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DISCUSSION
Many of the differences we noted between patients younger
than 36 years and 36 years and older reflect age differences
of the general population. Young breast cancer patients are taller,
thinner, and smoke more because young people in the general population
are taller, thinner, and smoke more, not because these factors
are associated with early onset breast cancer. The differences
in reproductive history we noted also may reflect changes in
the reproductive pattern of the US population.
The overrepresentation of Caucasians among patients younger
than 36 years in our study may reflect changes in the populations
our institution serves. The hospital borders East Harlem, populated
by African Americans and Hispanics, and New York's Upper East
Side, the most affluent section of New York City. Because the
population of East Harlem is younger than the population of the
Upper East Side, one would expect overrepresentation of African
Americans and Hispanics among the young breast cancer patients.
The racial differences we observed also
may be a consequence of the lower incidence of breast cancer
in African Americans and Hispanics10-12
except that, for unexplained reasons, populations with higher
rates of breast cancer do not have earlier age of onset of the
disease.10,11
The patients younger than 36 years in our study rarely had
mammography before diagnosis. Almost all
young patients are diagnosed with breast cancer after presenting
with a palpable mass.7,13,14
Mammography is not recommended for asymptomatic women under 35
because the high density of the breast tissue and the low incidence
of cancer limit the yield. When mammography was performed on
women younger than 36 years in our study, the malignancy was
often visible. Mammography should be used after the diagnosis
is made in young women to evaluate the contralateral breast and
assess the extent of disease on the affected side if breast conservation
is entertained.
Presentation with a palpable mass increases the likelihood
of diagnosis by fine needle aspiration cytology.7 Unfortunately
a consequence of presenting with a palpable mass is that the
cancer tends to be larger and more advanced. Breast
cancers of young patients are larger with more nodal involvement
than breast cancers in older patients.3-6,15
Young patients' cancers also are more
poorly differentiated and more likely to be estrogen receptor-negative.3,5,6,16
Flow cytometry demonstrates that these cancers are more often
aneuploid and the high S-phase fractions indicate that they are
growing more rapidly than cancers in older patients.16
The surgical treatment of breast cancer in young women is
shifting away from mastectomy toward greater use of breast conservation.7
The majority of young patients are still treated with mastectomy
at our institution and the majority of older patients receive
breast conservation. Geographic differences
in mastectomy rates exist within the United States and even greater
differences exist among different countries.17-19
Some studies report higher rates of breast conservation in younger
patients than in older patients.3,6,15
High rates of breast conservation lead
to higher rates of local recurrence among young patients than
among older patients.4,5,7,14,20
Anderson and coworkers7 noted that the rate of local recurrence
among young patients doubled as breast conservation rates rose
from 1% to 14% between 1969 and 1989 at their institution. Patients
younger than 36 years in our study had higher rates of local
recurrence than patients 36 years and older only if they had
been treated with breast conservation. The proportion of patients
younger than 36 years who recurred after mastectomy was the same
as the proportion of patients 36 years and older recurring after
mastectomy. We and others3-7 could not attribute the higher rate
of local recurrence after breast conservation in young patients
to larger tumor size, a higher rate of positive margins, or to
more involved nodes.
The adverse prognostic indices of cancers in young women adversely
affect outcomes. In all available studies of patients younger
than 36, rates of distant metastases are higher and survival
is lower than for older women.3-6,14 Controversy surrounds the
question of whether age alone, after consideration of other poor
prognostic features of cancers in young women, is a significant
independent prognostic variable. In our study, as in others',3
after consideration for tumor size and nodal involvement, age
younger than 36 was not a significant independent prognostic
factor. In other studies the poor prognosis of patients younger
than 36 could not be attributed to the association of young age
with other prognostic variables.4-6
Women under age 36 diagnosed with breast cancer differ from
their older counterparts in numerous respects. The diagnosis
of breast cancer is more often made by fine needle aspiration
cytology of a palpable mass. They rarely have had mammograms
before diagnosis. In our study a surprising number of cancers
were visible on mammography. As in other studies, cancers of
women under 36 were larger, more poorly differentiated, more
often estrogen receptor-negative, aneuploid, and had higher S-phase
fractions than cancers of older women.
Acknowledgment:
We would like to thank Dennis Timony (Cancer Registry Manager)
for his assistance.
Introduction
| Methods
| Results
| Discussion | References
JACS |
