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BREAST CANCER

Breast cancer is the commonest of all cancers in women.

Worldwide, it comprises 22.9% of invasive

cancers in females.

One woman in nine will develop breast cancer during her lifetime, making it the leading cause of death from cancer after lung cancer I n Western women.

25% of all breast cancers occur in women of childbearing age.

Only five percent of patients with breast cancer are less than 40 year old and 1.8% less than 35 years

Age-specific incidence of

breast cancer.

Age : Over 75% of cases in women above 50 years old Family History Proliferative breast diseases : especially when

associated with atypia Enviromental factors:exposure to ionizing radiation

especially at a young age. Obesity: especially in post menopausal. Paersonal history of malignancy: Breast,

endometrial, ovarian. Dietary Factors: high fat diets

Risk Factors

Hormonal factors:

Risk Factors

Endogeous exposure:NulliparityEarly menarcheLate menopause

Exogenous exposure:Hormonal replacement therapyOral contraceptive bills

PREGNANCY ASSOCIATEDBREAST CANCER

Definition:

Pregnancy associated breast cancer (PABC) is defined as any breast carcinoma diagnosed during pregnancy or during the first postpartum year.

Role of pregnancy in Breast Ca. protection

There is a known solid association between parity and a lifetime reduction in breast cancer risk.

Many theories were intoduced, one of which relate the cause to the cellular differentiation associated with pregnancy changes, thus epithelial cells are less liable to proliferate and less susceptible to carcinogenic stimulus.

Dual effect of pregnancy

However, studies of breast cancer incidence in young women demonstrate a clinically underrecognized transient increase in breast cancer risk in the years immediately following pregnancy where all parous women have higher incidence of breast cancer compared with nulliparous women.

This increase in risk has been shown to persist for at least 10 and up to 15 years after birth .

Dual effect of pregnancy

The main contributers to this risk are: 1- Maternal age at 1st full term pregnancy:

35

30

25

40

45

full-term pregnancy offers women some degree of protection

pregnancy is assocIat-ed with a permanent increase in breast cancer risk.

Dual effect of pregnancy

Age and parity appear to act synergistically: with high parity [≥5] and young age [≤20] at first birth associated with the greatest ultimate reduction in lifetime breast cancer risk

2 -Total number of pregnancies:

Dual effect of pregnancy

advanced maternal age and family history act synergistically to increase risk. Women 30 years of age or older at first birth with a family history have a three-fold increased risk over those with no family history, and this risk persists longer, for 20–30 years post-partum.

3 -Family history:

Epidemiology of PABC :

The incidence of PABC is estimated to be about 1 in 3000 pregnancies.

up to 3% of breast cancers are diagnosed in pregnant or lactating women.

10% of women under the age of 40 who develop breast cancer are pregnant when it is diagnosed.

At present, breast cancer is the second most common malignancy in pregnancy (after cervical cancer).

Once thought to be rare,it is expected to increase in frequency as women delay childbearing until later in life .

DIAGNOSIS AND WORK UP

P A B C

PABC usually come with an average delay of 5-7 months as breast changes are mistakenly related to pregnancy.

The average age of patients with breast carcinoma in pregnancy is between 35 and 38 years

History

Most women diagnosed with pregnancy-associated breast cancer will present with a painless mass in the breast .

80% of breast masses presenting during pregnancy are benign.

Clinical presentation

Two categories of radiation related effects in humans:

Imaging

Deterministic effects

Stochastic effects

Imaging

In general, a fetal exposure of less than 100 mGy is considered to provoke no deterministic effects and has an associated risk of stochastical effects of <1% which does not justify termination of pregnancy, according to the recommendations of the International Commission on Radiological Protection (ICRP-84) .

Imaging

Is the standard method for the evaluation of a palpable breast mass during pregnancy.

Ultrasonography

Imaging

Ultrasonography

can usually distinguish cystic lesions from solid lesions, and it is used to guide core biopsy or fine needle aspiration of suspicious breast lesions.

Imaging

Ultrasonography

Breast ultrasound has a high sensitivity and specificity for the diagnosis of PABC.

