Thomas Samuel, M.D., breast oncologist and Interim Cancer Center director at the Maroone Cancer Center at Cleveland Clinic Florida in Weston, Florida, talks about the effects breast cancer can have on young women.
Interview conducted by Ivanhoe Broadcast News in November 2016.
Are you seeing more younger women coming to you with breast cancer or is it more prevalent now?
Dr. Samuel: The prime demographic for women getting breast cancer is typically between the ages of 50 and 70, which is where the lion’s share of breast cancer patients are going to be seen. Patients under the age of 50, patients over the age of 70, these are the age groups where the prevalence starts to go down and we’re not seeing as many patients. I would say that the number of patients we see that are under the age of 40 is relatively rare, approximately 5-10 % of all the patients that we see. That’s also the group that’s not screened, patients who don’t typically fall into our standard screening guidelines. But when women of that age get diagnosed, there are some different issues that we have to address because of their age and the unique other things that may be going on in their life at that time.
Right, exactly and certainly as you say doctor in Yolanda’s case, she found her lump at home and that brought her eventually to you. When you are that age, as an oncologist who does see so many patients, were you surprised?
Dr. Samuel: Oh, absolutely, yes. We don’t see very many 30-year olds in our clinic. In a year’s time we may see a handful, I say maybe at most 10 patients who are in their thirty’s, and most of those patients are 35 to 40. To see a patient under the age of thirty-five, we may see one every 2-3 years. It’s an extremely unusual situation to see that young of a patient, and again, some of the things we have to think about in the population are quite a bit different than we have to think about in someone who is 50, 60 or 70.
What do you feel is important for a woman that age to know about obviously before she starts treatment or having surgery?
Dr. Samuel: Well, I think from an awareness standpoint, the first thing is education. One of the things we try to encourage, not just the patients who have been diagnosed, but with patients who haven’t been diagnosed, such as a primary care population, is to encourage breast health awareness at a very young age. We encourage all women to start doing regular self-breast exams on monthly basis, somewhere in their mid to early twenties. There are different guidelines but typically around age 25 is what we generally recommend for self-breast exams. We also do recommend women to have a physician breast exam (usually done by a primary care provider or a gynecologist) beginning around age 25 on an annual basis. Mammographic screening in this age group is just not done because of multiple reasons. One, it’s relatively a low yield procedure; there are so few patients you are going to catch and a large number of patients are going to be exposed to the excess radiation and false positive findings. The other concern is that a lot of these patients who get mammograms done end up having unnecessary biopsies and other procedures. We try to identify high-risk patients; i.e. those patients who really need to go to that next level of screening. The other important consideration is the patient’s potential genetic risk for getting breast cancer. Do they have a family history? Was there some other predisposition that we were not aware of? Maybe some exposure in the environment. The question that we attempt to answer is, “Why do young patients like this get breast cancer in the first place?” These are some of the initial conversations that we have when we talk to patients before we talk to them about some of the treatment related issues. We see a lot of patients who are sophisticated about their own family history. They know mom had breast cancer, an aunt had breast cancer, maybe grandmother had breast cancer as well, and so you have these 20-year olds who come to us and say, “I am scared and I need to know what my risk is.” Well, the good news is we actually have tools, formal mathematical tools, that we can use to help calculate a patient’s risk of developing breast cancer. Not only can we calculate the risk of developing breast cancer, we can also calculate their risk of having one of these genetic predispositions which places them in a higher risk category requiring more screening and early awareness. Let’s say you were adopted and you don’t know your family history but you are concerned about it. You may have had a friend who had breast cancer or someone else in the inner circle in your community, and you want to know. These are things we could actually address in a very formal way through breast cancer risk and assessment tools.
What are some other concerns?
Dr. Samuel: From a treatment standpoint, the unique sort of conversations we have to have with young patients really revolve around what’s happening in their life. For example, if you have someone who is in their late 20’s or early 30’s and have been diagnosed with breast cancer, one of the concerns is fertility. They are in that time where I think that they can really consider having children, growing their families and the concern is that many of the treatments, chemotherapy, radiation and surgery, will all have an impact on their ability to have children and to have a family. You need to have that conversation with them before you give them the treatment. Fertility is something that I address with all our young patients who are still having regular periods. “Listen you have an aggressive cancer, we need to talk about doing treatment but this treatment may impact your ability to have a family.” Some patients are concerned and some aren’t. Some of them have already had children and are no longer interested in further childbearing. They have their children and they don’t want to think about it; for them it’s easy. For women who haven’t gotten to that point yet, they have to think about egg or embryo preservation, going to see a reproductive endocrinologist to have the conversation and so forth: “What can I do to preserve my eggs? To preserve my fertility?” There are things that we can do actively from the start before we begin the treatment.
That’s great advice. What about if a woman is going to undergo surgery? What do you talk to them about when it come to their own body image and their own personal feeling about themselves, because they go through a lot?
Dr. Samuel: It’s a difficult conversation; we always say the most important thing we want to make sure is that we get the cancer taken care of; and that means we have to have all the options on the table ahead of time so patients are aware of it. But we want to be sure that once we have taken care of the cancer then what’s left is going to be conducive to a happy life and a quality of life. That’s where we have the discussions from a cosmetic standpoint for preserving body image. “Listen we are going to take care of your cancer, but we want you to know that there are options that can help to reconstruct your breast.” We make sure any of the treatment effects like hair loss, changes in a patient’s cycle, etc. are not going to affect the quality of life. There are ways we can actually help and improve those things.
Like you are saying all of that needs to be discussed beforehand with the patient, give them those options. If you are a younger patient and you do have kids, such as Yolanda already does addressing it with your children.
Dr. Samuel: Right.
That’s has to be one of the hardest things a parent has to do?
