JointStatementontheBreastCancerEducationandAwareness

RequiresLearningYoung(EARLY)Actof2009(H.R.1740,S.994)
ByYoungSurvivalCoalition,SusanG.KomenfortheCureAdvocacyAlliance,
LivingBeyondBreastCancerandBreastCancerNetworkofStrength

Eachyear,almost24,000womenunderage45arediagnosedwithbreastcancerintheU.S.,
andalmost3,000womenunderage45willdieofthediseasethisyear. i Todaythereare
more than 250,000 breast cancer survivors in the U.S. who were diagnosed at age 40 or
younger. ii Thebiologyandpsychosocialneedsofyoungwomenwithbreastcanceroften
differfromtheirolder,postmenopausalcounterparts.Whileadiagnosisofbreastcancer
isdevastatingatanyage,itisespeciallysoforyoungwomen.Abreastcancerdiagnosisat
theverybeginningofawomansadultlifecanderailhercareerpath,affectherabilityto
bearchildren,impactherabilitytopartnerandformany,leadtoprematuredeath.

Asharedgoalofourorganizationsistoincreasethequalityandquantityoflifeforyoung
women with breast cancer. We believe the Breast Cancer Education and Awareness
RequiresLearningYoungActof2009,orEARLYAct(H.R.1740,S.994),whichfocuseson
womenunderage45,willhelpfulfillthisgoal.

The Breast Cancer Education and Awareness Requires Learning Young Act of 2009,
referredtoastheEARLYAct,wasoriginallyintroducedintheU.S.House(H.R.1740)in
March2009byDebbieWassermanSchultz(DFL),SueMyrick(RNC),DonnaChristensen
(DVI)andRosaDeLauro(DCT).InMay2009,asimilarversionwasintroducedintheU.S.
Senate(S.994)byAmyKlobuchar(DMN)andOlympiaSnowe(RME).Thebillssponsors
haveworkedcloselywithourorganizationsstaffandscientificadvisors,aswellasothers
in the cancer community, to develop and enhance the language. Senator Klobuchars
version of the bill reflects this ongoing conversation by increasing the targeted age to
underage45,emphasizingevidencebasedmessagingandadherencetothepeerreviewed
guidelinesdevelopedbytheNationalComprehensiveCancerNetwork(NCCN).Thispaper
is based on the Senate version of the bill, which the House bill will be changed to reflect
duringmarkup.TheEARLYActwouldcreate:

A public health campaign to teach young women that breast cancer can and does
occur in young women, but more importantly to help them establi sh good breast
healthhabitstofollowastheymature;
An education campaign to increase awareness among health care providers that
breastcanceroccursinyoungwomenandknowledgeoftheriskfactorsforbreast
cancerinyoungwomen;and
Supportservicesforyoungwomenwithbreastcancer.
TheEARLYActdoesnot:

Formoreinformation,contactShelleyFuldNasso,DirectorofPublicPolicy,SusanG.KomenfortheCureAdvocacyAlliance(972.701.2080)
orMarciaStein,ChiefExecutiveOfficer,YoungSurvivalCoalition(6462573000).

JointStatementontheEARLYAct

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Advocatethatwomenunderage40haveregularscreeningmammography;nor,
Promotebreastselfexaminationastheonlymeansforbreastcancerdetection.

Thispositionpaperdiscusses(1)breastcancerinyoungwomen,(2)thelevelofknowledge
among young women about their risk of breast cancer and programs that target young
women, (3) the level of provider education about breast cancer in young women and (4)
theneedforsupportservicesforyoungwomenwithbreastcancer.

