Pregnancy influences breast cancer stage at diagnosis in women 30 years of age and younger

Breast cancer in pregnancy: concurrent cesarean section, nipple-sparing mastectomy, and immediate breast reconstruction-case report

Background

Pregnancy-associated breast cancer (PABC), with an incidence rate from 1:3,000 to 1:10,000 deliveries, is the most frequent cancer during pregnancy. PABC appropriate management must take into consideration both the maternal oncological safety and the fetal health, thus posing a challenge for the mother, the baby, and the clinicians. The treatment should adhere as closely as possible to the breast cancer (BC) guidelines. Therefore, surgery is a mainstay, and, when mastectomy is required, breast reconstruction (BR) is a topic of debate. To minimize the risks to the baby, most surgeons postpone BR to delivery. However, a delayed breast reconstruction (DBR) could affect the outcome. In the present case, we report cesarean section concurrent with mastectomy and immediate breast reconstruction (IBR).

Methods

A 37-year-old patient, at the 36th week of pregnancy with PABC, underwent simultaneous cesarean delivery, nipple-sparing mastectomy, and IBR. To minimize risks for the newborn, cesarean was firstly performed under spinal anesthesia. Immediately after, breast surgery, including mastectomy and IBR, was performed under general anesthesia. Partial submuscular IBR with an acellular porcine dermal matrix concluded the surgical procedure. Lactation was inhibited, and adjuvant chemotherapy and hormone therapy were administered to the patient.

Results

In a single surgical session, cesarean delivery, subcutaneous mastectomy, axillary dissection, and IBR were successfully carried out. No early or late postoperative complications were reported for both the patient and the newborn. Histopathological investigation reported a multifocal and multicentric infiltrating ductal carcinoma. After a 6-year follow-up, the patient is alive and well.

Conclusion

To the best of our knowledge, this is the first reported case of concomitant cesarean delivery, PABC mastectomy, axillary dissection, and IBR. This surgical strategy allowed PABC treatment by the BC guideline, minimizing the newborn's disadvantage and permitting, at the same time, the best final BR outcome.

Pregnancy-associated breast cancer: does timing of presentation affect outcome?

PURPOSE

Pregnancy-associated breast cancer (PABC) comprises breast cancer diagnosed during the gestational period or within 12 months postpartum. While the incidence of PABC appears to be increasing, data regarding prognosis remain limited.

METHODS

Here we evaluate clinicopathologic features, treatments, and clinical outcomes among women with stage 0-III PABC diagnosed between 1992 and 2020. Comparisons were made between women who were diagnosed with PABC during gestation and those who were diagnosed within 12 months postpartum.

RESULTS

A total of 341 women were identified, with a median age of 36 years (range 25-46). The pregnancy group comprised 119 (35%) women, while 222 (65%) women made up the postpartum group. Clinicopathologic features were similar between groups, with most patients being parous and presenting with stage I and II disease. Treatment delays were uncommon, with a median time from histologic diagnosis to treatment of 4 weeks for both groups. Recurrence-free survival was similar between groups: 67% at 10 years for both. While 10-year overall survival appeared higher in the postpartum group (83% versus 78%, p = 0.02), only the presence of nodal metastases was associated with an increased risk of death (hazard ratio 5.61, 95% CI 2.20-14.3, p < 0.001), whereas timing of diagnosis and receptor profile did not reach statistical significance.

CONCLUSION

Clinicopathologic features of women with PABC are similar regardless of timing of diagnosis. While 10-year recurrence-free survival is similar between groups, 10-year overall survival is higher among women diagnosed postpartum; however, timing of diagnosis may not be the driving factor in determining survival outcomes.

Prognosis of pregnancy-associated breast cancer: inferior outcome in patients diagnosed during second and third gestational trimesters and lactation

PURPOSE

Pregnancy-associated breast cancer, although most commonly defined as breast cancer diagnosed during pregnancy or ≤1 year following delivery, knows a variety of definitions, likely related to the diversity of reported clinicopathological features and prognosis. More insight into the different breast cancer subgroups during pregnancy, time after delivery and the postpartum period is therefore warranted.

METHODS

Patients with breast cancer diagnosed during pregnancy or ≤6 months postdelivery were included, and subdivided according to gestational trimester, and postpartum patients according to lactational status. Subgroups were compared to matched non-PABC patients, to investigate the influence of pregnancy and lactation on clinical course and outcome.

RESULTS

Overall, 662 PABC patients were included (median age 34 years, median follow-up 6.5 years). PABC patients showed an advanced stage at diagnosis and an inferior 5-years-OS (75.4% vs. 83.2%, p = 0.000) compared to 1392 matched non-PABC patients. In subgroup analysis, first trimester PABC patients showed a significantly lower tumor size and stage as compared to other trimesters. Patients diagnosed during the first trimester and postpartum non-lactating patients had a relatively good OS (81.3% and 77.9%, respectively) versus patients diagnosed during the second and third trimesters and during lactation (OS 60.0%, 64.9% and 65.6%, respectively, p = 0.003).

CONCLUSION

In this large (uniquely specified) PABC cohort, an inferior outcome was found for patients diagnosed within the second and third gestational trimesters and during lactation. These findings indicate that PABC is clinically a heterogeneous group of breast cancer patients that should be redefined based on trimester of diagnosis and lactational status.

Practical consensus recommendations for gestational breast cancer

This manuscript provides a practical and easy to use consensus recommendation to community oncologists on how to manage gestational breast cancer.

