Pregnancy and breast cancer

Pregnancy and breast cancer
By
Ahmed Elbohoty MD, MRCOG
Assistant professor of obstetrics and gynecology
Ain Shams University

What is your opinion ?
— Is pregnancy protective against breast cancer ?
— Does pregnancy associated breast cancer carry a worse
prognosis than breast cancer that is unrelated to pregnancy
?
— Is it a must to terminate pregnancy if breast cancer is
diagnosed ?
— What are the preferred diagnostic imaging to assess the
spread of breast cancer in pregnancy?
— What are the modalities of treatment that can be used ?
— Can the woman who had a breast cancer lactate ?
Ahmed Elbohoty MD. MRCOG 3/24/20

I would try to give spotlight on the
following:
— Risk factors for breast cancer which are related to
reproduction
— Management of Pregnancy-associated breast cancer
vClinical presentation
vImaging
vHistological diagnosis
vTreatment
vAntenatal care
vBreastfeeding
vContraception
— Pregnancy after treatment of breast cancerAhmed Elbohoty MD. MRCOG 3/24/20

Risk factors:
—Early menarche and late age at first pregnancy
—Nulliparity
—Parity
P Schedin: Nature Reviews
Cancer,2006
—Pregnancy in carriers
of BRCA1 and
BRCA2 mutations.
—Breastfeeding
conferred a weak
protective effect.Ahmed Elbohoty MD. MRCOG 3/24/20

Pregnancy-associated breast cancer
—It is defined as breast cancer diagnosed during
pregnancy or up to 1 year postpartum.
—Only about 3% of women diagnosed with
breast cancer will be pregnant.
—Breast cancer incidence is approximately 1 in
3000 pregnancies.
— It carries similar prognosis in the pregnant and
non-pregnant population by stage and grade.

Diagnosis
—Diagnostic delays of two months or longer
are common in women with gestational
breast cancer due to physiological changes
during the pregnancy and lactation.
—So this may be responsible for the larger
size of tumors and/or the higher number
of lymph nodes at diagnosis in pregnant
women.

Clinical presentation
—Breast cancer usually presents as a painless
lump.
—Occasionally, the disease can present as a bloody
discharge from the nipple
—Very rarely as an inflammatory breast cancer.
—Women presenting with a breast lump
during pregnancy should be referred to a
breast specialist team.Ahmed Elbohoty MD. MRCOG 3/24/20

Differential diagnosis of a breast lump
in pregnancy
— Invasive carcinoma
— Lactating adenoma
— Fibroadenoma
— Cystic disease
— Lobular hyperplasia
— Milk retention cyst (galactocele)
— Abscess
— Lipoma
— Hamartoma and, rarely, leukaemia
— Lymphoma
— Sarcoma
— Neuroma
— Tuberculosis

Imaging
— Helps to assess mass characteristics:
— Breast ultrasonography is often the first imaging test.
— It is helpful in distinguishing solid from cystic lesions of the
breast.
— Assessment of tumor spread (if cancer is confirmed):
— Mammography is pivotal (with fetal shielding) to assess the
extent of disease and the contralateral breast.
— Chest radiography and liver ultrasound.
— Skeletal MRI generally preferred than Tc99 bone scan or X ray
computed tomography.

Histological diagnosis:
—Ultrasoud guided tissue biopsy is better
than cytologly.
—You may consider temporary suppression
of lactation with cabergoline in lactating
woman to reduce the risk of milk fistula or
abscess formation.
—Histological grade, hormonal receptor
status and human epidermal growth factor
receptor 2 (HER2) inform treatment
planningAhmed Elbohoty MD. MRCOG 3/24/20

Treatment of breast cancer during
pregnancy
— The treatment regimens used will depend
vStage of the disease
vGestational age
vDesire to continue the pregnancy ?
— Treatment of a breast cancer should not be unnecessarily delayed
because of pregnancy. Delay or refusal to undergo therapy has
serious consequences.
— This will require sympathetic approach, involvement of
multidisplinary team
vThe Breast surgeon
vMedical oncologist
vThe obstetrician
vSpecialized oncology nurse
vThe radiotherapist.Ahmed Elbohoty MD. MRCOG 3/24/20

