Ann Partridge, MD, MPH: Treatment of Young Women With Breast Cancer
Dr. Ann Partridge discusses the differences, biologically, medically, and emotionally, in young women with breast cancer as compared to older women with breast cancer at the 34th Annual CTRC-AACR San Antonio Breast Cancer Symposium.
Dr. Partridge is the Clinical Director, Breast Oncology Center and Director, Program For Young Women With Breast Cancer at the Dana-Farber Cancer Institute. She is an Associate Professor at Harvard Medical School.
The Group Room at the 34th Annual CTRC-AACR San Antonio Breast Cancer Symposium was made possible by support from:
VIDEO TRANSCRIPT:
Selma Schimmel, Founder & CEO, Vital Options International:
Hello and welcome to the Group Room where we’re at the 34th Annual CTRC-AACR San Antonio Breast Cancer Symposium. I’m joined now by Doctor Ann Partridge, Clinical Director of the Breast Oncology Center, Director of the Program for Young Women with Breast Cancer, Associate Professor of Medicine at Harvard Medical School. Welcome.
Ann Partridge, MD, MPH, Clinical Director, Breast Oncology Center, Dana-Farber Cancer Institute:
Thank you.
Selma Schimmel:
And I’m very happy to talk to you because you’re doing an educational session here at the symposium on the treatment of young women with breast cancer, and I was a young woman with breast cancer in my 20s, 28-years ago. So I can’t wait to hear where are we today, clinically, on behalf of young women and breast cancer?
Ann Partridge, MD, MPH, Clinical Director, Breast Oncology Center, Dana-Farber Cancer Institute:
I think the good news is that we made a lot of strides over the last several years recognizing that breast cancer in young women is different. Young women are different from the standpoint of they tend to get more aggressive breast cancer, higher stage, more likely to have more aggressive biology on average, and young women are more likely to have a more difficult time with their breast cancer in terms of adjustment both physically and emotionally after the diagnosis and treatment. So with increased recognition of that we’ve actually gotten much better at targeted interventions to both figure out who’s at greater risk within young women for having a hard time either medically or emotionally, as well as developing treatments more focused on trying to improve how they do short- and long-term, both medically and emotionally. So there is a lot of work being done and really we’ve kind of seen kind of an explosion over the past ten years.
Selma Schimmel:
We understand about the women who have the Braca mutation and this subset of patients like myself who had young adult breast cancer. What are the percentages like of women who are diagnosed very young in their twenties and thirties but do not have the Braca mutation?
Ann Partridge, MD, MPH:
So the vast majority of women do not have a Braca mutation when they looked at unselected population. So groups of women who come in because they’re forty and under and some may have a family history some may not, what we found is that only approximately ten percent will have the BRCA-1 or BRCA-2 mutation. If you start selecting out from family history, or being a certain race or ethnic groups it can go a little bit higher and now we’re learning actually that women with triple negative breast cancer that is hormone receptor negative as well as Her2 new receptor negative breast cancer, if you have that type of breast cancer and you’re young, you actually can have a much higher risk of having one of those gene mutations. And so we’re kind of teasing it out within the subtypes but the fact is for the vast majority – even the young women – there’s no clear genetic culprit that we’ve been able to figure out yet.
Selma Schimmel:
So do we understand what really might be the trigger point in young adult women and breast cancer?
Ann Partridge, MD, MPH:
We really don’t yet. One of the big areas of interest for a research perspective – and I’ve been privileged to work with some groups on this – is how does a pregnancy and being post-partum play into the risk of developing breast cancer? Now most of us understand that pregnancies protect them, especially before age 30 but that’s for the vast majority of women with breast cancer – and remember, that’s the vast majority of women with breast cancer – are over 50 when they get breast cancer. If you drill down and look at women who develop breast cancer before 50, those women actually had – women before 50, regardless of whether they had breast cancer – they’re at higher risk of developing breast cancer after a pregnancy for a short period of time, between two to fifteen years. And then pregnancy, especially before age 30, is overall protective, again for the majority of women is post-menopausal breast cancer. So it’s very complicated.
Selma Schimmel:
But do we know the reasoning for this?
Ann Partridge, MD, MPH:
So one of the reasons we think is that something about the changes in a breast after a pregnancy – and it’s called involution, it’s when the breast has kind of fully differentiates and it calms down, is kind of my best way of explaining it – something about the changes that occur in the cells in the breast in some women can cause aberrant changes that turns into cancer. And they remain at risk for a period of time, and if you don’t get breast cancer then, which the majority of women don’t then their benefits in terms of reduction in the future. So it’s really complicated.