Imaging

With adequate abdominal shielding, a mammography presents little risk to the fetus all during the tree trimesters .

Mammography

Imaging

The increased water content, higher density and loss of contrasting fat in the proliferating mammary glands of young pregnant women may make mammographic diagnosis difficult (sensitivity less than 70%)

Mammography

Imaging

Digital mammography (DM) is as safe as film-screen mamorgraphy (FM) but more accurate in detecting breast cancer in women aged under 50 years , those who are pre- or perimenopausal, and those with heterogeneously dense.

Mammography

Imaging

MRI is not recommended during the first trimester because the developing embryo is susceptible to injury from various physical agents

MRI

Imaging

Chest radiography is used mainly in staging work up.

It can be carried out safely during pregnancy with proper using of abdominal shielding.

Chest X-ray

Imaging

CT of the abdomen and pelvis are by far the examinations with the highest radiation exposure to the fetus.

CT is used only in staging , however where possible, it should be replaced by ultrasound or MRI.

Computed Tomography

Approximate fetal doses from common radiological diagnostic procedures in the United Kingdom

Pathology

Biopsy of a suspicious mass is the gold standard for the diagnosis of breast cancer.

A core needle biopsy is the technique of choice. The sensitivity of core needle biopsy is around 90%.

Fine Needle aspiration cytology (FNAC) may be misleading and should not be performed during pregnancy.

Pathology

Breast cancers in pregnant women are histologically similar to those in non-pregnant women, with 75% to 90% being ductal cancers.

The incidence of inflammatory tumors probably lies between 1.5% and 4%.

Pathology

pathological lymph node involvement (56–67%)

Lymphovascular invasion

HER-2/Neu overexpression 36% to 58%

ER –PR negative tumors :54% and 80%

High grade

Staging The following points should be taken into

consideration:Staging of PABC is the same as TNM staging of

breast canerIf this risk is low, distance disease staging should be postponed to after delivery. Chest radiography with abdominal shielding to detect pulmonary metastasis .Ultrasound is the best to detect liver metastasis.

MRI is preferred to detect bone metastasis .Bone scan is only recommended in cases of uncertain MRI findings, or when MRI is unavailable.

Staging

Alkaline phosphatase levels may be falsely elevated. Ultrasound is the best to detect liver metastasis.

Echocardiogram prior to anthracycline- based regiments , and is safe.Sites concerning for metastatic disease should be biopsied whenever possible and safe

How to deal with a lady having PABC?

From the psychological point of view

Cancer during pregnancy puts the mother in a difficult situation. A new life is growing inside her and at the same time her own life is threatened.

Also, for the medical team it is a complex setting, because two individuals are involved: the mother and her unborn child.

This difficult situation cannot be helped by a standardised

treatment.

Should be performed by persons skilled in communication skills.

The whole situation should be clear: diagnosis , prognosis , risks and options of treatment.

The information should be given in pieces at several different appointments in a simple , clear and not a blunt language.

Breaking bad news

Communicating risk means confrontation with important uncertainties.

Shared decision-making means that patient with another person ; eg the partener, share in decision making based on the information they gained. It seems to be of benefits like improved patient satisfaction and clinical outcome .

Communicating risks and shared decision-making

As physicians, we have legal obligations , and moral obligations.

This creates a conflict between what we have to do according to medicine rules and the patient autonomy that takes into consideration her opinion and her fears respect.

It is a matter of balance and the art of tailoring.

Understanding the ethical framework

The patients should feel. that all medical stuff are caring for the mother–baby unit as a whole, the problem shouldn’t be considered as a matter of a breast and a uterus.

Inevitably, there will be phases of crisis during the pregnancy, which have to be responded to by psychologically trained members of staff

Bio- psychosocial care

TreatmentPABC

The protocol of treatment should be as close as possible to that offered to non-pregnant women.

Multidisciplinary approach is essential

Termination of pregnancy is indicated in:

Termination of pregnanacy

Advanced disease with dismal prognosis. Poor general patient condition. fetal exposure to more than 100 mGy during

the first trimester. Reluctancy of the parents to accept the risks.

