylene tetrahydrofolate reductase polymorphisms), and genetic assays were performed. Patient characteristics were compared by age group (<40 and ≥40 years). A Cox regression analysis was performed to evaluate the variables affecting the disease-free survival (DFS). Outcome data were obtained, and DFS was estimated.

Results

Among the 123 patients, 47 were 40 years of age or younger, and 76 were older than 40 years. Median follow-up duration was 58 months. Nine out of 47 patients <40 years (19.1%) experienced disease relapse in contrast to four out of 76 patients >40 years (5.2%). A wide immunohistochemical panel included Ki-67, cyclin B1, p53, platelet-derived growth factor receptor, and vascular endothelial growth factor receptor, and did not reveal any significant difference in these markers between the two age groups. Older patients had a larger percentage of Luminal A than younger patients. On multivariate analysis including age, stage, grade, and subtype, only age <40 and stage were significantly associated with shorter DFS with hazard ratios of 4 (p=0.03, 95% confidence interval [CI]: 1.1–13.5) and 3 (p=0.03, 95% CI: 0.8–14.9), respectively. The estimated 5-year DFS for patients >40 years was 90%, and for patients <40 years was 37%.

Conclusion

Being <40 years old was an independent risk factor for recurrence in this cohort of patients.

Establishment of a risk scoring system for predicting locoregional recurrence in T1 to T2 node-negative breast cancer patients treated with mastectomy: Implications for postoperative radiotherapy

To establish a risk scoring system for predicting locoregional recurrence (LRR) and explore the potential value of radiotherapy in T1 to T2 node-negative breast cancer patients treated with mastectomy. From January 2001 to February 2008, a total of 353 node-negative T1 to T2 breast cancer cases treated with mastectomy without adjuvant radiotherapy were retrospectively analyzed. Preliminary screening of the prognostic factors was accomplished by Kaplan-Meier univariate analysis, and survival curves between different groups were compared by log-rank test. Risk factors were determined using Cox proportional hazards model. A categorical risk scoring system was generated according to the Cox model, weighing the relative importance of each risk variable. Median follow-up was 115.7 months (range, 1.2-238.4 months). The overall 5-year locoregional recurrence-free survival (LRFS) was 89.8% (95% confidence interval [CI] = 86.7%-92.9%). Chest wall (53.8%) was found to be the most common site of LRR, followed by supraclavicular nodes (48.7%). Age ≤40 years, primary tumor size ≥4.5 cm and number of nodes resected ≤10 were found to be independent factors for poor prognosis of LRR. Two risk stratifications based on the scoring system were subsequently obtained. The 5-year LRFS was 91.6% (95% CI = 88.5%-94.7%) with low risk (score <2) and 75.7% (95% CI = 61.8%-89.6%) with high risk (score ≥2), respectively (χ = 7.544, P = .006). In addition, significant differences in overall survival (P = .045) and disease-free survival (P = .019) were presented between them. Patients with T1-2N0M0 breast cancer achieved favorable prognosis in general. Those with risk factors, including age ≤40 years, primary tumor size ≥4.5 cm and number of nodes resected ≤10, were at higher risk of LRR. The established scoring system could help to distinguish the subgroups that might potentially benefit from postoperative radiotherapy.

Prognostic value of ABO blood types in young patients with breast cancer; a nationwide study in Korean Breast Cancer Society

The purpose of this study was to investigate the relationship between ABO blood types and breast cancer survival in young Korean patients. This was a retrospective study of 115,474 patients who were surgically treated for primary breast cancer between 1987 and 2011 in Korea. All data were collected by the Korean Breast Cancer Society (KBCS) online breast cancer registry. Each hospital serologically examined the ABO blood types of patients before surgery. There was no significant difference in overall survival (OS) or breast cancer-specific survival (BCSS) among ABO blood types. Type of surgery; T stage; N stage; histologic grade; status of estrogen receptor, progesterone receptor, and HER2; and chemotherapy were significant prognostic factors of OS and BCSS in univariate analysis and multivariate analyses. Compared to women with blood type O, there was a difference in OS and BCSS for blood type A, blood type B, or blood type AB. Compared to blood group non-O, patients with blood group O were more likely to have favorable prognosis when younger than 40 years. Further follow-up studies are necessary to clarify the role of the impact of ABO blood types on prognosis of breast cancer.

