Breast Cancer in Young Women: Rani Bansal, MD, Discusses Subtypes, Disparities, and the Importance of Self-Advocacy

In this interview with The American Journal of Managed Care® (AJMC®), Rani Bansal, MD, medical oncologist at Duke Cancer Center Breast Clinic, continues her discussion on the rise of breast cancer in women aged younger than 50 years. Refer to Part 1 for Bansal's discussion of potential causes behind rising cancer rates and the role of risk-based screening.

Here, she addresses how breast cancer presents differently in younger patients, the disproportionate burden of triple-negative disease among African American women, and what young women should know about advocating for themselves. She also speaks to her work improving access to clinical trials in diverse and younger patient populations.

This transcript was lightly edited for clarity.

AJMC: Breast cancer in particular seems to be driving a lot of the conversation of cancer incidence in young people. Could you talk about how breast cancer is presenting differently in young women vs older patients?

Bansal: It seems like most of the rise in cases is in estrogen receptor (ER)-positive breast cancer. We typically think of breast cancer as 3 subtypes, including ER-positive disease, human epidermal growth factor receptor 2 (HER2)-positive disease, and triple-negative breast cancer, based on 3 markers we send on every breast cancer: the estrogen receptor, progesterone receptor, and the protein HER2. Most of what we are seeing increases in is ER-positive breast cancer, especially for younger patients. That being said, unfortunately for my patients who are African American, we do tend to see higher rates of triple-negative breast cancer. So, for younger patients, their background and ethnicity do play a role in what subtypes of breast cancer we see, and that of course affects how we approach treatment.

AJMC: Can you talk about how triple-negative breast cancer affects prognosis and treatment?

Bansal: Triple-negative breast cancer is considered one of the more aggressive types. We call it triple-negative because it lacks the 3 markers I just mentioned, and without those targets, we have fewer targeted treatment options, though research is ongoing. Unfortunately, my patients with triple-negative disease tend to have more aggressive presentations, can present at a later stage, and have a worse prognosis. These are my patients who are undergoing many rounds of chemotherapy, and often we are also incorporating immunotherapy. It is just very different in terms of how aggressive we need to be in treatment.

AJMC: What is something you want young women in particular to know about breast cancer and their risk?

Bansal: I always talk with my patients about being informed and knowing their family history in terms of breast cancer, ovarian cancer, and prostate cancer as well as making sure they are talking with their primary care provider about that history, especially if they have a first-degree relative who had breast cancer, particularly at a young age, meaning [younger than 50 years]. Those are the patients we want to make sure are screened at the appropriate time and, if needed, set up with a high-risk breast cancer clinic.

A lot of my younger patients did not think it was possible for them to have breast cancer. And frustratingly, some patients will notice changes in their breast, bring it up to a provider, and get dismissed with, "Oh, you're too young to have breast cancer." I always tell my patients, “If you feel like something is wrong, you know your body.” Advocate for yourself. If you truly feel something is new or different from your baseline, push to get that ultrasound or MRI. Yes, fortunately, overall rates of breast cancer in younger patients are still smaller than in older patients, but that is changing. We as a medical community need to be aware that this could be more than a cyst. It could be something serious, and we need to evaluate patients appropriately.

Something that comes up a lot with my young patients is that they ask, “Why me? What did I do to cause this?” And the important thing to know is that only about 10% to 15% of breast cancers are genetic and about 15% are familial. That means for almost 70% of breast cancers, we do not know why they happen. I remind my patients of this because younger patients especially come into clinic carrying a great deal of guilt and feeling they must have done something to cause their breast cancer at a young age. That really is not the case. Unfortunately, this is something that can happen. We do not yet know why it is happening at the rate we are seeing, but we have ways to treat it, and we are going to get our patients through it.

AJMC: You are also interested in improving access to clinical trials in diverse populations. What is the issue here, and how do we solve it?

Bansal: Clinical trials are how we move medicine forward, especially in oncology. Unfortunately, there has been demonstrated bias in terms of which patients are offered clinical trials or considered good candidates by providers. We really need to work on improving that, because if you look at many breast cancer trials, minority patients are usually poorly represented. That is problematic because this is where we get all our data on how drugs work, and if we are only looking at a certain patient population, we cannot collect data on how diverse patients actually do on those drugs, including the side effects they experience. That is something I am focused on at Duke: how we can improve representation, specifically for younger patients, as younger patients are not always well represented in trials either. A clinical trial could be part of the best treatment plan for a young patient, and we should not be afraid to suggest that just because they are young.