Breastfeeding in breast cancer survivors: pattern, behaviour and effect on breast cancer outcome

A survey of breastfeeding among women with previous surgery for benign breast disease: a descriptive exploratory study

BACKGROUND

Surgery is the primary treatment for benign breast disease and causes some disruption to the normal physiology of the breast, even when this disruption is localised, it remains unclear whether it affects women's ability to breastfeed. There are only a few studies describing the experience of breastfeeding in women who have undergone benign breast disease (BBD) surgery.

METHODS

We retrospectively analysed data from patients aged 20-40 years in Guangdong, China, who underwent breast lumpectomy for BBD in our department between 01 January 2013 and 30 June 2019, with a follow-up date of 01 February 2022. Patients were included who had a history of childbirth between the time of surgery and the follow-up date. By collecting general information about this group of patients and information about breastfeeding after surgery, we described the breastfeeding outcomes of women of a fertile age who had previously undergone surgery for benign breast disease.

RESULTS

With a median follow-up of 5.9 years, a total of 333 patients met the inclusion criteria. From the breastfeeding data of the first child born postoperatively, the mean duration of 'exclusive breastfeeding' was 5.1 months, and the mean duration of 'any breastfeeding' was 8.8 months. The rate of 'ever breastfeeding' is 91.0%, which is lower than the national average of 93.7%, while the exclusive breastfeeding rate at six months was 40.8%, was higher than the 29.2% national average. The any breastfeeding rate at 12 months was 30.0%, which was well below the 66.5% national average. The common reason for early breastfeeding cessation was insufficient breast milk. A total of 29.0% of patients who had ever breastfed after surgery voluntarily reduced the frequency and duration of breastfeeding on the operated breast because of the surgery.

CONCLUSIONS

There are some impacts of BBD surgery on breastfeeding and some may be psychological. Institutions should provide more facilities for mothers who have undergone breast surgery to help them breastfeed, such as conducting community education on breastfeeding after breast surgery, training professional postoperative lactation consultants in hospitals, and extending maternity leave. Families should encourage mothers to breastfeed with both breasts instead of only the non-operated breast.

A Narrative Review of Breastfeeding and Its Correlation With Breast Cancer: Current Understanding and Outcomes

Breastfeeding has been extensively studied in relation to breast cancer risk. The results of the reviewed studies consistently show a decreased risk of breast cancer associated with breastfeeding, especially for 12 months or longer. This protective effect is attributed to hormonal, immunological, and physiological changes during lactation. Breastfeeding also appears to have a greater impact on reducing breast cancer risk in premenopausal women and specific breast cancer subtypes. Encouraging breastfeeding has dual benefits: benefiting infants and reducing breast cancer risk long-term. Healthcare professionals should provide evidence-based guidance on breastfeeding initiation, duration, and exclusivity, while public health policies should support breastfeeding by creating enabling environments. This review examines the existing literature and analyzes the correlation between breastfeeding and breast cancer risk.

Psychological issues in breast cancer survivors confronted with motherhood: Literature review and a call to action

Breast cancer is currently the most common cancer among women worldwide; in 15-25% of cases, patients are premenopausal at the time of diagnosis, and 50% of women desire pregnancy after cancer diagnosis. Motherhood after breast cancer involves complex psychological challenges with long-term consequences, though it is safely pursuable with adequate support. The purpose of this mini-review is to analyze the psychological implications surrounding pregnancy and motherhood after breast cancer and promote action in addressing the challenges that might affect women facing these life events.

Breastfeeding and the patient's perspective

PURPOSE

The purpose of this article is to summarize available data on breastfeeding in patients with a cancer diagnosis.

MATERIALS AND METHODS

A review of available literature in the MEDLINE database was performed and the data summarized. In addition, two patient interviews were conducted to gain insight into the patient perspective.

