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Women under 40 years of age account for one in six cases of breast cancer diagnosed annually, yet diagnosis is often delayed impairing survival outcomes. General practitioners can play a crucial role including raising awareness, early detection, and referral to shared care with the oncology team to manage patients during systemic treatment.
Breast cancer is the most commonly diagnosed cancer in Singaporean women with nearly six new cases diagnosed each day. It is a lethal disease, being the leading cause of cancer deaths among Singaporean women and accounting for one in six of all-cause mortality.
Typical risk factors associated with breast cancer include:
However, the vast majority of four in five women diagnosed with breast cancer do not have any identifiable risk factors.
The incidence of breast cancer rises with age, with the peak incidence in the fifth to sixth decades of life.
It is important to remember that breast cancer can also affect younger women, with one out of six cases of breast cancer diagnosed in those under 40 years old, though this is often overlooked.
More aggressive cancer biology
Breast cancer in young women is associated with more aggressive biology being enriched for triple-negative, HER2-positive and luminal B subtypes. They are of a higher grade and tend to present at a later stage. The reasons for late stage of presentation are complex and multifactorial.
Lack of awareness and regular self-examination
Two in five young women do not do regular breast self-examinations (BSE), and a general lack of awareness about breast cancer results in delayed presentation to healthcare providers, delayed investigations and diagnosis, and hence delayed treatment.
Limitations of screening modalities
The current screening modalities such as mammograms are not always ideal for younger women due to differences in breast tissue density. Younger women tend to have denser breast tissue, resulting in lower sensitivity of mammography in detecting breast cancer.
Early diagnosis is associated with improved survival outcomes.
Primary care physicians play a key role in raising awareness, early detection and referral of breast cancer in young women.
They must work closely with the oncology team throughout the patient journey by helping to manage:
Side effects
Holistic care
Survivorship and wellness care
Patient background
Ms L is a 31-year-old single lady with no past medical history nor significant family history. She noticed a painful breast nodule in July 2022, and was then referred by her company doctor to see a breast surgeon in October 2022.
Investigations
A breast ultrasound detected a solid nodule, reported as probably benign. After consultation with the surgeon, she underwent an excision biopsy in late November 2022 which unfortunately revealed an aggressive invasive carcinoma.
Staging investigations done subsequently yielded extensive regional nodal involvement on PET CT. There was no evidence of distant metastasis.
Diagnosis
A lymph node biopsy confirmed the presence of nodal spread, hence a diagnosis of locally advanced, clinical T2N3M0 invasive breast carcinoma was confirmed.
Treatment
Due to the advanced nature of her breast cancer, she was recommended neoadjuvant chemotherapy with plans for subsequent surgery.
Increasingly, there is a move towards neoadjuvant chemotherapy prior to surgery for patients with breast cancer. This is especially the case for young women with locally advanced and aggressive tumours.
Benefits of neoadjuvant chemotherapy
Downstaging of the tumour - Increases rates of breast conservation surgery, in contrast with mastectomy
Early treatment of micrometastatic disease
Permits evaluation of effectiveness of systemic therapy in in situ tumour - Pathological complete response is a strong surrogate endpoint for event-free survival (EFS)
Allows tailoring of further adjuvant treatment by risk-stratifying higher-risk patients who have residual disease, to receive additional therapies or a change in therapies - E.g., capecitabine as per CREATE-X or T-DM1 as per KATHERINE
Allows time for genetic testing
Allows time to plan reconstruction (if desired)
Identifying symptoms
Breast cancer is often perceived as a disease that primarily affects older women, leading to a lower suspicion of breast cancer in young patients. This could potentially result in missing its early signs and symptoms.
Younger women may develop other breast lumps including fibroadenomas or have cyclical fibrocystic change. However, should symptoms persist, these patients should still receive an expedited referral for specialist breast evaluation including further imaging.
Importance of early referral
In Ms L’s case, five months had passed from her initial presentation to when she was able to start treatment for her breast cancer. With aggressive locally advanced breast cancers, treatment delays are associated with poorer overall survival rates.
Hence, it is imperative to commence treatment as soon as possible, and early referral to a breast surgeon is key if there is any clinical suspicion.
Self-examination
Screening mammograms do not start till age 40, hence most young patients only present after they exhibit symptoms.
