Leveraging Cervical Cancer Screening Frameworks to Promote Early Detection of Breast Cancer in Young Women

INTRODUCTION Breast cancer is the most commonly diagnosed cancer in women in the United States (US), with 376,000 cases annually, and worldwide, with 2.3 million cases in 2022. About 670,000 women die from it each year globally, including 42,250 in the US. These numbers are staggering, especially since breast cancer is one of those cancers that can be cured if detected early. Currently, there are no screening programs available for women under the age of 40. Yet, about 245,872 young women under 39 were diagnosed globally in 2022, a supporting notion that breast cancer might be a threat to every woman, no matter her age. The World Health Organization (WHO) predicts this number will increase significantly by 2050.[1] Although the rise in breast cancer in young women has only been observed in the last three decades,[2-4] the earliest three articles on metastases, surgery, and prognosis in young women with breast cancer can be traced back to 1949, 1951, and 1956.[5-7] While breast cancer accounts for 26.2% of newly diagnosed cancers in women under 39 (with 246,060 new cases) worldwide in 2022, cervical cancer is less common, representing 11.3% or 105,836 new cases [Figure 1a]. Cervical cancer develops very slowly, making it less aggressive. Thanks to the wider availability of the human papillomavirus (HPV) vaccine–a highly effective preventive measure–coupled with screening programs starting at age 21, the mortality rate from cervical cancer in the US and globally is decreasing, especially among younger women [Figure 1b]. The Centers for Disease Control and Prevention (CDC) estimates about 4300 women die each year in the US, which is roughly ten times fewer than from breast.[8,9]Figure 1: Worldwide status and trend of breast and cervical cancers and mortality among people under 39, according to the World Health Organization (WHO). (a) Status of women’s cancer in 2022; (b) The trend over time of the incidence of breast and cervical cancer and related deaths for people under 39 for the USA and for India as per WHO data; (*) Sub-national data. (c) The 2022 and projected worldwide incidence of breast and cervical cancer and related deaths for people under 39 from 2022 to 2050 based on WHO data; (d) The 2022 and projected global incidence of breast and cervical cancer and associated deaths for people under 39 from 2022 to 2045 based on WHO dataTo advocate for a policy that expands breast cancer screening to all women starting at age 21 – or even earlier, at age 18 – this article will draw a comparison to the success story of cervical cancer screening [Table 1].Table 1: Comparative status of cervical and breast cancer data for all ages and screening programs in the United States[ 8 , 9 ]CERVICAL CANCER AWARENESS AND PREVENTION MODELS Cervical cancer is caused almost exclusively by persistent infection with high-risk strains of HPV. Its progression from precancerous lesions–such as cervical intraepithelial neoplasia (CIN) cervical intraepithelial neoplasia–to invasive cancer typically takes 10–15 years, providing sufficient time for detection and intervention.[10-12] The worldwide incidence of cervical cancer and related deaths has been decreasing, and this trend is expected to continue through 2050, according to the WHO [Figure 1c and d]. Starting at puberty, young women are encouraged to begin seeing a gynecologist. According to the American Cancer Society and the CDC,[11] women should start getting Pap smear (Papanicolaou test, named after Dr. George Papanicolaou, who developed it)[12] screening tests beginning at age 21 to detect precancerous or cancerous cells through microscopic examination. The Pap smear screening is typically covered by insurance as preventive care, so there is usually no direct cost to the patient for this annual test, making it a highly effective and affordable option accessible to all socioeconomic groups. Despite the highly invasive nature of pap smears, screening participation for cervical cancer is very high, especially among young women, with 83% of women aged 21–65 being up to date with screening.[13] This is mainly due to the fact that cervical cancer screening begins at a young age and is part of any gynecological annual checkup, demonstrating how preventive care can be successfully integrated into routine exams. Recently, the Food and Drug Administration (FDA) has approved the Teal Wand, the first at-home self-collection device for cervical cancer screening in the US.[13] This device allows women to collect a vaginal sample in the comfort of their home and mail it to a lab for analysis of nucleic acids of all strains of HPV, providing an alternative to Pap smears traditionally done in the doctor’s office, further increasing access to preventive care and screening uptake. Interestingly, despite the high screening participation in a healthcare setting, major insurance companies have started reimbursing the Teal Wand, showing that they are willing to put resources toward home screenings. Since 2006, a preventive HPV vaccine has been available and has been shown to significantly reduce both the incidence and death rates of cervical cancer. The CDC recommends that girls receive the HPV vaccine at ages 11 or 12, and it can be administered as early as age nine.