One of my 19-year-old patients had a breast mass. She didn’t tell anyone it was there for five months! Fear? Denial? Probably both as her mother had breast cancer. She watched her mother go through surgery, chemotherapy and radiation, and she knows that her mother has an inherited gene mutation called BRCA 1.
Breast masses have many causes. They occur in about 3.2 percent of teen girls. Most are benign (not cancer) and most (95 percent) are fibroadenomas. A fibroadenoma feels like a marble — round, firm, mobile and usually non-tender. Fibrocystic changes cause benign breast masses and include fibrosis (scar-like tissue) and cysts (fluid-filled masses). Mastitis is caused by an infection in the breast, which causes painful breast masses.
Breast cancer in a teen girl is rare. In women, 20 percent of breast masses end up being cancer. The statistics are much different in teen girls, where only 0.02 percent of breast masses are cancer. Unfortunately, rare does not mean never and a breast mass in a teen needs to be evaluated by a doctor.
History, history, history. When I was in medical school, I was taught that a careful history will lead to the diagnosis 80 percent of the time. Questions include:
- How long has it been there?
- Has it changed in size?
- Has anyone in the family had breast cancer?
If the patient has a history of weight loss, night sweats, or fever, it is critical to rule out cancer.
Next, observe. Due to the fact that risk of breast cancer in teenagers is so low, we can often start by observing. Fibroadenomas and cysts may shrink on their own. Sometimes a radiologic test is needed. Because teens have denser breast tissue than adults, ultrasound provides better images than mammogram. Plus, there’s no radiation with ultrasound. If more information is needed, MRI is done. Again, there’s no radiation.
Following tests, surgery may be needed if the mass is enlarging or already large, or if there is pain, distortion of the breast shape or skin changes. With surgery, the mass is removed and biopsy will confirm whether it is cancerous or not.
What’s next for my patient? My patient had a fibroadenoma. But that doesn’t erase the fact that her mother has the BRCA 1 gene. I asked Kacie Baker, a licensed certified genetic counselor at the Helen F. Graham Cancer Center in Delaware, about genetic testing in my patient.
Genetic counselors tailor recommendations for each individual case specific to personal and family history. The National Society of Genetic Counselors has a tool to search for genetic counselors in your area.
“According to research, disease causing mutations in BRCA1/2 are not associated with child or adolescent cancers, making the need for testing under the age of 18 not medically necessary in most families,” Baker said. “With BRCA1/2, the breast cancer risk may be higher than 50 percent, and therefore testing requires an autonomous decision from an individual who is at an appropriate age to receive this type of medical information.”
In 2008, the United States passed the Genetic Information Nondiscrimination Act which prohibits discrimination in employment and health insurance coverage based on genetic information. However, for someone who tests positive for a hereditary cancer gene, purchasing life insurance and other luxury insurances may become a difficult and extremely expensive task, she said.
A woman living in the U.S. has a 12.4 percent, or 1-in-8 lifetime risk of being diagnosed with breast cancer. The National Comprehensive Cancer Network offers guidelines for identifying, educating and testing patients who are at high risk for breast cancer. They include:
- Teaching patients to be aware of changes in breasts beginning at age 18,
- Clinical breast exam every 6 to 12 months, beginning at age 25, and
- Annual breast MRI and mammogram beginning at age 25-to-40 (the age to begin screening depends on the type of gene mutation and/or youngest age of breast cancer in the family).
My advice? Talk with your daughters about breast masses and encourage them to tell you if they find anything unusual. Emphasize that most masses are benign, but they need to be checked by a doctor. The Save the Ta-tas Foundation and Ta-tas Brand was created in 2004 by clothing designer Julia Fikse to aid in the fight against breast cancer using laughter and fun—and it could serve as a conversation starter.