BreastCancerinYoungWomen

According to the American Cancer Society, about 250,000 breast cancer cases will be
diagnosed in the U.S. this year, of which about 10 percent will be diagnosed in women
under age 45. iii While 24,000 may seem small compared to the total number of women
diagnosed annually, it is a significant number especially when compared to other
cancers.Afterall,breastcanceristheleadingcauseofcancerdeathsinwomenunder40.
iv

Breastcancerinyoungwomentendstobemoreaggressiveandittendstobediagnosedat
laterstagesthanforolderwomen.Infact,accordingtocancerstatisticspresentedbythe
National Cancer Institute, the 5year relative survival rate is lowest in women diagnosed
withbreastcancerbeforeage40 (82 percent) compared to womendiagnosedat ages40
and older (89 percent). v When the numbers are separated by age, the disparities in
survivalratesamongyoungerwomenbecomemorestark. vi (SeeFigureI.)

FigureI:BreastCancerSurvivalRateinWomenbyAge

5 Year Survival Rates (%)

90

80

82
78

70

73

73
70

60
20 - 24

25 - 29

30 - 34

35 - 39

40 - 44

Age at Diagnosis (Years)

Source: Bleyer A, OLeary M, Barr R, Ries LAG (eds): Cancer Epidemiology in Older Adolescents and Young Adults 15 to 29 Years
of Age, Including SEER Incidence and Survival: 1975-2000. National Cancer Institute, NIH Pub. No. 06-5767. Bethesda, MD 2006.
Available online at http://seer.cancer.gov/publications/aya/

As can be seen in Figures II, IIIand IV,thedecreased survival rates in young women are
generally present at any stage of diagnosis, whether the breast cancer is localized to the

JointStatementontheEARLYAct

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breast,regional(cancerhasspreadbeyondthebreasttothelymphnodes),ormetastatic
(cancerhasspreadtootherorgans).

FigureII:BreastCancerSurvivalbyStageandAgeatDiagnosis
Localized
5 - Year Survival (%)

96
92

93

91
88

89
87

84

85

80
20 - 24

25 - 29

30 - 34

35 - 39

40 - 44

Age of Diagnosis (Years)

FigureIII:BreastCancerSurvivalbyStageandAgeatDiagnosis
Regional

5 - Year Survival (%)

80
76
70

71
65

60
58

59

20 - 24

25 - 29

50
30 - 34

35 - 39

40 - 44

Age at Diagnosis (Years)

FigureIV:BreastCancerSurvivalbyStageandAgeatDiagnosis
Metastatic

5 - Year Survival (%)

30
25

20

27

20
16
10

0
20 - 24

25 - 29

30 - 34

35 - 39

40 - 44

Age of Diagnosis (Years)

Source: Bleyer A, OLeary M, Barr R, Ries LAG (eds): Cancer Epidemiology in Older Adolescents and Young Adults 15 to 29 Years
of Age, Including SEER Incidence and Survival: 1975-2000. National Cancer Institute, NIH Pub. No. 06-5767. Bethesda, MD 2006.
Available online at http://seer.cancer.gov/publications/aya/

JointStatementontheEARLYAct

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BiologyofBreastCancerinYoungWomen.Breastcancerinyoungwomentends
tobeamoreaggressivedisease.ArecentstudybyAndersetalfoundthatwomenage45
andyoungeraremorelikelythanwomenage65andoldertohave: vii

Higherrateoftriplenegativebreastcancer, viii
Highergradetumors,
Largertumorsizes,and
Higherincidenceoflymphnodeinvolvement

Ultimately,womenage45andyoungerhavealowerdiseasefreesurvivalratethanwomen
age65andolderwomenunderage40hadanevenworsediseasefreesurvivalratethan
womenage40to45. ix

There are also racial and ethnic disparities in types of breast cancer among younger
women.Manysociopoliticalfactorscontributetohealthdisparitiesbyraceandethnicity,
includingaccesstohealthcareandbehavior.Yet,atleastsomeofthedifferencesinhealth
outcomes are related to differential incidence of breast cancer subtype by race and
ethnicity.TheCarolinaBreastCancerStudy,anexaminationofbreastcancersubtypesby
race, showed that 39 percent of premenopausal African American women had generally
moreaggressivetriplenegativebreastcancerversus16percent ofnonAfricanAmerican
women of all ages. x This highlights the particular risks young African American women
facewhendiagnosedwithbreastcancer.