Tidal chemotherapy in premenopausal patients with hormone receptor positive breast cancer

Neoadjuvant chemotherapy remains an inseparable part of systemic therapy for hormone receptor positive (HR+) advanced breast cancer. However, efficacy of neoadjuvant chemotherapy in this subtype of patients is inferior to its hormone receptor negative counterpart. Several preclinical and clinical studies have suggested that it was growth rate rather than hormone receptor status that determined sensitivity to chemotherapy. In addition, estrogen was proved to recruit more HR+ breast cancer cells into actively dividing phase according to various studies. For premenopausal females, sexual hormone like estradiol fluctuates with menstrual cycle. When menstruation occurs, women have the lowest level of estradiol, which is resemble to pharmaceutical effect of endocrine therapy. If chemotherapy is given to females during menstruation, it's almost equal to concurrent use of chemotherapy and endocrine therapy, which is not recommended by guideline. Accordingly, chemotherapy would attain best efficacy applied at the peak of estradiol, because more tumor cells being in actively dividing phase recruited by comparatively high level of estradiol would help cytotoxic agents function better given that majority of chemotherapeutic drugs are cellular phase dependent. We name this rhythmic mode of chemotherapy for premenopausal HR+breast cancer females, giving chemotherapy to patients when estradiol rises and avoiding prescription at menstruation, tidal chemotherapy. It's postulated that tidal chemotherapy would improve efficacy of neoadjuvant chemotherapy for premenopausal HR+breast cancer females, achieve more pathologic complete response and in the long run improve prognosis.

Retrospective analysis of breast cancer prognosis among young and older women in a Brazilian cohort of 738 patients, 1985-2002

Invasive breast cancer (BC) is infrequent among women aged ≤40 years, however, the disease outlook in these younger patients is generally worse than among older women. The present study aimed to compare socio-demographic, clinical and pathological characteristics, and their association with long-term survival, between two random cohorts of young (≤40 years) and older (50–69 years) Brazilian patients with BC. The cohort comprised of 738 randomly selected women who were diagnosed with BC at Barretos Cancer Hospital, Pio XII Foundation (Barretos, Brazil) between January 1985 and December 2002; the patients included young women (n=376) and older women (n=362). The current analysis suggested that BC in young women is associated with numerous pathological features of aggressiveness. Second cancer and bilateral BC were independent predictors of a poor outcome in the younger group. Furthermore, C-erB-2 was positively correlated with poor outcome in the older group, whereas estrogen receptor status and TNM stage were associated with disease prognosis in both groups. The overall survival rates of the two age groups were similar except when analyzed according the treatment period (1997–2002). Although patients aged ≤40 years harbored tumors with more aggressive clinicopathological characteristics, these characteristics were not independent predictors of overall survival. The present study indicates that medical advances associated with prevention of breast cancer may improve screening programs, which may therefore increase early diagnosis and subsequently lower mortality rates.

Risk of Premenopausal and Postmenopausal Breast Cancer among Multiple Sclerosis Patients

Objective

To investigate risk of premenopausal and postmenopausal breast cancer among Multiple Sclerosis (MS) patients, considering tumor stage.

Methods

The Swedish Patient Register identified 19,330 women with MS between 1968 and 2012, matched individually with a cohort of 193,458 without MS. Matching variables were year of birth, sex, region of residence and vital status at the time of diagnosis. The cancer register identified 471 and 5,753 breast cancer cases among the MS and non-MS cohorts, respectively. Cox proportional hazard models estimated hazard ratios (HR) and 95% confidence intervals (CI) for premenopausal and postmenopausal breast cancer.

Results

Overall risk of postmenopausal breast cancer was 13% higher among MS patients compared with women without MS (HR = 1.13, 95% CI 1.02–1.26). Stratified analyses showed that the risk was statistically significantly increased in women diagnosed between 1968 and 1980 and those who were diagnosed at age 65 or older age. We observed a non-statistically significant risk only for stage 0–1 postmenopausal breast cancer (HR = 1.17, 95% CI 0.93–1.48). MS was not associated with premenopausal breast cancer.

Conclusion

The modest increased risk of postmenopausal breast cancer in women with MS may be due to surveillance bias, where contact with health services for one disease increases the risk of a second diagnosis being recorded.

Breast cancer in women aging 35 years old and younger: The Egyptian National Cancer Institute (NCI) experience

OBJECTIVE

The aim is to identify the epidemiological and clinicopathological features associated with young breast cancer (BC) patients and to discuss factors affecting tumor recurrence and DFS.

PATIENTS & METHODS

A retrospective analysis was conducted based on medical records from young females patients aged ≤35 years with pathologically confirmed primary breast cancer treated during 2008-2010 at NCI. Cases with non invasive cancer and non carcinoma histology are excluded.

