Breast cancer in pregnancy is the second most common cancer, with recent incidences estimated at 1 in 3,000. Diagnosis is complicated by physiological changes during pregnancy, and management typically involves a multidisciplinary approach, with surgery being the preferred treatment for non-metastatic cases. Pregnancy has minimal impact on the disease itself, and prognosis remains similar between pregnant and non-pregnant women when adjusted for age and cancer stage.

1. BREAST CANCER IN
PREGNANCY

2. Incidence
• 2nd most common cancer in pregnancy (after cervical
cancer)
• Accounts for 3% of total Ca breast in women
• Exact incidence- difficult to estimate
• Recorded incidence- 1:5000- 1:50,000 (Smith et al, 2003)
• Recent studies- Incidence is 1:3000
• Pregnancy associated breast Ca (PABC)- Ca
diagnosed primarily during pregnancy or 1 year after
it’s termination
• Causes of increased incidence
1. Child bearing at late age
2. Life style changes

3. Effect of Pregnancy on Breast Cancer
• Not simply explained by high dose of estrogen
• Increased AFP and hCG are protective
• PABC are more likely to be advanced/ metastatic
(due to increased blood/ lymphatic supply)
• Microscopic lymph node involvement more likely
in pregnancy (60%)
• Stage I- 30%, Stage II- 30%, Stage III & IV- 40%
• Higher incidence of Inflammatory Cancers
• 80% lesions are ER/PR negative
• Interruption of pregnancy does not alter the
prognosis

4. Does Pregnancy Affect The Prognosis?
• Slight delay in diagnosis- mean delay 1-2 months
• 6 month delay increases chance of nodal
involvement by 10%
• Post-pregnancy breast remodeling may favour
tumour cell dissemination
• Breast cancer is always more aggressive in young
women (so more common at advanced stage)
• NO difference in 5 year survival between
pregnant and non-pregnant women when
matched with age and stage (Bladstrom et al, 2003; Beadle
et al, 2009)

5. Effect of Breast Cancer on Pregnancy
• Disease itself- very little effect, if any
• Adverse effects due to
1. Anaesthetic drugs
2. Radiation
3. Chemotherapy
4. Hormonal agents
• Placental metastasis
 Seen occasionally in inter-villus space
 No transmission to the fetus due to
immune rejection by the trophoblasts

6. Diagnosis
Clinical
• Any suspicious breast
mass must be
evaluated
• Physiological
changes, especially in
lactation makes
diagnosis difficult
• Friction-free
examination may help
Imaging
1. USG- Irregular borders with
shadowing is highly suspicious
2. Mammography
• Fetal exposure only 0.04 cGy
• False negative result 35-40% in
pregnancy
3. MRI
• More sensitive
• No ionizing radiation
• More false positive in pregnancy

7. Diagnosis (Contd.)
Tissue Diagnosis
• If the mass is suspicious/ non-diagnostic
in imaging
• Lactation should be suppressed to
decrease vascularity and chance of milk-
fistula
• Needs expert pathologist
1. FNAC
 High rate of insufficient samples
 Pregnancy induced changes (lobular
hyperplasia, galactostasis)
2. Core biopsy
 Standard of diagnosis
Normal
Pregnancy
Invasive
Cancer

8. Metastatic Workup
1. Chest X-ray-
Should be done (fetal exposure 0.08 cGy)
2. Alkaline Phosphatase-
Unreliable
3. CT scan abdomen
Usually avoided (fetal exposure <2 cGy)
4. Bone scan
Yield is low, selective use (fetal exposure 0.4 cGy)
5. MRI abdomen-
Safer alternative, when indicated clinicaly

9. Differential Diagnosis
Associated with pregnancy
• May undergo H/P changes due to
hormonal stimulation
1. Fibroadenoma
2. Lipoma
3. Papilloma
4. Fibrocystic disease
Peculiar to pregnancy
1. Lactating adenoma
2. Galactocele
3. Mastitis
4. Breast abscess (Wall should be
biopsied)
Bloody nipple discharge
• Cytology is always
warranted
• Not a contraindication to
breast-feeding
1. Physiological
2. Infection
3. Duct papiloma
4. Carcinoma

10. Management
• Multidisciplinary
approach
1. Obstetricians
2. Surgeons
3. Neonatologists
4. Medical Oncologists
5. Anaesthetists
6. Psychiatric Counselors
• Respect patient’s wishes
• If diagnosed post-partum-
lactation to be suppressed
and immediate treatment
to be started

11. Surgery
• Treatment of choice for non-metastatic disease
• Peri-operative hazards- position, anaesthesia, risk
of preterm labour
• Modified radical mastectomy (MRM) with
axillary clearance- done in most cases
• Breast Conserving Surgery (BCT)
 Lumpectomy/ Quadranectomy + Axillary Clearance
 Needs adjuvant RT after delivery (<8 weeks)
 Only for localized Tx diagnosed in 3rd trimester
• Sentinel LN biopsy
 Tc99sulphur colloid- NOT detrimental (fetal exposure 0.5
cGy)

12. Chemotherapy
• Indications- Axillary LN +ve, growth >1 cm, aneuploidy
• Early pregnancy- Teratogenic (3-8 weeks of embryonic
age) → needs MTP
• Late pregnancy- Can be given in late 2nd and 3rd
trimester
• Breast feeding should be avoided during chemo
 CAF (Cyclophophamide, Adriamycin, 5-FU) is the
preferred regime
 CMF-
Methotrexate (Mtx) instead of Adriamycin-
Controversial as Mtx can kill the trophoblasts

13. Other Therapies
• Radiotherapy
Contraindicated- deferred till delivery
Maternal dose of 5000 cGy exposes the fetus to 100-150
cGy
• Immunotherapy
• Trustuzumab-Herceptin (monoclonal Ab against
HER2/neu)
• Limited experience in pregnancy
• May cause oligohydramnios (Shrim et al, 2008; Sekar and Stone, 2007)
• Hormonal therapy
Tamoxifen is teratogenic (Cat D drug)
Aromatase inhibitors- may cause ambiguous genitalia
Oophorectomy- little help

14. Future Pregnancy
• ER/PR +ve breast Ca may be
theoretically aggravated by future
pregnancy (no evidence)
• Most of the recurrence- within 2-3 years
• Better to plan next pregnancy after 2-3
years of completion of therapy
• Chemo may cause POF
• No adverse effect on future obst outcome
• Survival is even BETTER! than those
who don’t conceive
• Breast feeding possible even from the
affected breast after BCT & RT

15. THANK YOU