- Hello, I'm Dr. Maya Hattan.
When I was 28 and just starting my residency,
I was diagnosed with stage two breast cancer.
I was scared and overwhelmed.
I just, I just didn't think it could happen
to someone my age.
I later learned that nearly 11% of all patients
diagnosed with breast cancer are under the age of 45.
My diagnosis was almost missed due to my age
which is why I devote my career to spreading awareness
about early onset breast cancer.
I hope that by drawing attention to this issue,
we as providers can increase the quality of care
for our young patients.
A breast or ovarian cancer diagnosis can be devastating
for a young patient.
It is often found at a later stage
when it can be more difficult to treat
and may be compounded by unique issues
like infertility, concerns about body image,
financial distress, and career stress.
As providers, there is a lot we can do
to inform our young patients and steps we can take
to improve their outcomes.
Today, I want to share information to help you talk
to your patients about breast cancer risk
and breast health, and provide you with information
that can help you identify patients
who may have an increased risk
for early onset breast cancer.
In this video, I will provide information on risk factors,
risk reduction strategies, medical interventions,
genetic counseling referrals, and risk management
for patients at high risk for early onset breast cancer.
I know it can be challenging to keep track
of all this information and talk to your patients
about these issues.
I will provide you with resources on breast cancer
in young patients.
First, there are modifiable risk factors
that apply no matter a patient's risk level.
These factors impact overall health
as well as risk reduction, and you need to keep them
in mind for all average or high risk patients
you see in your practice.
Weight gain after the age of 18, physical inactivity,
not breastfeeding babies if they have them,
and alcohol consumption.
By encouraging our patients to be mindful
of these risk factors, we empower them
to take their health into their own hands,
but for our patients, knowing these risk factors
is only the first step.
Practicing healthy behaviors that can reduce these risks
is the second.
Behaviors such as maintaining a healthy weight
through nutrition and exercise.
Adults need at least two hours and 30 minutes
of moderate intensity physical activity per week.
That's 30 minutes per day five days a week.
Eliminating alcohol consumption or limiting
to one alcoholic drink per day,
and paying attention to the health of their breasts.
Knowing how they look and feel and reporting
any unusual changes to their healthcare provider.
So those are the modifiable risk factors,
but what about non-modifiable risk factors?
Breast cancer is the most frequently diagnosed cancer
in women, but there are factors that increase
the risk for breast cancer in young patients.
There are some non-modifiable risk factors
that can affect breast cancer risk in all patients
including early onset menses and late childbearing.
We don't often discuss them, as there's not much
that can be done to change them in most cases,
but you should know if any of your patients
fall into these categories and consider them risk factors.
It is important to be aware of the non-modifiable factors
that do not apply to all women, but are strongly related
to increased risk for breast and ovarian cancer
at a young age.
Healthcare providers need to be looking
for these risk factors in our patients
under the age of 45 and work with patients
to develop a plan to manage it.
These risk factors that may put your patient
at a higher risk for getting early onset breast cancer
include family history of early onset breast cancer
or any ovarian cancer in females or any breast cancer
in males, being of Ashkenazi Jewish decent,
personal or family history of genetic mutations
like the B-R-C-A or BRCA gene mutation,
personal history of breast cancer or ovarian cancer,
personal history of other non-cancerous breast diseases,
personal history of chest radiation treatment,
being of African American heritage.
Let's discuss these risk factors in more depth.
Taking a detailed family history on both the maternal
and paternal sides of their families
is a healthcare provider's most powerful tool.
Explain this to your patients when you start
this conversation.
At a minimum, be sure to address each
of the following elements when digging
into your patient's family health history
whether there is a family history
of early onset breast cancer or any ovarian cancer
on either side of your patient's family.
Having a first-degree male relative with breast cancer
also raises a woman's risk and is often
an overlooked factor.
Most hereditary cancer syndromes are just as likely
to come from the father's side of the family
as the mother's side, so we should always consider
both sides of the patient's family history
when assessing their risk.
Find out about any cancer history
in first-degree relatives.
Siblings, parents, and children.
Ask about any cancer history in second-degree relatives.
Grandparents, aunts, uncles, grandchildren,
nieces, nephews, and half siblings on both maternal
and paternal sides of the family.
For each cancer case in the family,
establish the age at cancer diagnosis
and the type of primary tumor.
Uncover results of any cancer genetic testing
in any relative on both maternal and paternal sides
of the family.
Ask your patients if they have European Jewish ancestry.
One in 40 people of Ashkenazi Jewish decent
has a BRCA genetic mutation that puts them
at high risk for hereditary breast and ovarian cancer.
