Breast cancer and pregnancy: a diagnostic and management dilemma

Long-term Mortality in Individuals Diagnosed With Cancer During Pregnancy or Postpartum

Importance

Outcomes among patients with pregnancy-associated cancers (diagnosed during pregnancy or 1-year postpartum) other than breast cancer have received relatively little research attention. High-quality data from additional cancer sites are needed to inform the care of this unique group of patients.

Objective

To assess mortality and survival in premenopausal women with pregnancy-associated cancers, with a particular focus on cancers other than those of the breast.

Design, Setting, and Participants

This population-based retrospective cohort study included premenopausal women (aged 18-50 years) living in 3 Canadian provinces (Alberta, British Columbia, and Ontario) diagnosed with cancer between January 1, 2003, and December 31, 2016, with follow-up until December 31, 2017, or date of death. Data analysis occurred in 2021 and 2022.

Exposures

Participants were categorized as being diagnosed with cancer during pregnancy (from conception to delivery), during the postpartum period (up to 1 year after delivery), or during a time that was remote from pregnancy.

Main Outcomes and Measures

Outcomes were overall survival at 1 and 5 years and time from diagnosis to death due to any cause. Cox proportional hazard models were used to estimate mortality adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs), adjusting for age at cancer diagnosis, cancer stage, cancer site, and days from diagnosis to first treatment. Meta-analysis was used to pool results across all 3 provinces.

Results

During the study period there were 1014, 3074, and 20 219 participants diagnosed with cancer during pregnancy, postpartum, and periods remote from pregnancy, respectively. One-year survival was similar across the 3 groups, but 5-year survival was lower among those diagnosed with cancer during pregnancy or postpartum. Overall, there was a greater risk of death due to pregnancy-associated cancer among those diagnosed during pregnancy (aHR, 1.79; 95% CI, 1.51-2.13) and postpartum (aHR, 1.49; 95% CI, 1.33-1.67); however, these results varied across cancer sites. Increased hazard of mortality was observed for breast (aHR, 2.01; 95% CI, 1.58-2.56), ovarian (aHR, 2.60; 95% CI, 1.12-6.03), and stomach (aHR, 10.37; 95% CI, 3.56-30.24) cancers diagnosed during pregnancy, and brain (aHR, 2.75; 95% CI, 1.28-5.90), breast (aHR, 1.61; 95% CI, 1.32-1.95), and melanoma (aHR, 1.84; 95% CI, 1.02-3.30) cancers diagnosed postpartum.

Conclusions and Relevance

This population-based cohort study found that pregnancy-associated cancers had increased overall 5-year mortality, though not all cancer sites presented the same risk.

Breast cancer treatment patterns by age and time since last pregnancy in the Carolina Breast Cancer Study Phase III

PURPOSE

To describe breast cancer treatment patterns among premenopausal women by age and time since last pregnancy.

METHODS

Data were analyzed from 1179 women diagnosed with premenopausal breast cancer in the Carolina Breast Cancer Study. Of these, 160 had a recent pregnancy (within 5 years of cancer diagnosis). Relative frequency differences (RFDs) and 95% confidence intervals (CIs) were used to compare cancer stage, treatment modality received, treatment initiation delay (> 30 days), and prolonged treatment duration (> 2 to > 8 months depending on the treatment received) by age and recency of pregnancy.

RESULTS

Recently postpartum women were significantly more likely to have stage III disease [RFD (95% CI) 12.2% (3.6%, 20.8%)] and to receive more aggressive treatment compared to nulliparous women. After adjustment for age, race and standard clinical tumor characteristics, recently postpartum women were significantly less likely to have delayed treatment initiation [RFD (95% CI) - 11.2% (- 21.4%, - 1.0%)] and prolonged treatment duration [RFD (95% CI) - 17.5% (- 28.0%, - 7.1%)] and were more likely to have mastectomy [RFD (95% CI) 14.9% (4.8%, 25.0%)] compared to nulliparous. Similarly, younger women (< 40 years of age) were significantly less likely to experience prolonged treatment duration [RFD (95% CI) - 5.6% (- 11.1%, - 0.0%)] and more likely to undergo mastectomy [RFD (95% CI) 10.6% (5.2%, 16.0%)] compared to the study population as a whole.

CONCLUSION

These results suggest that recently postpartum and younger women often received prompt and aggressive breast cancer treatment. Higher mortality and recurrence among recently pregnant women are unlikely to be related to undertreatment.