[11] Catch-up vaccination is also recommended for individuals aged 26 and younger who were not fully vaccinated earlier. In the US, cervical cancer screening is offered to all women, regardless of risk factors, and remains an effective preventive measure. This successful public health story demonstrates that early education, detection, and accessible screening can save lives–even for diseases with relatively low prevalence when screening begins. BREAST CANCER IN YOUNG WOMEN Despite the worrying trend and the rapid progression of the disease, awareness of breast cancer in young women remains in the early stages of social recognition. Women under 40 are not routinely screened for breast cancer unless they are considered high-risk due to their family history and/or genetic predispositions that increase cancer risk. However, studies show that breast cancer rates are rising among women under 50, with some reports showing even sharper increases in women under 40.[2-4] The global incidence of breast cancer among individuals under age 39 and related deaths has been increasing, and this trend is projected to continue through at least 2050 according to WHO [Figure 1c and d]. Unlike cervical cancer, breast cancer does not typically follow a slow, predictable course. Quite the contrary, it tends to be biologically aggressive in young women, growing rapidly and often being diagnosed at a later stage. This late detection leads to more aggressive treatments and poorer outcomes. While cervical cancer can be directly linked to an HPV infection, understanding the main reason why a woman develops breast cancer is still challenging to explain – except, however, when she has one of the gene mutations known to significantly increase the chances to develop breast cancer, such as BRCA-1, BRCA-2, ATM, etc., However, the genomic basis only explains about 15% of breast cancer. Environmental factors are playing a larger role than initially anticipated with endocrine disruptors, stress, and pollution being very negative for breast health. In addition, young women are also subject to high hormonal fluctuations during their menstrual cycles, pregnancies, and postpartum, potentially feeding estrogenic- and progesterone-positive cancerous cells that thrive on those two hormones. Finally, lifestyle choices are now well documented to impact breast cancer prevention, with diet, alcohol consumption, and exercise regimen having a direct impact on breast health. The profound effects of breast cancer on young women are well recognized, including traumatic experiences such as body image issues from losing breasts and hair; early menopause caused by hormonal treatments; fertility problems; miscarriages; psychosocial challenges stemming from feeling out of sync with peers; income loss and financial difficulties; and family trauma, especially involving young children. These challenges contribute to significant hardship that can have severe and lasting consequences for the patient and her family. The rising incidence among younger women emphasizes the importance of increased awareness and early detection, even before age 40. By primarily focusing on screening programs that usually start at age 40 in the US, Breast Cancer Awareness campaigns can send the wrong message and lead to a false sense of security, making younger women believe they are not at risk. This misconception can result in young women being dismissed or doubted when they seek medical advice for a lump or other breast concerns. Both patients and clinicians must understand that, although less common, young women are still at risk and should have easy access to breast clinical evaluation and imaging options to address any concerns early and check for abnormalities. Mammography is the standard of care for breast screening, but it has notable limitations for young women, including: (1) exposing women to radiation, a known risk factor for early breast cancer;[14,15] and (2) reduced effectiveness in younger women due to denser breast tissue. The sensitivity of mammography can fall to 50% in highly dense tissue, and about 75% of women under age 40 have dense breasts.[15,16] Alternative imaging methods, such as ultrasound and magnetic resonance imaging (MRI), are costly, less accessible, or not standardized for women at average risk. Innovations in ultrasound technology, as well as computer-aided infrared imaging, are good options to assess breast health in young women as they are agnostic to breast density. They are radiation-free, so they are entirely safe, even for pregnant and lactating women. They are also painless and offer a great user experience, which is critical for adoption and repeat use. AI-powered infrared imaging is portable and cost-effective, making it a particularly good candidate for wider deployment in community health, schools, and primary care settings. Until these technologies become mainstream through additional validation and insurance reimbursement, it is crucial for young women to be aware that these options are already available and provide a good way to assess their breast health-until they become eligible to participate in conventional screening programs. Biomarkers are also a promising field for early detection of breast cancer through tear and blood analysis. However, their high false positive