Selma Schimmel:
So it’s not necessarily a hormonal issue. We don’t really know what it is.
Ann Partridge, MD, MPH:
It’s probably not a hormonal exposure issue per se but of course the hormones are probably what’s driving the changes in the breast. So they’re definitely related.
Selma Schimmel:
What about treatment? Where are we now in the choices that we have for some of the targeted therapies as well as chemotherapy, these combination therapies? Is it different for young women and are we able to heed caution and to try to protect their futility?
Ann Partridge, MD, MPH:
So I think big picture wise, it’s been really good news because every time you look at treatments they work as well if not better in younger women, which is terrific. For a long time we didn’t know Tamoxifen helped young women, and we determined in the late ‘90s that it offers a substantial risk reduction, nearly 50% in terms of risk recurrence. So that was a huge, huge advantage that we learned about now are benefiting from. We also know that young women are actually doing much better compared to older women in terms of their survival at this point than it used to be, which is terrific.
What you alluded to though, about the fact that young women are more likely to suffer is, we hit younger women harder in general because they tend to be at higher risk and the ramifications are more massive. For example, fertility being one of the most important ones, and so we’re doing a lot of work looking at how can we preserve fertility and get women the best treatment, allow the women to have their cake and eat it too even though they’ve been diagnosed with breast cancer.
And there is a lot of good work going into the fertility preservation strategies as well as helping women to deal emotionally at diagnosis the problem whether she should go in for fertility afterwards as well as once she’s in her survivorship where can she go for help with some of these very difficult decisions.
Selma Schimmel:
Are you still seeing cases that have been delayed in diagnosis because the age was really held against in the sense that you’re too young for breast cancer?
Ann Partridge, MD, MPH:
So I think historically that’s been a huge problem, and if you sit with groups of advocates – especially the young women advocates – and someone asks them did anyone ever tell you you’re too young? Half of them raise their hand at least, if not more, depending on the group. I do think that is changing, I think there’s an increased awareness that breast cancer can and does happen among young women. In fact, there was just part of health care reform in the United States included the Early Act, which was passed last year where there’s actually now money and a full advisory panel, and the CDC is working on improving early awareness about breast cancer in young women. So I do think that’s changing.
That being said, the risks are lower than average in young women but we also know that it can and does happen and we need to pay full attention to that.
Selma Schimmel:
I would also imagine that long term care after treatment becomes an issue for young women. It’s so easy to forget that we as women also are more prone to heart disease, and I am curious to know what’s the game plan when you look at long term survivorship issues, and how do we help young women understand that even though they have this big incident with their health early in their life, there’s whole other spectrum of normal health concerns that all women face but in particular if you’ve had radiation or you’ve had certain exposure to therapeutic agents that can be toxic to the heart. How do we follow these women?
Ann Partridge, MD, MPH:
So one of the problems right now is that we don’t have a great evidence base, we don’t have a whole lot of data to tell us how to follow these women, and groups of us are actually collecting that data from women who have been kind enough to volunteer to participate in our research so that we can, in the future, get a better sense of what the risks and what in terms of the number of women who do develop problems.
That being said, younger women are at risk for problems for a longer period of time just by virtue of being younger. And what does it mean in particular for a woman to go through a very premature menopause? It’s one thing to go through it at 50 or 49 when you’re probably going to go through it at 51 anyway as opposed to a woman who goes through menopause at 35, and has 15 extra years of low estrogen. How does that affect then, her future risk of heart disease, bone health problems, and even cognitive functioning? In other settings there’s some concern that really premature menopause may result or be associated with things like Alzheimer’s earlier and more likely. And we need to develop more and more information about these risks, and right now we’re kind of right at the beginning of understanding both the risks for long term survivors – young and older women – and all cancers. But also what we should do to monitor and prevent problems, and we’re trying and my recommendation for people – both patients and providers – is they need to be more vigilant about their own health and have the conversations and monitor when it feels appropriate and/or a problem arises. Don’t poopoo someone, remember they might be at higher risk.
Selma Schimmel:
The key points in educational session you presented to your colleagues here, what were some of the major talking points of your talk?