Prognosis of breast cancer diagnosed during pregnancy and early postpartum according to immunohistochemical subtype: A matched case-control study

PURPOSE

Pregnancy-associated breast cancer (PABC) poses a clinical challenge and its prognosis remains controversial. During the pregnancy and postpartum periods, the breast undergoes biological events that may uniquely influence disease behavior and treatment response. This study aimed to assess if a PABC diagnosis influences survival compared to non-PABC.

METHODS

A single-center record review was performed to identify PABC patients diagnosed from January 2007 through June 2018. Two controls were matched to each PABC case by stage, immunohistochemical (IHC) subtype, age (± 3) and year of diagnosis (± 2). Disease-free survival (DFS) and overall survival (OS) were estimated with the Kaplan-Meier method and compared with the log-rank test. Multivariate analysis was used to assess the impact of PABC on outcomes.

RESULTS

125 PABC patients (pregnant: 62; postpartum: 63) and 250 controls were included. Median follow-up was 67.7 and 73.4 months, respectively. 4-year DFS was 62% in pregnant vs 78% in controls (p = 0.010), and 63% in postpartum vs 83% in controls (p = 0.034). Subanalysis by IHC subtype revealed a significantly inferior DFS in PABC with hormone receptor-positive/HER2-negative (p = 0.032) and HER2-positive disease (p = 0.005) compared to corresponding non-PABC patients. 4-year OS was similar between case groups and controls. Multivariate analysis supported the independent impact of pregnant and postpartum status on DFS (p < 0.05).

CONCLUSION

Patients diagnosed during pregnancy and early postpartum are at high risk of recurrence. Further research is warranted to better characterize PABC tumor biology and enable the identification of novel therapeutic interventions to improve treatment outcomes.

Trastuzumab in the Treatment of Pregnant Breast Cancer Patients - an Overview of the Literature

Breast cancer is one of the most common malignancies which appear during pregnancy. Since women are increasingly not giving birth until they are at a more advanced age, it can be assumed that the incidence of pregnancy-related breast cancers will continue to increase in the future. Because of pregnancy-induced changes and conservative diagnosis, these carcinomas are frequently not detected until they are at an advanced stage and thus generally require systemic adjuvant therapy. The available data on optimal chemotherapeutic management are limited. Particularly for the use of the target agent trastuzumab which could crucially contribute to improving the prognosis in the therapy of HER2-overexpressing breast cancer in non-pregnant women, there is a lack of definitive information regarding the profile of action and safety in pregnancy as well as with regard to any long-term effects on the child. Thirty-eight pregnancies on trastuzumab for the treatment of breast cancer were able to be analysed in the literature currently available. Information can be gained from this and conclusions can be drawn which can individualise and decisively improve therapeutic options in the future for the pregnant breast cancer patient.

Long-term treatment after preoperative high-dose chemotherapy in a lactating breast cancer patient

Breast cancer during lactation is very rare, accounting for <3% of all breast cancers. Its diagnosis and treatment is often delayed during pregnancy. We report a case of female lactating breast carcinoma in a 29-year old patient. The disease was stage IIIB (T4N1M0). The patient received preoperative induction chemotherapy and high-dose chemotherapy with peripheral blood stem cell support, followed by adjuvant chemotherapy and endocrine therapy. The metastases were detected 17 months after operation, palliative treatment including different chemotherapy for 60 cycles, locoregional radiotherapy and endocrine therapy. The total number of cycles of chemotherapy was 67, and the survival time was 118 months. We discuss the diagnosis and treatment options for breast cancer during lactation, based on a literature review.

Increased mortality in women with breast cancer detected during pregnancy and different periods postpartum

BACKGROUND

Because of a continued trend toward postponed childbearing, the incidence of pregnancy-associated breast cancer (PABC) is likely to increase. This study investigated the mortality in women with PABC in relation to when the tumor was detected (during pregnancy, different postpartum periods) and by time since diagnosis, compared with women with non-PABC.

METHODS

A population-based cohort study of 15,721 Swedish women diagnosed with breast cancer between ages 15 to 44 years, of whom 1,110 (7%) had a PABC (diagnosed during or within two years after pregnancy). Information on outcome and potential confounders was obtained from population-based health registers. Mortality rates and HRs with 95% CIs were estimated.

