Physicians' Attitudes, Knowledge, and Perceived Barriers toward Fertility Preservation in Young Breast Cancer Patients in a Developing Country

BACKGROUND

In Mexico, up to 15% of breast cancer (BC) patients are 40 years or younger. Therefore, fertility preservation and pregnancy after cancer treatment are major concerns in this population. However, no data are available regarding Mexican physicians' knowledge and attitudes toward these issues.

OBJECTIVE

The objective of the study was to describe physicians' attitudes, knowledge, and perceived barriers toward fertility preservation among young women with BC (YWBC) in a developing country.

METHODS

A cross-sectional study was conducted among physicians attending the 2016 Mexican Society of Oncology (SMeO) Annual Meeting or affiliated to SMeO. Chi-squared tests were used to assess factors associated with a higher likelihood of disclosing infertility risks, discussing fertility preservation methods, referring to specialists, and effective counseling.

RESULTS

Of the 314 participants, 83% reported a high sense of responsibility about informing treatment-related infertility risks, 58% always informed patients about those risks, 38% always discussed fertility preservation procedures, 52% always referred interested patients to fertility specialists, and 24% wrongly considered pregnancy and GnRH analogs detrimental in YWBC. Barriers for discussing fertility preservation were costs, lack of specialists, and prognosis.

CONCLUSIONS

It is crucial to promote physicians' knowledge and to endorse policies to overcome barriers obstructing universal access to fertility preservation for YWBC in Mexico.

Adherence to Adjuvant Tamoxifen in Mexican Young Women with Breast Cancer

BACKGROUND

Breast cancer (BC) in young women is characterized by an unfavorable prognosis in hormone receptor-positive/HER2-negative tumors, which may be explained by low rates of tamoxifen adherence. In Mexico, up to 14% of all BC diagnoses occur in young women and no data on tamoxifen adherence has been reported.

OBJECTIVE

To estimate the rate of adherence to adjuvant tamoxifen in Mexican young women with BC (YWBC).

METHODS

A cross-sectional survey was conducted at the National Cancer Institute in Mexico City, among YWBC (≤40 years at diagnosis) receiving adjuvant tamoxifen. Adherence was measured subjectively, through self-reported surveys, and objectively, through medication possession ratio (MPR). Descriptive statistics were used to analyze sociodemographic characteristics. To compare associations between patients' characteristics and adherence, Chi-square test was used for categorical variables and Student's t-test or Mann-Whitney U-test for quantitative variables.

RESULTS

A total of 141 YWBC receiving adjuvant tamoxifen were included. Regarding subjective adherence, 95% expressed taking tamoxifen regularly, 70% reported missing 0 doses in the past 30 days, and 71.6% reported having adverse effects. Regarding objective adherence, 74.8% of patients had an MPR ≥80%. The association between subjective and objective adherence was statistically significant (p = 0.004). Subjective adherence was associated with not skipping tamoxifen doses when feeling worse. Objective adherence was associated with having a stable job, not skipping tamoxifen doses when feeling worse, taking additional medications, and time on tamoxifen treatment. Fifty-six percent considered the information on tamoxifen to be insufficient and 37% not understandable.

CONCLUSION

In our study, high subjective and objective adherence rates to adjuvant tamoxifen were reported, although an important proportion of women reported high rates of adverse effects and not fully understanding the benefits of tamoxifen. Strategies to increase tamoxifen adherence may be even more important now that longer durations of treatment or further ovarian function suppression have become the standard of care in YWBC.

Young Women With Breast Cancer in Mexico: Results of the Pilot Phase of the Joven & Fuerte Prospective Cohort

PURPOSE

The pilot-phase report of the Joven & Fuerte prospective cohort broadly characterizes and assesses the needs of Mexican young women with breast cancer (YWBC).

PATIENTS AND METHODS

Women age ≤ 40 years with nonmetastatic primary breast cancer were consecutively accrued from 2 hospitals. Data were collected at the first/baseline oncology visit and 2 years later using a sociodemographic survey, European Organisation for Research and Treatment of Cancer Quality-of-Life (QOL) Questionnaire Core 30 (QLQ-C30) and Breast Cancer-Specific QOL Questionnaire (QLQ-BR23), Hospital Anxiety and Depression Scale (HADS), Female Sexual Functioning Index (FSFI), Sexual Satisfaction Inventory, and patients' medical records. Pearson χ2 and 2-sided t tests were used for statistical analysis. An unadjusted P value < .05 was considered significant.

