2011 12 Pregnancy & Breast Cancer

Question 1

What is the most common cancer in women?

Answer 1

Breast cancer

Question 2

What is the lifetime risk of breast cancer in the UK?

Answer 2

1:9

Question 3

What proportion of breast cancer cases are diagnosed <45?

Answer 3

15%

Question 4

What is the rate of breast cancer in pregnancy?

Answer 4

1-2:10,000

Question 5

What is the 5-year survival for breast cancer in <50s?

Answer 5

80%

Question 6

What proportion of women become pregnant following a breast cancer diagnosis?

Answer 6

< 10%

Question 7

What imaging should be used for breast cancer diagnosis in pregnancy?

Answer 7

1. US & guided biopsy for discrete lump
2. Histology rather than cytology
3. Mammography with fetal shielding if cancer
4. Staging only if high clinical suspicion of mets: CXR & liver US
5. Not gadolinium MRI
6. Not CT or isotope bone scan

Question 8

What histological assessment is used in breast cancer, both in & out of pregnancy?

Answer 8

1. Histological grade
2. Receptor status
3. HER2

Question 9

What tumour markers are used in breast cancer in pregnancy?

Answer 9

None as may be misleading

Question 10

What are the surgical considerations for breast cancer in pregnancy?

Answer 10

1. Can do in all trimesters
2. Consider both mastectomy & breast-conserving surgery
3. Delay reconstruction
4. Sentinel nodes via radioisotope scintigraphy, not blue dye

Question 11

What are the considerations for radiotherapy with breast cancer in pregnancy?

Answer 11

Delay until after delivery
Unless life-saving or to preserve organ function?

Question 12

What are the considerations for chemotherapy with breast cancer in pregnancy?

Answer 12

1. Contraindicated in the 1st trimester
2. Offer from 2nd trimester
3. Anthracycline safe
4. Taxanes with N or M
5. Give standard antiemetics

Question 13

What drug treatments should not be used with breast cancer in pregnancy?

Answer 13

1. Tamoxifen
2. Trastuzumab (Herceptin)

Question 14

How should birth be timed with breast cancer in pregnancy?

Answer 14

1. Full term for most
2. If early IOL, consider steroids
3. Aim 2-3 weeks after last chemo, to allow bone marrow recovery

Question 15

Which breast cancer drugs cannot be given alongside breastfeeding?

Answer 15

1. Tamoxifen
2. Trastuzumab (Herceptin)
3. Chemotherapy: BF 14 days after

Question 16

What is the UKMEC category for hormonal contraceptives with current or recent breast Ca?

Answer 16

UKMEC 4

Question 17

How many years do women need to be breast cancer-free before hormonal contraceptives are considered?

Answer 17

5 years
UKMEC 3

Question 18

What advice should be given to women planning pregnancy following breast Ca?

Answer 18

1. Stop Tamoxifen 3m before TTC
2. Routine imaging before TTC
3. Don’t TTC if metastatic disease
4. Pregnancy doesn’t worsen long-term survival
5. Timing based on recurrence risk & Tx duration
6. Adverse outcomes are uncommon
7. Consider PGD with BRCA

Question 19

When is breast cancer recurrence highest?

Answer 19

3 years after diagnosis
2 years after treatment

Question 20

What is the recommended duration for Tamoxifen treatment?

Answer 20

5 years

Question 21

When women become pregnant after breast Ca Tx, how should they be managed?

Answer 21

1. Joint care: obs, onc & breast
2. Echo to detect cardiomyopathy, as anthracyclines are a risk
3. Temporary prosthesis as reconstructed breast may not grow

Question 22

What anthracyclines are used as chemotherapy in breast Ca?

Answer 22

1. Doxorubicin
2. Epirubicin

Question 23

What is the breastfeeding advice for breast cancer survivors?

Answer 23

1. Feed from unaffected breast
2. Possible survival benefit
3. Breast-conserving surgery may not inhibit lactation
4. Radiotherapy fibrosis makes feeding unlikely
5. Encouragement

Question 24

What are the effects of adjuvant chemo on fertility?

Answer 24

1. Permanent amenorrhoea
2. Transient amenorrhoea
3. Menstrual irregularity
4. Subfertility

Question 25

How do different breast cancer chemo regimes compare for fertility?

Answer 25

1. Alkylating agents eg cyclophosphamide v gonadotoxic 2. CMF regimen: cyclophosphamide, methotrexate & 5FU: high amenorrhoea 3. Anthracyclines better, FEC: 5FU, epirubicin, cyclophosphamide 4. Taxanes less gonadotoxic

Question 26

What fertility preservation is considered with breast Ca Tx?

Answer 26

1. GnRH analogues may offer some ovarian protection 2. Embryo freezing, with modified ovarian stimulation 3. Oocyte storage 4. Ovarian tissue storage only in research context