ORIGINAL RESEARCH

Breast cancer in very young womenda multicenter 10-year experience

I. F. Eiriz1*, M. Vaz Batista1, T. Cruz Tomás1, M. T. Neves2, N. Guerra-Pereira3y & S. Braga1,4,5
1
Oncology Department, Hospital Prof. Doutor Fernando Fonseca, Amadora, Lisbon, Portugal; 2Oncology Department, Centro Hospitalar Lisboa Ocidental, Hospital S.
Francisco Xavier, Lisboa, Portugal; 3Oncology Department, Centro Hospitalar Barreiro Montijo, Barreiro, Portugal; 4Oncology Department, Hospital Vila Franca de Xira,
Lisbon, Portugal; 5Oncology Department, Cuf Hospitals, Lisbon, Portugal

Available online 4 January 2021

Background: Breast cancer (BC) is the most prevalent cancer in adult young women in Europe. Although rare, it is one
of the leading causes of death in this age group. The aim of this study is to characterize a cohort of young women
regarding tumor stage, biology, treatment and survival.
Patients and methods: We present a multicenter retrospective analysis of women <35 years of age, diagnosed with BC
between 2008 and 2017. A total of 207 patients from five Portuguese centers were included, from whom 172 were
eligible for analysis. Data were analyzed using IBM SPPSS statistics.
Results: Median age at diagnosis was 31 years. Fifty-one percent of tumors were hormone receptor (HR)-positive/
human epidermal growth factor receptor 2 (HER2)-negative, 20% HR-positive/HER2-positive, 8% HR-negative/HER2-
positive and 20% triple-negative BC. Twenty-two percent of patients were diagnosed in stage I, 26% stage II, 45%
stage III and 6% had de novo metastatic cancer. Thirty-nine percent of patients were treated with neoadjuvant
chemotherapy. Mean follow-up time was 64.9 months and overall survival at 5 years, of the entire cohort and
metastatic patients, was 86.5% and 26%, respectively.
Conclusions: In our study we found similar population characteristics to other cohorts <35 years of age. To our
knowledge, this is one of the largest cohorts in very young women. BC in young women is an important issue and
further studies are needed to provide better care and survivorship to patients.
Key words: breast cancer, young women

INTRODUCTION Age is a major risk factor for BC, but recent studies have
Breast cancer (BC) is the most frequently diagnosed cancer shown increased incidence in premenopausal women.8 The
among women in Portugal and worldwide. The definition of GRELL study analyzed epidemiological data from seven Eu-
‘young women’ in the field of breast oncology is not stan- ropean countries and found the mean incidence of BC in
dardized, but most of the literature refers to women aged young women to be increasing 1.2% annually between 1990
40 years.1,2 In our study we decided to include patients and 2008. The increase was highest in the age group be-
<35 years of age. tween 15 and 34 years as compared with older women (34-
According to GLOBOCAN data, in 2018, approximately 2.1 39 years of age), especially in France and Portugal.8
million women were diagnosed with BC, which constitutes BC in young women is such a relevant matter that gave
11.6% of all malignant neoplasms.3 There were 1683 deaths rise to a periodical international consensus conference,
due to BC in women in Portugal in 2015.4 Although rare organized by the European School of Oncology (ESO) and
(2.5% before 35 years of age), BC is the most commonly European Society of Medical Oncology (ESMO). The guide-
diagnosed cancer among women aged 20-49 years.5,6 It is lines issued in this meeting should be taken into account
also the main cause of death in the group of patients aged when treating this population.9
30-49 years.7 An increase in patients diagnosed in advanced stages
could be a direct consequence of lack of screening in
this age group. Recent evidence found mammography
screening, beginning at 40 years of age, to be associated
*Correspondence to: Dr Inês F. Eiriz, Hospital Prof. Doutor Fernando Fonseca, with a relative reduction in BC mortality, which was atten-
IC 19, 2720-276 Amadora, Portugal. Tel: þ351214348424
E-mail: [email protected] (I. F. Eiriz). uated after 10 years, although the absolute reduction
y
remained constant.10 BC screening programs in Portugal
Deceased October 2019.
2059-7029/© 2020 The Authors. Published by Elsevier Limited on behalf of are primarily focused on women aged 50-69 years. Delayed
European Society for Medical Oncology. This is an open access article under the diagnosis may also be due to a lack of oncological
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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ESMO Open I. F. Eiriz et al.