Genetic Testing and Breast Cancer in AtRisk Populations. Genetic testing

providespeoplethechancetolearniftheirfamilyhistoryofbreastcancermaybeduetoa
BRCA1orBRCA2mutation.However,only5to10percentofbreastcancersarerelatedto
an inherited genetic mutation. xi Most breast cancers, even in young women, are not
relatedtoaclearinheritedgeneticmutationinBRCA1orBRCA2,butforpeoplewhohave
these mutations, the risk of breast cancer is greatly increased. In these cases, there are
certainstepspeoplecantaketotryanddecreasethisrisk.Althoughitiswidelyadvertised,
genetictestingisonlyrecommendedforpeoplewhohavethefollowing:

Astrongfamilyhistoryofbreastcanceratanearlyage
Afamilyhistoryofbreastandovariancancers
Afamilyhistoryofmalebreastcancer
Ashkenazi Jewish heritage whoalso have some familyhistory of breast or ovarian
cancer

Although BRCA testing requires just a blood sample, many risks and benefits should be
consideredbeforebeingtested.Becauseofthepotentialphysical,emotionalandfinancial
impact of knowing one's genetic status, testing for the BRCA mutation is recommended
only after genetic counseling for people with strong family or personal history of breast
cancerraceorethnicityaloneisnotareasonforpursuinggenetictesting.

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Psychosocial and Socioeconomic Issues for Young Women with Breast Cancer.
Breastcancerinyoungwomencomesattimeofgreatchangeinawomanslife.Careers,
dating,fertilityandchildrearingarehighprioritiesformostyoungwomen.

Acancerdiagnosishasparticularimplicationsforyoungwomeninthebeginningstagesof
their careers. The rigors of cancer treatment may force a person to cut back working
hours or leave the workforce entirely, which will set back their efforts to establish
themselvesprofessionally.Further,whenayoungcancersurvivorreenterstheworkforce,
shewillhavelessworkhistorytoreferencewhenseekingemploymentthansomeonewho
leaves the workforce at an older age. People with less work experience or inconsistent
work patterns are likely to earn less and are at a disadvantage when competing for jobs
andcareeradvancementsintodayshighlycompetitiveemploymentmarket.

FigureVpresentsmedianandaverageincomesforwomenindifferentagebrackets.
Fromacareerperspective,womenfromage20to45areinthebeginningstagesoftheir
earning capacity. As the figure shows, income increases dramatically for women during
thistimeperiodfrom$12,683to$34,870.

FigureV:IncomeDistributionAmongWomen
$40,000

$38,095

$35,000

$34,870
$31,108

Income (Dollars)

$30,000
$28,820
$25,000

$23,747

$20,000
$15,000
$10,000

$15,714
$12,683
$8,960

$5,000
$0
15 - 24

25 - 44

45 - 64

65+

Age (Years)
Median
Source: U.S. Census Bureau

Average

Unemployment is a significant issue with young breast cancer survivors. A review of

cancer survivors and unemployment studies showed that in the United States cancer
survivorsare1.37timesmorelikelytobeunemployedthantherestofthepopulation,with
increased risk for survivors of breast cancer, gastrointestinal cancer and cancer of the
female reproductive organs. xii This trend is borne out in the Young Survival Coalitions
2009ConstituentsurveyofitssurvivorbaseconductedinMayofthisyear,whichshowed
that the unemployment rate among young cancer survivors is a startling 22 percent. xiii

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Furthercorroboratingthepotentialdisruptiveeffectofbreastcancerinyoungwomen,the
surveyshowedthatwithinthefirsttwoyearsafterdiagnosis:
5percentwereinvoluntarilylaidoff
16percenthadtheiremploymenthoursreduced
13percentfeltdiscriminatedatworkbecauseoftheirbreastcancerdiagnosis

Another primary concern for young women being treated for breast cancer is loss of
fertility.Theearlymenopausethatcanbecausedbychemotherapycanbeverydifficult
for women who had hoped to either have a first child or add to the family they already
have. Chemotherapy and tamoxifen can each damage the ovaries, causing irregular
periodsorstoppingperiodsaltogether.

