Arthur I. Holleb, M.D.

Concomitant breast cancer occurs inabout three of every 10,000 pregnancies in large obstetrical services. In acancer hospital, one finds a relationshipbetween breast cancer and pregnancyin about 19% of cases of women withbreast cancer under the age of 35 years.

Pregnancy accompanying breast cancer poses additional problems to thatof detecting the cancer early enoughfor cure by conventional methods.Should the pregnancy be terminated?Should the young woman who has beentreated for breast cancer be advisedagainst having more children, and ifshe does become pregnant, should atherapeutic abortion be recommended?Literature on pregnancy termination isconfusing. From reports it is difficultto determine whether an abortion wasperformed as a therapeutic, or as aprophylactic procedure, also how oftenit was combined with castration. Thereis, however, uniform agreement that ifprimary treatment fails, the patientwill eventually die of breast cancer regardless of simultaneous or subsequentpregnancy. On the other hand, if thecancer is completely removed, there isno conclusive evidence of added riskto the patient because of co-existent orfuture pregnancies.

I)r. Hal/eli is Associate 3!edical Director amid,4 ssistammt A ft emmdinug Smergeon, 3!enuorial Hospitalfear Caamcer amid Allied Diseases, New York City.

A retrospective review of records ofpatients with breast cancer associatedwith pregnancy as a simultaneous, postpartum or subsequent event shows thefollowing. A very high percentage ofpatients whose breast cancers developed during one of the trimesters ofpregnancy or during the immediatepostpartum period had cancer beyondthe confines of the breast. Approximately 75% of these patients had involvement of the homolateral axillarylymph nodes. Accordingly, one wouldexpect a lower cure rate following radical mastectomy for the entire group.When the axillary lymph nodes are involved, the 5-year clinical cure ratemay be as low as 17%. However, whenthe disease is confined to the breast, the5-year clinical cure rate may reach65%. This speaks strongly for the importance of early diagnosis of breastcancer in the patient who is pregnantor who has just delivered.

It is essential to consider as a separate entity those patients who becomepregnant after breast cancer treatment, since this group is highly selective. Here one finds a low incidence ofinvolved axillary lymph nodes. Whenthe axillary lymph nodes are involved,the 5-year clinical cure rate is about38%. With uninvolved axillary lymphnodes, a 5-year clinical cure rate of64% may be obtained.

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There is no statistical proof that interruption of pregnancy per se will influence patient survival or have anydirect effect on the disease process.Data is insufficient, however, to be dogmatic about this fact since controlledexperiments are difficult to obtain.

Conclusions

On the basis of available information it may be noted that:

1. Breast cancer occurring during gestation or in the immediate postpartum period yields a poor prognosis when the axillary lymph nodesare involved, but one cannot statedogmatically that it is the pregnancy per se which accounts for unfavorable results of treatment, sincethe stage of disease is usually already advanced at the time of radical mastectomy.

2. There is no proof that interruptionof pregnancy improves the 5-yearclinical cure rate or increases thesurvival time.

3. Pregnancy subsequent to radicalmastectomy does not alter the prognosis whether or not a therapeuticabortion is done. However, thisgroup of patients is highly selected, not only by the aggressiveness of the disease but also by therecommendation usually made to

these patients to avoid pregnancyafter radical mastectomy, especiallyin cases in which the axillary lymphnodes are involved.

4. Interruption of pregnancy in theearly trimesters is indicated for thepatient with inoperable breast cancer. Interruption should be combined with oophorectomy as a therapeutic measure. There is not sufficient justification to warrant therapeutic abortion for the patient whohas breast cancer which is classifiedclinically as curable by radical mastectomy. Likewise, no proof existsof the value of therapeutic abortionfor the patient who has had a radical mastectomy and demonstratesno evidence of locally recurrent disease or distant metastases.

5. The relative infrequency of concomitant breast cancer and pregnancy precludes the compilation ofa large enough series for adequatestatistical evaluation.

6. Until therapeutic standards arefirmly established, the wisest policyis to treat cases individually, basedon anticipated prognosis, possiblerisks involved, religious convictions,attitudes of husband and wife toward parenthood, current size offamily, sociologic factors, and otheraspects less easily described.

VIRUSES

Modern conceptsof virusesas carcinogensare changing.A singlemechanism of tumorproduction has become most improbable. The virus need not infect; immunity need not bea deterrent. The gulf between virus cancers of animals and cancers of human beings remainsbut a bridge is visualized.

—¿�Editorial,“¿�CancerAnd Viruses.―JA.M.A. 192: 140, 1965.

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