awareness among practitioners who treat young women Statistical analysis was carried out using IBM® SPSS®
with breast alterations (during pregnancy, puerperium or statistics software version 26.0 (IBM Corp., Armonk, NY).
lactation).11 Categorical data were presented as counts and percentages
Identification of young patients is clinically valid, as BC in and were analyzed with chi-square test and Fisher's exact
that age group presents with certain biological differences test, as appropriate. The skewed distributions were
and often requires special management. Typically, BC in described with medians and interquartile ranges. Normal
young women has a more aggressive course, less favorable distributions were described with means and standard de-
prognosis and worse survival rates compared with older viations and were compared with the use of the Student's t-
subjects.12 Triple-negative BC (TNBC) and human epidermal test. Survival analysis was carried out using the Kaplane
growth factor receptor 2 (HER2)-positive disease are over- Meier method and the log-rank test was used to assess
represented in young patients compared with the overall differences among survival. The outcomes of interest were
population.12 Mutations in BRCA (BC gene) 1 may explain overall survival (OS) and disease-free survival (DFS). OS was
some of the TNBC and high grade observed in young defined as the period of time from diagnosis to time of final
women, but the majority of these tumors are not in the analysis or death, whichever came first. DFS was defined as
context of a familial cancer syndrome.13 Also, younger the period of time from diagnosis to cancer recurrence,
women with luminal tumors seem to have less favorable progression of disease or death, whichever came first. All P
outcomes than older women.2,5,14,15 This fact might be due values were two-sided and P < 0.05 was considered sta-
to biological factorsdprevalence of PIK3CA (phosphatidy- tistically significant.
linositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha)
mutationsdor decreased adherence to adjuvant endocrine
therapy.2,16 Additionally, this high deregulation of PI3K and RESULTS
Myc pathways, could have a role in endocrine therapy A total of 172 patients were included from an initial number
resistance.2 of 207. Baseline characteristics of the entire cohort are
The aim of this study was to characterize a cohort of young presented in Table 1. Median age was 31 years (inter-
women in five oncological centers in Portugal, with homo- quartile range 29.34). Ductal invasive carcinoma was found
geneous diagnostic and treatment practices, regarding tumor in 158 (91.9%) patients and 4 (2.3%) had lobular invasive
stage, biology, treatment and survival. carcinoma. Metaplastic carcinoma and invasive carcinoma
(not otherwise specified) were found in two (1.2%) patients
each, while one (0.6%) patient had papillary invasive car-
cinoma. Two patients had inflammatory carcinoma. Five
METHODS (2.8%) patients were diagnosed with other histologic types
We carried out a retrospective multicenter analysis con- of BC. Eighty-eight (51.2%) women had IHC subtype of
ducted in five Portuguese oncology departments in Lisbon hormone receptor (HR)-positive/HER2-negative tumors, 35
(Prof. Doutor Fernando Fonseca Hospital, Barreiro-Montijo (20.3%) had HR-positive/HER2-positive, 14 (8.1%) had HR-
Hospital Center, Occidental Lisbon Hospital Center, Vila negative/HER2-positive and 35 (20.3%) TNBC. Regarding
Franca de Xira Hospital and Lisbon CUF Hospitals). The study tumor size, 74 (46%) patients had tumors of 20 mm or less,
was approved by the health ethics committee (number 37/ 61 (38%) were between 21 and 50 mm and 22 (14%)
2019). Clinical data were obtained for 207 patients diag- women had tumors larger than 50 mm. When considering
nosed with BC from January 2008 to December 2017, who tumor grade, 12 (7%) were grade 1 (well differentiated), 72
were >18 and <35 years old. Thirty-five were excluded: 27 (42%) were grade 2 (moderately differentiated) and 79
due to lack of data, 1 due to two different synchronous (46%) were grade 3 (poorly differentiated). Proliferation
tumors and 7 due to histological ductal in situ carcinoma. index (Ki-67) was <20% in 25 (20%) tumors, between 21%
Epidemiological and clinical data collected from patients' and 40% in 34 (28%) tumors, 41%-60% in 23 (19%) tumors,
medical records included: age at diagnosis, histologic and 61%-80% in 18 (15%) tumors and >80% in 22 (18%) tumors.
immunohistochemistry (IHC) subtypes and staging. Early BC Distribution of patients according to staging at diagnosis
grouped all tumorenodeemetastasis stages I and II and was as follows: 82 (47.6%) patients had early BC (stages I
locally advanced included stage III (according to American and II), 77 (44.7%) had locally advanced BC (stage III), 11
Joint Committee on Cancer 7th Edition). Hormone (estrogen (6.4%) had metastatic BC and in 2 (1.2%) patients it was
and progesterone) receptors (HR) were considered positive unknown. Excluding metastatic patients at diagnosis, 29
if 1% or more of tumor cells demonstrated positive nuclear (16.8%) women experienced recurrence of disease [3 (1.7%)
staining on IHC. HER2 positivity was defined as IHC 3þ and had local recurrence and 26 (15.1%) distant metastasis].
when IHC 2þ it required a silver in situ hybridization test for Sixteen (43%) patients who developed metastasis had HR-
confirmation. If defined as IHC 1þ or 0, it was considered positive/HER2-negative disease, 11 (30%) were HR-positive/
negative. Type of treatment was also reviewed [surgery, HER2-positive, 2 (5%) patients were HR-negative/HER2-
chemotherapy (CT), endocrine therapy, biologic agents and negative and 8 (22%) were TNBC (Table 2). According to
radiotherapy (RT)], as well as prognostic variables such as IHC subtypes, HR-positive/HER2-positive more frequently
time-to-events of first relapse/progression of disease/death developed metastasis in three or more locations (13.5%
and metastasis sites. versus 8.1% in HR-positive/HER2-negative versus 2.7% in