Byage40,morethan95percentofwomenhavecompletedchildbearing. xiv Oneofthekey

decisionsayoungwomanhastomakeasherbreastcancertreatmentplanisdevelopedis
whether or not she wishes to have children. A recent study conducted by the Young
SurvivalCoalitionandtheDanaFarberCancerInstituterevealedthat: xv

48 percent of the women had at least one child prior to their breast cancer
diagnosis
56 percent of the women reported they were considering having additional
children
39 percentof the women surveyed indicated they wereeither concerned or very
concernedabouttheimpactofchemotherapyontheirfertility
This concern increased depending upon the age at diagnosis, marital status and
numberofpriorpregnanciesandlivebirths
29 percent of the women reported that their fertility concerns impacted their
chemotherapydecision

There are several steps women can take that may help preserve their ability to have
children after treatment. Because oftheseunique needs and challenges, it is critical that
youngwomenreceivethesupportservicestheyneedsothattheycansuccessfullynavigate
throughtheirbreastcancerdiagnosis.Thisisonereasonwhy theEARLYActsgrantsfor
support services targeted toward young women diagnosed with breast cancer are so
important.

KnowledgeAmongYoungWomenaboutBreastCancerRisk

AkeyquestionunderlyingtheneedfortheEARLYActiswhetheryoungwomenknowthey
cangetbreastcancer.The2009YSCConstituencySurveyofitssurvivorconstituentsasked
thisexactquestionofbreastcancersurvivors.Anastounding40percentofyoungwomen
with breast cancer responded that prior to diagnosis they did not know a young woman
couldgetbreastcancer.xvi

Given the large proportion of women unaware that breast cancer can occur in young
women,webelievethisisanopportunitytoteachyoungwomengoodbreasthealthhabits
thatcanbecarriedwiththemforalifetime.Andinaddition tobenefitingthemselvesthe

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information may also be shared with their mothers, grandmothers and older female
relativesandfriends.

Considerable time and effort is spent in the cancer community educating teenagers and
young women about the issues of breast health and cancer in general. The Lance
ArmstrongFoundationoffersafullydevelopedcancereducationcurriculumtalkingabout
cancerstartingfromtheelementaryschooltothecollegiatelevel. xvii SusanG.Komenfor
the Cure and its Affiliates have granted almost $3 million for secondary school breast
healtheducationprogramsoverthepastthreeyears.Since1990,BreastCancerNetwork
of Strength Just for Teens program has educated over 200,000 teens about the
importance of breast health and awareness. The Young Survival Coalition has offered a
highschoolandcollegiateprogramsince2006toeducateyoungwomenabouttheissuesof
breastcancerinyoungwomen.

While breast cancer in young women can be scary, if it is handled in a factual and age
appropriatemanner,itcangiveyoungwomenfactstheycanuse fortheirlifetimes.The
EARLY Act seeks to develop such a campaign with the advice of a council of medical
professionals and advocates. The intent of this collaboration would be to give young
womenthemostrecent,evidencebasedinformationaboutbreastcancerinyoungwomen,
ofwhichakeycomponentwouldbeinformationaboutbreastcancerscreening.

Screeningforbreastcancerinyoungwomen.TheEARLYActhasbeensubjectto
criticism because of the perception that the Act advocates the use of breast self
examination for early detection of breast cancer in young women, or that it encourages
mammographybeusedtoscreenyoungwomen.

There is currently no effective method for screening young women for breast cancer.
Because of the density of young womens breasts, mammography is often ineffective.
Similarly,breastdensityalsoimpactstheeffectivenessofbreastMRIinyoungwomen,and
MRIsareprohibitivelyexpensiveforroutinescreening.Notsurprisingly,nearly80percent
of young women ultimately diagnosed with breast cancer find their breast abnormality
themselves. xviii In the absence of an effective early detection methodology for young
women,thebestmessageswecangivethematthistimeistoknowyourbody,beaware
ofthesignsofbreastmalignancyandbeawareoftheirbreastcancerrisks.