RESULTS

Women with PABC had higher mortality compared with women with non-PABC diagnosed at the same age and calendar period. Among women with PABC, 46% died within 15 years after diagnosis, whereas 34% died among non-PABC patients. The mortality in both groups peaked at around two years after diagnosis, with the highest peak occurring in women diagnosed 4 to 6 months after delivery (HR = 3.8, 95% CI: 2.4-5.9). An increased mortality among women with PABC remained until 10 years after diagnosis.

CONCLUSIONS

Women with PABC had a poorer prognosis compared with women with breast cancer and no recent birth. The mortality increase was most pronounced in the subgroup of women diagnosed shortly after delivery.

IMPACT

An increased awareness among clinicians may help reduce the mortality in women with PABC, for example, by avoiding undue delays in diagnosis and treatment.

Diagnosis and therapy of gestational breast cancer: a review

PURPOSE

In spite of the general consensus on the issue, to point to major dilemmas which appear in this matter of multidisciplinary interest, and to review current concepts on how to achieve optimal diagnostic and therapeutic outcome.

RESULTS

Recent literature data show that the rate of gestational breast cancer, according to most protocols, range from 0.2% to 3.8%. By definition, the clinical manifestation of this type of carcinoma is expected to occur during pregnancy or within one year after delivery. The mode of treatment and prognosis is identical to those of women with breast carcinoma beyond pregnancy, except for radiotherapy that is not indicated during pregnancy and selective use of cytostatics in polychemotherapy during the first trimester. The only exceptions to this practice are women with any advanced stage of the disease due to delayed diagnosis. Results of large studies indicate that the therapy for breast cancer has no adversarial effect on the prognosis of subsequent pregnancy.

CONCLUSION

The evaluation and management of women with gestational breast cancer requires a multidisciplinary approach. A chemotherapeutic regimen should be individualised to a maximum reduction of risk, if applied in the second and third trimester. Surgical therapy may include mastectomy and sparing operative procedures. Sentinel node biopsy should be considered in node negative patients. Radiotherapy should be postponed to the postpartum period.

Successful pregnancy after breast cancer therapy: dream or reality?

Background

Nowadays, more breast cancer patients want to have children after the diagnosis of cancer. The purpose of this study is to review the possibility and risks of giving birth among women with breast cancer previously treated by chemotherapy.

Case presentation

Two young women aged 28 and 34 respectively, were treated in our clinic for breast cancer, the first (negative hormonal receptors) by surgery, chemotherapy and radiotherapy and the second (positive hormonal receptors) by surgery, radiotherapy and tamoxifen. They both became pregnant, 1 and 8 years after completion of the therapy respectively.

Results

Laboratory testing during pregnancy was negative in both cases and after an uneventful course each woman gave birth to a perfectly healthy child. The first patient breastfed her baby for three months, while the second one did not breastfeed her baby at all.

Conclusion

Women undergoing chemotherapy for breast cancer can maintain their fertility and get pregnant. Previous chemotherapy for breast cancer does not present any supplementary risks for the child's mental or physical health.

[Breast carcinoma during pregnancy]

Pregnancy associated breast cancer includes cancers concurrent with pregnancy and those diagnosed up to 1 year after delivery. The incidence of breast carcinoma in pregnancy is estimated to be approximately 1 in 3000 pregnancies. Due to the difficulties of clinical breast examination, diagnosis is frequently delayed and made when the cancer stage has progressed. Consequently, prognosis is usually poor. Treatment options are limited by concern about harming the fetus and depend on gestational age. We present the case of a 34-year-old woman who was diagnosed with cancer of the right breast in the 28th week of gestation. The patient underwent modified radical mastectomy. This association is uncommon but is not exceptional. Knowledge of cases such as that reported herein will allow early diagnosis and improve the prognosis of these patients.