Breast Cancer Treatment
—Locoregional control
—Surgery
—Radiation
—Systemic control
—Chemotherapy
—Hormonal therapy
during Pregnancy

Treatment Modalities :
— Breast surgery can be done for all stages (therapeutic or
palliative) regardless the gestational age with negligible risk to
the fetus.
— Chemotherapy is considered to be safe when used during the
second and third trimesters of pregnancy.
— Radiotherapy is contraindicated till delivery unless life saving
or to preserve organ function (eg. spinal cord compression).
— Hormonal and Monoclonal antibody therapy are not
recommended during pregnancy or lactation
— Haemopoietic growth factors may be employed to
ameliorate chemotherapy-induced neutropenia.

Therapeutic Breast surgery
— Modified radical mastectomy: is the standard procedure
for most of cases in stage I or II.
— Breast conserving surgery: Overall, it is not advisable in
pregnant women. However, it may be offered to women
who are diagnosed in the third trimester and to be followed
by radiotherapy after delivery of the baby.
— Sentinel node biopsy is indicated in women who have a
negative result from a preoperative axillary ultrasound and
needle biopsy. It is done by using radioisotope scintigraphy
not the blue dye.
— Axillary lymph node dissection is recommended in +ve
preoperative lymph nodes or senntinel node biopsy.
— Reconstruction should be delayed to avoid prolonged
anaesthesia and to allow optimal symmetrisation of the
breasts after deliveryAhmed Elbohoty MD. MRCOG 3/24/20

Chemotherapy
—Pregnancy-associated breast cancer is usually
associated with invasive and high-grade lesions,
making chemotherapy necessary.
—Chemotherapy may sometimes lead to preterm
delivery, low birthweight, transient tachypnoea
of the newborn and transient neonatal
leucopenia.
—Infant leucopenia have been reported when
chemotherapy is administered less than 3 weeks
before delivery.Ahmed Elbohoty MD. MRCOG 3/24/20

—A 4–6 month course is usually offered to node-
positive women or node-negative women with a
tumour larger than 1 cm.
—The timing of chemotherapy is crucial. A delay
in chemotherapy of 3 weeks following surgery is
thought to be associated with a significant
impact on the prognosis compared with early
commencement of chemotherapy.
—Cyclophosphamide, doxorubicin and
fluorouracil (CAF), is the recommended
combination of drugs used in adjuvant
chemotherapeutic regimens as in non pregnant.Ahmed Elbohoty MD. MRCOG 3/24/20

The role of termination of pregnancy
— There is no evidence to suggest that termination of
pregnancy improves prognosis.
— The decision to end pregnancy is either:
vA personal choice of the woman or the couple
following extensive discussions with a
multidisciplinary team.
vIt can also be considered in cases of advanced
disease stage at the time of diagnosis early in the first
trimester or where survival may be shorter than the
time needed to complete the pregnancy.

Modified radical
mastectomy +
chemotherapy
after 14/40
Breast coservative surgery +
radiotherapy & chemotherapy
after delivery
Delivery by 34 weeks
followed by surgery/
chemotherapy/radiotherapy
/hormonal
Consider termination or delay
treatment after 14 weeks
1ry systemic therapy+/-
palliative surgery
Delivery
followed by
surgery/
chemotherapy
/radiotherapy
/hormonal

Antenatal care:
—Additional ultrasound scans can be needed for
fatal growth as approximately 40% of babies will
experience low birthweight with chemotherapy,
which is usually due to fetal growth restriction.
—Prophylactic anticoagulation is considered if
breast surgery is performed during pregnancy or
pureperium.
—Nausea and vomiting associated with
chemotherapy can be safely treated with 5HT3-
serotonin antagonists or steroids.Ahmed Elbohoty MD. MRCOG 3/24/20

