Breast Cancer in Pregnancy

Steven Stanten MDRupert Horoupian MD

AltaBates Summit Medical CenterOakland, California

Introduction

• One of the most commonly diagnosed cancers of pregnancy– More advanced stage– Poorer prognosis

• Pregnancy-associated– During pregnancy– During lactation– Up to 12 months post-partum

Epidemiology

• 12.67% within their lifetime

• Mean age 61

• 12.7% between 20 and 44

• Of women with breast cancer before 40, 10% will be pregnant

• 1/3000 pregnancies

Pathology

• Invasive ductal predominates

• Larger in size at presentation

• Higher frequency of lymphovascular invasion

• Higher nuclear grade

• Higher hormonal independence

• Her-2/neu – no concensus

Diagnosis

• Clinical exam– Usually a mass– Broad differential diagnosis– Most are benign

• Medical Imaging– Mammography usually not helpful

• Safety and efficacy

Diagnosis (con’t)

• Medical Imaging– Screening - not when pregnant– UTZ– CXR– Other staging modalities

Diagnosis (con’t)

• Cytology and Histology

Biopsy recommended if questions persist

FNA, core needle biopsy, excisional biopsy

-rare milk fistula and infection

Treatment

• Surgery

• Radiotherapy

• Chemotherapy

• Obstetric outcome

• Endocrine therapy

• Supporting agents

Treatment (con’t)

• No longer a role for termination of pregnancy

• Goals are to achieve control of disease and prevent distant metastasis

• Fetal protective modifications• Multi-disciplinary team

– Medical oncology, surgical oncology, high-risk obstetrics, genetic counseling, psychological support

Treatment (con’t)

• Surgery– Lumpectomy– Mastectomy– Axillary dissection– Sentinel node biopsy

*Breast conservation is the standard of care when appropriate in a non-pregnant patient

Treatment (con’t)

• NSABP trials

– B06 - established the safety of breast conserving surgery for early stage breast cancer and demonstrated the importance of adjuvant breast radiation to minimize risk of in-breast recurrence.

Treatment (con’t)

• Surgery– Lumpectomy

• Anesthesia• Wire localization• X-ray confirmation• Wide margins

Treatment (con’t)

• Surgery– Try to wait until the 12th week– Breast conservation - i.e.. Lumpectomy– Need to consider need for XRT

• Don’t give during pregnancy

– Consider neo-adjuvant chemotherapy

Treatment (con’t)

• Axillary Surgery –

– 2003 - Veronessi demonstrated that sentinel lymph node biopsy was accurate and reliable.

– B32 – sentinel lymph node biopsy is safe and relaible

* ~8-10% false negative rate

Treatment (con’t)

• Axillary surgery– Blue dye– Radioisotope– Filtered vs. unfiltered– Injection site– Timing

Treatment

• Axillary Surgery– Increased incidence of nodal involvement– Consider neo-adjuvant treatment– UTZ and FNA– Sentinel node biopsy has problems

• Isosulfan blue• Radiocolloid

– Consider axillary dissection

Lymphoscintigraphy

Lymphoscintigraphy

Sentinel Lymph Node

Sentinel Lymph Node

Sentinel Lymph Node

Treatment (con’t)

• Radiation Treatment– Risks are highest during first trimester– Decrease gradually– Try to avoid during pregnancy– Risks may be overstated

Treatment (con’t)

• Chemotherapy– Important role– Advanced disease often – Teratogenic effects– Long term safety profile

• Preterm delivery• Low birth weight• Transient leukopenia• IUGR

Treatment (con’t)

• Chemotherapy– MD Anderson study– Anthracyclines– methotrexate

Treatment (con’t)

• Endocrine therapy– Contraindicated during pregnancy

Treatment (con’t)

• Other agents– Trastuzumab – unknown– Taxanes - unknown

Prognosis

• Use TNM staging

• Most women have stage II or III disease

• Same prognosis stage for stage

• Delay in diagnosis has impact

• 60-100% - 5 year survival

• 31-52% - 10 year survival

Pregnancy after Treatment

• Conflicting data

• 2 years

• 5 years

• Ever?

Conclusion

• Due to lack of prospective randomized clinical studies, both ongoing studies and future evidence are expected to solve problems related to breast cancer management during pregnancy.

• Must balance aggressive maternal care with appropriate modifications that will ensure fetal protection.