Breast Cancer in Young Women: Signs, Screening and When to Speak Up

Breast cancer diagnoses are rising among younger women, including many who are not yet old enough for routine mammograms. What warning signs should women in their 20s, 30s and early 40s recognize, and what should they do when a concern is dismissed?

Host Johanna Gomez, a breast cancer survivor, speaks with Dr. Starr Mautner, breast surgical oncologist, and Dr. Reshma Mahtani, chief of Breast Medical Oncology at Baptist Health Herbert Wertheim Cancer Institute. They explain why knowing what is normal for your body, understanding your personal risk and advocating for proper imaging or a biopsy can make a critical difference.

•  Why breast cancer rates are increasing in younger women 
•  Lumps, skin changes, nipple changes and other symptoms that should not be ignored 
•  How lifestyle, alcohol use, genetics and family history may affect risk 
•  When screening should begin and why dense breast tissue matters 
•  Why an ultrasound does not replace a mammogram 
•  When to push for a biopsy or seek a second opinion 
•  Fertility preservation and coordinated care for younger patients 
•  Practical steps women can take to protect their breast health 

Early detection matters. Know your body, understand your risk and do not ignore a change that does not feel normal for you.

Host:
Johanna Gomez
Award-Winning Host & Journalist

Guests:
Starr Mautner, M.D.
Breast Surgical Oncologist
Baptist Health Herbert Wertheim Cancer Institute

Reshma Mahtani, D.O.
Chief of Breast Medical Oncology
Baptist Health Herbert Wertheim Cancer Institute

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Life After Breast Cancer: Fear, Healing, and Hope

Young Women and Breast Cancer

Breast Cancer Survivorship: 10-Years Later

Transcript

SPEAKER_02 0:00

The issue with young women developing breast cancer is they're in the prime of their career, they're just starting families, they're extremely busy and they don't have time for cancer, but yet they need the most amount of resources. Because when you're diagnosed under the age of, let's say, 45, and you're either not done with childbearing or haven't started childbearing, some of the treatments for breast cancer can impact fertility. So starting that conversation early of whether or not you want to preserve your fertility has to happen at the first or second visit.

SPEAKER_00 0:28

Welcome to Baptist Health Talk, a podcast on all things healthcare, powered by Baptist Health South Florida, your trusted source for health care prevention and wellness.

SPEAKER_01 0:39

Hi everyone, I'm your host, Joanna Gomez. Welcome back to a new episode of Baptist Health Talk, where we answer your most search questions on trending health topics. Today we're talking about breast cancer in younger women, what's actually on the rise, and why this matters right now. From the signs that can be easy to miss to when to start thinking about screening and what a mammogram really means for you. We're breaking it all down so you know what to look for and when to take action. And this is a conversation that hits close to home for me because I've lived it. So today it's about making sure every woman has the information she needs that I wish more of us knew earlier. We are joined by Dr. Star Mottner, breast surgical oncologist, and Dr. Reshmat Matani, Chief of Breast Medical Oncology, both with Baptist Health Miami Cancer Institute. Ladies, it is great seeing you both and having you both here. Before we get into all the data and we get into all the details, can we define what the younger woman age range is?

SPEAKER_02 1:44

Sure. So it's typically defined as a woman that develops breast cancer before the age of 50 or at a premenopausal age, but I like to focus on those women that are not yet screening. So under the age of 45 or under the age of 40, where really they're coming in because they have found the mass themselves, because they felt it.

SPEAKER_01 2:00

Because they felt it on their own. The breast cancer rate is increasing in younger women. Yes. What does that mean?

SPEAKER_02 2:06

So in general, breast cancer rates have been increasing about 1% per year, but we're seeing an even steeper curve in those women that are under the age of 45, where it's more like 1.3, 1.4% per year. Okay. Um, and so that is a striking increase. And we're not sure completely of why we're seeing that trend, but definitely seeing more and more younger women being diagnosed under the age of 45 these days.

