Management of breast cancer in pregnancy

Contraception and sterilization selection at delivery among pregnant patients with malignancy

INTRODUCTION

Since malignancy during pregnancy is uncommon, information regarding contraception selection or sterilization at delivery is limited. The objective of this study was to examine the type of long-acting reversible contraception or surgical sterilization procedure chosen by pregnant patients with malignancy at delivery.

MATERIAL AND METHODS

This cross-sectional study queried the Healthcare Cost and Utilization Project's National Inpatient Sample in the USA. The study population was vaginal and cesarean deliveries in a hospital setting from January 2017 to December 2020. Pregnant patients with breast cancer (n = 1605), leukemia (n = 1190), lymphoma (n = 1120), thyroid cancer (n = 715), cervical cancer (n = 425) and melanoma (n = 400) were compared with 14 265 319 pregnant patients without malignancy. The main outcome measures were utilization of long-acting reversible contraception (subdermal implant or intrauterine device) and performance of permanent surgical sterilization (bilateral tubal ligation or bilateral salpingectomy) during the index hospital admission for delivery, assessed with a multinomial regression model controlling for clinical, pregnancy and delivery characteristics.

RESULTS

When compared with pregnant patients without malignancy, pregnant patients with breast cancer were more likely to proceed with bilateral salpingectomy (adjusted odds ratio [aOR] 2.30) or intrauterine device (aOR 1.91); none received the subdermal implant. Pregnant patients with leukemia were more likely to choose a subdermal implant (aOR 2.22), whereas those with lymphoma were more likely to proceed with bilateral salpingectomy (aOR 1.93) and bilateral tubal ligation (aOR 1.76). Pregnant patients with thyroid cancer were more likely to proceed with bilateral tubal ligation (aOR 2.21) and none received the subdermal implant. No patients in the cervical cancer group selected long-acting reversible contraception, and they were more likely to proceed with bilateral salpingectomy (aOR 2.08). None in the melanoma group chose long-acting reversible contraception. Among pregnant patients aged <30, the odds of proceeding with bilateral salpingectomy were increased in patients with breast cancer (aOR 3.01), cervical cancer (aOR 2.26) or lymphoma (aOR 2.08). The odds of proceeding with bilateral tubal ligation in pregnant patients aged <30 with melanoma (aOR 5.36) was also increased.

CONCLUSIONS

The results of this nationwide assessment in the United States suggest that among pregnant patients with malignancy, the preferred contraceptive option or method of sterilization at time of hospital delivery differs by malignancy type.

Pregnancy in a Young Patient with Metastatic HER2-Positive Breast Cancer-Between Fear of Recurrence and Desire to Procreate

Breast cancer is the most frequent neoplasm among women and the second leading cause of death by cancer. It is the most frequent cancer diagnosed during pregnancy. Pregnancy-associated breast cancer is defined as breast cancer that is diagnosed during pregnancy and/or in the postpartum period. Data about young women with metastatic HER2-positive cancer who desire a pregnancy are scarce. The medical attitude in these clinical situations is difficult and nonstandardized. We present the case of a 31-year-old premenopausal woman diagnosed in December 2016 with a stage IV Luminal HER2-positive metastatic breast cancer (pT2 N0 M1 hep). The patient was initially treated by surgery in a conservative manner. Postoperatively, the presence of liver metastases was found by CT investigation. Consequently, line I treatment (docetaxel l75 mg/m² iv; trastuzumab 600 mg/5 mL sq) and ovarian drug suppression (Goserelin 3.6 mg sq at 28 days) was administered. After nine cycles of treatment, the patient's liver metastases had a partial response to the therapy. Despite having a favorable disease evolution and a strong desire to procreate, the patient vehemently refused to continue any oncological treatment. The psychiatric consult highlighted an anxious and depressive reaction for which individual and couple psychotherapy sessions were recommended. After 10 months from the interruption of the oncological treatment, the patient appeared with an evolving pregnancy of 15 weeks. An abdominal ultrasound revealed the presence of multiple liver metastases. Knowing all the possible effects, the patient consciously decided to postpone the proposed second-line treatment. In August 2018, the patient was admitted in the emergency department with malaise, diffuse abdominal pain and hepatic failure. Abdominal ultrasound found a 21-week-old pregnancy which had stopped in evolution, multiple liver metastases and ascites in large quantity. She was transferred to the ICU department where she perished just a few hours later. Conclusions/Discussion: From a psychological standpoint, the patient had an emotional hardship to make the transition from the status of a healthy person to the status of a sick person. Consequently, she entered a process of emotional protection of the positive cognitive distortion type, which favored the decision to abandon treatment and try to complete the pregnancy to the detriment of her own survival. The patient delayed the initiation of oncological treatment in pregnancy until it was too late. The consequence of this delay in treatment led to the death of the mother and fetus. A multidisciplinary team worked to provide this patient with the best medical care and psychological assistance throughout the course of the disease.