Experiences and challenges in the management of pregnancy-associated breast cancer at the Korle Bu Teaching Hospital: a review of four cases

Breast cancer is the commonest female cancer worldwide and the most common malignancy during pregnancy. The current management of breast cancer is based on patient and tumour characteristics, preferences and disease stage. In pregnancy-associated breast cancer, the gestational age influences treatment options. Sequencing of therapies is guided by safe imaging options, timing of delivery and prognosis. Systemic therapy options in the neoadjuvant, adjuvant and palliative settings are limited due to safety concerns of the unborn foetus. In resource-constrained regions, the application of safe options may be challenging. This paper reports four of such cases managed in Ghana using a multidisciplinary approach and local resource-appropriate evidence-based practices. Maternal and foetal outcomes were acceptable with none resulting in termination of pregnancy.

Prognosis of pregnancy-associated breast cancer: a meta-analysis

BACKGROUND

Pregnancy-associated breast cancer (PABC) is defined as breast cancer that is diagnosed during pregnancy and/or the postpartum period. Definitions of the duration of the postpartum period have been controversial, and this variability may lead to diverse results regarding prognosis. Moreover, evidence on the dose-response association between the time from the last pregnancy to breast cancer diagnosis and overall mortality has not been synthesized.

METHODS

We systematically searched PubMed, Embase, and the Cochrane Library for observational studies on the prognosis of PABC published up to June 1, 2019. We estimated summary-adjusted hazard ratios (HRs) and the corresponding 95% confidence intervals (CIs). Subgroup analyses based on diagnosis time, PABC definition, geographic region, year of publication and estimation procedure for HR were performed. Additionally, dose-response analysis was conducted by using the variance weighted least-squares regression (VWLS) trend estimation.

RESULTS

A total of 54 articles (76 studies) were included in our study. PABC was associated with poor prognosis for overall survival (OS), disease-free survival (DFS) and cause-specific survival (CSS), and the pooled HRs with 95% CIs were 1.45 (1.30-1.63), 1.39 (1.25-1.54) and 1.40 (1.17-1.68), respectively. The corresponding reference category was non-PABC patients. According to subgroup analyses, the varied definition of PABC led to diverse results. The dose-response analysis indicated a nonlinear association between the time from the last delivery to breast cancer diagnosis and the HR of overall mortality (P < 0.001). Compared to nulliparous women, the mortality was almost 60% higher in women with PABC diagnosed at 12 months after the last delivery (HR = 1.59, 95% CI 1.30-1.82), and the mortality was not significantly different at 70 months after the last delivery (HR = 1.14, 95% CI 0.99-1.25). This finding suggests that the definition of PABC should be extended to include patients diagnosed up to approximately 6 years postpartum (70 months after the last delivery) to capture the increased risk.

CONCLUSION

This meta-analysis suggests that PABC is associated with poor prognosis, and the definition of PABC should be extended to include patients diagnosed up to approximately 6 years postpartum.

Combinatorial Electrophoresis and Mass Spectrometry-Based Proteomics in Breast Milk for Breast Cancer Biomarker Discovery

Innovations in approaches for early detection and individual risk assessment of different cancers, including breast cancer (BC), are needed to reduce cancer morbidity and associated mortality. The assessment of potential cancer biomarkers in accessible bodily fluids provides a novel approach to identify the risk and/or onset of cancer. Biomarkers are biomolecules, such as proteins, that are indicative of an abnormality or a disease. Human milk is vastly underutilized biospecimen that offers the opportunity to investigate potential protein BC-biomarkers in young, reproductively active women. As a first step, we have examined the entire protein pattern in human milk samples from breastfeeding mothers with cancer, who were diagnosed either before or after milk donation, and from women without cancer, using mass spectrometry (MS)-based proteomics.

Cancer in Pregnancy

This article reviews some of the more common types of cancer that may be encountered during pregnancy. It reviews the unique challenges with the diagnosis and treatment of breast, cervical, hematologic, and colon cancers in pregnant patients.

Pregnancy-associated breast cancer in rural Rwanda: the experience of the Butaro Cancer Center of Excellence

BACKGROUND

Breast cancer is the most common malignancy encountered during pregnancy. However, the burden of pregnancy-associated breast cancer (PABC) and subsequent care is understudied in sub-Saharan Africa (SSA). Here, we describe the characteristics, diagnostic delays and treatment of women with PABC seeking care at a rural cancer referral facility in Rwanda.

METHODS

Data from female patients aged 18-50 years with pathologically confirmed breast cancer who presented for treatment between July 1, 2012 and February 28, 2014 were retrospectively reviewed. PABC was defined as breast cancer diagnosed in a woman who was pregnant or breastfeeding. Numbers and frequencies are reported for demographic and diagnostic delay variables and Wilcoxon rank sum and Fisher's exact tests are used to compare characteristics of women with PABC to women with non-PABC at the alpha = 0.05 significance level. Treatment and outcomes are described for women with PABC only.

RESULTS

Of the 117 women with breast cancer, 12 (10.3%) had PABC based on medical record review. The only significant demographic differences were that women with PABC were younger (p = 0.006) and more likely to be married (p = 0.035) compared to women with non-PABC. There were no significant differences in diagnostic delays or stage at diagnosis between women with PABC and women with non-PABC women. Eleven of the women with PABC received treatment, three had documented treatment delays or modifications due to their pregnancy or breastfeeding, and four stopped breastfeeding to initiate treatment. At the end of the study period, six patients were alive, three were deceased and three patients were lost to follow-up.

CONCLUSIONS

PABC was relatively common in our cohort but may have been underreported. Although patients with PABC did not experience greater diagnostic delays, most had treatment modifications, emphasizing the potential value of PABC-specific treatment protocols in SSA. Larger prospective studies of PABC are needed to better understand particular challenges faced by these patients and inform policies and practices to optimize care for women with PABC in Rwanda and similar settings.