Regular monthly BSE is also often neglected in the young and should be emphasised. In a 2017 survey commissioned by the Breast Cancer Foundation (BCF), though the majority of Singaporeans regard breast cancer as dangerous, only 62% of females reported ever doing a BSE.
Symptoms
Young patients may present with symptoms similar to older patients, including:
These symptoms may occur with other benign conditions, however having a low index of suspicion should prompt earlier evaluation, imaging and specialist consultation.
Breast cancer in young women presents multiple challenges and should be managed by a dedicated multidisciplinary team with special focus on their specific needs.
Unique issues faced by young women with breast cancer include:
Facing the often unexpected diagnosis of cancer, together with the barrage of attendant issues above, can often be overwhelming and isolating. The care of a young woman with breast cancer requires a dedicated, specialised team trained to actively look out for and manage all the medical and non-medical aspects of treatment (Figure 3).
While patients undergo treatment, most will experience some side effects. Some of these patients may present to primary care, especially if after-hours.
Conditions that require attention during systemic treatment include:
Uncontrolled vomiting Patients are given antiemetics. However, despite this, some patients continue to have significant vomiting and should be referred back to hospital if they exhibit signs of dehydration.
Fever Patients with ongoing chemotherapy are at risk for myelosuppression and neutropaenia. If they present with a high fever of 38 degrees or above, they should be assessed for risk of febrile neutropaenia and referred back to hospital for further management.
Mucositis Patients may consult their GP for pain relating to oral ulcers and mucositis.
After treatment is complete, the oncology team will work closely with the primary care team to:
Help the patient integrate back to a new normal
Monitor for medical and non-medical issues that may occur while on surveillance
Follow-up on her cancer
Young women do get breast cancer, and these women have unique needs and issues.
A strong support system is essential to management, which requires a dedicated and specialised multidisciplinary team working hand-in-hand with the patient, family and primary healthcare team.
Early detection and treatment of breast cancer improves survival greatly.
Increased awareness of the importance of regular monthly BSE, even in young women, should be emphasised with early referral for assessment and treatment if required.
The Young Women with Breast Cancer programme (also known as YoWo) was set up to help support and guide these young women through all the emotions, decisions and challenges unique to their stage in life.
Encompassing a multidisciplinary team of medical oncologists, breast surgical oncologists, radiation oncologists, genetics specialists, fertility specialists, supportive care physicians, psychologists and social workers, and featuring our dedicated and experienced breast care nurses (BCNs) at the centre of the programme, we provide a comprehensive support programme for young women throughout their journey battling breast cancer.
YoWo specially curates resources for them – relating to the aforementioned unique issues and other common questions they may have.
Your Breast Health: Making Informed Choices (SingHealth) www.singhealth.com.sg/patient-care/patienteducation/breast-health A specially curated booklet with a summary of the common breast conditions, breast cancer, screening recommendations, etc. Available in English and Mandarin.
Guiding Young Women with Breast Cancer (National Cancer Centre Singapore) www.nccs.com.sg/patient-care/Pages/Guiding-young-women-with-breast-cancer-.aspx An introduction to SingHealth YoWo.
Breast Self-examination Video (Singapore Cancer Society) www.youtube.com/watch?v=JV0WdDKExEsAlso available in Mandarin, Malay and Tamil.
Dr Tan Si Ying is an Associate Consultant at the SingHealth Duke-NUS Breast Centre. She graduated on the dean’s list at the Yong Loo Lin School of Medicine, National University of Singapore in 2009. She became a Fellow of the Royal College of Surgeons (Edinburgh) and registered as a specialist in general surgery in 2018. She has a keen interest in bettering multidisciplinary and holistic care for young women with breast cancer. Her current research interests are in mucinous breast carcinoma, patient-reported outcome measures in breast cancer patients and exercise and breast cancer.
Dr Ma Jun graduated from Monash University, Australia with MBBS (Hons) and completed her specialty training in medical oncology at the National Cancer Centre Singapore. She currently specialises in breast cancer. Her key areas of interest include breast cancer in young women and supportive care needs in breast cancer. GPs can call the SingHealth Duke-NUS Breast Centre for appointments at the following hotlines or click here to visit the website:
Singapore General Hospital: 6326 6060 Changi General Hospital: 6788 3003 Sengkang General Hospital: 6930 6000 KK Women’s and Children’s Hospital: 6692 2984 National Cancer Centre Singapore: 6436 8288
Tags: CHEST;Breast
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