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I. F. Eiriz et al. ESMO Open

Table 1. Patients' characteristics Table 1. Continued

Median age (years) 31 (IQR 29.34) DFS at 5 years (%) 80

Histologic subtype N (%) (non-metastatic patients) HRþ/HER 2: 83
Ductal invasive carcinoma 158 (92) HRþ/HER 2þ: 71
Lobular invasive carcinoma 4 (2) HR/HER 2þ: 91
Metaplastic carcinoma 2 (1) TNBC: 76
Papillary invasive carcinoma 1 (0.6) DFS, disease-free survival; ET, endocrine therapy; HER2, human epidermal growth
Invasive carcinoma NOS 2 (1) factor receptor 2; HR, hormone receptor; IQR, interquartile range; NOS, not
Others 5 (3) otherwise specified; OS, overall survival; TNBC, triple-negative breast cancer.
a
Tumor subtype N (%) Forty-nine missing values; Ki-67 only routinely carried out since 2010.
b
Nine missing values.
HRþ/HER 2 88 (51) c
Two missing values.
HRþ/HER 2þ 35 (20) d
Seven patients received pertuzumab considering neoadjuvant dual HER 2 blockade
HR/HER 2þ 14 (8) therapy protocol implementation since 2014.
TNBC 35 (20) e
Two patients received pertuzumab considering metastatic dual HER2 blockade
Tumor size N (%) therapy protocol implementation since 2015.
0-20 mm 74 (46)
21-50 mm 61 (38)
>50 mm 22 (14) HR-negative/HER2-positive disease versus 5.4% in TNBC),
Proliferation index (Ki-67)a N (%)
[0%-20%] 25 (20)
while HR-positive/HER2-negative was the subtype which
[21%-40%] 34 (28) more frequently developed metastasis only in one site
[41%-60%] 23 (19) (21.6% versus 5.4% in HR-positive/HER2-positive versus
[61%-80%] 18 (15) 2.7% in HR-negative/HER2-positive versus 8.1% in TNBC)
[81%-100%] 22 (18)
Tumor gradeb N (%) (Table 2). Patients with TNBC and HR-positive/HER2-
G1 12 (7) positive tumors had more central nervous system (CNS)
G2 72 (42) metastasis (13.5% each), while HR-negative/HER2-positive
G3 79 (46)
Stagingc N (%)
and HR-positive/HER2-negative tumors developed CNS
Early breast cancer 82 (48) Id38 (22) metastasis in 5.4% each. Visceral metastases were more
IId44 (26) common in HR-positive/HER2-positive and HR-positive/
Locally advanced IIId77 (45)
Metastatic IVd11 (6)
HER2-negative tumors (24.3% each versus 2.7% in HR-
BRCA-mutated N (%) negative/HER2-positive versus 13.5% in TNBC). Bone me-
Yes 3 (2) tastases were more frequent in HR-positive/HER2-negative
No 64 (37) tumors (35.1% versus 16.2% in HR-positive/HER2-positive
