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Am I at Risk for Breast Cancer?

Information for Survivors of Childhood, Adolescent, and Young Adult Cancers

When Ashley, 28, had her last mammogram, it revealed a suspicious-looking spot.

It required additional images with an ultrasound and magnetic resonance imaging (MRI) of her breasts. Breast MRI is a routine part of Ashley’s annual breast screening appointments.

After a closer look, radiologists didn’t find anything to indicate cancer.

“It was nerve-wracking,” Ashley said. “I’ve already been through cancer once. It’s scary to think I could go through it again.”

Ashley, a leukemia survivor, shares her experience with follow-up care to screen for breast cancer.

Ashley, a leukemia survivor, shares her experience with follow-up care to screen for breast cancer.

But Ashley wants to stay informed about her health, so she can take action if needed. In general, cancer is most treatable when found early.

When Ashley was 19, she was diagnosed with myelodysplastic syndrome (MDS). MDS is a blood disorder than sometimes develops into acute myeloid leukemia. Ashley was diagnosed with leukemia about a month after her original diagnosis.

Ashley had a hematopoietic cell transplant (commonly known as bone marrow transplant or stem cell transplant) to cure her disease. That involved getting radiation treatment throughout her body. It wiped out her immune system, a necessary step in preparing her body to receive blood cell-forming (hematopoietic) cells from a donor.

Because of the treatment she received, Ashley has a higher risk of developing breast cancer than other women her age.

Studies show that females who receive radiation to the chest have an increased risk of developing breast cancer later in life. Their risk is comparable to women with BRCA gene mutations in the general population.

“Since I had total body irradiation that means I had radiation to my chest,” Ashley said.

Ashley was 26 when she had her first mammogram and MRI. In general, most women don’t have their first mammogram until they’re 50 or older.

Ashley has a higher risk of developing breast cancer than other women her age because of cancer treatment she received.

Ashley has a higher risk of developing breast cancer than other women her age because of cancer treatment she received.

What Are the Risk Factors?

All women, including survivors of childhood/ adolescent cancers, are at increased risk of developing breast cancer as they age. Childhood cancer survivors who received certain treatments are at increased risk for developing additional cancers later in life. Breast cancer is the most common of these in female childhood cancer survivors.

Most women who have survived childhood/ adolescent cancer will not develop breast cancer. But some treatments do put them at higher than average risk.

  • Radiation to the chest is the strongest risk factor, according to several studies. Survivors of Hodgkin lymphoma, for example, have often received chest radiation in order to cure their lymphoma. This was more common in the past. Now that doctors know more about the late effects of chest radiation, it is used less often.
  • Recent research indicates that high doses of anthracycline drugs such as doxorubicin are a risk factor for breast cancer. Anthracyclines are a type of chemotherapy used to treat many types of cancer. They damage the DNA in cancer cells and cause them to die. Examples of other anthracyclines include daunorubicin, epirubicin, idarubicin, and mitoxantrone.
  • Certain gene mutations and inherited conditions elevate secondary breast cancer risk.
    • Li Fraumeni syndrome. These patients have a mutation in the TP53 gene.
    • Mutation in BRCA 1 or BRCA2 genes
    • Family history of breast cancer

Chest radiation: Studies show that radiation to the chest as part of cancer treatment may increase risk for breast cancer. Individuals who received 10 Gy or higher doses of chest radiation have a greater risk for breast cancer. Gy is an abbreviation for gray, a unit of radiation.

Early breast cancer screening is recommended for patients who received any cancer-directed radiation to the chest. Shared decision-making between patients and providers is recommended in order to account for patient preferences and additional risk factors.

Anthracycline drugs: Studies have shown that doses of anthracycline drugs of 250 mg/m or greater are associated with increased risk of breast cancer. Anthracyclines include doxorubicin, daunorubicin, epirubicin, idarubicin, and mitoxantrone.

Screening guidelines have not yet addressed screening for breast cancer after anthracycline exposure. Shared decision-making between patients and providers is recommended to account for patient preferences and additional risk factors.

How Can I Take Care of My Health?

Take a copy of your Survivorship Care Plan to each health care visit. This plan has your treatment history and recommended health screenings.

Discuss your unique health care needs with your primary health care provider.

What are the Breast Cancer Screening Guidelines for Survivors?

It is recommended that survivors in high-risk groups begin breast cancer screening much earlier than other women.

Childhood/adolescent cancer survivors who received chest-directed radiation typically develop breast cancer at a younger age than women in general and cancer survivors who were not exposed to radiation.

Subsequent breast cancer typically occurs in survivors between the ages of 30 and 40. In the general population, women usually develop primary breast cancer at age 50 or older.

Studies have shown that the risk for breast cancer in childhood cancer survivors begins to increase at about 8 years from chest radiation exposure or age 25, whichever occurs later. This risk continues to rise as patients get older.

The Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Cancers recommend:

  • Yearly mammograms and breast MRIs for women who received radiation to the chest, underarm, or total body. These tests should begin at age 25 or 8 years after receiving radiation (whichever comes last).
  • Yearly clinical breast exams beginning at puberty until age 25, then every 6 months thereafter.
  • Monthly self-exams beginning at puberty.

Why Do I Need Both a Mammogram and an MRI?

In childhood cancer survivors, studies have shown that having both a mammogram and MRI at each screening visit is the most effective strategy for identifying breast cancers in earlier stages.

The recommendation for these women to receive both a mammogram and MRI in their 20s and 30s is different than the recommendation other women may have received. Screening in the general population does not begin until women are in their 40s to 50s.

But childhood cancer survivors are at risk in their 20s to 30s. Younger women have denser breast tissue that makes it more difficult to notice abnormalities with a mammogram alone. An MRI increases the ability to identify some of these subtle changes.

Information gained from the mammogram is still very important. Studies have shown mammography is better than MRI for detecting ductal carcinoma in situ (DCIS), a specific type of breast cancer. In younger women, DCIS is associated with a much higher rate of recurrence and death than among older women.

Mammograms do expose patients to small amounts of radiation to create images of breast tissue. The dose of radiation received from a mammogram is a fraction of that used to treat childhood cancer. Cancer survivorship experts agree that the benefits of mammography far outweigh the risk of added radiation exposure. But women are encouraged to discuss these risks and benefits with their care team.

Healthy Lifestyle Choices May Reduce Breast Cancer Risk

Making healthy choices will improve your overall health and may reduce your breast cancer risk.

If you have questions about your breast cancer risk or healthy lifestyle decisions, please discuss them with your care provider.