Breast Cancer and Pregnancy: A Review

Breast cancer is one of the most commonly encountered types of malignancy during pregnancy. Here, we review the most recent data with regards to this special patient population. Current evidence shows that it is appropriate for oncologists to treat these patients carefully with a coordinated multidisciplinary approach.

Imaging in pregnancy-associated breast cancer: a case report

BACKGROUND

PABC (pregnancy-associated breast cancer) is a rare condition that appears as a malignancy in 1 per 3000 pregnant women and is one of the most common cancers diagnosed during pregnancy or the postpartum period. If a woman who is pregnant or within a year after delivery has complaints of a palpable breast mass, it could undeniably be a malignant mass of the breast. That is why an ultrasound should be performed for all pregnant or lactating women who detect a palpable breast mass that persists for two or more weeks.

CASE REPORT

Our case report presents a pregnant 40-year-old previously healthy female at 36 weeks gestational age with a complaint of a palpable left breast mass for two months period. The initial ultrasound showed a breast tumour of irregular shape, solid and hypervascular mass.

CONCLUSIONS

Early diagnostics of PABC is of crucial importance in order to offer the best possible outcomes for the patient and foetus.

Outcomes of children exposed in utero to chemotherapy for breast cancer

INTRODUCTION

The incidence of breast cancer diagnosed during pregnancy is expected to increase as more women delay childbearing in the United States. Treatment of cancer in pregnant women requires prudent judgment to balance the benefit to the cancer patient and the risks to the fetus. Prospective data on the outcomes of children exposed to chemotherapy in utero are limited for the breast cancer population.

METHODS

Between 1992 and 2010, 81 pregnant patients with breast cancer were treated in a single-arm, institutional review board-approved study with 5-fluorouracil, doxorubicin, and cyclophosphamide (FAC) in the adjuvant or neoadjuvant setting. Labor and delivery records were reviewed for each patient and neonate. In addition, the parents or guardians were surveyed regarding the health outcomes of the children exposed to chemotherapy in utero.

RESULTS

In total, 78% of the women (or next of kin) answered a follow-up survey. At a median age of 7 years, most of the children exposed to chemotherapy in utero were growing normally without any significant exposure-related toxicity or health problems. Three children were born with congenital abnormalities: one each with Down syndrome, ureteral reflux or clubfoot. The rate of congenital abnormalities in the cohort was similar to the national average of 3%.

CONCLUSIONS

During the second and third trimesters, pregnant women with breast cancer can be treated with FAC safely without concerns for serious complications or short-term health concerns for their offspring who are exposed to chemotherapy in utero. Continued long-term follow-up of the children in this cohort is required.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00510367. Other Study ID numbers: ID01-193, NCI-2012-01578. Registration date: 31 July 2007.

[Pregnancy-Associated Breast Cancer: An analytical observational study]

BACKGROUND AND OBJECTIVE

Pregnancy-associated breast cancer is defined as breast cancer diagnosed during pregnancy and up to one year postpartum.

PATIENTS AND METHOD

A retrospective, analytical, observational study comparing 56 cases of breast cancer and pregnancy (PABC) diagnosed 1976-2008 with 73 patients with breast cancer not associated with pregnancy (non-PABC) was performed. Demographic data, prognostic factors, treatment and survival were reviewed and compared.