Our organizations have been in the forefront of advocating that breast selfexamination
should not be relied on as a screening methodology. We, like the other major cancer
organizations and NCCN, advocate breast selfawareness. As part of selfawareness, a
womanisencouragedtobeawareofhowherbreastsnormallylookandfeelifachange
isfound,ayoungwomanshouldseektheadviceofahealthprofessional.Atthesametime,
young women are encouraged to know their risk including family medical history and
personalriskfactors,aswellasgetrecommendedmammogramsandclinicalbreastexams
attheappropriateageandtimeintervalasdirectedbytheirhealthcareproviders.Breast
selfexaminationshouldnotbesubstitutedfortheseotherscreeningtests.

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BoththeAmericanCancerSociety xix andtheauthoritativeNationalComprehensiveCancer

Network (NCCN) say women should be familiar with their breasts and promptly report
changestotheirhealthcareprovider.TheNCCNgoesontosaythatperiodic,consistent
breast selfexamination may facilitate breast selfawareness. xx While it is entirely
acceptablenottodoregularbreastselfexamsornottodoitonafixedschedule,ifyoudo
regular breast exams, you get to know how your breasts normally look and feel, and can
moreeasilynoticechanges.

The Senate version of the EARLY Act proposes that the breast health program follow
standardacceptedguidelinesfromNCCN,whicharedevelopedandreviewedregularlybya
multidisciplinarygroupofbreastcancerexperts,andtheHouseversionwillbechangedto
match,duringthemarkupofthebill.Furthermore,alackofcumulativeanswersforrisk
reduction and early detection methods for young women does not justify ignoring this
population. Rather, the EARLY Act rightly bases outreach to young women on the
recommendationsofanadvisorycommitteeofbreastcancerexperts,sothatasthescience
evolvesandnewevidencebasedmethodsaredevelopedso,too,willthemessaging.

Finally, we believe more research is needed to find a costeffective screening tool to

diagnosebreastcancerinyoungwomen.

KnowledgeAmongProvidersaboutBreastCancerinYoungWomen

OneofthekeyaspectsoftheEARLYActisprovidereducationaboutbreastcancerinyoung
womenandtheuniquechallengesyoungwomenface.Theissueistwofold:(1)primary
careprovidershavenotintegratedintotheirstandardcarescreeningforwomenathigh
risk of breast cancer xxi and (2) when presented with a young woman with a breast
abnormality, breast cancer is too often overlooked or considered an unlikely diagnosis,
resultingindelayedormisseddiagnosis.

A recent multicenter study of young women diagnosed with breast cancer from Dana
FarberCancerInstitutefoundthatnearly25percentdelayedseekingmedicalattentionand
25percentexperiencedadelayindiagnosisafterseekingmedicalattention. xxii Inaddition,
Oeffinger et al., recently studied the surveillance practices among women previously
treated with chest radiation for childhood cancer women at increased risk of breast
canceratayoungageandforwhomscreeningmammographyisrecommendedstartingat
age 25 or eight years after radiation. Nearly twothirds (63.5 percent) of those age 25
through39hadnotbeenscreenedintheprevioustwoyears,andthetwomostoftencited
reasonsweretheirdoctordidntorderit(31percent)andImtooyoung(30percent).

Therearealsolegalandfinancialreasonsforproviderstolearnmoreaboutbreastcancer
in young women. Delayed diagnosis and misdiagnosis of breast cancer in young women
arefrequentmalpracticeclaims.Ina2002BreastCancerStudyconductedbythePhysician
Insurers Association of America, the leading insurance trade association of medical
professionalliabilitycompanies,revealed,that69percentofthebreastcancermalpractice
claims were for women in their 40s and under and 33 percent of the claims were for
womenintheir20sand30s. xxiii Theaveragesizeoftheawardforawomaninher30swas

JointStatementontheEARLYAct

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$508,000.In2006inMassachusetts,a$10.7millionmalpracticeawardwasawardedtoa
38yearoldbecauseofmisdiagnosisbyhergynecologist.