Ann Partridge, MD, MPH:
So the major points were we’ve done a lot of work looking at whether or not age alone is a predictor of not doing as well. That’s been shown historically in the past but they never controlled for a type of breast cancer a woman got, and we know that younger women are more likely to get those more aggressive biology tumors like triple negative as I just discussed earlier, or Her2-Positive, we think, or if they get hormone receptor positive breast cancer, it tends to be the more aggressive type higher grade. And so we’ve done some analysis as have others that are suggesting that as you start to control for the tumor subtype the effects of age alone tend to wash out. And so that’s really interesting and important because we’re going to get better and better at just figuring out what type of breast cancer a woman has, and while age is completely important in terms of how a woman reacts toward the treatments for sure, we don’t want to necessarily pick treatments and have a kneejerk approach just based on age.
So for example, historically, if a young woman walked in even with a wimpy appearing tumor doctors are afraid not to give her chemotherapy even if you would never give it to someone with this kind of tumor if they were older but they were just afraid because they didn’t feel confident that a woman could still do well with a wimpy tumor if she was young. And I think our evidence is suggesting as well as others that young women can do very well with maybe just a hormonal approach without throwing the kitchen sink at her. So that was one of the main points.
And then I discussed in my talk the issue of how do we better care for young women both in diagnosis and in follow-up in terms of trying to get all their needs addressed. And we’re doing a lot of work looking at intervening to make sure that fertility issues are addressed at diagnosis and in follow up because historically we’ve not been really good at that as providers. Genetics issues – we want to make sure that we test women if they’re interested in testing before they make their definitive surgical recommendations because if a woman would have had a mastectomy if she’s a gene mutation carrier and she goes on and gets radiation, well then, she’s had that unnecessarily, perhaps. So issues like that, and of course emotional issues. How can we better support these women?
Selma Schimmel:
And family history. How important is family history for the young adult woman?
Ann Partridge, MD, MPH:
So I think it’s really important, the biggest predictor of breast cancer in young women is a strong family history. And so any time a person comes in diagnosed with cancer, particularly cancer diagnosed at a young age, we look at each other and say ‘how did this happen’? And a family history can unlock the key to that; not in all situations but for many women. And it also has implications for how we follow women if they have a mutation and for their families.
Selma Schimmel:
And if one doesn’t have the mutation or knowledge of it and they do have a breast cancer family history – not necessarily as a young person but they have a family member who is a breast cancer survivor – is that of any consequence? Should that young woman for any reason be more diligent if it was an aunt, let’s say, that had breast cancer when she was young?
Ann Partridge, MD, MPH:
So I think the key – and you just alluded to that – is a relative at a young age at diagnosis, and then it’s how is that relatively linked to you? So we always say first degree relatives, especially if there’s more than one. But it’s a little tricky when you’re talking about the paternal line. So men don’t tend to get breast cancer even when they are genetic carriers for the BRCA-1 or 2 mutation. But if it’s a woman’s father’s sister who had the breast cancer at a young age, that aunt is not a first degree relative but that aunt may put the patient at as much risk as a first degree relative. So it’s a little a little tricky, and what I would suggest is, anybody with lots of family members with breast cancer or men with a lot of prostate cancer, certainly someone with breast and ovarian cancer in their family, it’s worth hashing this out with their primary care doctor and trying to get a sense of is this breast cancer or ovarian cancer I need to worry about? Or does this happen with age?
Selma Schimmel:
Well I really want to thank you for what you’re doing on behalf of young women. It’s inspiring to me; I feel so lucky that I survived it at a time when we knew so little. And it’s funny, at that time they said ‘oh you’re not going to meet too many young women with breast cancer. You’re an anomaly’, and when we started Vital Options it was really the number one disease we were seeing, and now it just seems that there’s young women everywhere with breast cancer.
Ann Partridge, MD, MPH:
Right. I don’t think that the incidence is increasing; I think women are more comfortable telling their stories. I think it’s become a more socially acceptable thing to say ‘hey this is a problem. Let’s focus on it a little bit, and you’re inspiring for me’.
Selma Schimmel:
Thank you, Doctor Partridge. Doctor Partridge is the Clinical Director of the Breast Oncology Center, Director of the Program for Young Women with Breast Cancer, Associate Professor at Harvard Medical School. They’re lucky to have you there in Boston.
Ann Partridge, MD, MPH:
Thank you.
Selma Schimmel:
You’re welcome.
END OF VIDEO