SPEAKER_01 2:30

Does it matter like racial ethnic groups are you looking at, maybe environmental?

SPEAKER_02 2:36

I think it's a combination of many factors, and I think we're going to delve into that in our conversation today. Why?

SPEAKER_03 2:43

That's a great question. I think that's something that we're all struggling to understand. And as Dr. Mottner pointed out, our rates are very much consistent with what we're seeing nationally. So younger women are developing breast cancer more frequently. And the thought is that this is not just due to one factor. So when we um think of multiple things, we call that multifactorial. A lot of it may factor in in terms of women delaying childbearing later in life, um, increasing rates of obesity, uh, increasing use of alcohol. Of course, genetics also plays in, but it doesn't reliably capture what we're seeing. So that's why it's so important for us to uh have more research into this area so that we can dive deep into these important questions and try to address why we're seeing these rates, not just locally here at our institution, but nationally.

SPEAKER_01 3:43

Um, a lot of times we all just wonder like, are there some signs that we should be looking out for? Anything that maybe I even question myself, is there anything that I missed?

SPEAKER_02 3:52

Right. So in this group of younger women, as I said, many of them are not screening at that point, right? I see women as young as their 20s and 30s that are coming in because they felt a palpable mass. And what happens is because they are so young, oftentimes these signs are ignored for a period of time. Yeah. Or the patient is reassured, no, this must be benign, even by their gynecologist or primary care doctor, because you are so young. And so you see that often. Um, and it's very unfortunate because these young women develop aggressive cancers. And so if you don't catch it immediately, by the time they present to me six months or a year later, that cancer has had the ability to grow in size and then potentially spread to lymph nodes.

SPEAKER_01 4:31

Yeah. And I think it depends like where you're at in your life. Like I remember I was breastfeeding, I was just done. And I was like, oh, it's just maybe something with my milk ducts. And I kind of just brushed it off to the side because the reality is that was like, well, I'm young, I'm healthy. There's nothing for me to worry about. That's a myth that I think somehow we just need to kind of just get out, debunk, as they say.

SPEAKER_03 4:54

It's absolutely a myth. And we are all seeing these younger women in our clinics who are being um diagnosed later because their symptoms are not, their signs and symptoms are not being addressed. And we know that diagnosing a breast cancer at an earlier stage impacts outcomes. So when these women come to us with tumors that have spread to lymph nodes with locally advanced disease, it means more treatment. Yeah. It means more local treatment sometimes, it means more systemic treatment, and it it uh impacts our ability to cure women.

SPEAKER_01 5:31

How about um a healthy lifestyle? We talk about that a lot. Does that have anything to do with it, especially when you're young?

SPEAKER_03 5:37

Absolutely. Lifestyle is important. And we know that uh maintaining a healthy uh body weight, limiting alcohol intake, having a diet that's uh plant forward, so to speak, can absolutely help support you through a breast cancer diagnosis and can decrease your risk. But unfortunately, there are plenty of women that show up in clinic that have done everything right, so to speak, and still have a breast cancer diagnosis. So lifestyle is not enough to prevent a diagnosis. Yeah.

SPEAKER_02 6:08

So I started having this conversation now at early and earlier ages. I mean, I've been speaking to high school students, college students, because at that age, number one, you have breasts, right? So you should start to just get to know your own body. And number two, that's really where alcohol starts to come into the scene, right? In high school, college. And you're young and your cells are young, and the most damage can really be done at that age. And we know that it's a group one carcinogen. It's not good for you. And I think that, especially when I was in college, like it was I not that I drank a lot, but it wasn't out there that this could lead to your risk of breast cancer. No one talked about it. No one talked about it. So now it's starting to be spoken about. And I do think that the younger um girls are probably hesitant to start drinking a little bit um because of this information that's out there, and that's a good thing.

SPEAKER_01 6:58

Is the feedback that you're hearing positive, or is it kind of like, well, no one like is this just like a new thing? Because there's so many things right now that you're just like, okay, it's just a new thing that you can't do.