RESULTS

Breastmilk is the nutritional standard for human infants and understanding the implications of a cancer diagnosis on lactation is important in optimizing maternal and infant outcomes. Though limited, available data suggest that breastfeeding may be a safe and appropriate option for some patients undergoing treatment of a malignancy.

CONCLUSIONS

Patient experiences with breastfeeding in the setting of a cancer diagnosis vary widely, and depend on the type of malignancy, the timing of the diagnosis, and the indicated treatment. Breastfeeding may be an appropriate option for certain patients after multidisciplinary counseling. Alternatives to breastfeeding exist for patients who are unable to or do not desire to breastfeed.

[Cancer during pregnancy: Proposal of a clinical care pathway based on a regional cohort]

OBJECTIVES

Cancer during pregnancy affects 1 in 1000 pregnancies. This situation requires multidisciplinary team, however there is no care pathway dedicated to these patients. The main objective was to describe oncological, obstetrical, and neonatal care through a regional inventory. Our secondary objective was to define a regional "cancer and pregnancy" care pathway.

MATERIAL AND METHOD

We carried out an observational, retrospective study from 2013 to 2019 including 48 women (all cancer types) from 2013 to 2019 in Occitania. Then, we defined an "optimal care pathway" and we assessed whether it was respected in the breast cancer subgroup of our cohort.

RESULTS

Live births occurred in 79% of the women included. Maternal treatment was initiated during pregnancy for 67% of our population (44% chemotherapy). The most frequent pregnancy complication was preterm delivery (39%), mainly iatrogenic (86.6%). No patient in the group of breast cancer benefited from all of the ten criteria of the "optimal care pathway" that we proposed.

CONCLUSIONS

A coordinated regional care pathway seems necessary to optimize communication between the healthcare providers (oncologists, gynecologists and multidisciplinary prenatal diagnosis centers, pharmacologists, pediatricians, psychologists, and general practitioners). This study identifies weaknesses in the management of women with cancer during pregnancy and suggests regional improvement opportunities.

Micronucleated erythrocytes in peripheral blood from neonate rats fed by nursing mothers exposed to X-rays

Most women with breast cancer can become pregnant and give birth while undergoing radiation therapy and breastfeeding is generally not contraindicated. The induction of long-lived reactive species in proteins, such as casein by X-ray radiation and DNA damage to unexposed organisms, has been shown when ingesting irradiated cheese. To determine whether exposing lactating rats to X-rays increases the number of micronucleated erythrocytes (MNEs) in peripheral blood of their unexposed or breastfeeding rat pups, 15 female Wistar rats were divided into three groups: Negative control; Experimental group exposed to X-rays, and group exposed to X-rays plus vitamin C. The mothers of groups 2 and 3 were irradiated for three consecutive days after giving birth, returning them to their respective cages each time to continue lactation. A blood sample was taken from the mothers and pups at 0, 24, and 48 hr. Blood smears were stained with acridine orange to analyze MNEs. In mother rats, the frequency of micronucleated polychromatic erythrocytes (MNPCEs) increased significantly at 24 and 48 hr in both study groups exposed to radiation. Likewise, in rat pups the MNPCE and MNE frequencies increased in both groups with radiation and radiation plus vitamin C at 24 and 48 hr, and a protection from vitamin C was observed. In conclusion, the genotoxic damage produced in rat pups that were lactated by mothers irradiated with X-rays is possibly due to the effect of long-lived reactive species that were formed in the breast milk of female Wistar rats during the irradiation process.

Breastfeeding is Possible: A Systematic Review on the Feasibility and Challenges of Breastfeeding Among Breast Cancer Survivors of Reproductive Age

BACKGROUND

Breastfeeding is the biologically normative mode of feeding human infants, and reduces the risk of breast cancer for mothers. This systematic review assesses engagement in breastfeeding and the factors associated with breastfeeding among breast cancer survivors.

METHODS

An online literature search was performed using the PubMed, Embase, CINAHL, PsychInfo, and Web of Science databases. Inclusion criteria were original research articles written in English, published in peer-reviewed journals from 1 January 1990 to 25 November 2019, and included data on breast cancer survivors who attempted breastfeeding.