RESULTS

Ninety patients were included, all with government health care coverage. Most had low monthly household incomes (98%) and at least a high school education (59%). There was a considerable prevalence of unpartnered patients (36%) and unmet parity (25%). Patients' most common initial symptom was a palpable mass (84%), and they were most frequently diagnosed with stage III disease (48%), with 51% having had a physician visit ≤ 3 months since detection but 39% receiving diagnosis > 12 months later. At baseline, 66% of patients were overweight/obese, and this proportion had significantly increased by 2 years (P < .001). Compared with baseline, global QLQ-C30 had improved significantly by 2 years (P = .004), as had HADS-Anxiety (P < .001). However, both at baseline and at 2 years, nearly half of patients exhibited FSFI sexual dysfunction.

CONCLUSION

These preliminary findings demonstrate that YWBC in Mexico have particular sociodemographic and clinicopathologic characteristics, reinforcing the necessity to further describe and explore the needs of these young patients, because they may better represent the understudied and economically vulnerable population of YWBC in limited-resource settings.

Suboptimal Use of Effective Contraceptive Methods in Young Mexican Women With Breast Cancer

Purpose

Contraceptive counseling and adherence in young women with breast cancer (BC) is a relevant issue because chemotherapy and hormonal treatment resulting in amenorrhea do not preclude unintended pregnancies. Currently, there is limited evidence from high-income countries; however, there are no studies regarding use of contraceptives in patients with BC in Mexico. This study aimed to determine the rate of contraceptive use in young Mexican women with BC during cancer treatment, characterize their contraceptive preferences, and assess contraceptive counseling by Mexican physicians.

Patients and Methods

A cross-sectional survey was conducted regarding contraceptive use and counseling among women age 40 years or younger at BC diagnosis who had completed chemotherapy in the previous 5 years or who were currently receiving long-term treatment with hormonal therapy and/or trastuzumab at a large tertiary health care facility in Mexico.

Results

Of a total of 104 eligible women with median age at diagnosis of 34 years, 51.1% reported using a contraceptive during chemotherapy and 45.7% reported using a contraceptive during other types of cancer treatment (hormonal therapy and trastuzumab). Of the 51 patients (49%) who were sexually active during chemotherapy, 76.5% used contraception, but only 29.4% used an effective contraceptive method. When asked about contraceptive counseling, only 16.7% recalled being advised by their health care provider. Sexually active women who received contraceptive counseling used contraceptives more often than women who were not counseled (83.3% v 22.2%).

Conclusion

A minority of young women with BC in Mexico use effective contraception methods during cancer treatment and receive contraceptive counseling. Informing all premenopausal patients with BC about effective use of contraception methods during treatment should be an essential aspect of the supportive care of young women.

Abstract P1-11-17: Effects of depression, anxiety, and sexual functioning on quality of life among young breast cancer patients in Mexico

Background: Despite the disproportionately high-rates of breast cancer (BC) in young women in Mexico, cancer-control efforts have been predominantly aimed at improving oncological treatment, bypassing survivorship issues and supportive care for this group. The “Joven & Fuerte” cohort, the first supportive care and research program for young BC patients in Latin America, aims to describe and assess the burden of BC in young Mexican women. In this study, we focused on evaluating the association between quality of life (QoL) and anxiety, depression, and sexual functioning in young women with BC (≤ 40 years).

Methods: This study included non-metastatic and non-recurrent patients belonging to the cohort's pilot phase. QoL was assessed with the EORTC QLQ-C30 global score. Patients were classified in the domains of anxiety and depression with the Hospital Anxiety and Depression Scale (HADS) as either probable case, doubtful case, or not a case. Sexual functioning was assessed with the Female Sexual Function Index (FSFI) and the sexual functioning and enjoyment domains of the EORTC QLQ-BR23. Assessments were performed at baseline, 6 months, 1 year, and 2 years. Pearson chi-square and analysis of variance (ANOVA) were used for analysis. Nominal unadjusted significance is reported with p&lt;0.05.

