Breast cancer in pregnancy

Defined by most researchers as breast cancer diagnosed during or up to 1 year post partum.

Breast cancer incidence during pregnancy and lactation is the same as in control, with similar prognosis for age matched controls.

Frequency ranges from 1 in 3000 to 1 in 10,000 deliveries.

Accounts for 0.4% of all breast cancers.

Second most common malignancy in pregnancy after cervical cancer.

The incidence of cancer during pregnancy or lactation is increasing, as the age of childbearing is increasing.

10% of patients with breast cancer who are younger than 40 years will be pregnant at diagnosis.

Patients with pregnancy associated breast cancer are significantly younger than those women with non-pregnancy related breast cancers.

Patients with pregnancy associated breast cancer are twice as likely to be diagnosed with T3-4 primary tumors.

Patients with pregnancy related breast cancer are twice as likely to be HER2 overexpressed and hormonally negative as are non-pregnant associated breast cancer patients.

Usually presents as a painless mass or thickening, but occasionally is associated with nipple discharge.

Imaging studies should avoid radiation with ultrasound regarded as safe, as are chest x-rays and mammograms when shielding is used.

CT should be avoided during pregnancy.

Standard of care is the same for pregnant women as for nonpregnant women.

Studies reveal that breast surgery in pregnancy is safe with no significant excess of obstetrical neonatal or surgical complications.

Patients are more likely to present at a higher stage than nonpregnant counterparts.

Associated with high rates of poor differentiation, hormone receptive negative status, HER-2 positive status, lymphovascular invasion which may not be in excess of and age matched population.

Mean delay in diagnosis 1-2 months.

Meta-analyses show that women diagnosed and treated during pregnancy have no increase in risk of death do the concomitant pregnancy.

MRI evaluation of a breast lesion during pregnancy is not indicated as intravenous gadolinium, which is contraindicated during pregnancy, can cross the placenta and cause fetal abnormalities in animals.

Unenhanced MRI of the breast is not useful for the evaluation of breast cancer.

Evaluating a breast mass during pregnancy can be achieved with ultrasound as opposes no risk to the fetus and has a sensitivity for malignancy approaching 100% (Yang W).

Mammography during pregnancy poses little risk to the fetus and this technique is considered safe with a radiation dose to the fetus from standard bilateral mammography using abdominal shielding estimated to be 0.004 Gy of radiation, but does well below the threshold for malformation in the fetus of 0.05 gray of radiation (Greskovich JF).

Mammography early in pregnancy is associated with lower exposure to the fetus.

Sentinel lymph node sampling during pregnancy is problematic in that isosulfan blue dye and methylene blue dye are vital dye is an pregnancy category C. drugs and radial colloid exposes the fetus to radiation.

Vital blue dyes should not be used during pregnancy, but radial colloid exposure is below the threshold for malformation (Pandit-Taskar N).

Successful radioactive tracer localization of the sentinel lymph nodes without adverse fetal outcome has been demonstrated in the small series (Mondi MM).

During pregnancy and axillary node dissection can be used safely for staging the axilla.

Radiation exposure to a fetus during breast radiotherapy is the result of internal scatter, leakage of radiation from the tube head of the linear accelerator, scatter from the collimator, and other machine components.

There is no dose below which the consequences of radiation exposure to the fetus is nonexistent.

Radiation exposure during weeks 8-25 of gestation exposes the fetus to central nervous system damage risks which may impair intellect from a mild to severe degree depending on the dose and timing of exposure (Kal

Radiation exposure in utero causes an increased lifetime risk of developing a HB). malignancy (Kal HB).

Radiation dose of 50Gy to the whole breast will result in exposure to the fetus of roughly 0.1% to 0.3% of the total dose.

Chemotherapy is avoided in the first trimester, when the risk for getting malformation in the fetus is greatest.

Chemotherapy after the first trimester utilizes regimen of agents.

Taxane therapy usage is typically delayed after delivery because of concerns high levels cytochrome P-450 in pregnant women may increased metabolism of these drugs and limit their effectiveness.

Chimeric agents such as trastuzumab are given after delivery because of the concern that these agents could cross the placenta and cause fetal abnormalities are abnormal development.

Tamoxifen is not givien during pregnancy because it is associated with birth defects.

Postpartum breast cancer is a high risk, underrecognized subset of breast cancer.

Most patients with pregnancy associated breast cancer are diagnosed as s self-palpated breast mass, as they have not undergone screening mammography.

Pregnancy has a dual effect on the incidence of breast cancer, initially promoting it and eventually protective against breast cancer.

Childbirth increases the risk of breast cancer for a decade or more after giving birth.

Eventually prior pregnancies confirm reduction in the risk of postmenopausal breast cancer, especially if a woman was younger than 30 years of age at the time of her first childbirth.

As a result of epidemiologic changes the incidence of postpartum breast cancer will increase worldwide.

Pregnancy associated breast cancer diagnosed during pregnancy is distinct from cases in patients who develop breast cancer several years postpartum.

The 2 types of breast cancer associated with pregnancy are distinct in that they have different levels of risk for recurrence and death.

Women diagnosed with breast cancer five years or more after giving birth to their last child have a threefold increase risk of breast cancer metastases and death.

It is estimated that as many as 12,000 women annually are diagnosed with postpartum breast cancer up to five years from their last childbirth.

The routine termination of pregnancy after a diagnosis of breast cancer does not improve survival (Cardonick E)

The evaluation of survival by stage for a primary diagnosis during pregnancy is similar to that of nonpregnant women matched for stage.

About half of young women with breast cancer wish to become pregnant after completing therapy, and the chances of subsequent pregnancy are reported to be 40-60% lower than in the general population.
Presently, cryo-preservation of oocytes and embryos after controlled ovarian stimulation is the standard strategy for fertility preservation in adult women: several studies have reported that ovarian stimulation for fertility preservation in the setting of breast cancer is safe with regard to relapse free and overall survival.
In a Swedish study of  425 women with breast cancer who underwent fertility preservation at the time of breast cancer diagnosis was associated with significant higher rate of post diagnosis live births and assisted reproduction treatments, without any negative association with all-cause survival during fertility preservation.
Among select women with previous hormone receptor positive early breast cancer, temporary interruption of endocrine therapy to attempt pregnancy did not confirm a greater short-term risk of breast cancer events, including distant recurrence, than that in an external control cohort.
Data have shown that pregnancy following anti-cancer treatments is safe and breast, cancer survivors, even in patients with a prior history of hormone receptor positive disease.
POSITIVE trial shows after completing 18 to 30 months of adjuvant endocrine therapy a temporary interruption for a maximum 24 months does not seem to worse in the prognosis of a young woman with HR positive disease at low or intermediate risk of recurrence.


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