Drivers of advanced stage at breast cancer diagnosis in the multicountry African breast cancer - disparities in outcomes (ABC-DO) study

Breast cancer (BC) survival rates in sub-Saharan Africa (SSA) are low in part due to advanced stage at diagnosis. As one component of a study of the entire journey of SSA women with BC, we aimed to identify shared and setting-specific drivers of advanced stage BC. Women newly diagnosed in the multicountry African Breast Cancer-Disparities in Outcomes (ABC-DO) study completed a baseline interview and their stage information was extracted from medical records. Ordinal logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for advanced stage (I, II, III, IV) in relation to individual woman-level, referral and biological factors. A total of 1795 women were included from Nigeria, Uganda, Zambia, and the multiracial populations of Namibia and South Africa, 1091 of whom (61%) were stage III/IV. Stage was lower in women with greater BC knowledge (OR 0.77 (95% CI: 0.70, 0.85) per point on a 6 point scale). More advanced stage was associated with being black (4.00 (2.79, 5.74)), having attended Collapse

Key Words

• breast cancer
• stage at diagnosis
• sub-Saharan Africa
• survival

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MESH Headings

• Africa
• Breast Neoplasms/diagnosis
• Breast Neoplasms/pathology
• Female
• Health Services Accessibility
• Humans
• Logistic Models
• Middle Aged
• Neoplasm Staging/methods
• Odds Ratio
• Population Groups
• Prospective Studies
• Referral and Consultation

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Grants

• 001 World Health Organization
• R01 CA192627 NCI NIH HHS

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Affiliation(s)

Fiona McKenzie Section of Environment and RadiationInternational Agency for Research on CancerLyonFrance
Annelle Zietsman Windhoek Central HospitalWindhoekNamibia
Moses Galukande Makerere UniversityKampalaUganda
Angelica Anele Federal Medical CentreOwerriNigeria
Charles Adisa Abia State University Teaching HospitalAbaNigeria
Groesbeck Parham University of North CarolinaChapel HillUSA
Leeya Pinder University of North CarolinaChapel HillUSA
Herbert Cubasch University of the Witwatersrand, Chris Hani Baragwanath Academic HospitalJohannesburgSouth Africa
Maureen Joffe University of the Witwatersrand, Chris Hani Baragwanath Academic HospitalJohannesburgSouth Africa
Frederick Kidaaga Namibian Institute of PathologyWindhoekNamibia
Robert Lukande Makerere UniversityKampalaUganda
Awa U. Offiah Abia State University Teaching HospitalAbaNigeria
Ralph O. Egejuru Federal Medical CentreOwerriNigeria
Aaron Shibemba University Teaching HospitalLusakaZambia
Joachim Schuz Section of Environment and RadiationInternational Agency for Research on CancerLyonFrance
Benjamin O. Anderson Fred Hutchinson Cancer Research CenterSeattleWashingtonUSA
Isabel dos Santos Silva Department of Non‐Communicable Disease EpidemiologyLondon School of Hygiene & Tropical MedicineLondonUK
Valerie McCormack Section of Environment and RadiationInternational Agency for Research on CancerLyonFrance

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Human Chorionic Gonadotropin and Breast Cancer

Breast cancer is well known as a malignancy being strongly influenced by female steroids. Pregnancy is a protective factor against breast cancer. Human chorionic gonadotropin (HCG) is a candidate hormone which could mediate this antitumoral effect of pregnancy. For this review article, all original research articles on the role of HCG in breast cancer were considered, which are listed in PubMed database and were written in English. The role of HCG in breast cancer seems to be a paradox. Placental heterodimeric HCG acts as a protective agent by imprinting a permanent genomic signature of the mammary gland determining a refractory condition to malignant transformation which is characterized by cellular differentiation, apoptosis and growth inhibition. On the other hand, ectopic expression of β-HCG in various cancer entities is associated with poor prognosis due to its tumor-promoting function. Placental HCG and ectopically expressed β-HCG exert opposite effects on breast tumorigenesis. Therefore, mimicking pregnancy by treatment with HCG is suggested as a strategy for breast cancer prevention, whereas targeting β-HCG expressing tumor cells seems to be an option for breast cancer therapy.

Management of pregnancy associated breast cancer with chemotherapy in a developing country

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The use of chemotherapy in our series for pregnancy associated breast cancer was successful with resulting healthy babies.

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Chemotherapy was done from the second trimeater.

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The choice of drugs were doxorubicin and cyclophosphamide administered by a slow infusion protocol.

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The babies did not require ICU care.

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Breast conservation was successfully used in one of the cases who is clinically disease free 5 years post diagnosis.

Context

Although breast cancer is a common cancer, Pregnancy associated breast cancer is uncommon. Adjuvant chemotherapy administered intrapartum has been resolved to be safe from the second trimester.

Objective

To review cases of pregnancy associated breast cancer managed with adjuvant intrapartum chemotherapy.

Patients and method

Gravid patients diagnosed with breast cancer had chemotherapy administered by a slow infusion protocol at 3 weekly interval from the second trimester till 4 weeks to expected date of delivery. Obstetric scans were done to monitor fetal growth and development. Requisite surgery was carried out intrapartum and postpartum.