RESULTS

Thirteen studies were included in the systematic review. Between 7.7 and 90.9% of women attempted breastfeeding. Breastfeeding among participants varied from a few weeks to approximately 2 years. Common factors leading to breastfeeding were use of the contralateral breast, support from others, lactation counseling and advice from an International Board-Certified Lactation Consultant, being motivated to breastfeed, frequent feedings, and use of galactagogues. Common barriers were medical counseling against breastfeeding, insufficient milk production, lack of support, refusal of the infant to breastfeed from the treated breast, and being tired from relying on one breast.

CONCLUSIONS

Breastfeeding from the unaffected breast is feasible for some breast cancer survivors. Successful breastfeeding may require multilevel support and expert advice.

Lactation during and after Breast Cancer

Breastfeeding is an important aspect of mother-newborn relationship and is of great benefit for the baby. Unfortunately, many drugs taken by the mother may pass into her milk and exert an effect on the newborn. Very limited data is available and a cautionary approach is warranted especially when the woman receives anticancer treatment including chemotherapy , hormonal treatment and the recently introduced target agents as well as monoclonal antibodies. In all these conditions breastfeeding should be put on hold.More and more often physicians are faced with women that are pregnant years after the diagnosis of cancer: this has long been considered dangerous for the mother, but data show that prognosis is definitely not worse. If the woman is no longer being actively treated, breastfeeding is advisable every time it is possible, even if patients that received breast radiation may be unable to produce a sufficient amount of milk on that side.

Radiotherapy in Pregnancy-Associated Breast Cancer

Breast radiotherapy during pregnancy is a matter of debate as both the efficacy of treatment and the safety of the developing fetus should be considered. Currently there is not enough data to support the safety of in-utero exposure to radiation even with modern radiotherapy techniques. So it is highly recommended that breast radiotherapy is postponed to after delivery, though it might be considered in very selected patients according to risk-benefit assessment.

Breast cancer and pregnancy

Background In the past decades the incidence of pregnancy-associated breast cancer (PABC) increased. Possible explanations are the trend to postpone childbearing and the general increase in the incidence of breast cancer. Materials and methods A sytematic review of the literature was performed with the aim to report on incidence, diagnosis, treatment and prognosis of breast cancer during pregnancy. We also cover the issue of pregnancy following a diagnosis of breast cancer including fertility preservation and prognosis. Results Ultrasound is the imaging method of choice in pregnancy, but mammography can also be performed as the fetal irradiation dose is low. To avoid a delay in diagnosis every sonographic mass in pregnant women which does not clearly correspond to a cyst needs further investigation by biopsy. Treatment should follow as close as possible the guidelines for non-pregnant patients. Administration of chemotherapy is possible after the first trimester. There is a large body of evidence for the use of anthracyclines. In contrast radiotherapy, trastuzumab and antihormonal treatment by tamoxifen are contraindicated during pregnancy. Pregnancy does not seem to influence prognosis. Most adverse obstetric outcomes are related to preterm delivery, which should therefore, whenever possible, be avoided. Young patients with breast cancer and incomplete family planning should be referred for counseling about fertility preservation options before the initiation of adjuvant treatment. A pregnancy following breast cancer does not have a negative impact on prognosis. Conclusion Multidisciplinary management of women with breast cancer in pregnancy is mandatory and data should be collected to allow further improvement in management.

Malignancies in pregnancy

Malignancy complicating pregnancy is fortunately rare, affecting one in 1000 to one in 1500 pregnancies. Optimal treatment involves balancing the benefit of treatment for the mother while minimizing harm to the fetus. This balance is dependent on the extent of the disease, the recommended course of treatment, and the gestational age at which treatment is considered. Both surgery and chemotherapy are generally safe in pregnancy, whereas radiation therapy is relatively contraindicated. Iatrogenic prematurity is the most common pregnancy complication, as infants are often delivered for maternal benefit. In general, however, survival does not differ from the nonpregnant population. These patients require a multidisciplinary approach for management with providers having experience in caring for these complex patients. The aim of this review was to provide an overview for obstetricians of the diagnosis and management of malignancy in pregnancy.

