breast cancer during pregnancy
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
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
Middleton LP , et al. Cancer 2003;98:1055-6013/46
+ve ER , PR < 30 %
Her-2 / neu over expression 28-58%
p53 50 %
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
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
Teratogenic16 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
26/46
Gold standard
BCS
2nd - 3rd trimester
Axillary LN dissection
SLNB not recommended 27/46
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 29/46
Not offered during pregnancy
Threshold fetal dose for complication
– 10-15 rad 20 wks gestation– 25-50 rad after
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
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 33/46
G-CSF:
- Reduce duration of neutopenia
- Improve overall survival
- safe ?
34/46
• Erythropoietin Scott LL et al.Erythropoietin use I pregnancy: two cases & review
Am JP parinatol 1995;12:22-4
• Ondansteron , metochlopramide
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 forresectable 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 duringpregnancy 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