Results: 73 out of 96 (76%) pilot phase patients met the inclusion criteria and had complete assessments up to 2 years follow-up. Global QoL was significantly worse for cases with anxiety and depression at baseline (means for non-cases, doubtful cases and cases, respectively: for anxiety, 81.09, 69.54, and 61.54, p&lt;.001; and for depression, 75.63, 64.17, and 55.00, p=0.01) and depression at 6 months (76.55, 66.67, and 35.42, respectively, p&lt;.001). Classification of case level anxiety was associated with FSFI morbidity during the first year (baseline, p=0.03; 6 months, p=0.09; 1 year, p=0.04). There was no significant association between case level depression and FSFI morbidity in the first 2 years. Neither anxiety nor depression was generally associated with significantly different BR23 sexual functioning or sexual enjoyment; however, a sporadic association was observed between anxiety and BR23 sexual functioning at 6 months (p=0.04).

Conclusion: This study confirmed an association between anxiety and/or depression and worse QoL at diagnosis of BC and after 6 months. Additionally, worse sexual function was significantly associated with the classification of case level anxiety. These findings support the current recommendation that physicians should regularly assess patients' psychosocial health and sexual functioning and provide prompt referral to corresponding supportive care services. Additional efforts must be conducted in low-resource settings, where sexual health and psychosocial care are not considered routine cancer treatment. Dedicated programs that promote multidisciplinary and supportive care services, such as “Joven & Fuerte”, should be incorporated into institutional health-care protocols to systematically address patients' emerging needs and improve QoL.

Citation Format: Villarreal-Garza C, Platas A, Miaja M, Lopez-Martinez EA, Muñoz-Lozano JF, Fonseca A, Pineda C, Barragan-Carrillo R, Martinez-Cannon BA, Chapman J-AW, Goss PE, Bargallo-Rocha JE, Mohar A, Castro-Sanchez A. Effects of depression, anxiety, and sexual functioning on quality of life among young breast cancer patients in Mexico [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-17.

Clinicopathological Characteristics and Outcomes of the Ongoing “Joven & Fuerte” Cohort of Young Women With Breast Cancer in Mexico

Background: Despite high rates of breast cancer (BC) in young women from low and middle income countries, their needs and concerns are not systematically studied or addressed. Understanding the characteristics of young women with BC in limited-resource settings and the issues they face is of great relevance to the medical community, to tailor clinical interventions and supportive care for this unique and understudied patient population. The Mexican cohort Joven & Fuerte has the goal of comprehensively characterizing and assessing the needs of YWBC in Mexico using patient- and physician-based surveys. Aim: The Mexican cohort Joven & Fuerte has the goal of comprehensively characterizing and assessing the needs of YWBC in Mexico using patient- and physician-based surveys. Methods: A prospective cohort of newly diagnosed YWBC was established at the three Joven & Fuerte sites. Eligible women answer electronic surveys on relevant topics, such as sociodemographic characteristics, fertility, genetics, and psychosocial needs, among others, while clinicians complete prespecified surveys registering clinicopathologic features and outcomes. Patients are evaluated at diagnosis, after 6 months, and annually for 5 years. Substudies assessing changes in cognition, sexual function and satisfaction, quality of life, and depression/anxiety are being carried out, and biologic samples are obtained and stored frozen for future research. Here, we report the baseline clinicopathological characteristics of patients included up to March 2018, as well as data on recurrence and mortality. Results: To date, 276 young women with BC with median age at diagnosis of 36 years (2140 y) have been accrued. 22% were single and 23%, childless. 42% had higher education and 31% were used. 80% presented with a self-detected mass. Clinical stage at diagnosis was distributed as follows: stage 0: 3%, I: 11%, IIA: 26%, IIB: 18%, III: 36%, and stage IV: 8%. The most frequent subtype was hormone-receptor (HR) pos/HER2 neg (52%), followed by triple neg (23%), HER2 pos/HR pos (17%) and HER2 pos/HR neg (8%). Histologic grade distribution among the patients was as follows: low grade (16%), intermediate grade (18%), and high grade (66%). Up to June 2017, 15 patients out of 120 (12.5%) have developed distant recurrences, and 12 patients (10%) have died as a consequence of breast cancer. With a median follow-up of 19 months, breast cancer free survival and overall survival was 87.7% and 89.9%, respectively. Conclusion: To our knowledge, this represents the first prospective cohort of young women with BC in Latin America. We are expanding this project to other centers in the region. Our findings will help develop culturally tailored interventions aimed at improving the medical and psychosocial outcomes of this vulnerable patient population.