Results

There were three cases of pregnancy associated breast cancer Age range 32–33 years, mean 32.5 years. Two cases presented in the second trimester while one presented in the third trimester. The second case had overt metastatic disease and was grave in respiratory distress. Histology showed invasive lobular carcinoma in two cases and extensive intraductal carcinoma with invasive component in the third. Immunohistochemistry showed triple negative in the first case and hormone positive in the third case. Wide local excision was done for a 3 cm lump in the first case and mastectomy postpartum in the third case. but had no surgery. Doxorubicin and cyclophosphamide was administered three weekly from the second trimester up to 32 weeks and continued postpartum. Taxanes was administered afterwards. The grave clinical state of the second case was markedly improved with the first cycle of chemotherapy instituted. All cases had spontaneous vaginal delivery with good apgar scores. Children had normal developmental milestones. First case with breast conservation is clinically disease free, the second case demised postpartum from disease progression while the third had a mastectomy and is on cue for radiotherapy.

Conclusion

Adjuvant intrapartum chemotherapy had a successful outcome with birth of normal babies with normal developmental milestones in our miniseries.

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.

Pregnancy-associated breast cancer: clinicopathological characteristics of 20 cases with a focus on identifiable causes of diagnostic delay

BACKGROUND

The primary objective of this study was to evaluate the clinicopathological characteristics of patients with pregnancy-associated breast cancer (PABC), with a special focus on diagnostic delays and the identifiable causes of diagnostic delays.

PATIENTS AND METHODS

Clinicopathological data of patients treated for PABC between 2003 and 2012 at Hacettepe University Hospital was retrospectively reviewed.

RESULTS

20 patients with PABC were included. The pathological examination revealed predominance of invasive ductal carcinoma (80%), grade III tumors (65%) and advanced-stage (III-IV) disease (75%). In 8 patients (40%), there was a diagnostic delay between occurrence of the presenting symptoms and the initiation of breast mass workup. For these 8 patients, the main identifiable causes of diagnostic delay were the attribution of disease-related symptoms to pregnancy or lactation in 5 (63%) and negligence of symptoms in 2 (25%).

CONCLUSIONS

PABC mostly presents with advanced-stage disease, and there can be a substantial diagnostic delay before these patients receive treatment. Preconceptional, gestational and postpartum examination of women of reproductive age should include a thorough breast examination and should provide adequate information regarding the physiological changes in breast tissue and the possible pathological symptoms.

Pregnancy-associated breast cancer: optimal treatment options

Cancer is diagnosed approximately once per 1,000 pregnancies; most commonly due to the reproductive age of the women, these include breast, cervical, melanoma, thyroid, and Hodgkin’s lymphoma diagnoses. As a single diagnosis, breast cancer is the most common cancer diagnosed during pregnancy. Cancer is expected to complicate pregnancy more often due to the trend for women to delay child bearing to later maternal ages. Delayed first birth is itself a risk factor for breast cancer. Termination of pregnancy has not been shown to afford a survival benefit. While protecting the interests of mother and unborn fetus, breast cancer can be safely diagnosed, staged, and treated during pregnancy with good outcomes for both. Some modification of the protocols used for nonpregnant women with suspicious palpable breast masses is required. This article reviews the challenges for physicians in making the diagnosis of breast cancer during pregnancy and upon diagnosis, counseling patients about treatment options. The consequences of diagnostic investigations and cancer treatment for the exposed fetus are also addressed.

Locoregional treatment of breast cancer during pregnancy

The management of patients with breast cancer during pregnancy is very demanding and it should be better performed in highly qualified and experienced centers. Referral to institutes and physicians trained in this special clinical scenario allows reducing the risk of both overtreating and undertreating the patients. Moreover, patients can receive appropriate information regarding safety of treatments without old-fashioned taboo. The purpose of the current paper is to discuss the main issues concerning surgical management and in general locoregional treatment of patients diagnosed with breast cancer and treated during gestation, focusing on those women who chose to continue their pregnancy. We cover the issues regarding type of breast surgery, radiation therapy, immediate reconstruction during mastectomy, and management of the axilla.

Breast cancer in women younger than 30 years: prevalence rate and imaging findings in a symptomatic population

Introduction

To identify the prevalence rate of primary breast cancer in women younger than 30 years of age in a symptomatic population in Riyadh, Kingdom of Saudi Arabia. To analyze the imaging pattern and possible risk factors in cases with cancer. Breast cancer in this age group is generally rare and not clearly understood.

Methods

At King Abdulaziz Medical City for National Guard, Riyadh, a retrospective 5-year (January 2006 to December 2010) data was collected from the Medical Imaging departmental records on breast imaging. Patients younger than 30 years of age were identified including those with breast cancer. The clinical presentation, risk factors, imaging findings and final outcomes were analyzed in a descriptive way. The total number of patients diagnosed with primary breast cancer was recorded.

Results

Seventeen out of a total of 4873 patients younger than 30 years examined had primary breast cancer constituting a rate of 3.5 per 1000 symptomatic patients. The age range was 17 to 29 with mean of 27. The total number of patients with primary breast cancer diagnosed during that period was 413 making a percentage of 4.1% (17 out of 413) in those younger than 30 years. First presentation with a palpable mass and imaging findings of unequivocal category 5 of Breast Imaging Reporting and Data System (BI-RADS) occurred in all. Eight patients had stage I and II while nine had stage III and IV cancers. Only 2 of the 17 had first-degree family history. The youngest was 17 years old.

Conclusion

A prevalence rate of 3.5 per 1000 primary cancer occurred in the symptomatic population studied and 4 in every 100 primary cancer diagnosed in the unit occurred in women younger than 30 years. First presentation, low family trait and typical imaging features of malignancy was found in all cases.