SPEAKER_02 7:08

I think in general, a healthier lifestyle is becoming trendy, which is a really good thing. You know, exercising and taking care of yourself, self-care, limiting alcohol intake, and just choosing non-alcoholic beverages when you're out socializing. Um, and I think that that hopefully will cause a positive trend in the future where we maybe a decade from now do start seeing some of these numbers decline.

SPEAKER_01 7:31

Yeah, hopefully, uh, from your mouth to God's ears. I found it because I found a lump, like I said, and I was like, oh, there's a lump. Oh, wait, there's two, and then there's three lumps. And that was my situation and my journey. I know other women who've had other ways that they've actually have seen some symptoms like siblings, skin changes. Can you talk a little bit about that?

SPEAKER_02 7:54

Sure. So I try to remind women to feel it on the first. And what that means is to be performing a self-breast exam once a month. And even if you don't know exactly what you're doing, the whole point of doing that exam is to be able to notice a subtle difference and a change in the way either your breast looks or feels. And so the first step in doing a self-exam is to look in the mirror. Yeah. Um, raise your hands above your head and then put your hands on your hips. And what you're looking for is symmetry side to side. And it is very common to have one breast slightly different size than the other. So if it's always been that way, that's not something to be concerned about. However, if your breasts were always the same size and then all of a sudden one is shrinking or one is growing, that can be a sign of something that's growing in the breast that's causing a change in the shape or size, pulling or dimpling on the skin. So you may not even notice it unless you specifically look for that and look in the mirror and say, hey, my nipple was never really inverted before, but now I'm seeing pulling behind the nipple. Um, that would be a sign as well. Um, other than that, skin changes, you know, obviously if the breast is very red and hot, that can indicate an infection, but it also can indicate a very aggressive form of breast cancer called inflammatory breast cancer. So these are all things to look for. And as you said, when you develop these signs in the setting of either pregnancy or breastfeeding, it can be extremely difficult to rule that out, you know, as being some sort of infectious process or a clogged duct. And so, you know, pregnancy-associated breast cancer is an entire other category of young breast cancer where we see delays in diagnoses.

SPEAKER_01 9:20

Um, how about menstrual cycles? I I know that a lot of times it changes. Sometimes some women have more lumps and feel other things. Should they be alarmed about that as well?

SPEAKER_03 9:30

So there are changes that can occur around the menstrual cycle, but I think the more important thing is to understand what's normal for you and what represents a change. If there's always breast tenderness at a certain time in the cycle and that's a normal thing for you, there may not be concern. But if there's a change in how you're feeling or uh the symptoms that we've discussed, I think the important take-home point is to be your own best advocate and not to uh ignore those issues. It's it's a common misconception that younger women do not develop breast cancer. So I can't tell you how many times women have been told it's fine, it's nothing, not even sent for imaging. And then they come to us six months, eight months later with a cancer that's a lot larger than it would have been if it had been worked up appropriately.

SPEAKER_01 10:25

I am sitting here nodding, agreeing with you because I have so many friends that I know that that was their story, but what you just said was their story. And I don't think that the word is even out there remotely enough as it should be, because there are so many misconceptions. Speaking of misconception misconceptions, the options for patients with late-stage disease.

SPEAKER_03 10:48

This is one of the biggest misconceptions out there. Of course, uh stage four breast cancer is uh a type of cancer that we generally at this point now say is not a curable condition. Correct. But uh there are advances that have been dramatic. We've had an explosion of new therapies. One of the issues that uh, or one of the statistics that I like to point out is that death rates are falling from breast cancer. And that's great news. That's great. It's great news. And the reason that death rates are falling is twofold. One, we're getting the word out about the importance of screening mammographies. And as I mentioned, we're finding cancers at a smaller stage where there's more likely cure, uh a chance of cure. But the other reason that our death rates are falling is because of the advances in our systemic therapies and specifically for women with later stage disease. As I mentioned, there's been an explosion of new therapies, including immunotherapy, antibody drug conjugates, targeted treatments. We're now able to offer very personalized treatments for women, even with later stage disease. Many of these women are living with metastatic breast cancer for many, many years, and it's become a chronic condition.