Abstract P4-10-09: Delay in diagnosis of breast cancer in Mexican young women: Report of the “Joven y Fuerte” prospective cohort pilot phase

Background: Delay in diagnosis and treatment initiation of breast cancer (BC) has been associated with advanced stages and poor outcome. In developed countries, age has not been solely reported as an independent predictor of diagnosis delay. In Mexico, median time since tumor detection to treatment initiation is about 7 months, but young women are underrepresented in these studies. We aim to describe time intervals related to diagnosis in Mexican young women with BC (YWBC).

Methods: Newly diagnosed YWBC were invited to participate as part of this prospective cohort. Patient accrual began in November 2014 at two public cancer centers in Mexico. Patients completed self-report surveys including questions regarding mode of detection, time from first symptom to medical appointment (patient interval) and time from first symptom to diagnosis (total interval). Pearson chi-square tests were used to examine the effects of patient and clinical characteristics on patient interval and clinical stage.

Results: 96 YWBC with median age at diagnosis of 35 y (range 21-40) were enrolled in our pilot phase. 82.3% had tumor detected by self or partner. 62.5% of YWBC were diagnosed as locally advanced disease (IIB-IIIC). Median tumor size was 3.5 cm (0.5-12.0), with node involvement in 66.7%. 53.1% of YWBC had a patient interval of &lt;6 months, but roughly 27.1% had a total interval &lt;6 months. While only 13.5% had a patient interval &gt;12 months, 39.6% reached a total interval &gt;12 months. Patient interval and clinical stage were not significantly associated with occupation, education, marital status, current partner or method of detection.

 N(%)TimePatient intervalTotal interval&lt;1 month29 (30.2)7 (7.3)1-3 months18 (18.8)9 (9.4)4-6 months4 (4.2)10 (10.4)7-12 months10 (10.4)24 (25.0)&gt;12 months13 (13.5)38 (39.6)No symptoms0 (0.0)3 (3.1)NA22 (22.9)5 (5.2)Method of Detection Patient/Partner detected tumor79 (82.3)Clinical detection0 (0.0)Image detected9 (94)NA8 (8.3)Clinical stage 02 (2.1)IA13 (13.5)IB1 (1.0)IIA14 (14.6)IIB17 (17.7)IIIA28 (29.2)IIIB8 (8.3)IIIC7 (7.3)IV6 (6.2)

Conclusions: In this cohort, most patients had a greater total delay than previously reported in Mexico, possibly attributed to long health-system intervals, which could contribute to worse outcomes in YWBC. The prospective nature of this study allows the recollection of biologic characteristics, treatment scheme and adherence to treatment, to determine their impact on clinical outcome besides diagnosis delay. “Joven & Fuerte”, the first dedicated program for the care of young breast cancer patients in Latin America, aims to develop YWBC-tailored interventions to early diagnose or “downstage” BC among young women by endorsing patient navigation, increasing general population awareness and improving providers' knowledge in low-middle income countries, such as Mexico.

Citation Format: Castro-Sanchez A, Barragan-Carrillo R, Miaja M, Platas A, Martinez Cannon BA, Fonseca A, Vega Y, Bukowski A, Chapman J-A, Goss P, St. Louis J, Bargallo-Rocha JE, Mohar A, Peña-Curiel O, Villarreal-Garza CM. Delay in diagnosis of breast cancer in Mexican young women: Report of the “Joven y Fuerte” prospective cohort pilot phase [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-09.

Abstract P6-11-09: Physician knowledge and attitudes towards fertility preservation in Mexican young breast cancer patients

Background: In Mexico, approximately 30% of young women with breast cancer (YWBC) are childless and &gt;40% express concern about infertility risk secondary to cytotoxic treatment. However, only 30% of patients recall being disclosed by their physician of such risk. The aim of this study was to characterize and analyze the caregivers' behavior, attitudes and knowledge towards fertility preservation in YWBC in a limited resource setting, such as Mexico.

