Cancer Survivorship and the Young Breast Cancer Patient: Addressing the Important Issues

Introduction

For a young woman in particular, receiving a diagnosis of breast cancer can be devastating. In addition to the challenges that all women with breast cancer face, there are also certain concerns that are unique to this younger cohort of patients. Younger women tend to exhibit more aggressive forms of breast cancer [1], which may necessitate more intensive treatment. The impact on their lives can be significant, at a time when they may be in college, working, raising a young family, or in some instances, balancing all three roles. Fertility, body image, and sexual function also may be compromised by treatment, while the onset of early menopause can negatively affect the physical, emotional, and psychosocial well-being of young women, in particular. Living with the aftermath of diagnosis and treatment can be difficult, with the physical and emotional sequelae compromising the young cancer survivor's quality of life (QOL). Health care practitioners must recognise these unique challenges, attend to the particular needs of young women with breast cancer, and support their return to the “new normal” way of life.

Breast Cancer in Young Women: Delineating the Issues

Recognizing that younger breast cancer survivors have specific physical and emotional challenges that need to be addressed is the key to providing comprehensive solutions that will improve their QOL. Systemic breast cancer treatment in younger women can commonly lead to amenorrhea. While in many instances menstruation cycles may recommence following the end of treatment, a proportion of patients will progress to early menopause [2]. In addition, a significant proportion of patients will have compromised ovarian function, leading to premature ovarian failure (POF) [3]. The early onset of menopause is particularly challenging for younger women. The physiological changes to their body, the negative effect on their fertility, and the emotional trauma that underpins the physical reality can be devastating for women of child-bearing age whose sexual function and fertility are compromised.

The Physical Burden for the Young Breast Cancer Survivor

The debilitating physiological changes that occur can influence both physical and emotional well-being, particularly as these changes appear more severely in young women undergoing treatment-induced early menopause compared with their older counterparts experiencing a normal menopausal transition [4]. Reduction in estrogen levels can result in complications such as hot flashes, night sweats, and vaginal dryness, while compromised ovarian function following treatment can lead not only to decreased fertility but also to declining androgen levels, thus contributing to reduced sexual drive.

Weight gain is a common consequence of breast cancer treatment, but recent data suggest that weight gain is more extensive following treatment-induced menopause [5]. Fatigue and sleep disturbance are also significant problems for younger women experiencing an early menopause following breast cancer treatment [6]. Reduction in bone mineral density (BMD) is also a consequence of treatment-induced menopause, opening up the future risk of developing osteoporosis or other bone-related deficiencies [7]. Cardiovascular health also may be compromised.

The Emotional Burden for the Young Breast Cancer Survivor

In addition to the negative physical impact, young women also experience significant mental/psychosocial sequelae associated with the aftermath of breast cancer treatment. It is important to realize that this emotional and mental burden may be more pronounced for younger women and that additional psychosocial support is often warranted.

Depression and anxiety, linked to both the physical effects of therapy and to the psychological aspects of diagnosis, treatment, and the associated reduction in fertility can be overwhelming [8]. In addition to the significant fertility issues outlined above, POF and its side effects can contribute to reduced sexual interest and decreased sexual function. Sexuality issues are complex for young breast cancer survivors and can be influenced by problems with body image associated with breast surgery or increased weight gain and by other physical issues, such as vaginal dryness and dyspareunia [9]. There are also suggestions that cognitive function may be impaired in women with POF, although additional studies are required to support this hypothesis [10].

A further challenge relates to information available and the provision of this information to those who require it. Research has shown that younger women with breast cancer, in general, feel less informed than their older counterparts, and the enormity of the challenge that they face (which in many cases may be the first major hurdle in their young lives) can contribute to feelings of isolation and to increased anxiety, depression, and other psychosocial problems [11].

Returning the Young Breast Cancer Survivor to the “New Normal” Way of Life

As outlined above, the challenges that face the young breast cancer survivor are complex and, in many cases, interrelated. But are we addressing their needs? Research has indicated gaps in the supportive care of the young breast cancer patient, which has an impact on their concerns relating to fertility, early menopause, genetic risk, body image and sexuality, depression, and anxiety [12].

Given the varied concerns outlined above, it is clear that a comprehensive approach is required. Recognizing this need, the Dana-Farber Cancer Institute and the Brigham and Women's Hospital developed the Program for Young Women with Breast Cancer [13]. Initiated in 2005 to address the unique needs of this vulnerable patient population, this program provides an overarching approach, encompassing clinical care, education (for both patients and health care providers), and research, all directed toward addressing the complex issues associated with a breast cancer diagnosis in younger women. Thus, women can access linked services for optimal treatment, genetic counseling, fertility preservation, psychosocial consultations, sexual health clinics, and survivorship programs in a comprehensive framework that is tailored and customized to their current and emerging needs. Since its inception, this program has catered for the needs over 2,000 women, aged 42 years or younger, with newly diagnosed breast cancer. The program is constantly evolving, with needs assessment approaches allowing refinement, underpinning the delivery of the required information and support to the patients in a comprehensive and timely fashion.

Conclusion

Treatment modalities for breast cancer are becoming more successful, leading to impressive improvements in survival outcomes. However, the cancer survivors often face new problems that must be addressed to enable women to return to active living. For young women with breast cancer, a number of unique challenges arise, particularly in the area of treatment-induced early menopause and its physical and psychosocial sequelae. Recognizing these issues, which may be complex and multifactorial, is key to developing solutions that restore the quality of life of young breast cancer survivors. A comprehensive programmatic approach encompassing supportive care, education, and research provides the necessary quality and rigour to respond to the needs of this vulnerable population.

Disclosures

The author indicated no financial relationships.