Breast Cancer in Pregnancy

Breast Cancer in Pregnancy Steven Stanten MD Rupert Horoupian MD AltaBates Summit Medical Center Oakland, 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

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.

Breast Cancer in Pregnancy