BREAST CANCER IN PREGNANCY

DEFINITION
- Gestational breast cancer (or pregnancy-associated breast cancer) is defined as breast cancer that is
diagnosed during pregnancy, in the first postpartum year, or any time during lactation.

EVALUATION
- Diagnosis via triple assessment
 MMG not contraindicated
 For bilateral breast assessment.
 Done with fetal shielding,
 Biopsy not contraindicated. However, FNA is not accurate due to proliferative changes. CNB
recommended.
- 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.

MANAGEMENT
- Multidisciplinary approach
- Informed consent is a critical component of choosing appropriate therapy
- Termination of Pregnancy (TOP) is last option. TOP do not improve survival
- Aim:
 Mother : Start treatment as early as possible like non pregnant patients.
 Fetus : Full term delivery at 38 weeks. Earliest is 34 weeks.

LOCOREGIONAL MANAGEMENT
- 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 surgery
 Axillary surgery

BREAST
- Mastectomy
 Avoid need for RT
 Breast reconstruction should be delayed until after delivery
- BCS
 BCS restricted by need for RT to ↓ LR.
 Decision based on need for chemotherapy as RT is given after chemo.
 Chemotherapy indicated
 BCS in 2nd & 3rd trimester.
 Chemotherapy not indicated
 BCS in 3rd trimester
- RT
 Contraindicated in pregnancy even with fetal shielding.
  Radiation sequalae to fetus include pregnancy loss, malformation, growth disturbance,
mutagenic
AXILLA
- ALND
 Standard approach for LN positive & IBC
- SLNB
 Controversial role.
 Sulfur colloid is safe with minimal dose of 500 mCi since fetal exposure is very low.
 Isosulfan blue & methylene blue is contraindicated.

SYSTEMIC THERAPY
- Principles of treatment
 RT is contraindicated during pregnancy
 Chemo is only contraindicated in 1st trimester
 Endocrine therapy in contraindicated in pregnancy
 Trastuzumab is contraindicated in pregnancy

CHEMOTHERAPY
- Delay in chemotherapy is associate with ↓ DFS & OS
- Timing
 Contraindicated in 1st trimester (organogenesis) as associated with congenital abnormalities.
 Can be used in 2nd & 3rd trimester although associated with IUGR, prematurity, LBW.
- Timing of delivery
 Stop chemotherapy 3 – 4 weeks before delivery
 Maternal sepsis & bleeding (thrombocytopenia)
 Risk of transient neonatal myelosuppression & sepsis
- Breast feeding
 Breast feeding should be avoided in women on chemotherapy, endocrine & HER2 therapy.
- Choice of Chemotherapy
 Antracycline based
 Treatment with AC or FAC is safe. Doxorubicin is preferred.
 Taxanes based
 Treatment is feasible
 Methotrexate
 Contraindicated because of teratogenic potential.

ENDOCRINE THERAPY
- Contraindicated in pregnancy & breast feeding (suppress lactation)
- Associated with vaginal bleeding, miscarriage, malformations & death.
- AI with LHRH agonist is also contraindicated.

HER 2 THERAPY
- Trastuzumab in contraindicated in pregnancy.
 Exposure leads to oligohydramnios, pulmonary hypoplasia, skeletal abnormalities & neonatal
death.
- Lapatinib is erbB 2 tyrosine kinase inhibitor. Inhibit HER2 & EGFR.
 Medication is new with no data regarding pregnancy & lactation.
SUPPORTIVE THERAPY
- Antiemetic : Safe in pregnancy
- G-CSF : Sage in pregnancy

TOP (Termination of Pregnancy)

- Decision for TOP is individualized as early termination do not improve outcome.
- Patient has 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.

BREAST FEEDING
- Safe & feasible. Most successful in contralateral breast.
- Affected breast can produce milk but ↓ amount.
- Contraindicated during adjuvant therapy.