Unknown 105 (61)
Treatments N (%) versus 2.7% in HR-negative/HER2-positive versus 10.8% in
Mastectomy 105 (66) TNBC) (Table 2).
Breast-conserving surgery 54 (34) Three (1.7%) patients were BRCA-mutated, in 64 (37.2%)
Neoadjuvant therapy 67 (39)
Taxanes 56 (84) no mutation was found and in 105 (61%) it was unknown.
Platins 2 (3) Regarding surgical treatment, 105 (66%) patients under-
Anthracyclines 62 (93) went mastectomy and 54 (34%) breast-conserving surgery
Alkylating agents 6 (9)
Pyrimidine analogues 4 (6) (BCS). In stage I tumors, 19 (11.9%) were treated with
Anti-HER 2d 16 (24) mastectomy and 17 (10.7%) with BCS. In stage II, 24 (15.1%)
Adjuvant therapy 143 (83%) patients underwent mastectomy and 20 (13.6%) BCS. In
Taxanes 63 (44)
Platines 7 (5) stage III, mastectomies were carried out in 56 patients
Anthracyclines 76 (53) (35.1%) and BCS in 26 (10.1%). In total, 67 (39%) patients
Alkylating agents 21 (15)
Pyrimidine analogues 12 (8)
received neoadjuvant CT: patients with tumors larger than 2
ET 101 (71) cm and/or positive lymph nodes, or TNBC (if more than 0.5
Anti-HER 2 33 (23) cm) or HER2-positive tumors (if more than 1 cm), and in-
Metastatic therapy 37 (22%)
flammatory BC. Twelve percent of those patients achieved
Taxanes 25 (68)
Platins 10 (27) pathological complete response. One hundred and forty-
Anthracyclines 12 (32) three (83.1%) patients were treated with any kind of
Alkylating agents 10 (27)
Vinca alkaloids 14 (38)
adjuvant therapy [96 (67%) had CT, 101 (71%) had endo-
Pyrimidine analogues 16 (43) crine therapy and 33 (23%) anti-HER2 therapy]. Thirty-one
Antimetabolites 3 (8) (18%) were treated with endocrine therapy exclusively.
ET 12 (32)
Anti-HER 2e 12 (32) Neoadjuvant, adjuvant and metastatic adopted treatments
Ovarian function suppression 84 (68) are listed in Table 1. Among those women with HR-positive
Radiotherapy 124 (72) disease, 84 (68.3%) underwent ovarian function suppres-
OS at 5 years (%) 87
HRþ/HER 2: 92
sion, 30 (24.4%) did not and in 9 (7.3%) patients this status
HRþ/HER 2þ: 86 was unknown. One hundred and twenty-four (72.1%) pa-
HR/HER 2þ: 83 tients were also treated with RT.
TNBC: 75
The entire cohort had an OS at 5 and 10 years of 86.5%
Continued
[95% confidence interval (CI) 83.5-89.5] and 71.1% (95% CI

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ESMO Open I. F. Eiriz et al.