SPEAKER_01 12:08

Yeah. And how wonderful like AI has helped so much with this. And because every time I go back, I was diagnosed in 2017 and I read of other things, I'm like, wow, that wasn't around. So it is just constantly changing for the better. Absolutely. Yeah, it is wonderful. Uh, Dr. Martner, I am curious about one thing because we talk a lot about younger women getting their mammograms, getting screenings. What does that really look like? And if you feel something and your doctor just kind of says, like, you're fine, what should we do? So it's a two-part question. Sure.

SPEAKER_02 12:41

So when we talk about screening annually with a mammogram, in general, we start at the age of 40. However, there have been new guidelines that have been set out to start screening younger women depending on risk factors. And so by the age of 25, it is now recommended to at least have the conversation with your doctor, whether it be your gynecologist or primary care doctor, to run a risk assessment model and see what your risk of breast cancer is based on personal factors and your family history. And if you are in that higher risk category, then we will offer screening at a younger age, usually starting with a breast MRI, followed by mammography. But what happens is in these younger women that are starting screening at younger ages, they have very dense breast tissue. And it can be difficult to see masses on that mammogram. So mammograms are a great tool for screening, but they are not perfect. And many young women have dense tissue. And because lesions can hide within that dense tissue, you often need to supplement that mammogram with at least an ultrasound. And if you're high risk, consider supplementing with a breast MRI as well. In terms of what to do, if your physician tells you that, you know, you don't have anything to worry about because you are young despite feeling a mass, do not take no for an answer. So the rule of thumb is any solid palpable mass needs a biopsy to rule out cancer. No one can tell you based on exam alone or even on imaging alone that a mass is truly benign. And so I have had patients go for imaging and be told, oh, that looks like a benign fibroadenoma, but it's not biopsied. Um so to take it a step further, let's say your physician does the right thing and they do order imaging, but then you're told the mass is a benign solid mass, I would still push for the biopsy because I have had patients be misdiagnosed and be told that they have a benign fibroadenoma without an actual biopsy. Heartbreaking. Yes. And that can happen, especially in a woman who's in her 20s or 30s that presents with a solid mass. Um, so push for that biopsy. Don't take no for an answer. And if someone tells you no, go see a second opinion.

SPEAKER_01 14:42

Yeah, and you have to understand your personal risk. Also, like family genetics history. I have no family history at all. That was not my story, but here I am. So I'm glad that I ended up pushing.

SPEAKER_03 14:54

Right. So there's a saying, tissue is the issue.

SPEAKER_01 14:58

Uh-huh.

SPEAKER_03 14:59

So we we use that to get across the point that, uh, as Dr. Mottner said, without a biopsy, without having that piece of tissue to look at under the microscope, we can't tell definitively whether something's cancer or not. And importantly, there are also important markers on those cancer cells that allow us to provide a personalized treatment uh regimen to the individual who's been diagnosed. So getting that biopsy is really important. And to build on your point about genetics, most women with a breast cancer diagnosis are not with an inherited gene mutation. One in eight women will develop breast cancer. Only about 5% of all breast cancers that are diagnosed are diagnosed on the basis of a genetic predisposition, most commonly the BRCA mutation. Now we're seeing that there are other mutations that can also increase the risk of breast cancer. But the majority of women who come in with a breast cancer diagnosis may have some family history. Some have no family history at all. And the majority do not have a BRCA mutation. So that's another common misconception that I don't have this in my family. Why did I develop breast cancer? And women say, Well, I don't have any risk factors. And I say, Well, you do. You're a woman. One in eight women will develop breast cancer.

SPEAKER_01 16:25

Is it the tissue is the issue? And tissue is the issue. Tissue is the issue. Can I just stick to maybe just doing an ultrasound and not doing a mammogram because it hurts? It's painful, it's invading my personal space.