Breast surgery can be offered safely during pregnancy.

Surgery:

Mastectomy

Conservative

The question is: or

The answer depends mainly on “when the diagnosis is made”

surgery:

Is write option at any time of pregnancy .

Here , radiotherapy can be delayed after delivery

Mastectomy

At the end of second and at the third trimester . Radiotherapy again is delayed until after childbirth.

Conservative

So it seems that radiotherapy derives the choice of the type of surgery

?Is there a role for radiotherapy in PABC ?

Radiation doses used in cancer therapy are usually within the range of 4000–7000 cGy which is more than 1000-fold the level in diagnostic radiology.

Radiotherapy

Definitly , radiotherapy is contraindicated in pregnancy

Fetal exposure > 100 mGy can result in abortion or major fetal malformation in the 1st trimester. while exposur to > 250 m Gy in late pregnancy increase incidence of childhood cancer.

Radiotherapy

The only role for RT is in a woman who has a diagnosis of breast cancer made during the first, or early in the second trimester, and insist on preserving her breast.

Here , radiotherapy option should be well discusssed with the patient and her family. RT is given in the 1st or early 2nd trimester with peoper shielding.

Due to their relatively low molecular weight, most cytotoxic agents can cross the placenta.

Chemotherapy

In pregnancy, most chemotherapy are classified as a class D category.

Anthracyclines-based regimens are the most widely used In PABC and has been shown to be associated with favorable safety profile

Chemotherapy

In the metastatic setting, anthracycline-based regimens remain the best choice as well. For patients who are not good candidates for anthracycline-based regimens, single agent taxane would be a preferred option.

Chemotherapy is contraindicated during the first trimester “period of organogenesis”, and should be postponed till the second and third trimester.

Chemotherapy

Chemotherapy should not be given after 34-35 weeks of gestation as spontaneous delivery can occur before bone marrow recovery and before the baby eleminates the chemotherapt by the placenta.

PABC is definitly associated with poor prognosis

Prognosis..

Delayed diagnosis Late stage Young age

Prognosis..

Non PABC PABC TUMOR

38–54% 56–89% LN Metastases

2 cm 3.5 cm Tumor size

The pregnant women had a 2.5-fold higher risk

Diagnosis. at II and III stage

45–66% 65–90% Diagnosed as metastatic

Prognosis..

However, many studies were done to investigate the role of pregnancy itself as an independent predictor of worse survival.

These studies suggesting a similar stage-for-stage prognosis as breast cancer in age matched non- pregnant women.

Therefore, pregnancy itself should not be regarded as a poor prognostic indicator

BREAST CANCER &BREAST FEEDING

Breast cancer diagnosed during Breastfeeding is also included under the term:

PABC

Ultrasound....DD: galactoceleMammography....Dense breast

MRI

Biopsy

Treatment

women undergoing active chemotherapy should not breastfeed. Cytotoxic agents can be detected in small quantities in breast milk and are potentially toxic for the baby.

There should be a time interval of 14 days or more from the last chemotherapy session to resume breastfeeding.

Women taking tamoxifen should not breastfeed.

?Can I breastfeed my baby?

Breast cancer survivors who becomePregnant…

Breast cancer survivors who becomepregnant should be encouraged to breastfeed.

YES

A history of breast surgery and radiation may affect milk supply. Mothers who have undergone mastectomy but no radiation to the remaining breast can often develop a full supply for one infant

Some researchers believe that breastfeeding after breast cancer will have a protective effect on the contralateral breast

Subsequent pregnancy after breast cancer

Amenorrhea is a common problem following adjuvant chemotherapy given to premenopausal women with breast cancer.

Regiments containing Cylophosphamide or taxanes are associated with high level of ovarian failure.

Fertility preservation options:

Gonadotropin releasing-hormone (GnRH) agonist for ovarian protection

Ovarian cortex cryopreservation

oocyte cryopreservation

Embryo cryopreservation

Patients are generally advised to wait at least two years after diagnosis before becoming pregnant.

For women receiving TAM it is better to wait untill the end of the 5 year treatment time before getting a pregnancy.

Thank YOU