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Breast cancer in women age 40 and younger tends to have a worse prognosis. Just 5% of breast cancers occur in this age group in the United States, but in lower-income countries 20% of breast cancers are diagnosed in these younger patients, noted authors of a study in

Hiba Moukadem, MD, of the American University of Beirut Medical Center in Lebanon, and colleagues examined disease characteristics and outcomes in this patient group, analyzing the medical records of 386 patients ages 40 and younger treated at their institution from 2010 to 2018.

"Application of modern multidisciplinary management produced improved overall survival rates of 76% at 10 years in young patients with breast cancer. Ten-year survival rates of young patients with early breast cancer reached 87%, and patients with locally advanced and metastatic breast cancer reached rates of 68.7% and 48.4%, respectively," the researchers reported.

"Modern multidisciplinary management, guided by biology and modern therapies, can help us remove the stigma of poor prognosis in young women with breast cancer," the authors continued. "Our data, coming from a LMIC [low- or middle-income country], show that improvement is achievable everywhere when resources are available and treatment is accessible."

Moukadem discussed additional details and findings in the following interview.

Why does breast cancer occur more often in patients younger than 40 in lower-income countries?

Moukadem: Factors studied for breast cancer diagnosed at early age are fertility rates, westernization, genetic factors, and hormonal changes or exposure to hormones. However, scarce data are available to explain earlier breast cancer in LMICs compared with high-income developed countries.

Most of the variation in risk is thought to be environmental factors (see .). The presence of pollution may be the cause of carcinogenesis leading to cancer at a young age. In Lebanon, for example, there are no data that report the causative factor of breast cancer at young age.

How would you characterize access to treatment for patients with breast cancer in lower- and middle-income countries?

Moukadem: The main limiting factor for treatment of cancer in LMICs is the access to medication. In Lebanon, before the financial and economic crisis that started in 2019, national guidelines for cancer treatment almost overlapped with international guidelines, and medications were readily available. The medical coverage was mainly through private insurance companies and through the National Security Service Fund. Otherwise, medications were provided to patients through the Lebanese Ministry of Public Health (MOPH) for free.

A study by in 2018 calculated that the cost of oncology drugs dispensed by the Lebanese MOPH from 2014 to 2016 was about $140 million U.S. dollars. Trastuzumab ranked first in total expenditures for 2014 and 2015. In 2016, expenditures increased by 27% with the introduction of immunotherapy drugs (mainly pembrolizumab and nivolumab).

After the economic collapse, the majority of people depended on MOPH for medical coverage. However, the MOPH disclosed major financial limitation and is no longer able to afford high-cost medications. Therefore, a new national guideline for cancer treatment was initiated to cope with the current failure, restricting the use of expensive medications (such as trastuzumab, pertuzumab, TDM-1, and pembrolizumab) to certain essential indications that show major benefit.

Patients who wish to receive medications outside the new budget-restricted national guideline have to pay for them. In addition, new medications that are now the new standard of care in breast cancer by international guidelines such as T-deruxtecan or sacituzumab are not yet officially registered, and thus not available in the country.

What did you find in terms of disease characteristics such as stage, grade, and hormone receptor status in these patients?

Moukadem: In our study, which included young patients with breast cancer from 2010 till 2018, the median age was 36. Most patients were diagnosed at an early stage: 22.4% at stage I, 41.2% at stage II, and 23.2% at stage III. Just 13.2% of patients were diagnosed at an advanced stage (stage IV).

Of the 386 patients included in our study, 94.3% had ductal carcinoma, while 1.3% had lobular carcinoma. The rest were DCIS [ductal carcinoma in situ]. Grade 1 disease was present in 8.7% of patients, grade 2 in 36.0%, and grade 3 in 54.6%. The proportion of HER2+ patients was 26.2%, while HR+ patients accounted for 74.6%. Finally, 16.6% had triple-negative breast cancer.

Is there anything else you would like to make sure oncologists understand about your study or this issue?

Moukadem: Our study showed improved survival of young patients less than 40 treated for breast cancer through modern multidisciplinary cancer treatment. Awareness campaigns for self-examination and early detection of breast cancer are important to increase the rate of cancer diagnosed at an early stage.

It is important to mention that in Lebanon, the MOPH offers campaigns for awareness about breast cancer, teaching self-breast examination, in addition to free mammograms in multiple areas of the country during the last 3 months of the year. Similar efforts are also undertaken by many non-governmental organizations including the Lebanese Breast Cancer Foundation and the Cancer Support Fund at the American University of Beirut Medical Center.

The detection of early breast cancer with small tumors increases the rate of partial surgeries instead of total mastectomies. The role of surgical oncology training is essential to increase the rate of breast-conservation surgeries and also axillary management through sentinel expertise, hence reducing lymphedema. Neoadjuvant treatment is used to make locally advanced large tumors operable.

The addition of targeted therapy or immunotherapy to neoadjuvant chemotherapy increases the rate of complete pathologic response, which correlates with survival benefit. Also, radiotherapists use advanced techniques for local control after surgery or even in the palliative setting.

All these methods of treatments are discussed in multidisciplinary tumor boards at weekly meetings and in the presence of the different subspecialty experts in breast cancer.

Read the study here.