SPEAKER_02 16:37

Okay, so first of all, as you know, a mammogram does not take that long. You know, it's 30 to 60 seconds of compression. And while it may be slightly uncomfortable, I don't find it to be that painful. Um, but the the issue with that is that doing an ultrasound alone is not an adequate screening tool. Ultrasound is great for further adding sensitivity to the mammogram. But the role of a mammogram is it's an x-ray of the tissue, black and white. And what you're really looking for are subtle changes to the tissue year by year to compare from prior to this year. Right. And microcalcifications, white little dots. And those white little dots, when they appear to be new or clustered, can be the very beginnings of breast cancer. That's stage zero, stage one, when it's highly, highly curable. So the whole point of a screening test is to be able to catch something early before you can feel it. Usually, by the time you see it as a mass on ultrasound, it's somewhat palpable. Um, and so you want to catch it by mammogram. And even if you have dense tissue, even if you have the most dense tissue, you can still see calcium on that mammogram. So it does have a role in catching cancer early. You can't omit your mammogram. You may need to add to the mammogram if you have dense tissue, but you can't get rid of it altogether unless you've had a mastectomy.

SPEAKER_01 17:54

What if we just go like every three months instead of every six months? Is that not anything? It's just gonna be more stress for us.

SPEAKER_02 18:02

So typically, in order to appreciate a substantial change from exam to exam, you're going to need more than a three-month period. Okay. For BRACA genetic mutation carriers, we know that their cancers can form more quickly within a six-month interval. So for those patients, we do alternate their screening with mammogram versus MRI every six months. But for the general population that does not carry a genetic mutation, usually once a year is enough. You would still supplement if you needed to, if you were high risk or with dense tissue with an ultrasound or MRI, but once a year should be adequate to catch a small lesion within that time period.

SPEAKER_01 18:37

And you also want to see the change, right? Right.

SPEAKER_02 18:39

You want to be able to appreciate the change. And obviously these tests have radiation exposure, not a large amount, but you don't want to be doing them every month if you don't need to. Yeah.

SPEAKER_01 18:46

Yeah, no, good point. Listen, these are all questions that people are always wondering about. And that's why we're having this conversation because I've also seen the conversation has shifted to younger women when it comes to breast cancer. Is it because of the numbers, because of the data that we're seeing?

SPEAKER_03 19:02

Well, I think that there is the feeling that we are capturing more diagnoses as we're getting more uh doing better with getting the word out about screening mammography, but that alone does not account for the increasing rates that we're seeing. Uh, there's clearly something else going on. Again, we talked about it being multifactorial. We don't know what is uh playing into this entirely. That's why it's so important to do research. And as part of our initiative in starting the Young Breast Cancer Women's Clinic, uh, we are hopefully going to be able to interrogate this database of patients that have been seen to ask these important research questions.

SPEAKER_01 19:47

Yeah. Outside of cancer treatments, there are other things that women, young women that are going through breast cancer, either starting their journey in the middle of it, they are dealing with. Fertility is one of them. Sometimes you haven't started your family or you're just about to. There are services there for them as well.

SPEAKER_02 20:05

Absolutely. So the the issue with young women developing breast cancer is they're in the prime of their career. They're just starting families, they're extremely busy and they don't have time for cancer, but yet they need the most amount of resources because when you are diagnosed under the age of, let's say, 45 and you are either not done with childbearing or haven't started childbearing, some of the treatments for breast cancer can impact fertility. So starting that conversation early of whether or not you want to preserve your fertility has to happen at the first or second visit. And that's very overwhelming for cancer patients. You're just learning that you have breast cancer, and now you need to make a decision about whether or not you want to have kids in the future. Um, so that alone is one aspect of where you're overwhelming. Then you need to deal with genetic testing because even though a majority of these patients won't carry a mutation, when you're young and you have breast cancer, it is absolutely indicated to do the testing to determine if there was a genetic component. Aside from that, there's psychological issues that come into play. A lot of these women also want to see a plastic surgeon. They need to have a medical oncologist on board. It's truly multidisciplinary. And so we've created this clinic to serve the needs of these young women. We have all of these resources under one roof at Miami Cancer Institute, but we wanted to package them up front to make it as least stressful for the patient and also the physician and set up some of these appointments ahead of time.