Pregnancy-associated breast cancers are driven by differences in adipose stromal cells present during lactation

INTRODUCTION

The prognosis of breast cancer is strongly influenced by the developmental stage of the breast when the tumor is diagnosed. Pregnancy-associated breast cancers (PABCs), cancers diagnosed during pregnancy, lactation, or in the first postpartum year, are typically found at an advanced stage, are more aggressive and have a poorer prognosis. Although the systemic and microenvironmental changes that occur during post-partum involution have been best recognized for their role in the pathogenesis of PABCs, epidemiological data indicate that PABCs diagnosed during lactation have an overall poorer prognosis than those diagnosed during involution. Thus, the physiologic and/or biological events during lactation may have a significant and unrecognized role in the pathobiology of PABCs.

METHODS

Syngeneic in vivo mouse models of PABC were used to examine the effects of system and stromal factors during pregnancy, lactation and involution on mammary tumorigenesis. Mammary adipose stromal cell (ASC) populations were isolated from mammary glands and examined by using a combination of in vitro and in vivo functional assays, gene expression analysis, and molecular and cellular assays. Specific findings were further investigated by immunohistochemistry in mammary glands of mice as well as in functional studies using ASCs from lactating mammary glands. Additional findings were further investigated using human clinical samples, human stromal cells and using in vivo xenograft assays.

RESULTS

ASCs present during lactation (ASC-Ls), but not during other mammary developmental stages, promote the growth of carcinoma cells and angiogenesis. ASCs-Ls are distinguished by their elevated expression of cellular retinoic acid binding protein-1 (crabp1), which regulates their ability to retain lipid. Human breast carcinoma-associated fibroblasts (CAFs) exhibit traits of ASC-Ls and express crabp1. Inhibition of crabp1in CAFs or in ASC-Ls abolished their tumor-promoting activity and also restored their ability to accumulate lipid.

CONCLUSIONS

These findings imply that (1) PABC is a complex disease, which likely has different etiologies when diagnosed during different stages of pregnancy; (2) both systemic and local factors are important for the pathobiology of PABCs; and (3) the stromal changes during lactation play a distinct and important role in the etiology and pathogenesis of PABCs that differ from those during post-lactational involution.

Prognosis of pregnancy-associated breast cancer: a meta-analysis of 30 studies

BACKGROUND

Pregnancy-associated breast cancer (PABC) is relatively rare with considerable controversy regarding its prognosis.

PATIENTS & METHODS

Two of the authors independently performed a literature search with no date or language restrictions. Eligible studies were control-matched, population-based and hospital-based studies that addressed the outcome of patients diagnosed during pregnancy or 1-year afterwards. The primary and secondary end-points were overall and disease-free survival respectively. Pooling of data was done using the random effect model.

RESULTS

30 studies were included in this meta-analysis (3,628 cases and 37,100 controls). PABC patients had a significantly higher risk of death compared to those with non-pregnancy-related breast cancer (pooled hazard ratio (pHR): 1.44; 95% CI [1.27-1.63]). The same results were encountered on restricting the analysis to HRs of multivariate analyses (pHR: 1.40 [1.17-1.67]). A clearer trend of poorer outcome was seen in those diagnosed postpartum (pHR: 1.84; 95% CI [1.28-2.65]) than those diagnosed during pregnancy (pHR: 1.29; 95% CI [0.74-2.24]). DFS analysis showed a significantly higher risk of relapse associated with PABC as well (pHR: 1.60 [1.19-2.16]).

CONCLUSION

Our results show that PABC is independently associated with poor survival particularly those diagnosed shortly post-partum. This underscores a possible impact of the pregnant breast microenvironment on the biology and consequently the prognosis of these tumors.

Survival outcomes in pregnancy associated breast cancer: a retrospective case control study

Pregnancy-associated breast cancer (PABC) has been defined as breast cancer diagnosed during pregnancy or within one year of delivery. It is believed that after adjusting for age and stage, the 5-year survival rates are the same in both pregnant and nonpregnant women. We conducted a retrospective case-control study among patients treated at our institution between 1990 and 2005 to compare the 5-year survival outcomes for PABC with women treated for breast cancer who were not pregnant. Overall survival (OS) and disease-free survival (DFS) were estimated by the Kaplan-Meier method, and log rank tests were used to assess the associations between OS, DFS and pregnancy status, HER-2 status, ER/PR status, and family history. The median age was 33 years (range 24-42) for both groups. Twenty-two (55%) patients with PABC were ER/PR receptor positive compared with 20 (50%) for the controls. Ninety percent of patients with PABC received chemotherapy compared with 87.5% in the nonpregnant group. 91.5% of patients with PABC had breast-conserving surgery and 8.5% had mastectomies compared with 86% and 14%, respectively, for the control group. The median OS was 4.9 years in the PABC group compared with 6 years for the controls (p = 0.02). The median DFS was 2.7 years for the PABC group compared with 5.1 years for the controls (p = 0.01). The most common site of relapse was bone for the PABC group (27%) and local recurrence (33%) for the controls. Univariate analysis revealed that OS and DFS were associated with pregnancy status, family history, ER/PR status, and stage. After adjusting for age and stage, PABC patients had higher risk of both death (p = 0.01) and recurrence (p = 0.02) compared with nonpregnant controls. Women with PABC had significantly shorter OS and DFS compared with nonpregnant age and stage-matched controls.