67.6-83.9), with no statistical significance (log-rank P ¼

Table 2. Metastatic disease according to IHC subtypes
0.266) (Figure 2).
HRD/HER HRD/HER HRL/ TNBC Women with metastatic disease (N ¼ 37) had an OS
2L 2D HER 2D
(since metastatic disease diagnosis) at 5 years of 51.8%
OS at 5 years (%) 26 (95% CI 56.5-73.9) with a mean follow-up time of 72.7  7.8
61 60 0 23
Number of 16 43% 11 30% 2 5% 8 22%
months (95% CI 57.4-88). Survival at 5 years of patients with
patients metastatic disease was different between IHC subtypes
Location of [61% (95% CI 46.8-62.4) for HR-positive/HER2-negative
metastasis
CNS 2 5.4% 5 13.5% 2 5.4% 5 13.5%
versus 60% (95% CI 44.5-75.5) for HR-positive/HER2-
Bone 13 35.1% 6 16.2% 1 2.7% 4 10.8% positive versus 0% for HR-negative/HER2-positive versus
Skin 0 0% 3 8.1% 0 0% 0 0% 23.4% (95% CI 4.4-42-4) for TNBC], although it had no
Visceral
Number of
9 24.3% 9 24.3% 1 2.7% 5 13.5%
statistical significance (log-rank P ¼ 0.258) (Figure 3). Me-
metastatic sites dian time from last palliative CT to death was 1.7 months.
1 8 21.6% 2 5.4% 1 2.7% 3 8.1%
2 5 13.5% 4 10.8% 0 0% 3 8.1%
>3 3 8.1% 5 13.5% 1 2.7% 2 5.4%
DISCUSSION
CNS, central nervous system; HER2, human epidermal growth factor receptor 2; HR, The choice of 35 years old was made considering the
hormone receptor; IHC, immunohistochemistry; TNBC, triple-negative breast cancer.
different cut-offs used in international literature. Indeed,
there is heterogeneity of criteria for definition of younger
age, with some publications referring to <30 years, <35
64.8-77.4), respectively, with a mean follow-up time of 64.9 years, <40 years or even all premenopausal patients.1,8,17-19
 2.9 months (95% CI 59.1-70.6). Considering IHC subtypes, Comparing with other cohorts including women <35
OS at 5 years in HR-positive/HER2 negative disease was years old, our study included more patients in the same
91.9% (95% CI 88.4-95.4), in HR-positive/HER2-positive period of time (10 years) and had very similar population
patients it was 86.3% (95% CI 79.9-92.7) at 5 years, in characteristics. Particularly, IHC subtype distributions were
HR-negative/HER2-positive patients it was 83.3% (95% CI comparable, with approximately 70% of HR-positive dis-
72.5-94.1) at 5 years and in TNBC patients OS at 5 years was ease, 30% of HER2-positive disease and 20% of TNBC.20-22
75.3% (95% CI 66.7-83.9), with no statistical significance One study also had around 45% of poorly differentiated
(log-rank P ¼ 0.292) (Figure 1). tumors, while the other two studies had higher percentages
In the non-metastatic population, DFS at 5 and 10 years (60%-80%).20-22 Concerning metastatic patients at diag-
was 79.7% (95% CI 76-83.4) and 73.3% (95% CI 68.7-77.9), nosis, we found 11 (6%) in our study, which is exactly the
respectively, with a mean follow-up time of 64.6 months same proportion found by Liukkonen et al.21 and slightly
(95% CI 58.6-78.6). Patients with HR-positive/HER2-negative higher than that found in an Israeli cohort (4.7%).20,21 We
disease had a DFS at 5 years of 82.7% (95% CI 77.6-87.8), in had more patients receiving neoadjuvant CT (N ¼ 67; 39%)
HR-positive/HER2-positive patients it was 71.3% (95% CI than the other two studies (3%-22%), which might be due
61.9-80.7), in HR-negative/HER2-positive it was 90.9% (95% the period of analysis and clinical practices contemporary to
CI 82.2-99.6) and in TNBC patients it was 75.8% (95% CI the period of analysis.20,21 These two studies were carried

