Breast Cancer during pregnancy
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Breast Cancer during pregnancy

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Breast Cancer during pregnancy Breast Cancer during pregnancy Presentation Transcript

  •  
  •  
    • Cancer complicate 1 / 1,000 pregnancies
    • 1/3 maternal death during pregnancy
    • Commonly diagnosed cancer during pregnancy:
          • Breast cancer
          • Cervical ca
          • Melanoma
          • Thyroid ca
    2/46
    • Diagnostic delay is not rare
    • The management of pregnant mother is difficult
    • Concern :
          • Save mother’s life
          • Protect fetus
          • Intact reproductive system
    3/46
  • 4/46
    • Tumours diagnosed during pregnancy or within one year post partum
    5/46
  • 6/46
    • Diagnosed 1 / 3000 pregnancies
    • Incidence 0.76 – 3.8 %
    • Median age 33 ( 23 - 47 y)
    Saunders CM,Baum M Breast cancer and pregnancy review .J R Soc Med 1993;86:162-5 7/46
  • 8/46
    • Similar to non pregnant lady
    - Painless mass - Nipple discharge - Inflammatory breast 9/46
  • 10/46
  • Histopathology LN Status Receptor status 11/46
  • Histopathology Invasive ductal ca Invasive lobular ca Inflammatory breast ca Middleton LP , et al. Breast carcinoma in pregnant women.Assissment of clinicopathologic & immunohistochemical features. Cancer 2003;98:1055-60 12/46
    • Similar to non pregnant women in :
        • Histological frequencie
        • Grade
    Histopathology Middleton LP , et al. Cancer 2003;98:1055-60 13/46
    • +ve ER , PR < 30 %
    • Her-2 / neu over expression 28-58%
    • p53 50 %
    Receptor status Elledge RM ,et al ER , PR and Her-2/neu protien in breast cancer from pregnant patients. Cancer 1993;71:2499-506 14/46
    • Involved in 60 - 90 %
    • Similar to general population
    LN status Isaac J . Cancer of the breast in pregnancy. Surg clin North Am 1995;75:47-51 15/46
  •  
    • Diagnostic delay
    • Average delay 8.2 months ‘ 2-15 months ‘
    • Advanced breast cancer ‘ 2.5 fold ‘
    Moore HCF, Foster Jr Rs. Breast cancer and pregnancy Semin oncol.2000;27:646-53 17/46
    • FNA
    • Core biopsy – Cost effective
    • Early stage breast ca accounts 60%
    Sorosky JI ,Scott-conner. Breast cancer complicating pregnancy.Obst Gynecol clin North Amer 1998;25(2):353-63 18/46
  •  
  • Radiation effect Dose dependant Gestational age 20/46
  • < 0.1 Gy > 3 Gy Dose No effect Fetal malformation 21/46
  • Teratogenic Gestational age 16 w 2 w Abortion 25 w Sterility malignancy Mole RH.childhood cancer after prenatal exposure to diagnostic x-ray examinations in Britain. Br J Cancer 1990;62:152-68 22/46
    • Ultrasound sensitivity 93 %
    • Diagnostic Mammogram:
    • - 0.004 Gy
    • - sensitivity 70%
    Nicklas A, Baker M. Imaging strategies in pregnant caner patients. Semin oncol 2000;27:623-32 23/46
    • Staging – CXR , Ultrasound
    • Avoid CT
    • Pvlidis NA. The oncologist 2002;7:279-87’
    • MRI
    • - No proof of safety
        • Aloraini et al Ann.Saud.Med. July-Aug. 2006
    24/46
  •  
  • Surgery Chemotherapy Radiotherapy 26/46
    • Gold standard
    • BCS
    • 2 nd - 3 rd trimester
    • Axillary LN dissection
    • SLNB not recommended
    Surgical Rx 27/46
    • Chemotherapy
    Chemotherapy 28/46 teratogenic
    • 2 - 3 trimester
    • CAF , CMF
    • Giacalone PL.et al chmotherapy for breast carcinomaduring
    • pregnancy . Cancer 1999;86:2266-72
    • Epirubicin not recommended
    • Peccatori F. chemotherapy during pregnancy : what is really safe?
    • Lancet oncol 2004;5:398
    • Taxol
    • Eur J Cancer care 2000;9:235-7
    Chemotherapy 29/46
    • Not offered during pregnancy
    • Threshold fetal dose for complication
          • 10-15 rad 20 wks gestation
          • 25-50 rad after
    Radiotherapy Woo JC et al Breast cancer in pregnancy: a literature review. Arch Surg 2003;138:91-8 30/46
  •  
    • Inadequate information
    • Delivery 2-3 wk after Rx
    • Similar survival rate among pregnant & non pregnant lady
    Mother and fetal outcome Petrek JA et al. Prognosis of pregnancy associated breast cancer. Cancer 1991;67:869-72 32/46
    • Rate of malformation 2-3%
    • Stillbirth 5-15%
    • Breast feeding – not recommended
    • Suppression of lactation does not improve prognosis
    Mother and fetal outcome 33/46
    • G-CSF:
    • - Reduce duration of neutopenia
    • - Improve overall survival
    • - safe ?
    Supportive drug 34/46
    • Erythropoietin
    • Scott LL et al.Erythropoietin use I pregnancy: two cases & review
    • Am JP parinatol 1995;12:22-4
    • Ondansteron , metochlopramide
    Supportive drug 35/46
  •  
    • Recommended 1950-1960s
    • Abortion doesn’t prolong survival
    • Currently indicated in :
    • - Very aggressive tumor
    • - Advanced disease with dismal
    • prognosis
    Petrek JA et al. Prognosis of pregnancy associated breast cancer. Cancer 1991;67:869-72 37/46
  • Petrek JA et al. Prognosis of pregnancy associated breast cancer. Cancer 1991;67:869-72
    • Chemotherapy may cause premature ovarian failure
    • Depending upon the woman’s age & the Rx regimen Bonadonna and Valgussa ‘
    39/46
    • CMF
    • > 40 y 96% developed amenorrhoea
    • < 40 y 54%
    • Doxorubicin
    • < 35 y 9% permanent amenorrhea
    • Taxol ???
    40/46
    • Resumption of menstruation doesn’t confirm restoration of fertility
    • It seems that pregnancy after Rx for breast cancer has an increased chance of spontaneous pregnancy loss
    Bonadonna G, Valgussa P. Adjuvant systemic therapy for resectable breast cancer . J Clin Oncol 1985:3:259–75. 41/46
    • Long-term survival after breast cancer not affected by pregnancy
    • five-year survival rate of 80%
    • The survival of women who were node-negative was 90% at ten years
    42/46
    • No difference between those who had subsequent pregnancies & who did not
    43/46
    • Delay pregnancy < 33 years
    • Decisions about future conception based on prognosis :
    • - Stage IV deferring pregnancy for 5 y
    • - Recurrent stage-I or -II should not
    • contemplate conception
    44/46
    • It is recommended that pregnancy should be deferred for at least 2 years after treatment
    Berry et al . Management of breast cancer during pregnancy using a standardized protocol J Clin Oncol 1999 45/46
    • Women planning a pregnancy after Rx for breast cancer should consult their obstetrician, breast surgeon and clinical oncologist
    46/46
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