Pregnancy associated breast cancer and pregnancy after breast cancer treatment

Breast cancer is one of the most common cancers diagnosed during pregnancy and its frequency is increasing as more women postpone their pregnancies to their thirties and forties. Breast cancer diagnosis during pregnancy and lactation is difficult and complex both for the patient and doctors. Delay in diagnosis is frequent and treatment modalities are difficult to accept for the pregnant women. The common treatment approach is surgery after diagnosis, chemotherapy after the first trimester and radiotherapy after delivery. Even though early stage breast cancers have similar prognosis, advanced stage breast cancers diagnosed during pregnancy and lactation have poorer prognosis than similar stage breast cancers diagnosed in non-pregnant women. Women who desire to become pregnant after treatment of breast cancer will have many conflicts. Although the most common concern is recurrence of breast cancer due to pregnancy, the studies conducted showed that pregnancy has no negative effect on breast cancer prognosis. In this review we search for the frequency of breast cancer during pregnancy, the histopathological findings, risk factor, diagnostic and treatment modalities. We reviewed the literature for evidence based findings to help consult the patients on the outcome of breast cancer diagnosed during pregnancy and lactation, and also inform the patients who desire to become pregnant after breast cancer according to current evidences.

Current or recent pregnancy is associated with adverse pathologic features but not impaired survival in early breast cancer

BACKGROUND

Pregnancy-associated breast cancer (PABC) may be defined as breast cancer diagnosed during pregnancy or within 1 year of giving birth. Conflicting data exist regarding the impact of pregnancy on clinical features and prognosis of breast cancer.

METHODS

A single-institution retrospective chart review was performed of 99 patients identified with PABC between 1992 and 2007. Non-PABC controls were matched 2:1 to PABC cases by year of diagnosis and age. The differences in clinical features were compared between cases and controls using chi-square tests. Univariate and multivariate analyses were performed to assess the effect of PABC on survival.

RESULTS

Of the 99 PABC cases, breast cancer was diagnosed during pregnancy in 36 patients, and after delivery in 63. PABC cases were more likely than controls to be negative for estrogen receptor (59% vs 31%, P < .0001) and negative for progesterone receptor (72% vs 40%, P < .0001). Cases were also more likely to have advanced T class (P = .0271) and N class (P = .0104) and higher grade tumors (P = .0115). With a median follow-up of 6.3 years for cases and 4.7 years for controls, overall survival did not differ between cases and controls (P = .0787). On multivariate analysis, the independent prognostic factors for overall survival were estrogen receptor status (P = .0031) and N class (P = .0003). The diagnosis of PABC was not an independent prognostic factor (P = .1317).

CONCLUSIONS

PABC is associated with more adverse tumor features than non-PABC matched for age and year of diagnosis. After correcting for pathologic features, the diagnosis of PABC is not in itself an adverse prognostic factor for survival.

Breast cancer during pregnancy

Breast cancer in pregnancy is an uncommon situation but poses dilemmas for patients and their physicians. There is a paucity of prospective studies regarding diagnosis and treatment of breast cancer during pregnancy. Women diagnosed with breast cancer during pregnancy have similar disease characteristics to age-matched controls. Current evidence suggests that diagnosis may be carried out with limitations regarding staging. Surgical treatment may be performed as for non-pregnant women. Radiotherapy and endocrine or antibody treatment should be postponed until after delivery. Chemotherapy is allowed after the first trimester. Physicians should be aggressive in the workup of breast symptoms in the pregnant population to expedite diagnosis and allow multidisciplinary treatment without delay.

Breast cancer before age 40 years

Approximately 7% of women with breast cancer are diagnosed before the age of 40 years, and this disease accounts for more than 40% of all cancer in women in this age group. Survival rates are worse when compared to those in older women, and multivariate analysis has shown younger age to be an independent predictor of adverse outcome. Inherited syndromes, specifically BRCA1 and BRCA2, must be considered when developing treatment algorithms for younger women. Chemotherapy, endocrine, and local therapies have the potential to significantly impact both the physiologic health-including future fertility, premature menopause, and bone health-and the psychological health of young women as they face a diagnosis of breast cancer.

Cytotoxic chemotherapy for pregnancy-associated breast cancer: single institution case series

Background. Pregnancy-associated (PA) breast cancer is a rare disease state that poses unique management challenges, specifically controlling the cancer and maximizing the survival of the expectant mother balanced with the health and safety of the developing fetus. As more women delay pregnancy into their 30s and 40s it is expected that this may become a more important clinical problem in the future. Existing data on PA-breast cancer comes from case series using older chemotherapy drugs. A review of practice was carried out to assess current experience with PA-breast cancer, particularly relating to current cytotoxic drugs and targeted agents.

Methods. The St James’s Hospital breast cancer registry, a prospectively maintained database, was used to identify cases of PA-breast cancer over a 6.5-year period and a chart review carried out. Chemotherapy administered during pregnancy, breast cancer specific outcomes, and fetal outcomes were assessed.

Results. Five patients were identified with PA-breast cancer; median age 34 years (range 28—35). The median gestation at presentation was 18 weeks (range 14—29). Four women received chemotherapy during pregnancy; three received doxorubicin and cyclophosphamide (AC) and one paclitaxel. These agents were generally well tolerated. At median gestation of 36 weeks (range 35—40 weeks) four elective caesareans and one spontaneous delivery occurred. There were no fetal abnormalities.

Conclusions. Common cytotoxics can safely be delivered in pregnancy. Further research on newer therapies such as trastuzumab is needed.

Breast cancer stroma frequently recruits fetal derived cells during pregnancy

INTRODUCTION

Breast carcinomas associated with pregnancy display a high frequency of inflammatory types, multifocal lesions and lymph node metastasis. Because pregnancy results in transfer to mothers of foetal stem cells that can migrate and differentiate into various tissues, we addressed the issue of whether such cells are present in breast carcinoma associated with pregnancy.