Having a genetic mutation like BRCA increases the risk
of developing hereditary breast and ovarian cancer.
If your patient has a history of breast cancer
in a family member younger than 50
or any ovarian cancer and any family history
of male breast cancer, consider their likelihood higher
than average of having a hereditary genetic mutation
that increases their risk of breast and ovarian cancer.
Carrying one of these gene mutations
can mean a lifetime risk for breast cancer
of 45 to 65% and more than 50% of those cancers
occur in women younger than 50 years old.
The lifetime risk for ovarian cancer
with one of these gene mutations is 20 to 40%.
You're also at risk if you've had breast or ovarian cancer
in the past.
Patients who have had breast cancer are more likely
to get breast cancer a second time.
Additionally, some non-cancerous breast diseases
such as atypical hyperplasia, Li-Fraumeni syndrome,
Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome,
and lobular carcanoma in situ are associated
with a higher risk of getting breast cancer.
Patients who have had radiation therapy
to the chest or breasts before age 30,
maybe for a condition like childhood cancer
or Hodgkin's lymphoma, have a higher risk
of getting breast cancer later in life.
African American women under age 35
have breast cancer rates that are two times higher
than white women of the same age,
but research has not yet told us why.
Ask your patients who are African American
about their family histories to assess their risks further
and advise them to know the look and feel
of their breasts and report any changes to you.
Patients may feel nervous or overwhelmed
to learn that they are at high risk.
Advise them that there are steps they can take
to manage their risk and that being at risk
does not mean they will get cancer,
though the changes are increased.
While we can never completely eliminate the risk
of cancer, there are steps patients can take
to manage their risk.
For more information, including tips
on collecting family history and tools
that can be used in your practice,
see the resources section in the description below.
Patients who have a high likelihood of a gene mutation
based on these factors, or the family history information
you gather, need to be told about their risk
and referred for genetic counseling.
If genetic counseling leads to genetic testing
and they are found to be positive for a gene mutation,
there are consistent recommendations
for cancer screening to help them manage their risk.
Some patients may be reluctant to undergo genetic testing
because they are afraid of what they will learn.
If your patient is concerned, let them know
that a genetic counselor can explain their options
and the implications of learning their genetic risk.
They can also help patients weigh those options,
discuss what might happen next if a test is positive,
and provide emotional support.
You can tell your patients that while a gene mutation
does increase their risk, it does not guarantee
that they will develop breast cancer,
but it could help them and their providers
create a roadmap to manage that risk.
Remind your patients that the choice is always theirs.
You may also choose to share some
of the following statistics.
About 50 out of 100 women with BRCA mutations
will develop breast cancer by age 70.
Many of these cases will develop
before the women turned 50 years old.
About 30 out of 100 of these women
will develop ovarian cancer by age 70.
Genetic counselors are equipped to discuss
all outcomes of tests, talk about your patient's options,
and next steps for management if they test positive
for a gene mutation, and provide emotional support
as needed.
Refer your high risk patients to genetic counselors
unless you are credentialed as a genetic counselor.
For more information on genetic counseling and testing,
see the resources section in the description below.
You can advise your patients that there are options
to managing the risk that could include
active surveillance to test your patient for cancer
every six months to a year.
Some medications may be prescribed to help prevent
breast cancer in at-risk patients.
Surgical options, such as preventive mastectomy
or oophorectomy, to prevent breast and ovarian cancer.
The United States Preventive Services Task Force
recommends biennial screening mammography
for patients 50 to 74 years whose risks is average.
For most of the population with
an average breast cancer risk, they do not recommend
regularly screening under the age of 50.
However, they suggest that the decision
to start regular biennial screening mammography
before the age of 50 be made on an individual basis
that takes patient context into account,
including the patient's values regarding specific benefits
and harms.
Different screening and risk management protocols
have been established for patients at high risk
for early onset breast cancer.
If a patient is at high risk, review and follow
the high risk protocol for the specific population.
This could include some of the risk management strategies
we discussed earlier.
Surveillance, medication, or surgery.
You can find more information about protocols
for specific population in the resources section
in the description below.
Finally, remember that you and your patient
are always a team with each of you contributing
your own area of expertise.
Your patient is the expert about their own body
and family history and you are the expert
on their risk level and recommended next steps.
This is a collaborative conversation,
not one person dominating the exchange.
By being aware of the risk factors and protocols
for early onset breast cancer and effectively communicating
with our patients, we can hopefully catch more cases earlier
and provide more of our patient with the support,
testing, and treatment they need.
Thanks for taking the time to learn more
about early onset breast cancer.
For more information about any of the topics
we discussed today, please visit the resources section.