Breast cancer in children and adolescents

ALSO KNOWN AS: Phyllodes tumors

RELATED CONDITIONS: Adenocarcinoma

DEFINITION:Breast cancer is a malignant tumor that originates from breast cells. Most breast masses in children and adolescents are benign rather than cancerous in nature. The most common breast malignancies in children and adolescents are phyllodes tumors, breast carcinoma—particularly juvenile secretory carcinoma, and metastases from other types of cancer.

Although usually seen in women in their forties, breast sarcomatous tumors, called phyllodes tumors, may occur at any time during the lifespan, including childhood and adolescence. These tumors may be benign, intermediate, or malignant. Another form of breast cancer in adolescents is primary breast carcinoma. However, in children and adolescents, most malignant breast masses are metastases from other cancers, such as Hodgkin disease, non-Hodgkin lymphoma, primary hepatocellular carcinoma, neuroblastoma, and rhabdomyosarcoma.

Risk factors: Risk factors for breast cancer in adolescents include having received chest-wall radiation and having a family history of breast cancer. If a child or adolescent receives radiation therapy to treat cancer of the chest area, the person’s risk for developing breast cancer later in life is significantly higher. The younger radiation was initiated, the higher the risk. This is especially the case when radiation is given to girls whose breasts are developing.

Etiology and the disease process: Breast masses in children before and during puberty usually are breast buds. The development of breast buds in children is usually the first sign of puberty. The development of breast buds in children who are too young for puberty may indicate premature thelarche, or precocious puberty. is warranted for cystic lesions that do not resolve with and for suspicious solid lesions.

Some cancers start in glandular tissue that basically produces and secretes a substance. The ducts and lobules of the breast are glandular tissue, and the cancers starting in these areas are sometimes called "adenocarcinomas."

Incidence: Breast cancer in children and adolescents is rare. Around 0.1 percent of all breast cancer diagnoses are from children and adolescents, and one percent of all pediatric cancer cases are breast cancer. Globally, and in terms of all ages, breast cancer incidence rates are highest in Australia and New Zealand, Western Europe, and North America and lowest in Asia and Africa, according to the Journal of Clinical Oncology's 2023 estimates.

Symptoms: The most common finding with breast cancer in adolescents is a hard, irregular mass, and usually one that does not cause symptoms. As the cancer grows, symptoms may include a change of shape, size, and feel of the breast. Another symptom is bloody, yellow, or green, puslike drainage from the nipple. Advanced symptoms include bone or breast pain, swelling of the arm on the same side of the body as the breast with cancer, and weight loss. If metastasis occurs, other symptoms can include difficulty breathing, generalized skin rash, limb swelling, and back pain.

Screening and diagnosis: Because a mass may not produce symptoms in the initial stages, all adolescents, especially girls with a family history of breast cancer or other malignancies, should have their breasts clinically examined regularly. Ultrasonography is the preferred imaging modality for breast masses in adolescents because of the increased density of the adolescent breast. Also the large amount of fibroglandular tissue makes mammography difficult to interpret.

The stage of cancer is based on tumor size; involvement of the skin, chest wall, or local lymph nodes; and whether the cancer has spread to other organs (metastasis). Stage I and Stage II are referred to as early stage or localized breast cancer. In Stage I, the tumor size is smaller than two centimeters with no lymph node involvement. Stage II can exhibit lymph node involvement, but the nodes are small. The size is larger than two centimeters but not larger than five centimeters. A tumor that is larger than five centimeters must be node-negative to be considered early stage.

Stage III breast cancers are referred to as locally advanced breast cancer. In this stage, the tumors are large and greater than five centimeters across. There can be extensive axillary nodal involvement or nodal involvement of the soft tissues above or below the collarbone. A tumor is also designated Stage III if it extends to underlying muscles of the chest wall or the overlying skin. In Stage III, the breast may be undergoing the inflammatory process and appear red and swollen.

Stage IV breast cancer, also known as metastatic breast cancer, consists of tumors that have spread to areas such as the brain, bones, skin, and even other organs. There may be any number of affected lymph nodes, and the primary tumor may be any size.

Treatment and therapy: The subsequent management of the adolescent with a breast mass depends on the type of mass. Surgical (excisional biopsy) may be necessary for cystic lesions that do not resolve with aspiration, when aspiration is not productive or not feasible, and for suspicious solid lesions. Although uncommon, more advanced forms of breast cancer have the potential to be treated similarly to the condition found in adults.

Prognosis, prevention, and outcomes: The five-year survival rate refers to the number of patients who live at least five years after their cancer is found. The American Cancer Society (ACS) reported in 2024 that the five-year survival rates for persons with breast cancer that is appropriately treated were 95 percent for localized cancer, or cancer contained within the breast; 86 percent for regional cancer, or cancer that has only spread beyond the breast to the lymph nodes or nearby structures; and 31 percent for cancer that has metastasized into distant parts of the body.

Overall, the five-year survival rate for children and adolescents with cancer has improved significantly in recent decades. Between 2013 and 2019, the five-year survival rate for children aged five to nine with cancer was 85 percent. This is a significant increase from the 1970s, when the five-year survival rate was only 58 percent.

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