rate is a significant issue to address to target wider adoption. Ongoing research aims to develop more accurate and reliable blood biomarkers to improve diagnostic accuracy. There remains a lot of work to be done as the field of breast cancer diagnosis still lacks a widely validated, noninvasive screening and diagnostic tool that can be used in community settings to address concerns among young women. It is equally important to focus on implementing personalized screening models instead of relying solely on age-based guidelines. BCYW BOTTLENECKS: LESSONS FROM THE CERVICAL CANCER MODEL A direct comparison of cervical and breast cancer awareness and screening models reveals several challenges for breast cancer, ranging from differences in the biology of the two cancers to easily adoptable lessons from cervical cancer for BCYW. It is worth noting that the success of the cervical cancer model is mainly due to its causative etiology and the availability of the HPV vaccine. However, despite clear differences in etiology and pathobiology between cervical cancer and breast cancer, as well as the polygenic nature of spontaneous breast cancer, there are still areas where lessons from cervical cancer early detection and prevention could be effectively applied to BCYW. Some of these are exemplified here. Lack of effective, routine screening tools for young women Cervical cancer is effectively screened using the Pap smear and HPV testing. Mammography is less effective in young women because of dense breast tissue and lower disease prevalence. There is no validated alternative for early detection in asymptomatic young women in the US. It is crucial that insurance companies allocate research and resources toward validating a technology designed to meet young women’s needs. Low perceived risk in young women Many young women don’t consider themselves at risk for breast cancer and therefore do not seek preventive screening; in contrast, cervical screening is often associated with sexual activity, which makes it more common among youth to adopt; self-breast exam is not widely taught or reinforced, yet it is one of the best tools available to young women at this point. Guidelines exclude young women Young women are often excluded from standard breast cancer protocols, while cervical screening begins at age 21, promoting earlier normalization of preventive behavior. Cost and access to screening Making the Pap smear an integral part of the annual women’s checkup has been critical to emphasize the importance of detection and in minimizing the cost to the patient. MRI and ultrasound are more effective for young women with dense breasts but tend to be more expensive and less accessible. New AI-based imaging tests are now available options to young women to assess their breast health, but they are not covered by insurance (yet). Pap tests are affordable and widely available. The lack of universal insurance coverage for enhanced breast imaging in young women presents a barrier for many. Genetic testing barriers BRCA and other genetic tests can inform early intervention, but they’re costly and underused; many high-risk women remain untested due to a lack of awareness or access. Limited primary care engagement Cervical screening is part of standard primary and gynecologic care; however, breast cancer risk assessment is seldom discussed during routine visits in young adulthood. General practitioners and gynecologists must be educated about the new FDA-cleared technologies that have become commercially available over the last few years, offering young women an option for assessing their breast health and providing them with the peace of mind that comes from being proactive. Inconsistent messaging and education Public health messaging about cervical cancer and HPV is clear and widespread; unfortunately, breast cancer awareness mainly targets older women and uses “pink-purple ribbon” and “pink ribbon” campaigns, with less emphasis on young women’s risks or actionable prevention. Stigma and fear Young women might avoid discussing breast health because of fear of diagnosis, embarrassment, or discomfort with self-exams or doctor visits. They also worry about body image or fertility. These emotional and social factors are often overlooked in outreach efforts. Having access to breast health assessments that provide a user-friendly experience is important to encourage young women to get their breast health checked. Research gaps Most breast cancer research and clinical trials focus on postmenopausal women. There is a lack of data on effective prevention, screening, and treatment strategies specific to younger populations. RAISING BCYW AWARENESS According to the new guidelines from the American Academy of Radiology published in May 2023, young women are encouraged to start a risk assessment at age 25 to evaluate their lifetime breast cancer risk and discuss it with their doctor. It is critical to enable every young woman to know her family history, her genetic risks, and her breast density – a risk factor now well-documented and acknowledged by the FDA, as evidenced by their new rule to disclose breast density to every woman undergoing a mammogram, which took effect in 2024.