RESULTS

Of the 5408 cases diagnosed with breast cancer, 554 were young. Four hundred & fifty eight patients representing 9.2% were within our inclusion criteria. Almost half of the patients (45.9%) presented with stage III. Axillary nodes involvement was in 63.9%, 83.3% were grade 2. More than one quarter of tumors was hormone receptors negative (28.8%) & Her2 was over-expressed in 30%. Mastectomy was offered in 72% while conservative breast surgery in 26%, 69.2% received chemotherapy either adjuvant, neoadjuvant or both, 82.5% received adjuvant radiotherapy, 68.6% received hormonal therapy. Metastatic disease developed in 51.3%, with 31% having more than one site of metastases. After a median follow up period of 66 months, the median DFS of patients was 60 months. The median DFS was significantly shorter among patients with positive lymph nodes (P < 0.0001), ER negative disease (P = 0.045) and stage III disease (P < 0.0001).

CONCLUSION

Breast cancer in young women is aggressive from the time of diagnosis. Our results provide baseline data of young BC in the Middle East & North Africa region; thus, contributing to future epidemiological and hospital-based researches.

Ten-year survival in women with primary stage IV breast cancer

PURPOSE

To evaluate breast cancer-specific survival at 10 years in patients who present with primary stage IV breast cancer, and to determine whether survival varies with age of diagnosis.

METHODS

We retrieved the records of 25,323 women diagnosed with primary stage IV breast cancer in the surveillance, epidemiology, and end results 18 registries database from 1990 to 2012. For each case, we extracted information on age at diagnosis, tumour size, nodal status, oestrogen receptor status, progesterone receptor status, ethnicity, cause of death and date of death. The Cox proportional hazards model was used to estimate the unadjusted and adjusted hazard ratio (HR) of death due to stage IV breast cancer, according to age group.

RESULTS

Among 25,323 women with stage IV breast cancer, 2542 (10.0 %) were diagnosed at age 40 or below, 5562 (22.0 %) were diagnosed between ages 41 and 50 and 17,219 (68.0 %) were diagnosed between ages 51 and 70. After a mean follow-up of 2.2 years, 16,387 (64.7 %) women died of breast cancer (median survival 2.3 years). The ten-year actuarial breast cancer-specific survival rate was 15.7 % for women ages 40 and below, 14.9 % for women ages 41-50 and 11.7 % for women ages 51 to 70 (p < 0.0001). In an adjusted analysis, the risk of death from breast cancer at 10 years was significantly lower for women ages 40 and below (HR 0.78; 95 % CI 0.74-0.82; p < 0.0001) and for women ages 41-50 (HR 0.82; 95 % CI 0.79-0.85; p < 0.0001), compared to women ages 51-70.

CONCLUSIONS

Approximately 13 % of women with primary stage IV breast cancer survive 10 years after diagnosis. Women diagnosed with stage IV breast cancer before age 50 have better survival at 10 years compared to older women.

Long-term outcome in young women with breast cancer: a population-based study

Purpose

Whether young age at diagnosis of breast cancer is an independent risk factor for death remains controversial, and the question whether young age should be considered in treatment decisions is still to be answered.

Methods

From a population-based cohort of 22,017 women with breast cancer, all women <35 years (n = 471) were compared to a random sample of 700 women aged 35–69 years from the same cohort. Information on patient and tumor characteristics, treatment, and follow-up was collected from the medical records. Tissue microarrays were produced for analysis of classical biomarkers. Breast cancer-specific survival (BCSS), distant disease-free survival (DDFS), and locoregional recurrence-free survival (LRFS) by age were compared using women 50–69 years as reference.

Results

At 10 years follow-up, women <35 years and 35–39 years had a worse BCSS [age <35 years 69 % (HR 2.75, 95 % CI 1.93–3.94), age 35–39 years 76 % (HR 2.33, 95 % CI 1.54–3.52), age 40–49 years 84 % (HR 1.53, 95 % CI 0.97–2.39), and age 50–69 years 89 % (reference)]. The worse BCSS was statistically significant in stages I–IIa and Luminal B tumors. At multivariate analysis age <35 years and 35–39 years confined a risk in LRFS (HR 2.13, 95 % CI 1.21–3.76 and HR 1.97, 95 % CI 1.06–3.68) but not in DDFS and BCSS. In the subgroup of women <40 years with luminal tumors stage I–IIa, low age remained an independent risk factor also in DDFS (HR 1.87, 95 % CI 1.03–3.44).

Conclusion

Young women have a high risk of systemic disease even when diagnosed in an early stage. The excess risk of relapse is most pronounced in Luminal B tumors, where low age is an independent prognostic factor of DDFS and LRFS.

Electronic supplementary material

The online version of this article (doi:10.1007/s10549-016-3983-9) contains supplementary material, which is available to authorized users.

