Breast Cancer in Pregnancy

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Breast Cancer in Pregnancy

• Steven Stanten MD
• Rupert Horoupian MD
• AltaBates Summit Medical Center
• Oakland, California

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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

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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

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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

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Diagnosis

• Clinical exam
• Usually a mass
• Broad differential diagnosis
• Most are benign
• Medical Imaging
• Mammography usually not helpful
• Safety and efficacy

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Diagnosis (cont)

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

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Diagnosis (cont)

• Cytology and Histology
• Biopsy recommended if questions persist
• FNA, core needle biopsy, excisional biopsy
• -rare milk fistula and infection

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Treatment

• Surgery
• Radiotherapy
• Chemotherapy
• Obstetric outcome
• Endocrine therapy
• Supporting agents

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Treatment (cont)

• 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

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Treatment (cont)

• Surgery
• Lumpectomy
• Mastectomy
• Axillary dissection
• Sentinel node biopsy
• Breast conservation is the standard of care when
  appropriate in a non-pregnant patient

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Treatment (cont)

• 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.

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Treatment (cont)

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

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Treatment (cont)

• Surgery
• Try to wait until the 12th week
• Breast conservation - i.e.. Lumpectomy
• Need to consider need for XRT
• Dont give during pregnancy
• Consider neo-adjuvant chemotherapy

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Treatment (cont)

• 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

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Treatment (cont)

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

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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

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Lymphoscintigraphy
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Lymphoscintigraphy
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Sentinel Lymph Node
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Sentinel Lymph Node
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Sentinel Lymph Node
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Treatment (cont)

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

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Treatment (cont)

• Chemotherapy
• Important role
• Advanced disease often
• Teratogenic effects
• Long term safety profile
• Preterm delivery
• Low birth weight
• Transient leukopenia
• IUGR

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Treatment (cont)

• Chemotherapy
• MD Anderson study
• Anthracyclines
• methotrexate

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Treatment (cont)

• Endocrine therapy
• Contraindicated during pregnancy

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Treatment (cont)

• Other agents
• Trastuzumab unknown
• Taxanes - unknown

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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

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Pregnancy after Treatment

• Conflicting data
• 2 years
• 5 years
• Ever?

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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.