Materials and Methods: A 20-item survey was designed and validated by an expert panel, which was answered by participants of the annual meeting of the Mexican Society of Oncology 2016, as well as by physicians affiliated to the same association via web. Pearson chi-square tests were used to assess factors associated with the likelihood of disclosure of infertility risk, discussion about methods of fertility preservation and referral to a reproductive health specialist.

Results: The participants' demographic characteristics are displayed in Table 1 and are associated with the main areas of interest in Table 2.

Characteristics%Age ≤40y56&gt;40y44Gender Male69Female31Specialty Medical36Surgical53Other12Clinical Practice Public26Private9Both65Knowledge safety subsequent pregnancy Fair64Not fair36Knowledge safety ovulation inductors Fair38Not fair62Knowledge safety GnRH analogues Fair37Not fair63

 Inform about infertility riskInform about preservation strategiesRefer to a specialist %p%p%pAge      ≤40y56.5 46.2 54.9 &gt;40y44.5.8653.8.00845.1.72Gender      Male67.6 73.1 65.4 Female32.4.7226.9.14934.5.24Specialty      Medical30.2 31.1 28.4 Surgical57.7 57.7 60.5 Other12.1.579.2.4211.1.18Clinical practice      Public19.8 12.6 19.8 Private19.8 21.0 15.4 Both60.4.0266.4.00264.8.51Sense of responsibility      Low-Middle8.8 5.0 8.0 High91.2&lt;.00195.5&lt;.00192.0&lt;.001Inform about infertility risk      Always--94.1 64.8 Not always--5.9&lt;.00135.2.013

The caregivers' most influential factor in all areas was their self-reported sense of responsibility on disclosing patients about infertility risk. Those physicians that inform patients about infertility risk are statistically more likely to discuss fertility preservation strategies and to refer to a reproductive health specialist. As for the main barriers for fertility preservation, costs were the most frequently mentioned (29.6%), followed by lack of specialists (11.2%), and patient's prognosis according to clinical stage (11.2%).

Conclusions: This represents the first Latinamerican study evaluating the YWBC's caregivers' attitudes and practices towards fertility preservation, as well as their general knowledge concerning oncofertility issues. The fact that only one third of the enquired physicians were aware of the safety of ovulation inductors and use of GnRH analogues in YWBC is striking, which may translate into worse survivorship care. Furthermore, physicians reported that access barriers were the most prevalent factors that hindered appropriate referral. Health-care providers play a major role in the timely detection of the patient's interest in future offspring, thus it is crucial to promote knowledge about this relevant topic and endorse policies that can provide universal access to assisted reproductive technologies.

Citation Format: Villarreal-Garza CM, Barragan-Carrillo R, Bargallo-Rocha JE, Peña-Curiel O, Martinez-Cannon BA, Platas A, Torres J, Mohar A, Rivera S, Garcia-Valdovino VJ, Garcia-Leon GA, Castro-Sanchez A. Physician knowledge and attitudes towards fertility preservation in Mexican young breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-11-09.

Adherence to tamoxifen in Mexican young women with breast cancer

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Background: Young age has been associated with significantly increased risk of breast cancer (BC) death among women with luminal BC. One contributing factor might be the low rate of tamoxifen (TMX) adherence previously reported in this young group. Given that in Mexico a disproportionate rate of BC is diagnosed among YW, information regarding TMX adherence is particularly relevant. Our study's aim was to report TMX adherence in Mexican YW and its associated determinants. Methods: Consecutive patients ≤40y at diagnosis at the National Cancer Institute in Mexico City, under TMX treatment, completed a multiple-choice survey regarding the use and attitudes about hormonal therapy and adherence. Data of TMX disposal was collected from the pharmacy’s records, and the medication possession ratio (MPR) was calculated; an MPR ≥80% was considered adherent. Results: 135 YW with a median age at diagnosis of 35.7y (24-40) were included. 77% were undergraduate, 28% unpaired and 33% childless. Median follow-up was 26 months. 95% of patients reported a regular TMX intake: 70% did not miss any doses, while 25% missed 1-6 doses a month. Only 45% considered that the information received regarding TMX therapy was sufficient and for 37% was incomprehensive. 43% thought TMX significantly reduced their recurrence-risk and 60% strongly believed that they needed to be on TMX treatment. 73% of women reported adverse effects, being menopausal symptoms the most frequent, but only 27% were worried about the treatment long-term effects. From the 99 patients with a pharmacy record, 73% had an MPR > 80%. No significant factor was statistically associated with TMX adherence. Conclusions: Although Mexican YW and pharmacy data surprisingly sustained higher rates of TMX adherence compared to previous data, still a significant proportion of patients were non-adherent. Two-thirds of our patients reported having adverse effects, which might contribute to late TMX discontinuation. Since the newer recommendations of double hormonal blockade could lead to higher withdrawal rates of endocrine therapy in YW, adherence should be emphasized and closely monitored. Accordingly, hormonal treatment adherence should be a key component in the medical assessment of young luminal BC patients.