Breast cancer in young women of Chinese Han population: A retrospective study of patients under 25 years

BACKGROUND

Breast cancer has aggressive clinical and pathological features in younger women and is characterized by poorer prognosis than in older women. However, data on women <25 years are limited.

OBJECTIVE

The aim of the present study was to evaluate the different pathological characteristics and prognostic factors in Chinese women with breast cancer <25 years at the time of diagnosis.

METHODS

This retrospective study included 94 patients (aged <25) of Chinese Han population with operable breast cancer at the National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences between January 1, 2000 and September 30, 2015. Univariate and multivariate Cox regression analysis were performed. The median follow-up duration was 64 months (range, 11-200 months).

RESULTS

The HER2-positive and triple-negative groups had a higher T (P=0.002) and N stage than the luminal A group (P=0.014). The 5-year overall survival (OS) was 90.4%, and the disease-free survival (DFS) was 74.5%. The 5-year DFS varied among the four groups were 94.1 vs. 76.9 vs. 45.5 vs. 66.7%, respectively; P=0.009. Multivariate analysis showed that only estrogen receptor (ER) status was a significant predictor of OS and DFS [Hazard ratio (HR)=5.3, 95% confidence interval (CI)=1.11-25.27, P=0.036; HR=2.712, 95%CI=1.27-5.80, P=0.01).

CONCLUSION

HER2-positive and triple-negative breast cancer are more likely to have poor prognosis in patients<25years. Hence, ER status may be identified as an independent prognostic factor for predicting young women with breast cancer.

Triple negative breast cancer: looking for the missing link between biology and treatments

The so called “Triple Negative Breast Cancer” (TNBC) represents approximately 15-20% of breast cancers. This acronym simply means that the tumour does not express oestrogen receptor (ER) and progesterone receptor (PR) and does not exhibit amplification of the human epidermal growth factor receptor 2 (HER2) gene. Despite this unambiguous definition, TNBCs are an heterogeneous group of tumours with just one common clinical feature: a distinctly aggressive nature with higher rates of relapse and shorter overall survival in the metastatic setting compared with other subtypes of breast cancer. Because of the absence of well-defined molecular targets, cytotoxic chemotherapy is currently the only treatment option for TNBC.

In the last decades, the use of more aggressive chemotherapy has produced a clear improvement of the prognosis in women with TNBC, but this approach results in an unacceptable deterioration in the quality of life, also if some support therapies try to relieve patients from distress. In addition, there is the general belief that it is impossible to further improve the prognosis of TNBC patients with chemotherapy alone. In view of that, there is a feverish search for new “clever drugs” able both to rescue chemo-resistant, and to reduce the burden of chemotherapy in chemo-responsive TNBC patients.

A major obstacle to identifying actionable targets in TNBC is the vast disease heterogeneity both inter-tumour and intra-tumour and years of study have failed to demonstrate a single unifying alteration that is targetable in TNBC. TNBC is considered the subtype that best benefits from the neoadjuvant model, since the strong correlation between pathological Complete Response and long-term Disease-Free-Survival in these patients.

In this review, we discuss the recent discoveries that have furthered our understanding of TNBC, with a focus on the subtyping of TNBC. We also explore the implications of these discoveries for future treatments and highlight the need for a completely different type of clinical trials.

Oncological Safety of Breast Conservation Surgery in Young Females

Breast conservation surgery (BCS) is the standard of care in early breast cancer. The oncological safety of this procedure has been proven beyond doubt in several randomised control trials. But there are concerns regarding the safety of this procedure in young females. The concern is regarding increased risk of local recurrence. This issue has not been addressed in any major trial. In this prospective study we intend to look into the oncological safety of BCS in young patients who are less than forty years of age.

Palliative systemic therapy for young women with metastatic breast cancer

PURPOSE OF REVIEW

Breast cancer in young women age less than 40 years remains a relatively rare disease. Emerging data suggest that the biology of breast cancer in younger women may differ from that of older women. Although metastatic breast cancer remains incurable, it is definitely treatable; especially in this era of emerging novel therapeutics.

RECENT FINDINGS

Most women have hormone receptor-positive disease and strategies that interfere with proliferation and the PI3 kinase pathway are reporting exciting results. The prognosis of the metastatic HER2 subtype has been extended to a median survival of 56 months with dual HER2 targeting agents in the first-line setting. Finally, triple negative breast cancer has an enlarging range of therapeutic options including immunotherapy, antiangiogenesis therapy, and targeted therapies including agents that interfere with androgen receptor signaling.

SUMMARY

Combined palliative and holistic approaches are essential to help young women navigate the marathon of treatment for metastatic breast cancer.