1.00
log-rank P = 0.292

0.75

0.50

0.25
HR+ HER2– HR+ HER2+
HR– HER2+ TNBC
0.00
0 50 100 150
Months
Number at risk
HR+ HER2– 86 48 13 1
HR+ HER2+ 34 22 7 0
HR– HER2+ 14 9 2 0
TBNC 34 16 8 0

Figure 1. Overall survival according to IHC subtypes.

HER2, human epidermal growth factor receptor 2; HR, hormone receptor; IHC, immunohistochemistry; TNBC, triple-negative breast cancer.

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I. F. Eiriz et al. ESMO Open

1.00 log-rank P = 0.266

0.75

0.50

0.25
HR+ HER2– HR+ HER2+
HR– HER2+ TNBC
0.00
0 50 100 150
Months
Number at risk
HR+ HER2– 81 43 11 1
HR+ HER2+ 31 17 6 0
HR– HER2+ 13 9 1 0
TNBC 33 14 6 0

Figure 2. Disease-free survival in non-metastatic patients according to IHC subtypes.

HER2, human epidermal growth factor receptor 2; HR, hormone receptor; IHC, immunohistochemistry; TNBC, triple-negative breast cancer.

out between 1997 and 2007 and 2000 and 2010. Regarding group, but also a longer delay in diagnosis is reported when
surgical treatment, our population had the same proportion compared with patients >40 years of age.25 Another
of BCS (N ¼ 54; 34%) and mastectomies (N ¼ 105; 66%) possible reason might be the fact that these patients are
than in the study by Liukkonen et al.21 (32% BCS and 66% only diagnosed when they have symptoms. Mammography
mastectomies). The Israeli study had fewer mastectomies is widely used to diagnose BC, but young women have
(40%) and more BCS (55%).20 OS at 5 years was approxi- dense breast parenchyma, which could reduce the sensi-
mately 85% in all of these studies.20,21 According to tivity and accuracy of digital mammography.26 Also, there is
CONCORD-3, Portugal has the fifth best BC survival in no evidence of a mortality benefit from mammographic
Europe.23 screening of women under the age of 35 years.6
TNBC and HER2-positive disease are more prevalent in Due to over-representation of more aggressive molecular
younger patients than in older women.6 As expected, the subtypes and advanced stages of disease at diagnosis,
main histological subtype was ductal invasive carcinoma an important number of women in our study developed
and this pattern does not differ from general BC patients.24 metastasis (N ¼ 26; 15%). HER2-positive disease was the
BC in younger women is often diagnosed in more subtype which developed more CNS metastasis, while
advanced stages of disease. The main reason for that is the luminal-type tumors were those which spread more
lack of screening, which is not recommended in this age frequently to bone, as expected. In proportion, the

1.00
HR+ HER2– HR+ HER2+
HR– HER2+ TNBC
0.75

0.50

0.25

log-rank P = 0.258
0.00
0 50 100 150
Months
Number at risk
HR+ HER2– 16 8 2 0
HR+ HER2+ 10 6 1 0
HR– HER2+ 2 0 0 0
TNBC 8 2 1 0

Figure 3. Overall survival in metastatic patients according to IHC subtypes.

HER2, human epidermal growth factor receptor 2; HR, hormone receptor; IHC, immunohistochemistry; TNBC, triple-negative breast cancer.