Basedonboththemalpracticeinformationandexistingstudies,ourorganizationsadvocate
forprovidertrainingthatfocusesonrecognizingriskfactorsforearlybreastcancerandif
theyarepresentedwithabreastmasstoconsiderandappropriatelyruleoutbreastcancer
accordingtostandardguidelinessuchasthosedevelopedbytheNCCN.

Conclusion

Breast cancer is relatively rare in young women. But when breast cancer is detected,
prognosis is often worse than for older women. Younger women are often less likely to
seek early medical attention, leading to later detection, which likely contributes to
diagnosesat moreadvanced stages. In addition, breast cancer in younger women is also
often a more aggressive disease than in older women, which is associated with worse
survival rates for the same stage of disease at diagnosis. Evidencebased information is
neededforyoungerwomenandtheirhealthcareprofessionalstohelpdetecttheircancers
earlyandgivethosewhoarediagnosedthegreatestchanceforsurvival.

AboutUs

YoungSurvivalCoalition(YSC)isthepremierinternationalorganizationdedicatedtothe
critical issues unique to young women and breast cancer. YSC works with survivors,
caregiversandthemedical,research,advocacyandlegislativecommunitiestoincreasethe
qualityandquantityoflifeforwomendiagnosedwithbreastcancerages40andunder.
http://www.youngsurvival.org

TheSusanG.KomenfortheCureAdvocacyAllianceisthenonpartisanvoiceformore
than2.5millionbreastcancersurvivorsandthepeoplewholovethem.Ourmissionisto
translate the Komen promise to end breast cancer forever into action at all levels of
governmenttodiscoveranddeliverthecures.
http://www.komenadvocacy.org

Living Beyond Breast Cancer assists women at all stages of diagnosis, treatment and
recovery.Ourmissionistoempowerallwomenaffectedbybreastcancertoliveaslongas
possible with the best quality of life. We offer specialized programs and services for the
newlydiagnosed,youngwomen,womenwithadvancedbreastcancer,womenathighrisk
for developing the disease, and AfricanAmerican and Latina women. We also offer
programsforcaregiversandhealthcareprofessionalstohelpthembettermeettheneedsof
womenaffectedbybreastcancer.
http://www.lbbc.org

Breast Cancer Network of Strength, formerly known as YME National Breast Cancer
Organization, provides immediate emotional relief to anyone affected by breast cancer.
The mission of Breast Cancer Network of Strength is to ensure, through information,
empowermentandpeersupport,thatnoonefacesbreastcanceralone.
http://www.networkofstrength.org/

JointStatementontheEARLYAct

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iAmericanCancerSociety,BreastCancerFacts&Figures20072008.
iiYoungSurvivalCoalitionestimatesbasedonthe2000U.S.Censusdata.
iiiAnestimated192,370newcasesofinvasivebreastcancerareexpectedtooccuramongwomenintheU.S.

in2009.Inadditiontoinvasivebreastcancer,62,280newcasesofinsitubreastcancerareexpectedtooccur
amongwomenin2009;ofthese,approximately85percentwillbeductalcarcinomainsitu(DCIS),foratotal
ofabout250,000cases,accordingtoAmericanCancerSociety,CancerFacts&Figures2009.Nearly10
percent(23,790)oftotalnewbreastcancercaseswerediagnosedinwomenunderage45in200716,150
invasiveand7,640carcinomainsitu,accordingtoAmericanCancerSociety,BreastCancerFacts&Figures
20072008.

ivIbid.
vRiesLAG,MelbertD,KrapchoM,MariottoA,MillerBA,FeuerEJ,CleggL,HornerMJ,HowladerN,EisnerMP,

ReichmanM,EdwardsBK(eds).SEERCancerStatisticsReview,19752004,NationalCancerInstitute.
Bethesda,MD,http://seer.cancer.gov/csr/1975_2004/,basedonNovember2006SEERdatasubmission,
postedtotheSEERwebsite,2007.

viBleyerA,OLearyM,BarrR,RiesLAG(eds):CancerEpidemiologyinOlderAdolescentsandYoungAdults15to

