Breast cancer presents special problems for younger women

Retching your guts out after a round of chemotherapy is bad enough, but imagine being sick while your toddler is whining for you to read to him.

Breast cancer is always a blow, but younger patients face many issues their older counterparts don't, including worries about fertility, pregnancy, breast-feeding and child care.

And the cancer itself is usually more aggressive when it strikes women in their 20s and 30s, according to Dr. K.M. Steve Lo, an oncologist at the Bennett Cancer Center in Stamford, Conn.

"The cancer seems to be more aggressive and the prognosis is generally not quite as good" in younger patients, Lo said. "And we don't really know why."

These woman generally have the same type of surgery as older patients, followed by chemotherapy or radiation or both.

"The chemotherapy can induce premature menopause," Lo said. "It tends to do that for the older ones, women in their 40s, who are closer to menopause. For women in their early 30s, the chance is lower, but it can happen."

The good news, he says, is that women who continue to menstruate after chemotherapy generally don't have decreased fertility and can have normal pregnancies.

"We usually have them wait a couple of years before thinking of getting pregnant," Lo said. "There's some suggestion that maybe there is less recurrence if they hold off for a couple of years.

"The problem is that there isn't an adequate amount of data to totally support that that is the safest thing to do," he said. So if a woman who completes her therapy is eager to have children right away, she and her oncologist can discuss that.

Another problem is that many women who complete their therapies are prescribed the anti-cancer drug tamoxifen for five years. "In a small subset of women, depending on age, tamoxifen can push one into early menopause."

Fertility is a major concern for young patients, but Lynn Prowitt Smith's biggest worry was whether she could wear her wedding dress.

"I was diagnosed at age 31, four months before my wedding day," said Prowitt Smith, who lives in Westport, Conn.

That was four years ago. She had found a lump in her breast, but didn't think much of it since she knew many women have fibrous breasts. At her regular gynecological checkup, her doctor urged her to see a surgeon, who said it was probably not cancer, but scheduled a needle aspiration anyway. The surgeon told her the results were a little suspicious, and scheduled surgery for after his vacation.

"I was in the midst of wedding planning," she said. "I was so blase. It was like having a wart removed."

Her mother was less blase, and urged her to seek a second opinion, so Prowitt Smith passed her lab results to a friend at Memorial Sloan Kettering, who passed them on to a pathologist there.

"On April 30, I called my dear friend, and she was the one who had to tell me it was cancer," she said.

She had a lumpectomy, which didn't remove all of the cancerous cells, so then she had a mastectomy, followed by chemotherapy and reconstruction.

"The way they do the reconstruction is they take out the breast tissue and stick in an expander, and they pump it up to stretch your skin," she said. "They pump you up to like a triple E. Toward the end, I was looking really lopsided. I had my permanent saline implant two weeks before my wedding day."

Her dress was sleeveless with a fitted bodice, and looked great.

"I stopped chemo just long enough to feel good through my wedding and honeymoon," she said, resuming the therapy the day after she got back. Her hair didn't fall out.

After waiting for two years, she became pregnant, and is now the mother of 15-month-old Cole. "I nursed him for over a year on the one side," she said. "It was 'super boob.' I was determined to make it work."

Lo said one of the most devastating scenarios is when women are diagnosed with breast cancer while they are pregnant.

"Fortunately, it doesn't happen often," he said. "If the breast cancer was found during the third trimester, the woman would have surgery and delay chemotherapy until after delivery. There's no breast-feeding during chemotherapy.

"If it's found during the first trimester, we feel very uncomfortable delaying. We do the surgery and do the chemotherapy during pregnancy.

"Fortunately, most of the time we have a healthy child."

Like Prowitt Smith, most young patients are diagnosed after finding a lump during a self-exam, according to the Young Survival Coalition, a New York-based advocacy group. Mammograms are less useful for younger women because their breast tissue is denser, making abnormalities harder to see.

Michele Ganon of Danbury, Conn., 43, was diagnosed with breast cancer at age 39. Her lump was found during a baseline mammogram, and she had a lumpectomy, removal of lymph nodes, chemotherapy and radiation. "Because of my age, they thought I could handle it," she said.

Ganon, a professor of accounting at Western Connecticut State University, discovered the Young Survival Coalition on the Internet. "I was interested in trying to find a group that was not a support group but was interested in doing advocacy."

The Young Survival Coalition was founded in New York in 1998 by three women who were diagnosed younger than age 30. As a member of the coalition, Ganon has lobbied in Washington, D.C., twice and attended advocacy training sessions.

The coalition doesn't necessarily promote mammograms for younger women, she says, but "young women find lumps that doctors tell them is nothing and don't follow up."

Distributed by the Los Angeles Times-Washington Post News Service