Delivery
— Time of delivery should be individualized but
preterm delivery is the usual.
— Ideally, delivery should be postponed 3 weeks after
stoppage of chemotherapy.
— Administering betamethasone to the mother should
be considered to decrease neonatal morbidity.
— It is worthwhile assessing placental histology after
delivery in all cases even if it appears
macroscopically normal. In general, the presence of
placental metastases indicates a poor maternal
prognosis.Ahmed Elbohoty MD. MRCOG 3/24/20

Breastfeeding
— Lactation is usually contraindicated during
chemotherapy. If milk secretion is maintained
throughout chemotherapy, breastfeeding can be
allowed 3–4 weeks after the last administered dose of
chemotherapy.
— There is no evidence that women who have completed
treatment for breast cancer cannot breastfeed safely
from the unaffected breast.
— Breast-conserving surgery may not inhibit lactation but
radiotherapy causes fibrosis and lactation is unlikely in
an irradiated breast.Ahmed Elbohoty MD. MRCOG 3/24/20

Contraception
—Effective and safe method should be used as
early as possible.
—All hormonal containing methods should be
avoided even L-IUS. Although it may reduce
the risk of endometrial abnormalities during
tamoxifen therapy, further evidence is required
on its safety in breast cancer survivors
—So Cu-IUCD or irreversible methods either for
the woman or her husband seem logic to be
used.Ahmed Elbohoty MD. MRCOG 3/24/20

Effects of treatment on fertility
— Chemotherapy may cause premature ovarian failure,
depending upon the woman’s age and the treatment
regimen.
— 96% of women over 40 years of age and receiving six
or 12 cycles of CMF for breast cancer developed
amenorrhoea after treatment, whereas 54% of women
under 40 years experienced amenorrhoea that was
reversible in 23%.
— 9% of women younger than 35 years and receiving
fluorouracil, doxorubicin and cyclophosphamide
developed permanent amenorrhoeaAhmed Elbohoty MD. MRCOG 3/24/20

Can fertility be preserved before
treatment?
A fertility specialist incorporation and meticulous counselling
are mandatory before starting the chemotherapy.
— GnRH analogues ?
— Cryopreservation ?
Embryo cryopreservation
Oocyte storage ?
Immature oocytes ??
Ovarian tissue storage ???
— Donated eggs !!!Ahmed Elbohoty MD. MRCOG 3/24/20

Pregnancy after treatment of breast
cancer
— Up to 7% of women who are fertile after treatment
for breast cancer will subsequently have children
—Long-term survival after breast cancer does not
appear to be affected by pregnancy.
—Women planning a pregnancy after treatment for
breast cancer should consult their obstetrician,
breast surgeon and clinical oncologist.
—Any routine imaging should be done before
trying to conceive.

Interval before attempting conception
— Women with stage-I or II disease with estrogen
receptor negative should consider deferring pregnancy
for at least 2 years after treatment.
— Women with stage-III disease or estrogen receptor
positive disease should consider deferring pregnancy
for at least five years after treatment and to stop it at
least 3 months before pregnancy planning.
— Women with stage-IV disease (with a five-year survival
of less than 15%) or recurrent tumours should not
contemplate conception

Outcome of pregnancy
— Women can be reassured concerning the risk of
malformation in children conceived after treatment for
breast cancer.
— Women who are known to be breast cancer gene (BRCA)
carriers may wish to consider preimplantation genetic
diagnosis.
— Pregnancy following breast cancer should be jointly
supervised by the obstetrician, oncologist and breast
surgeon.
— Echocardiography should be performed during pregnancy
in women at risk to detect cardiomyopathy through resting
left ventricular ejection fraction.Ahmed Elbohoty MD. MRCOG 3/24/20

Again, What is your opinion ?
— Is pregnancy protective against breast cancer ?
— Does pregnancy associated breast cancer carry a worse
prognosis than breast cancer that is unrelated to pregnancy ?
— Is it a must to terminate pregnancy if breast cancer is
diagnosed ?
— What are the preferred diagnostic imaging to assess the
spread of breast cancer in pregnancy?
— What are the modalities of treatment that can be used ?
— Can the woman who had a breast cancer lactate ?

THANK YOUAhmed Elbohoty MD. MRCOG 3/24/20

Pregnancy and breast cancer

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