Attitudes on fertility issues in breast cancer patients: an Italian survey

BACKGROUND

Fertility issues should be discussed with young women before the start of any anticancer treatment. The study is aimed to investigate the attitude on fertility among Italian oncologists and breast surgeons dealing with BCa, and to report the consensus achieved on specific statements.

METHODS

One hundred and sixty-two panelists anonymously expressed an opinion through a web-based platform on 19 statements based on the Delphi method.

RESULTS

Ninety-one percent of oncologists considered important to discuss with patients about fertility issues and 83% believed estrogens could stimulate the growth of hidden cancer cells in ER(+) tumors. Difficulties in accessing fertility preservation procedures were mainly due to patients' reluctance, but also to lack of coordination with the assisted reproduction specialists. No full consensus was reached on the prognostic role of pregnancy after BCa. Fifty-four percent of oncologists declared that pregnancy does not affect oncologic prognosis. Treatment with GnRHa during chemotherapy was considered the only mean for preserving ovarian function.

CONCLUSIONS

Fertility preservation in BCa patients is a well-accepted practice among Italian oncologists. A poor knowledge of this specific issue emerged from the survey, even if a certain degree of agreement was observed on most fertility-related issues.

Fertility preservation and breast cancer: a review

Breast cancer is the most common malignancy in women, and its incidence increases with age, with the majority of patients diagnosed after menopause. However, in 15–25% of cases, patients are premenopausal at the time of diagnosis, and about 7% of them are below the age of 40. Therefore, a considerable amount of young women are diagnosed with breast cancer during their reproductive life. Within this group, most cancer cases require cytotoxic chemotherapy and/or hormone therapy, which are responsible for a decrease in the patients’ reproductive function, along with their age. The efficacy of such treatments, among other factors, has led to a high five-year-survival rate, which results in an increasing number of young women who survive breast cancer before having fulfilled their reproductive wishes, especially considering the current trend to delay pregnancy until the late 30s or early 40s in developed countries. The combination of these factors justifies the importance of fertility preservation and reproductive counselling at the time of breast cancer diagnosis in young women.

A wide range of fertility preservation techniques has been developed, such as ovarian suppression, oocyte and embryo cryopreservation, immature oocyte retrieval and in vitro maturation, and ovarian tissue cryopreservation.

Early counselling and referral of these patients to fertility specialists are fundamental factors in order to maximise their chances of pregnancy. This review aims to update the knowledge about the influence of breast cancer in fertility, the influence of pregnancy and fertility preservation techniques in breast cancer patients and assessment of ovarian reserve for a better treatment choice. A special section dedicated to BRCA-mutation carriers has been included because of their specific features.

A comprehensive literature search has been conducted, including publications from the last five years.

Cancer and pregnancy: an overview for obstetricians and gynecologists

A relatively rare occurrence, pregnancy-associated cancer affects approximately 1 in 1000 pregnancies. Optimizing treatment of the cancer and minimizing harm to the fetus are often dependent on the extent of disease, treatment options required, and the impact on the pregnancy as well as the gestational age of pregnancy. When malignancy is diagnosed, the obstetrician-gynecologist plays a key role in the diagnosis, initial evaluation, and coordination of patient care. Furthermore, the obstetrician-gynecologist may be asked to assist in fertility planning for young women with a new diagnosis of cancer and may be responsible for addressing questions about family-planning needs and the safety of future pregnancy. Therefore, the purpose of this article was to provide the obstetrician-gynecologist with a relevant overview of the current literature regarding concurrent pregnancy and cancer diagnoses, management options, including maternal and neonatal outcomes, as well as the future needs of young women diagnosed with cancer who desire fertility preservation.