[17,18] Ideally, every young woman should be equipped with relevant knowledge that enables early detection, leading to better treatment options and increased chances of a cure and successful outcomes. Raising awareness among both young women and their physicians is critical: Young women need to be empowered by the data that most breast cancer cases, about 85%, have no family history, highlighting the importance of living a healthy lifestyle and maintaining good breast care habits Young women need to be informed that those with a family history are at higher risk and therefore require careful self-breast care and regular by their young women any breast they should their for further evaluation and testing Young women should know that from to breast are to lifestyle and risk factors linked to breast cancer Young women should understand their risks, and for them so that they can any that a breast lump is only one of the many Young women need to advocate for imaging when they a lump or have a family history – even if guidelines do not require it is need to be better to in young women and to to their up any concerns regardless of age. They should avoid a to diagnostic Young women and physicians should understand that the of in young breast is than in later stages of the biology of and the factors contribute to the late diagnosis of the disease in young women. crucial to start young women all through programs that especially for those more to develop breast cancer, as well as individuals with healthcare access and low health Until a preventive screening is available for young women, there are effective to lower young women should focus on positive that they can about all the factors women can to reduce the chances of breast self-breast exam – for every woman to understand her is for and detect any – a healthy diet, focus on and informed about the known risks of linked to breast about and their role in breast cancer as well as the of endocrine in care the risks associated with of aware of the risks of during women should consider which has been linked to a reduced risk of breast young women on a of breast cancer risk factors by and validated over time a breast health assessment – BCYW the challenges of breast cancer in young women a at and public A focus should be for policy that the rising incidence and often of breast cancer in younger women, the need to from screening guidelines to personalized models that consider risk the should inform women about all available options to them about their breast health. Both the and insurance companies need to the data on technologies that show as options for women to assess their breast health, regardless of their breast density. for programs that provide affordable breast screening to women under 40 is these could data demonstrating the of early detection and the lower financial of important is to research on breast cancer detection methods, and risk specific to young women. should for and clinical validation of AI-based screening studies can the for insurance of screening starting at age routine breast into annual visits for all women, regardless of also early awareness and public awareness campaigns should by directly breast and cervical cancer screening in young women, and policy – BCYW Cervical cancer has a a effective prevention methods, and a public health young women are still not educated about their breast health, even with new screening options now available for this age Although cervical cancer is less common than breast cancer, particularly among young women, strategies from cervical cancer prevention could improve breast cancer in younger populations. Cervical cancer screening programs that awareness campaigns, early detection, with healthcare and community engagement are a clear message makes prevention a of early awareness and detection and detection are yet young women are often in routine breast cancer screenings. by cervical screening, there is to affordable using biomarkers or In addition, promoting routine risk family history, genetic and dense breast increasing awareness about risk factors early on can improve outcomes. and The cervical cancer on girls who are at high risk early in the women can be more for those at low risk. young women at high as those with mutations or a family through polygenic risk can be detected early and as part of a personalized screening with strategies to and Public health campaigns and The success of the cervical cancer mainly on public awareness campaigns that increased screening rates and with prevention. breast cancer in young women is often diagnosed at later stages and tends to be more aggressive. should focus on younger by and social to awareness about and the importance of family and social models women diagnosed with cervical cancer often challenges related to and leading to the of care designed to address these young breast cancer patients experience yet psychosocial which could inform the of specific to young breast cancer In cervical cancer on regular Pap smears, with education, accessible and being to encourage women to participate in breast cancer prevention is beginning to focus on education, young women, informed about a few lifestyle factors, and genetic testing to assess high risk. In the of a understanding of the the rising incidence of breast cancer in young women, early and awareness of risk factors, starting from and are to young women’s in breast cancer prevention. availability