29YearsofAge,IncludingSEERIncidenceandSurvival:19752000.NationalCancerInstitute,NIHPub.No.06
5767.Bethesda,MD2006.Availableonlineathttp://seer.cancer.gov/publications/aya/.
viiAndersCKetal,YoungAgeatDiagnosisCorrelateswithWorsePrognosisandDefinesaSubsetofBreast

CancerswithSharedPatternsofGeneExpression,JournalofClinicalOncology,Vol.26,No.20,July10,2008,
33243330.
viiiAtriplenegativetumorisestrogenreceptornegative(ER),progesteronereceptornegative(PR)and

HER2/neunegative(HER2).Becauseoftheirtriplenegativequalities,currenttreatmentchoicesforthese
tumorsarelimited.Triplenegative/basalliketumorsareoftenaggressiveandareassociatedwithapoorer
prognosiscomparedtotheestrogenreceptorpositivesubtypes.
ixAndersetal,JournalofClinicalOncology.
xCareyetal,Race,breastcancersubtypesandsurvivalintheCarolinaBreastCancerStudy,Journalofthe

AmericanMedicalAssociation,Vol.295,No.21,June7,2006,pp.24922502.Availableonlineat
http://jama.amaassn.org/cgi/reprint/295/21/2492.
xiNationalCancerInstitute.Geneticsofbreastandovariancancer(PDQ).Availableonlineat

http://www.nci.nih.gov/cancertopics/pdq/genetics/breastandovarian/HealthProfessional/page1.
xiiDeBoerA.G.E.M.,CancerSurvivorsandUnemployment:AMetaanalysisandMetaregression,Journalof

theAmericanMedicalAssociation,Vol.301,No.7,February18,2009,pp.753762.Availableonlineat
http://jama.amaassn.org/cgi/content/full/301/7/753.
xiii2009YoungSurvivalCoalitionConstituencySurvey.
xivCentersforDiseaseControlandPrevention.

xvSeePartridgeA.H,etal.,WebbasedSurveyofFertilityIssuesinYoungWomenwithBreastCancer,
JournalofClinicalOncology,Vol.22,No.20,October15,2004,pp.41744183.Availableonlineat
http://jco.ascopubs.org/cgi/content/abstract/22/20/4174.
xvi2009YoungSurvivalCoalitionConstituencySurvey.
xviiLearnmoreabouttheLanceArmstrongFoundationLiveStrongYoungAdultAllianceonlineat

http://www.livestrong.org/site/c.khLXK1PxHmF/b.2661399/k.71A4/Young_Adult_Alliance.htm.
xviiiBasedonasurveyof222womenunderage40withrecentlydiagnosedbreastcancerinaprospective
multicentercohortstudystartedinlate2006.SeeRuddyK.J.etal,Presentationofbreastcancerinyoung
women,ASCOMeetingAbstracts27:6608.Availableonlineat

JointStatementontheEARLYAct

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http://www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_detail_view&confID=65&abstractID=349
26.
xixAmericanCancerSociety,BreastCancerFacts&Figures:20072008.
xxTheNationalComprehensiveCancerNetwork(NCCN),anotforprofitallianceof21oftheworldsleading

cancercenters,developsvaluableinformationforthenumerousstakeholdersinthehealthcaredelivery
system.NCCNguidelinesforscreeningandearlydetectionofbreastcancercanbefoundonlineat
http://www.nccn.org/professionals/physician_gls/PDF/breastscreening.pdf.

xxiOeffinger,KC,etal,BreastCancerSurveillancePracticesAmongWomenPreviouslyTreatedwithChest

RadiationforaChildhoodCancer,JournaloftheAmericanMedicalSociety,Vol.301.No.4,July2,2009,p.
404414.Availableonlineathttp://jama.amaassn.org/cgo/reprint/301/4/404.
xxiiRuddyetal,ASCOMeetingAbstracts.
xxiii2002BreastCancerStudyconductedbythePhysicianInsurersAssociationofAmerica.