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Information Sheets > Breast cancer in younger women calls for flexibility in imaging

The dread of breast cancer far exceeds its actual incidence, especially in young women. Yet certain women are at risk for developing breast cancer in their thirties or even younger.

Mammography has several disadvantages for screening young women, primarily due to the high density of tissue in the young breast. Ultrasound has become a most important breast imaging modality that is more sensitive than mammography. Radiologists need to be flexible regarding the imaging modality chosen, and must collaborate well with referring physicians to make sure that a proper history has been obtained on such patients.

Primary relative with premenopausal diagnosis

In women who are 30 and younger, the lifetime risk of getting breast cancer is at most one in 5,000, according to breast imaging expert Dr. Michael Linver who is clinical associate professor of radiology at the University of New Mexico. In contrast, women who are 50 years old have a one-in-50 lifetime risk, Linver said. "By the age of 85, the lifetime risk is one out of 8," He encouraged radiologists to discuss these statistical nuances to counter the simplistic message in mainstream media that one of every eight women gets breast cancer.

For women in their twenties, the general risk is infinitesimal, according to Dr. Daniel Kopans, a professor of radiology at Harvard Medical School and the director of breast imaging at Massachusetts General Hospital, both in Boston. "Breast cancer is, fortunately, rare among women 35 years old and younger," he said. "For women age 20 there are approximately one to two cases of breast cancer each year for every 100,000. For women age 25, there are approximately eight cases per 100,000."

"Among women who get early breast cancer, such women are more likely to have mothers or primary relatives who had breast cancer before menopause," Linver explained. "They tend to get breast cancer 10 years earlier than their mothers were diagnosed. In addition, women who have BRCA1 and BRCA2 mutations tend to develop the disease before menopause. Therefore, there is more of a genetic and familial component to early breast cancer."

Self-breast exams and clinical exams are usually the way suspicious lumps in young women are found, Linver said. "When I ask, ‘Who found this, you or your doctor?’ half of the time the woman found it herself, and half of the time it was the doctor."

Mammography and ultrasound for women with a family history of premenopausal breast cancer should begin when the patient is 10 years younger than the relative was when her cancer was diagnosed.

Kopans suggested that women who have or are at risk of having BRCA1 or BRCA2 mutations might want to start investigations at approximately 25 years of age. Ultrasound is the initial investigation of choice in at-risk young women.

Linver agreed with this assessment. "Thirty is the cut-off because the breast is more sensitive to radiation before that age," he said. "There is a minimal risk that can’t be ignored in those women, with some very special exceptions." Among women younger than 30 who want to be screened, a strong history must be present in order to justify mammography, he said.

However, all suspicious lesions should be investigated, Kopans cautioned. "If a woman has a lump or suspicious area on her clinical examination, and she is 30 years old or over, a mammogram may be helpful," he said. "Ultrasound is useful to determine if a lump is a benign cyst. Some believe they can differentiate benign lesions from malignant lesions with ultrasound."

In women younger than 30, a palpable lump is almost always a benign fibroadenoma, and cysts constitute only 3% of palpable lesions.

Ultrasound should be used in the young breast, though. If the patient is under 30, ultrasound is the place to start. We can find breast cancers sometimes on ultrasound that we can’t find on mammography.

Patients with vertebral compression fractures can benefit from treatment of their osteoporosis, the authors explain, but little is known about the current evaluation and treatment of patients with such fractures.

Ultrasound is more sensitive than mammography, but less specific. The additional advantage of ultrasound is that it is useful in guiding a biopsy site.

With adolescents and young women, less is more

All of the experts interviewed argued against a quick use of imaging with adolescents, even if they have suspicious family histories. Kopans said, "There is virtually no reason to image the adolescent breast. If any imaging is needed, ultrasound is safe, but since all of the masses in this population are either normal breast tissue, or fibroadenomas, clinical management is usually all that is needed."

Linver agreed that if any imaging is appropriate, ultrasound is a good starting point. If it’s a cyst, you get the answer immediately, and you don’t need follow-up imaging. If a highly suspicious lesion is found, a focused, coned, tangential mammogram may be appropriate for women in their twenties, but almost never in teenagers. Start with a good physical exam, to be conducted by the woman’s physician. If imaging is appropriate, perform an ultrasound. Then you can decide if anything else is needed. If necessary, a fine-needle aspiration biopsy can be conducted under ultrasound guidance.

Counseling useful for addressing fear

For women who are absolutely paranoid of breast cancer, counseling may be appropriate, Sometimes such women can be reassured by showing them the Gale model, a statistical formula that can calculate an individual woman’s risk relative to the general population. According to this model, Linver said, 75% of women have no breast cancer risk factors. The Gale model will mathematically calculate a women's risk for developing breast cancer, using validating risk factors of age and sex, number of first degree relatives who have had breast cancer, age of the first menstrual period, age of first child and any previous biopsies (tissue sampling) which showed "atypical hyperplasia," or abnormal breast tissue.

References

"Sydney Breast Imaging Accuracy Study: Comparative sensitivity and specificity of mammography and sonography in young women with symptoms," American Journal of Roentgenology, April 2003, Vol. 180:4, pp. 935-940.

"Familial risks, early-onset breast cancer, and BRCA1 and BRCA2 germline mutations," Journal of the National Cancer Institute, March 19, 2003, Vol. 195:6, pp. 448-457.

"Mammography screening matters for young women with breast carcinoma: evidence of downstaging among 42-49-year-old women with a history of previous mammography screening," Cancer, January 15, 2003, Vol. 97:2, pp. 352-358.

"A gene-expression signature as a predictor of survival in breast cancer," New England Journal of Medicine, December 19, 2002, Vol. 347:25, pp. 1999-2009.

"High-risk screening: multi-modality surveillance of women at high risk for breast cancer (proven or suspected carriers of a breast cancer susceptibility gene)," Journal of Experimental and Clinical Cancer Research, September 2002, Vol. 21:3 supplement, pp.103-106.

"Gray-scale sonography of breast masses in adolescent girls," Journal of Ultrasound in Medicine, May 2001, Vol. 20:5, pp. 491-496.

"Spectrum of US findings in pediatric and adolescent patients with palpable breast masses," Radiographics, November-December 2000, Vol. 20:6, pp. 1613-1621.