METHODS

We analyzed women presenting with such tumours who were pregnant with male foetuses using fluorescence in situ hybridization (FISH), targeting X and Y chromosomes. The foetal cell phenotype was then determined by combining FISH and immunohistochemistry with various antibodies. Statistical analysis was performed using t-test or nonparametric Wilcoxon's test.

RESULTS

We found that foetal cells were present in nine out of 10 carcinomas, in contrast with none of four benign mammary lesions (P < 0.05). Counting foetal and maternal cells showed that the mean number of foetal cells per million maternal cells was 36 in breast cancers and 0 in control samples (P < 0.01). By combining FISH and immunolabelling, we found that foetal cells expressed mainly mesenchymal or, to a lesser degree, epithelial or endothelial markers, but never leucocytes.

CONCLUSION

These findings demonstrate the frequent presence of foetal derived cells essentially in tumour stroma. Given the role played by stroma in tumour proliferation, these findings raise the issue of whether foetal cell can be targeted to influence tumour behaviour.

Surgical management of breast cancer

Breast cancer treatment outcomes have improved as a result of early detection and multidisciplinary treatment approaches. Treatment options continue to expand as understanding increases regarding the relationship between disease burden, biology, and outcome. In this article we present the current principles and challenges that face the clinician who is treating breast disease. Better understanding of the biology of high-risk lesions and the significance of minimal metastatic disease permits better treatment. Advances in reconstructive surgery, continued refinement of resection techniques, and the management of less common presentations of breast cancer are presented.

Pregnancy-Associated Breast Cancer: A Literature Review

Breast cancer is one of the most commonly diagnosed cancers of pregnancy. The diagnostic and therapeutic implications in this population are special. These women typically present with more advanced disease that carries a poorer prognosis. This article highlights patient care in this population, where aggressive care must be modified to ensure fetal protection.

Imaging of breast cancer diagnosed and treated with chemotherapy during pregnancy

PURPOSE

To retrospectively assess mammography, high-frequency-transducer ultrasonography (US), and color Doppler US for the initial and subsequent evaluation of breast cancer diagnosed and treated with chemotherapy during pregnancy.

MATERIALS AND METHODS

A retrospective study of clinical records between January 1989 and December 2003 of women with breast cancer diagnosed and treated with chemotherapy during pregnancy was performed after waiver of informed consent was obtained. The study was approved by an institutional review board and was HIPAA compliant. Mammograms and sonograms were reviewed by two mammographers using the Breast Imaging Reporting and Data System (BI-RADS) mammographic and US lexicon. US assessment of the regional lymph node basins, including the axillary, infraclavicular, internal mammary, and supraclavicular regions, was documented. US was used to evaluate response to therapy in the breast and the regional lymph nodes in women who underwent neoadjuvant chemotherapy.

RESULTS

Twenty-three women with 24 cancers that were imaged prior to surgery with mammography (n = 3), US (n = 4), or mammography and US (n = 17) were included in the study. The histologic diagnosis of the primary tumor was invasive ductal cancer in 22 lesions, and the diagnosis was invasive carcinoma in the two other cancers. The median age in this study was 34 years (range, 24-45 years). Of the 20 women who underwent preoperative mammography, findings were positive for malignancy in 18 of 20 (90%) cancers despite dense breast parenchymal patterns (BI-RADS types 3 and 4). A mass in all 21 cancers (100%) was depicted in the 20 women who underwent breast and nodal US. US correctly depicted axillary metastasis in 15 of 18 women who underwent US nodal assessment. Of the 12 patients who were evaluated for response to chemotherapy, US demonstrated complete response in two patients, partial response in three, stable findings in one, and progression of disease in six.

CONCLUSION

Breast cancer diagnosed during pregnancy is mammographically evident despite dense parenchymal background. US, when performed, demonstrates all masses and provides information regarding response to neoadjuvant chemotherapy.

Treatment of pregnant breast cancer patients and outcomes of children exposed to chemotherapy in utero

BACKGROUND

As women in the US delay childbearing, it has been hypothesized that the incidence of breast cancer diagnosed during pregnancy will increase. There are very little prospective data on the treatment of pregnant women with breast cancer with chemotherapy and even less data on the outcomes of their children who were exposed to chemotherapy in utero.

METHODS

Fifty-seven pregnant breast cancer patients were treated on a single-arm, multidisciplinary, institutional review board-approved protocol with FAC (5-fluorouracil, doxorubicin, cyclophosphamide) in the adjuvant (n = 32) or neoadjuvant (n = 25) setting. Parents/guardians were surveyed by mail or telephone regarding outcomes of children exposed to chemotherapy in utero.

RESULTS

Of the 57 women, 40 are alive and disease-free, 3 have recurrent breast cancer, 12 died from breast cancer, 1 died from other causes, and 1 was lost to follow-up. Of the 25 patients who received neoadjuvant FAC, 6 had a pathologic complete response, whereas 4 had no tumor response to chemotherapy and eventually died from their disease. All women who delivered had live births. One child has Down syndrome and 2 have congenital anomalies (club foot; congenital bilateral ureteral reflux). The children are healthy and those in school are doing well, although 2 have special educational needs.

CONCLUSIONS

Breast cancer can be treated with FAC chemotherapy during the second and third trimesters without significant short-term complications for the majority of children exposed to chemotherapy in utero. Longer follow-up of the children is needed to evaluate possible late side effects such as impaired cardiac function and fertility.