Current evidence supporting fertility and pregnancy among young survivors of breast cancer

Approximately 6% of invasive breast cancer is diagnosed in women younger than age 40 of age childbearing potential. Cancer-directed therapies can cause hormonal and anatomical changes that negatively affect the reproductive potential of young survivors of breast cancer. Recent national guidelines on fertility preservation are widely available. However, gaps in care exist in the interdisciplinary evidence-based management of young survivors of breast cancer with fertility and parenting concerns after cancer treatment.

Chemotherapy, targeted agents, antiemetics and growth-factors in human milk: how should we counsel cancer patients about breastfeeding?

An increasing number of women are diagnosed with cancer during pregnancy and lactation. Women are usually advised to interrupt breastfeeding during systemic anticancer treatment for fear of serious adverse effects to the nursed infant. However, the issue is poorly addressed in the literature and very few studies have evaluated the safety of breastfeeding during or after cytotoxic drugs or target agents administration. In this review we will analyze the available evidence that addresses the issue of anticancer drugs, targeted agents, antiemetics and growth-factors excretion in human milk. This could serve as a unique resource that may aid physicians in the management of breastfeeding cancer patients interested in maintaining lactation during treatment.

Prognostic impact of pregnancy after breast cancer according to estrogen receptor status: a multicenter retrospective study

PURPOSE

We questioned the impact of pregnancy on disease-free survival (DFS) in women with history of breast cancer (BC) according to estrogen receptor (ER) status.

PATIENTS AND METHODS

A multicenter, retrospective cohort study in which patients who became pregnant any time after BC were matched (1:3) to patients with BC with similar ER, nodal status, adjuvant therapy, age, and year of diagnosis. To adjust for guaranteed time bias, each nonpregnant patient had to have a disease-free interval at least equal to the time elapsing between BC diagnosis and date of conception of the matched pregnant one. The primary objective was DFS in patients with ER-positive BC. DFS in the ER-negative cohort, whole population, and overall survival (OS) were secondary objectives. Subgroup analyses included DFS according to pregnancy outcome and BC-pregnancy interval. With a two-sided α = 5% and β = 20%, 645 ER-positive patients were required to detect a hazard ratio (HR) = 0.65.

RESULTS

A total of 333 pregnant patients and 874 matched nonpregnant patients were analyzed, of whom 686 patients had an ER-positive disease. No difference in DFS was observed between pregnant and nonpregnant patients in the ER-positive (HR = 0.91; 95% CI, 0.67 to 1.24, P = .55) or the ER-negative (HR = 0.75; 95% CI, 0.51 to 1.08, P = .12) cohorts. However, the pregnant group had better OS (HR = 0.72; 95% CI, 0.54 to 0.97, P = .03), with no interaction according to ER status (P = .11). Pregnancy outcome and BC-pregnancy interval did not seem to impact the risk of relapse.

CONCLUSION

Pregnancy after ER-positive BC does not seem to reduce the risk of BC recurrence.

The European Society of Breast Cancer Specialists recommendations for the management of young women with breast cancer

EUSOMA (The European Society of Breast Cancer Specialists) is committed to writing recommendations on different topics of breast cancer care which can be easily adopted and used by health professionals dedicated to the care of patients with breast cancer in their daily practice. In 2011, EUSOMA identified the management of young women with breast cancer as one of the hot topics for which a consensus among European experts was needed. Therefore, the society recently organised a workshop to define such recommendations. Thirteen experts from the different disciplines met for two days to discuss the topic. This international and multidisciplinary panel thoroughly reviewed the literature in order to prepare evidence-based recommendations. During the meeting, two working groups were set up to discuss in detail diagnosis and loco-regional and systemic treatments, including both group aspects of psychology and sexuality. The conclusions reached by the working groups were then discussed in a plenary session to reach panel consensus. Whenever possible, a measure of the level of evidence (LoE) from 1 (the highest) to 4 (the lowest) degree, based on the methodology proposed by the US Agency for Healthcare Research and Quality (AHRQ), was assigned to each recommendation. The present manuscript presents the recommendations of this consensus group for the management of young women with breast cancer in daily clinical practice.