Dr. Samuel: Yeah, it’s very, very difficult and I can speak on that on two levels. I’m actually the son of a breast cancer survivor. My mom is a twenty-year breast cancer survivor so I remember when she was first diagnosed. Getting that information and how I processed it, before I became a doctor, I can understand it from both sides. The other aspect of it is we actually ask patients: “Have you communicated this to your family including your children and other members?” Some patients confess: “I just don’t know how to talk to them; I just don’t know how to face them.” We have a few patients who won’t tell their children; even grown children, even in their late teens; they won’t explain it to them because they are afraid of what they might have to feel or go through. We actually have a great support service. Our social worker is able to provide materials for really young patients on how to communicate, like children’s books that help to explain what a breast cancer diagnosis is like and how and what the treatments might be like so they know when they see mom lose her hair, or they see mom looking different. They can somehow explain that in a way that is helpful and educational but also very protective of their stage of growth. We have a couple of different ways we can do that.
For a younger patient, is it something that where to have the knowledge of all of this, of all the things you discussed, does it help do you think to discuss those things early on and face those things early on; does it help in your treatment and recovery?
Dr. Samuel: Yeah, as far as discussing it with your family, in my mind, the earlier you do it the better. Children are incredibly resilient at all ages. Most people are surprised when they do finally have that conversation with their family members as to how supportive they are, or how understanding they are and how responsive they are toward what’s going on; we underestimate them and protect them; that’s the parent’s natural inclination, to protect them from bad news or bad experiences. But actually, it could be incredibly comforting and it brings the family closer together when everyone is going through it but not at the same time. I remember when my mom was diagnosed, one of the things that I really felt was a great support for her was that we brought the whole community together; it wasn’t just with our whole family. We brought the whole church in and we brought our neighbors in, everybody was in the house at that point and it really helped; to be able to get support through treatments and having your family member know that they are not alone. We try to communicate that there is really a team that is going to help you go through this diagnosis.
I think that’s great. I think it’s going to help Yolanda as support from her family was the biggest thing for her. Genetic testing, you talked about screening, you talked about fertility and how prevalent is breast cancer in young women?
Dr. Samuel: I would say about ten percent of women are diagnosed under the age of forty with breast cancer, and again, when you get to the really younger ages those numbers are getting really small. In my own career, I’ve seen probably about 20-30 patients out of about 1,000 and those patients were mostly above the age of 35. Obviously, that’s the group we are not screening or just not screening effectively.
Is there any research specifically in that area that is pointing to reasons why?
Dr. Samuel: It’s hard to get research in that group because it’s not that common. Most of the resources we have are retrospectives series of those patients who are reported in the literature and a lot of what we do for these patients is extrapolation. We have done most of our breast cancer research on the 50-year olds and the 60-year olds and are extrapolating down to our younger patients which may not be the most effective way to approach these patients. They have different issues which we need to be ready to discuss; for example a 60-year old is not going through the same issues a 30-year old is going through.
I did hear it like certainly in younger African American women, it seems to be more of an aggressive tumor?
Dr. Samuel: Yeah, and so we know that breast cancer as a whole is more common in Caucasian populations. That might sound great for African American populations but the problem is that when African American women get diagnosed, they get diagnosed younger, and with more aggressive cancers. It’s sort of good news, bad news. They are less likely to get cancer, but when they do, it tends to be more aggressive and they get diagnosed much younger. Triple negative breast cancer, which is one of the more difficult types of breast cancer to treat, has a higher prevalence in African American populations. That’s the type of breast cancer that we have less effective therapies for and have poorer outcomes. When we have a combination of all those bad features, young patients and, triple negative, we know that’s going to be a difficult profile to manage. And fortunately for Ms. Jenkins, since she wasn’t in that exact profile, I think the expectations are a little better.
I have heard of a triple negative. Are there any stats on comparing the percentage of younger African American women, who are getting cancer versus the percentage of younger Caucasian women?
Dr. Samuel: We know that of the women who are under the age of 40 who get diagnosed with breast cancer and are triple negative, forty percent of them are going to be African American. Now let me say that doesn’t mean the other sixty percent will be Caucasian; but forty percent when you are thinking of population you know only ten percent of the population is African American so they are much more likely to get triple negative breast cancer when they are younger.
Are you guys doing it for targeted therapy or are you working on targeted.
Dr. Samuel: That’s the Holy Grail of research right now; the Holy Grail of research is finding a targeted therapy that is for triple negative breast cancer. Triple negative breast cancer right now doesn’t have a target, they are all negative so we have to find the fourth receptor or another target that’s going to give us something that we can latch on to and target. There are some really promising ideas that may be targeted and I know the future is exciting as far as options are concerned. But at the moment, right now, this remains a very difficult disease.
If you are a younger woman really right now your only way of being checked is to start the self-check breast exam early.
Dr. Samuel: Self-awareness; self-preservation. If you have level of concern for whatever reason, if it’s a family history or if it’s a community issue, whatever it is, if you have a sense that your breast cancer risk may be elevated, you can go speak with a breast cancer professional who can actually do a formal risk assessment and put some of the characteristics into a mathematical tool that I mentioned and can actually calculate your chances of getting breast cancer.
If your risk assessment puts you in a high-risk category, maybe we do need to start your screening earlier or maybe we need to do something more proactive to help lower that risk. That is a service that is available to everyone. You can go to Google and type in breast cancer risk assessment. The first website that comes up is the National Cancer Institute Breast Cancer Assessment Tool. You can go to that page, answer a series of eight questions and it will calculate your five-year risk of developing breast cancer and your lifetime risk of developing breast cancer. The only caveat is that you have to be older than 35 to be able to do it.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Thomas Samuel, MD
954-659-5000
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