Ovarian function and childbearing issues in breast cancer survivors

The increasing number of breast cancer survivors makes the issues of ovarian dysfunction and childbearing ability more and more relevant for the quality of life of these patients. The incidence of ovarian dysfunction is related to patient age, the specific agents used and the total dose administered, especially the dose of alkylating agents such as cyclophosphamide. Amenorrhea rates following combination chemotherapy consisting of cyclophosphamide + methotrexate + 5-flurouracil (CMF regimen) range from 21 to 71% in women aged 40 years and younger, and from 40 to 100% in older ones. In most series anthracycline-based adjuvant chemotherapy regimens appear to have a lower incidence of amenorrhea, which is probably due to the lower cumulative cyclophosphamide dose administered compared with that given in the CMF regimen. Few data are currently available regarding ovarian function in women treated with taxane-based chemotherapy. In a recent retrospective study on 191 patients, the amenorrhea rate was 64% for women who received doxorubicin + cyclophosphamide (AC regimen) followed by a taxane, compared with 55% (p = 0.05) for those treated with AC alone. Forty percent of women aged 40 years or younger resumed menstruation, whereas the amenorrhea was more likely to be irreversible in older women; however, the addition of a taxane did not change the reversibility rate. Ovarian reserve can be tested with serum assays of follicle-stimulating hormone, inhibin B, estradiol and anti-Müllerian hormone, as well as by ultrasound assessment of antral follicle count. A review of literature data failed to show that a subsequent pregnancy increases the risk of recurrence and death in breast cancer survivors, and some series have even detected longer survival for patients who get pregnant after breast cancer treatment. This apparent survival benefit, probably due to a selection bias called the 'healthy mother effect', suggests that breast cancer survivors who subsequently conceive are a self-selecting group of women with better prognosis. The little available information appears to show no increase in the incidence of prematurity, stillbirth or congenital malformations in their babies. In conclusion, future pregnancy is a viable option for a woman treated for early-stage breast cancer and does not appear to be detrimental to either the mother or her offspring.

Contraindications of sentinel lymph node biopsy: are there any really?

BACKGROUND

One of the most exciting and talked about new surgical techniques in breast cancer surgery is the sentinel lymph node biopsy. It is an alternative procedure to standard axillary lymph node dissection, which makes possible less invasive surgery and side effects for patients with early breast cancer that wouldn't benefit further from axillary lymph node clearance. Sentinel lymph node biopsy helps to accurately evaluate the status of the axilla and the extent of disease, but also determines appropriate adjuvant treatment and long-term follow-up. However, like all surgical procedures, the sentinel lymph node biopsy is not appropriate for each and every patient.

METHODS

In this article we review the absolute and relative contraindications of the procedure in respect to clinically positive axilla, neoadjuvant therapy, tumor size, multicentric and multifocal disease, in situ carcinoma, pregnancy, age, body-mass index, allergies to dye and/or radio colloid and prior breast and/or axillary surgery.

RESULTS

Certain conditions involving host factors and tumor biologic characteristics may have a negative impact on the success rate and accuracy of the procedure. The overall fraction of patients unsuitable or with multiple risk factors that may compromise the success of the sentinel lymph node biopsy, is very small. Nevertheless, these patients need to be successfully identified, appropriately advised and cautioned, and so do the surgeons that perform the procedure.

CONCLUSION

When performed by an experienced multi-disciplinary team, the SLNB is a highly effective and accurate alternative to standard level I and II axillary clearance in the vast majority of patients with early breast cancer.

Pregnancy-associated breast cancer and metastasis

Pregnancy-associated breast cancer, which has a poor prognosis, is often overlooked by clinicians and researchers alike. With the trend towards delayed child-bearing, an increase in the occurrence of breast cancer complicated by pregnancy is anticipated. The mechanisms that have been proposed to account for this poor prognosis, including increased hormone exposure, might not contribute significantly to the observed increase in metastasis seen in these patients. Instead, the mammary microenvironment might become tumour-promoting after pregnancy because of the remodelling of the mammary gland to its pre-pregnant state. This remodelling, which is associated with pro-inflammatory and wound-healing mechanisms, is proposed to support tumour-cell dissemination. This hypothesis will be discussed.

A Qualitative Analysis of Reproductive Issues Raised by Young Australian Women with Breast Cancer

Available literature concentrates on infertility concerns of young women with breast cancer, while attention to psychosocial issues related to maintained or regained fertility is scarce. As part of a longitudinal, qualitative study of experiences of young women with breast cancer (diagnosed at 40 years or younger); (n = 13), concerns about fertility, contraception, pregnancy, and breastfeeding after breast cancer were expressed. Using semistructured, one-to-one interviews over three time phases, we explored these women's experiences. Perceptions of fertility changed over time. Contraception issues were raised together with recurrence fears related to pregnancy and breastfeeding after breast cancer. Decisions related to unplanned pregnancies and breastfeeding were described as particularly onerous.