Fertility after breast cancer

Breast cancer is the most common tumor in childbearing women. In the last decades, considerable improvement in breast cancer-related death has been achieved with adjuvant therapies (chemotherapy, endocrine and targeted therapies, radiotherapy) but at cost of significant long-term sequels, including infertility. Reproductive issues are of great importance to young women, in particular for those who did not complete their families before breast cancer diagnosis: patients should be adequately informed at the time of diagnosis about the risk of infertility and the available methods for fertility preservation. This review will focus on incidence and impact of infertility secondary to breast cancer treatment, the available options for ovarian function preservation, including embryo and oocyte cryopreservation, ovarian tissue cryopreservation, and ovarian suppression with gonadotropin-releasing hormone agonists. We will also discuss the optimal time of subsequent pregnancy, the potential risks for the mother and the fetus, and the impact of therapies on breastfeeding.

Pregnancy after Breast Cancer: Myths and Facts

Most young breast cancer survivors consider reproductive issues to be of great importance, but many questions remain undervalued and unanswered. Overall, available data support the safety and feasibility of pregnancy and breastfeeding after breast cancer. The accuracy of the evidence is however limited by: i) the retrospective and frequently incomplete population-based nature of the data, ii) data not representing the entire population, iii) patient-related effects, iv) underpowered sample size, and v) lack of control for biological factors and risk determinants. We review the available evidence in light of these limitations which outline the need for prospective data collection and focused priority research.

Motherhood after breast cancer: searching for la dolce vita

Advances in the field of adjuvant therapy in breast cancer have led to significant improvements in breast cancer survival. This has resulted in a progressive decline in breast cancer-related mortality, such that in 2010 there were estimated to be 400,000 breast cancer survivors under the age of 40 in the USA. Hence, enquiry into the feasibility of fertility preservation, subsequent pregnancy and breastfeeding is increasingly encountered. Fertility counseling remains suboptimal in breast cancer clinics, and there is a wide perception that pregnancy could worsen the prognosis of young breast cancer survivors, despite the lack of evidence supporting this notion. In addition, fertility preservation by means of embryo or oocyte cryopreservation requires ovarian stimulation, which is associated with a significant rise in estradiol levels and might delay initiation of therapy. All these factors, and others, have influenced the quality of fertility counseling offered to young breast cancer patients. In this article, we will critically analyze the available clinical and biological evidence on the safety and feasibility of pregnancy and breastfeeding following breast cancer. In addition, we will discuss the different fertility-preservation techniques available for these patients.

Long-term toxic effects of adjuvant chemotherapy in breast cancer

Breast cancer is the most common malignant tumor affecting women. Adjuvant systemic therapies have been shown to have a significant impact on reducing the risk for breast cancer recurrence and overall mortality. Chemotherapy remains an important and frequently used treatment option in the adjuvant setting, and the associated short-term adverse events are very well described. However, there is insufficient information regarding the long-term sequelae of most chemotherapeutic agents. In this review, we describe different potential long-term adverse events associated with adjuvant chemotherapy in breast cancer, with a particular focus on long-term cardiac toxicity, secondary leukemia, cognitive function, and neurotoxicity. In addition, we discuss the effect of adjuvant chemotherapy on fertility and sexual function of young breast cancer patients. These adverse events are frequently overshadowed by the well-demonstrated clinical efficacy and/or reassuring short-term safety profiles of the different chemotherapy regimens commonly used today. We believe that a proper understanding and appreciation of these adverse events will enable us to refine our strategies for managing breast cancer. The fact that adjuvant chemotherapy is often given to patients who might not really need it urges us to consider the whole spectrum of chemotherapy risks versus benefits to maximize benefit without compromising quality of life.