Rationale for a diagnostic chain in gestational breast tumor diagnosis

Due to the physiological tissue alterations of the breast during pregnancy and lactation the diagnosis of a breast tumor by palpation, imaging and fine-needle biopsy is difficult and often unreliable. The purpose of our study was to review the value of imaging (mammography and ultrasonography) and biopsy techniques in order to work out a reliable protocol for evaluating gestational tumors. We performed a retrospective analysis of 25 patients with clinical diagnosis of gestational breast tumors during a 4-year period from 1995 to 1999. Specimens were obtained by core biopsy for histological examination. Invasive breast cancer was diagnosed in five patients, malignant lymphoma of the skin in one patient. The tumors in the remaining 19 patients proved benign. The overall accuracy was 0.91 for conventional mammography, 0.76 for conventional and panoramic ultrasound and 0.48 for color-coded sonography. Mammography as the most reliable imaging method should be used to evaluate all patients in whom ultrasonographic findings are suspicious for tumor. Radiation phobia should not prevent the performance of mammography under these circumstances. Nevertheless, all pre-operative methods of diagnosing gestational breast tumors other than core biopsy are unreliable.

Breast Cancer in Pregnant and Postpartum Women

Breast cancer is reported to occur in from 1 in 3000 to 1 in 10,000 pregnancies worldwide. In the United States, 10% to 20% of breast cancers occur in women of childbearing age. Diagnosis and treatment of breast cancer during pregnancy present many additional challenges.

Pregnancy and breast cancer: a population-based study

The incidence of pregnancy-associated breast cancer, i.e. during pregnancy and lactation, and of pregnancy subsequent to a breast-cancer diagnosis will increase as more women choose childbearing at a later age. Few larger series are published on pregnancy-associated breast cancer. In a population-based study, we evaluated the outcome and prognostic factors in 173 breast-cancer patients. One hundred and twenty-two patients had pregnancy-associated breast cancer (20 coincident with pregnancy and 102 during lactation) and 51 patients had pregnancy subsequent to breast cancer. The median follow-up time was 151 months. Histopathological parameters and immunoreactivity for oestrogen and progesterone receptors c-erbB-2 and c-erbB-4 were studied. All three groups had tumours with high histological grade, low frequency of hormone receptors and high expression of c-erbB-2. The pregnancy and lactation groups were near identical with regard to all histopathological parameters and outcome. In the two pregnancy-associated breast-cancer groups, tumours were significantly larger, with more extensive lymph-node involvement. For node-negative tumours the respective 5- and 10-year survival rates were 62% and 50% in the pregnancy group and 60% and 50% in the lactation group. For node-positive tumours, respective 5- and 10-year survival rates were 50% and 34% in the pregnancy group and 50% and 33% in the lactation group. In the subsequent group, overall survival was high in both node-negative and -positive groups, with 5- and 10-year survival rates of 80% and 73% and 86% and 76%, respectively. Tumour size, lymph-node status, histological grade, progesterone receptor, oestrogen receptor and c-erbB-2 were significant prognostic factors in the pregnancy-associated breast-cancer patients.

Management of breast cancer diagnosed during pregnancy

Breast cancer during pregnancy is generally defined as cancer occurring during pregnancy or within 1 year of delivery, although treatment options are the most complicated when the disease is diagnosed during gestation. The challenges of treatment during gestation are discussed in this article. In general, a pregnant woman with breast cancer should be treated similarly to the nonpregnant patient, with specific recommendations tailored to gestational age at diagnosis, stage of the tumor, and the personal preferences of the patient. Despite the increasing literature focusing on treatment decisions, there are little prospective data regarding treatment or long-term outcome information to provide toxicity data that can be used to advise patients and guide decisions. Most of the retrospective and anecdotal data are based on the possibility of fetal loss or demise with specific treatment or treatment administered at specific times during pregnancy. Therefore, it is impossible to accurately quantify risks to the fetus or the mother, and decisions should be made after careful discussion between the patient, her family, and the medical team. The physician must have a clear understanding of the pharmacology and teratogenic potential of individual agents, thus limiting risks.

Breast cancer among young African-American women: a summary of data and literature and of issues discussed during the Summit Meeting on Breast Cancer Among African American Women, Washington, DC, September 8-10, 2000

BACKGROUND

African-American women younger than age 45 years have a higher risk of incidence and mortality due to breast cancer than other women. The reason for this disparity in risk is not well understood.

METHODS

This review summarizes the literature on the topic of breast cancer in young women and presents a summary of a discussion on this topic during a national forum on breast cancer among African-American women.

RESULTS

The occurrence of breast cancer among African-American women younger than the age of 45 years has not been well studied. There is a clear and long-term pattern of higher incidence and mortality and poorer survival in this population subgroup.

CONCLUSION

Research is needed to understand the reasons for these disparities and to reduce or eliminate them. Studies focused on hormonal factors, genetic factors, diet and obesity, and timely access to state-of-the-art prevention, information, screening, diagnosis, and treatment are likely to produce important new knowledge in this area.

Hormone replacement therapy for survivors of breast and endometrial cancer

Indirect evidence suggests that endogenous and exogenous estrogen does not influence the outcome of patients treated for breast or endometrial cancer. However, many reports have affirmed beneficial effects of hormone replacement therapy (HRT) in preventing multiple disease states and improving the quality of life of individual patients. Every practitioner of urogynecology understands the benefits of local and systemic therapy to women who suffer from urinary incontinence and/or loss of pelvic floor support. Thus, it seems appropriate to suggest that survivors of breast or endometrial cancer who request information on HRT for relief of their menopausal symptoms and for other benefits, of which patients are becoming increasingly aware, deserve a comprehensive explanation.

Breast cancer in pregnancy

Breast cancer in pregnancy is likely to become more common because more women have been waiting to bear children until they are in their 40s. This article presents an overview of pregnancy-associated breast cancer and a review of surgical, chemotherapeutical, and radiation principles as they pertain to pregnancy.