🤰Breast cancer in pregnancy

Question 1

pregnancy-associated breast cancer Definition

Answer 1

Gestational breast cancer (pregnancy-associated breast cancer) - breast cancer diagnosed during pregnancy or in the first postpartum year

Question 2

Principle of investigating for breast cancer in pregnancy

Answer 2

Evaluation

• Diagnosis via triple assessment
  
  • MMG not contraindicated
    
    • For bilateral breast assessment.
    • Done with fetal shielding,
  • Biopsy not contraindicated.
    
    • CNB recommended. FNA not accurate due to proliferative changes.
• Staging in LABC
  
  • CXR with fetal shielding with U/S liver.
  • MRI spine for bone mets.
• Consider Familial Breast Cancer as patient are generally young.
• Fetal USG scan to assess baseline abnormalities.

Question 3

Principle of management for breast cancer in pregnancy

Answer 3

Principles of Management

• Multidisciplinary approach
• Psychiatric assessment and consultation
• Fertility preservation
• Fetal assessment
• Informed consent is a critical component of choosing appropriate therapy
• Termination of Pregnancy (TOP) is last option. TOP do not improve survival
  
  • Mother : Start treatment as early as possible like non pregnant patients.
  • Fetus : Full term delivery at 38 weeks. Earliest is 34 weeks.
• Genetic counselling and testing (if Treatment oriented, test then decide too go for definitive same setting)

Question 4

Surgical / Adjuvant therapy

Answer 4

• Surgery is mainstay of treatment.
  
  • Surgery is avoided in 1st trimester due to ↑ risk of spontaneous abortion & low birth weight.
  • Surgery is preferred in 2nd trimester and 3rd trimester.
  • Divided into : Breast and Axilla if early breast ca. ( Mx like early breast cancer algorithm) or LABC algorithm
• Chemotherapy- only contraindicated in 1st trimester (organogenesis completed by 18wks, 2nd & 3rd trimester associated with IUGR, prematurity, LBW)
• RT - contraindicated throughout pregnancy even with fetal shielding
• ET - contraindicated throughout pregnancy
• HT - Trastuzumab, contraindicated throughout pregnancy (oligohydramnios, pulmonary hypoplasia, skeletal abnormalities & neonatal death.)
• Breast feeding - avoided in women on chemotherapy, endocrine (SERM, AI, LHRH agonist - suppress lactation) & HER2 therapy.

Breast

• Mastectomy - Avoid need for RT, Delayed reconstruction until after delivery (to avoid prolonged surgery)
• BCS - restricted by need for RT to ↓ LR. Decision based on need for chemo as RT given after chemo.
  
  • Chemotherapy indicated - BCS in 2nd & 3rd trimester.
  • Chemotherapy not indicated - BCS in 3rd trimester
• RT - Contraindicated throughout pregnancy even with fetal shielding. Pregnancy loss, malformation (Ambiguous genitalia, Goldenhar’s syndrome – Facioauriculovertebral abnormalities), growth disturbance, mutagenic

Axilla

• ALND - Standard approach for LN positive & IBC
• SLNB - Controversial. Sulfur colloid is safe with minimal dose 50 mCi - fetal exposure is very low.
  
  • Isosulfan blue & methylene blue is contraindicated.
  • The maximum absorbed dose to the fetus of 4.3 mGy calculated for the worst-case scenario is well below the 50 mGy that is believed to be the threshold absorbed dose for adverse effects.

Question 5

Role of Systemic Therapy in breast cancer in pregnancy

Answer 5

Chemotherapy

• Delay post OP is associated with ↓ DFS & OS (most effective if CT given 6 wks, if > 3 mths not effective)
• Timing of delivery
  
  • Stop chemotherapy 3 – 4 weeks before delivery
    
    • Maternal sepsis & bleeding (thrombocytopenia)
    • Risk of transient neonatal myelosuppression & sepsis
• Choice
  
  • Anthracycline based - AC or FAC (5-FU, Doxo, Cyclo) is safe. Doxorubicin preferred.
  • Taxanes based - Treatment is feasible
  • Methotrexate - Contraindicated because of teratogenic potential.

HER 2 Therapy

• Lapatinib is erbB 2 tyrosine kinase inhibitor. Inhibit HER2 & EGFR - Medication is new with no data regarding pregnancy & lactation.

Supportive Therapy - Safe in pregnancy

• Antiemetic
• G-CSF (Granulocyte-colony stimulating factor - Neupogen) - stimulates the bone marrow to produce granulocytes and stem cells

Question 6

Role of Termination of Pregnancy ( TOP)

Answer 6

TOP (Termination of Pregnancy)

• Decision is individualized, early termination do not improve outcome.
• Advanced breast Ca and metastatic – can consider termination.
• Patient to consider
  
  • Risk of fetal toxicity for treatment during pregnancy
  • Prognosis & ability to care for her offspring.
  • Effect on future fertility.

Prognosis

• Pregnancy has no negative impact on survival.
• Pregnancy has no negative impact on fetal development.
• Future pregnancy is possible after adjuvant therapy.

Question 7

Breast Feeding

Answer 7

Breast Feeding

• Safe & feasible when not on systemic therapy. Most successful in contralateral breast.
• Affected breast can produce milk but ↓ amount.
• Contraindicated during adjuvant therapy.

Question 8

Sample of Treatment Plans !

Answer 8

Question 9

Overview of Management in difference Trimester of pregnacy

Answer 9

Question 10

Post Pregnancy Counselling

Answer 10

Post Pregnancy Counselling

Discussion regarding Future pregnancy

• Contraception
• Delaying subsequent till completion of adjuvant therapy (e.g HT till 5 to 10 yrs)

Question 11

Overview or first trimester management

Answer 11

Question 12

Overview of 2nd Trimester

Answer 12

Question 13

Overview of 3rd trimester management

Answer 13

Question 14

Overview of the use of anticancer treatments for breast cancer diagnosed during pregnancy.

Answer 14