Authored by Meric Berrendaffan
Art by Fiona Reilly
Breast cancer is the second deadliest cancer for women, accounting for approximately one third of all diagnosed cancer cases in the United States each year [1]. Every October, there are marathons and fundraisers decorated in notorious pink ribbons in hopes of finally curing this disease, but even the millions of dollars donated for research and awareness each year haven’t helped the alarming increase in cases of breast cancer over the last decade, specifically in young women.
Although the median age of breast cancer diagnosis is 62, breast cancer has become one of fourteen types of cancers that have increased in young adults in the past thirteen years and now has the highest number of early-onset diagnoses, meaning that patients are diagnosed at or younger than the age of 40 [2, 3]. According to the Journal of the American Medical Association (JAMA), between 2010 and 2019, cases of early-onset breast cancer rose a total of 7.7% [2]. Between 2015 and 2019, the number of cases increased by two percent each year [3].
While those are some admittedly bleak statistics, a slightly more comforting one is that the five-year survival rate for women diagnosed with non-metastatic breast cancer is 99%, meaning that 99% of women diagnosed before the cancer can spread to other organs will still be alive five years later [4]. However, early-onset breast cancer has different clinical characteristics from breast cancer diagnosed in later years, one of which is its genetic component. Early on-set breast cancer is more likely than typical clinical presentations of breast cancer to be caused by mutations in the BRCA1 and BRCA2 genes. According to the American Cancer Society, women who inherit a mutated BRCA1 or BRCA2 gene have approximately a 70% chance of developing breast cancer by the age of 80 [5]. The most worrying difference, however, is that early-onset breast cancer is considered more aggressive and more likely to be diagnosed in Stages II, III, or IV, meaning that the cancer is more likely to have spread beyond the breast tissue before diagnosis [6]. This means that most early-onset breast cancer patients don’t fall into the 99% five-year survival rate and early diagnosis becomes even more crucial.
Early diagnosis seems like the best solution for early-onset breast cancer, the best currently available solution being putting these patients in the 99% of patients with a five-year survival rate, but that is where a lot of problems arise. Breast cancer is one of the few types of cancer in which at-home screenings are encouraged, but the most common type of clinical diagnosis of breast cancer is with a mammogram, a special type of x-ray specific for the shape and tissue of the breast. The accessibility of annual or biannual mammograms has increased overall in the past two decades, but not necessarily for younger generations now at higher risk. The recommended start of breast cancer screenings during women’s yearly physical exams was 40 years-old up until 2009 when it was changed to 50 years-old [3]. According to Dr. Steven Isakoff, an assistant professor at Harvard Medical School and the director of Breast Cancer Clinical Research at Massachusetts General Hospital’s Cancer Center, the recommended age of screening was raised because, “the harms that were considered in [the] evaluation were things like the psychological impact and anxiety associated with getting a false positive, the risk of a biopsy, or the risk of additional follow-up” [3]. It’s easy to say that it is probably common sense to most people, especially those who are aware of the dangers of early-onset breast cancer that this reasoning, to put it mildly, goes against the overall best interest of women at risk. Dr. Isakoff himself even called it “paternalistic” [3]. Since then, the recommended age for a woman to begin breast cancer screenings has been lowered to 40 and the Affordable Care Act mandates that preventive mammograms must be fully covered by insurance for women over the age of 40 [7]. Medicare even covers one mammogram between the ages of 35 and 39 [8].
While the Affordable Care Act and expansion of Medicare truly offered a breakthrough for affordable preventative care for women, there are so many caveats, that these new policies leave thousands of women behind. Genetic testing for mutated BRCA1 and BRCA2 genes is widely available, but there are no federal mandates requiring insurance companies to cover the cost of genetic testing or preventative prophylactic mastectomies [9, 10]. Medical insurance companies only fully cover the cost of mammograms if a woman is not experiencing symptoms of breast cancer, meaning that a normal annual screening is free, but if a woman feels a lump or tells her doctor about other signs of breast cancer, she has to pay at least some money out of pocket for her first mammogram. Insurance is also not required to cover biopsies or 3-D mammograms, both second-line defense methods of diagnosis required if an abnormality is detected on the initial mammogram. None of the latter are covered for women under the age of 40, who are now increasingly affected by both breast cancer and its price tag. The recommended age to start screenings for breast cancer and the minimum age when mammograms are covered by insurance is still the lowest threshold of when breast cancer becomes a more common occurrence. So what are women supposed to do if they are in the ever-growing minority?
References
American Cancer Society Staff Writers. Key Statistics for Breast Cancer. American Cancer Society https://www.cancer.org/cancer/types/breast-cancer/about/how-common-is-breast-cancer.html#:~:text=younger%20than%2045.-
Koh, B., Tan, D.J.H., Ng C.H., et al. (2023). Patterns in Cancer Incidence Among People Younger Than 50 Years in the US, 2010 to 2019. JAMA. August 16, 2023. https://doi.org/10.1001/jamanetworkopen.2023.28171
Harvard Gazette Staff. Why start mammograms at 40? Doctor explains new advice. Harvard Gazette. May 12, 2023. https://news.harvard.edu/gazette/story/2023/05/why-start-mammograms-at-40-doctor-explains-new-advice/#:~:text=GAZETTE%3A%20In%20the%20past%2C%20mammogram
Dang HT, D.O., Smith W, M.D. 2020, September 30. Commentary: Neglected breast cancer is an all too common occurrence. Daily Pilot. https://www.latimes.com/socal/daily-pilot/opinion/story/2020-09-30/commentary-neglected-breast-cancer-is-an-all-too-common-occurrence
American Cancer Society Staff Writers. Breast Cancer Risk Factors You Cannot Change. American Cancer Society https://www.cancer.org/cancer/types/breast-cancer/risk-and-prevention/breast-cancer-risk-factors-you-cannot-change.html
Cavallo, Jo. 2022, October 25. Why Are Young Adult Women Developing Later-Stage, More Aggressive Breast Cancer Than Older Women? The ASCO Post. https://ascopost.com/issues/october-25-2022/why-are-young-adult-women-developing-later-stage-more-aggressive-breast-cancer-than-older-women/
WebMD Contributors. 2022, September 17. Free Breast Cancer Screening: Affordable Care Act. WebMD. https://www.webmd.com/health-insurance/free-breast-cancer-screening
Department of Health and Human Services Staff Writers. Mammogram Insurance Coverage. Medicare.gov. https://www.medicare.gov/coverage/mammograms
American Society of Clinical Oncology Staff Writers. Genetic Testing Coverage and Reimbursement. American Society of Clinical Oncology. https://old-prod.asco.org/news-initiatives/current-initiatives/genetics-toolkit/genetic-testing-coverage-reimbursement
National Cancer Institute Staff Writers. 2013, August 12. Surgery to Reduce the Risk of Breast Cancer. National Institute of Health, National Cancer Institute. https://www.cancer.gov/types/breast/risk-reducing-surgery-fact-sheet#does-health-insurance-cover-the-cost-of-risk-reducing-surgeries