SPEAKER_01 21:26

How are you guys doing that, making it easy for us?

SPEAKER_03 21:28

So a cancer diagnosis never comes at a good time. And all of these issues that have been highlighted are things that these women who are newly diagnosed have to face. And so, as part of our initiative in this clinic, we take some of the stress of coordinating all of that off the individual and put it on us as it should be. Patients should have their care coordinated under one roof. So part of the process involves highlighting all the different things that need Be done, the visit with the fertility specialist, the breast MRI, the genetics, all of that is coordinated up front. And we're trying to take that stress off the individual and put it onto us so that they can focus on the important decisions that they need to make.

SPEAKER_01 22:18

I love that you guys are doing this because I I think it doesn't matter how old you are when you get diagnosed with breast cancer or any type of cancer. It is hard and it really changes your life. And it just feels like everything just stops and everything is moving around you way too fast. So the fact that you guys are taking the time to have this program for women, this center where you answer all these questions and give them all the needs and to kind of just check that list off of them, it just makes it easier because there are so many questions. So before I let you both go, I am curious, what would you want women in their 20s and 30s to do? What should they know? I'll start with you.

SPEAKER_02 23:00

Sure. Um I would say that living a healthy lifestyle is good for your overall health and your breast health. So, number one, we want to try to focus on exercise at least five days a week. We want to eat healthy, avoid processed foods if possible, because I know it's difficult. Um, cut down on alcohol intake, you know. Every social event if you're if you're in a career or in an environment where you're going out several times a week, it is so easy to have one to two drinks each time you go out. That all adds up. That's you know, five to seven drinks a week, and that's too much. And so that will increase your risk of uh breast cancer. And it's a relatively easy one to cut down on or cut out. You can go out and socialize and not drink. And so I think those three lifestyle modifications are like the top three that I would say. Aside from that, knowing your family history and knowing your genetics. And so some people will have the misconception that only their mother's family history matters, but you get half your genes from your mom and half from your father. And so knowing your father's side of the family history, knowing your ancestry, if you're Ashkenazi Jewish, you would qualify for genetic testing because one in 40 Ashkenazi Jews carries a bracket genetic mutation. Um, these are proactive measures that you can take. And then starting that conversation early with your gynecologist or primary care doctor of what is your risk, they can run a risk assessment model. It's called the Gale model, and tell you, you know, what your risk is and should you start screening before the age of 40. So being super proactive with your breast health, as we know, it is the most common cancer in women, and we are seeing rates rise in young women. So be proactive about it. It is worth it.

SPEAKER_01 24:33

Early, early, early.

SPEAKER_02 24:34

Yes.

SPEAKER_03 24:35

Well, in addition to all of that, uh, I would add to be your own self-advocate. As mentioned earlier, do not take no for an answer. If you're not getting the care and the need that you uh need, uh move on, get another opinion, and uh make sure that you understand your risk, get that risk assessment and uh recognize what's normal for you. And if you're feeling something that's not normal for you, don't ignore it. I find that a lot of women are very scared at the thought of a diagnosis. And it's very easy to put the care that you need aside, but the take-home point is finding something earlier makes it more likely that it's gonna be curable. So don't ignore it out of fear. Uh, it's always best to know what you're dealing with.

SPEAKER_01 25:25

As someone who has been through this, I know how early action makes a big difference. And also being an advocate for yourself, it's also very intimidating when you're trying to talk to doctors and get everything. So I think really having a good plan is the best way to go. And that's why we are having this conversation. So thank you so much for your time and for sharing your insights with all of us. And remember, viewers, be sure to hit that subscribe button on our channel here to keep up with the latest health and wellness information and tips from our experts. Thank you so much for watching and be safe.

SPEAKER_00 25:57

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