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ESMO Open I. F. Eiriz et al.

prevalence of IHC subtypes at metastasis is higher in HER2- 86%.5 Including all patients, OS at 5 years was 87% and in
positive disease (35%) and TNBC (22%). We also want to HR-positive/HER2-negative disease patients (92%) it was
highlight the great amount of CNS metastatic involvement, better when compared with HER2-positive, either HR-
which is higher than that described for all ages of BC pa- positive (86%) or -negative (83%), and TNBC (75%),
tients, as we also saw in our previous work.27,28 In a pre- although with no statistical significance.
vious retrospective analysis carried out in one of the Besides the previously mentioned limitation of low
hospitals included in this study, we found, from an overall prevalence of testing for germline genetic alterations, and
population of 217 metastatic BC patients of all ages, 21 since this is a retrospective study, we could not access
(9.7%) with brain metastasis, with a median age of 45 years sociodemographic characteristics of these patients, like
old (minimum 28 and maximum 66), which is much less educational degree, marital status, reproductive history,
than what we found in this young population (37.8%). It estrogen exposure, tobacco use and alcohol consumption.
should be highlighted that our previous work included a These are very important issues to be discussed with these
large number of metastatic elderly patients. Other studies patients, not only for treatment decision-making, but also
found that the most consistent features for predicting CNS during survivorship. BC in young women is becoming more
metastasis include estrogen receptor negativity and young prevalent and a major clinical issue. Cancer diagnosis and
age.29 In this analysis, the majority of patients who devel- oncological treatment strongly impacts quality of life.
oped CNS metastasis had HER2-positive disease or TNBC. Management of these patients needs a dedicated approach
Genetic factors are even more meaningful in younger involving a multidisciplinary team. Besides antineoplastic
patients, because lifestyle and environmental issues (life- treatment, there are survivorship issues that need to be
time exposure to endogenous and exogenous estrogen, taken into consideration. Health care professionals should
tobacco use, dietary and lack of physical activity) usually address physical and psychological morbidity during and
only have impact in the development of malignancy after after antineoplastic treatments.38 These patients might
decades of exposure.30 Since this is a retrospective study, experience modification of body image and sexual func-
we only had access to BRCA status of 39% of our population tioning, prematurely induced menopause and infertility.
and found a lower than expected percentage of BRCA Other issues that also need to be taken into account are
mutation.31,32 This in an important limitation of our study, sustaining careers and parenting of young children.13,39,40
since it does not allow us to characterize possible genetic Furthermore, the risk of secondary malignancies needs to
causes in our population. For further improvement, these be addressed in these young patients. Further studies
patients should have BRCA mutation testing. This is relevant characterizing this population are needed to provide better
since this allows specific management and treatment care to these patients. Guidelines like ESO-ESMO 4th In-
decision-making that may improve survival, like pharmaco- ternational Consensus Guidelines for Breast Cancer in Young
logic interventions and risk-reducing surgeries (bilateral Women are measures carried out by experts that bring a
oophorectomy and mastectomy). Additionally, family great benefit by standardizing and spreading the best
members should also have genetic counseling. treatment than can be provided to these patients.9
It is known that age should not be the only reason for It would be interesting to follow a group of such patients
overtreatment and age alone should not determine in- prospectively focusing mainly on lifestyle, therapeutics and
tensity of treatment.33 Neoadjuvant CT was offered to 39% survivorship issues.
of patients. Twelve percent achieved complete pathological
response and this number is similar to that found in liter- FUNDING
ature (15%).34 Eighty-three percent of patients received
adjuvant treatment and decision about adjuvant CT regi- None declared.
mens followed local oncological centers practices. We want
to highlight that the low percentage of ovarian function DISCLOSURE
suppression might be due to the fact that positive results of The authors have declared no conflicts of interest.
ovarian suppression function in DFS for premenopausal
women in SOFT and TEXT trials were only known since
2014.35,36 We also found that the median time from last REFERENCES
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