Sexual function and satisfaction in Mexican young women undergoing breast cancer treatment

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Background: Compared to other regions, the burden of breast cancer (BC) in Mexico is disproportionately borne by younger women. Yet, their particular needs and concerns have remained understudied, including treatment-related sexual adverse effects. We aim to assess the sexual function and satisfaction in Mexican young women with BC undergoing treatment. Methods: This is a prospective sexual assessment study in BC patients of the pilot phase of the Joven y Fuerte Mexican cohort (N=96). Sexual health was assessed using the Female Sexual Function Index (FSFI) and the Sexual Satisfaction Inventory (SSI) at two points in time: baseline (BL) and 6-months follow-up (6-FU). FSFI and SSI scores lower than 26.55 and 111, respectively, were defined as sexual morbidity. Differences between proportions of BL and 6-FU were examined with Pearson chi-square test. Matched t-tests were used to test for differences in the domains of the FSFI and in the SSI total score. Results: 70 women completed the FSFI at both time points and 69 the SSI. Our results showed a high percentage of sexual dysfunction among Mexican women at BL and 6-FU (61.4% and 74.3%, respectively, p<0.001), as well as an elevated proportion of sexual low satisfaction at both time lines (40.6% and 43.5%, p=0.004). Most 6-FU FSFI domain scores were significantly worse than those at BL (Table 1). There were no significant differences in the SSI total score (102.31 [BL] vs 96.11 [6-FU], p=0.16). Conclusions: Mexican young patients with BC report significant sexual morbidity at BL, which even worsens after the first short follow-up. Reasons for the low sexual performance among Mexican women remain understudied and should be actively sought. In this prospective study, data will be annually collected for five years. This information will provide valuable information in an often-neglected matter of BC patients’ care. [Table: see text]

Fertility concerns among breast cancer patients in Mexico

OBJECTIVE

Young women represent a high proportion of the total number of breast cancer (BC) patients in Mexico; however, no previous studies addressing their attitudes regarding the risk of chemotherapy-induced infertility and its contributing factors are available. The aim of this study was to evaluate the concerns of young women with BC towards the risk of infertility in two referral centers in Mexico with access to public health services.

METHODS

A cross-sectional study including women with newly or previously detected BC aged 40 years or younger at diagnosis was conducted. Variables regarding concerns about fertility were collected from an adapted version of the Fertility Issues Survey.

RESULTS

134 consecutive eligible women responded to the in-person paper survey. 55% were partnered, 35.1% had no children, and 48% reported willingness to have children prior to BC diagnosis. Only 3% of patients considered to be able to afford extra expenses. At diagnosis, 44% of women expressed some level of concern about infertility risk. The only factor significantly associated with fertility concern was the desire of having children prior to diagnosis (OR 11.83, p = 0.006). Only 30.6% patients recalled having received information regarding infertility risk from their physicians.

CONCLUSION

A minority of young women with breast cancer in Mexico is informed about the risk of BC treatment-induced infertility, despite substantial interest. Informing all patients about infertility risk and available options for fertility preservation should be an essential aspect of the supportive care of young women with BC, even in low-middle income countries such as Mexico.

Preface

Breast cancer (BC) is the most frequently diagnosed malignancy in young women and is the leading cause of cancer-related mortality in this age group. This issue represents a major public health problem in developing countries, where the incidence of BC is rapidly increasing and where young women represent a higher proportion of the total BC patient population compared to developed countries. In Latin America, BC among women aged 40 years or less accounts for up to 11% of new BC cases and 7% of all BC deaths. In Mexico, a very high proportion of the total number of BC patients are diagnosed in their early years, reaching up to 15% in some healthcare institutions.