RESULTS

The prevalence of PABC in our center is 8.3/10,000. The highest frequency (62%) appeared during the postpartum period. The stages are higher in PABC, being 31.3% advanced (EIII and EIV) in PABC versus 13.3% in non-PABC (P < .05). Regarding prognostic factors, 27.3% in PABC had a tumoral grade 3 versus 15.8% of non-PABC. Among women with PABC, 33.3% had negative estrogen receptors, 48.7% negative progesterone receptors and 34.5% positive Her2Neu compared with 22.2, 24.1 and 31%, respectively of non-PABC patients. Finally, positive lymph nodes were found in 52.8% of PABC, versus 33.8% non-PABC (P < .05). Overall and disease-free survival rate at 5 years for PABC was 63.7 and 74.2%, respectively.

CONCLUSIONS

The poorer survival observed is possibly due to the presence of adverse prognostic features such as lymph node metastases, negative hormone receptors, tumoral grade iii, as well as a delay in diagnosis with a higher rate of advanced stages.

Two lives intertwined: pregnancy-associated breast cancer

The incidence of concurrent breast cancer and pregnancy (also known as pregnancy-associated breast cancer [PABC]) may increase as women delay child bearing. Because of the physiologic changes associated with pregnancy, diagnosis often is delayed, lending to poorer prognostic factors on presentation. Therefore, the clinical challenge in managing PABC involves controlling the cancer while maximizing survival outcomes for the expectant mother without compromising the health and safety of the fetus. Collaboration and communication between multidisciplinary team members are crucial. Education is key in providing a general overview of available diagnostic modalities, endorsing the multidisciplinary approach to care and treatment for the mother and fetus, and identifying the oncology nursing role specific to this patient population. Women with PABC must be kept informed of all aspects of care to ensure active participation in the decision-making process, as they are not only concerned for their own well-being but also that of their unborn child. Anxiety levels often run high and steady communication offers a modicum of control to this already-stressed patient population.

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.

Cancer during pregnancy: 10-year experience at a regional cancer reference center in Mexico

INTRODUCTION

Cancer during pregnancy is uncommon. However, recent trends in the prolongation of the childbearing age have made cancer-associated pregnancies more frequent. The objective of our study was to describe the frequency, types of cancer, and treatment with this association in our institution.

MATERIAL AND METHODS

The clinical records of 36 patients who presented to a regional reference center in Mexico over 10 years were reviewed collecting demographics, pregnancy characteristics and outcomes, type of cancer, clinical stage, treatment, and oncological outcome.

RESULTS

The following tumors were observed: Uterine cervix (20), breast (7), ovary (3), non-Hodgkin Lymphoma (2), and other malignancies (4). The mean age of the patients was 30 (range 20-39) years. Mean follow up was 17.8 (range 1-74) months. The pregnancies were synchronous in 23 cases and 13 were diagnosed in the following 12 months after birth. Mean gestational age of the product was of 37.4 weeks, resulting in 15 deliveries with healthy products, four abortions and four deaths. The majority of patients had advanced clinical stages. Overall survival was 36.4%.

DISCUSSION

Cancer during pregnancy appears to have a worse outcome when compared to the results reported in the literature of non-pregnant women with the same conditions. This may be related to the advanced clinical stages we found. Cancer during pregnancy requires specialized attention to improve both fetal and maternal outcomes.

Cancer during pregnancy: 10-year experience at a regional cancer reference center in Mexico

INTRODUCTION

Cancer during pregnancy is uncommon. However, recent trends in the prolongation of the childbearing age have made cancer-associated pregnancies more frequent. The objective of our study was to describe the frequency, types of cancer, and treatment with this association in our institution.

MATERIAL AND METHODS

The clinical records of 36 patients, who presented to a regional reference center in Mexico over 10 years were reviewed collecting demographics, pregnancy characteristics and outcomes, type of cancer, clinical stage, treatment, and oncological outcome.

RESULTS

The following tumors were observed: Uterine cervix (20), breast (7), ovary (3), non-Hodgkin Lymphoma (2), and other malignancies (4). The mean age of the patients was 30 (range 20-39) years. Mean follow up was 17.8 (range 1-74) months. The pregnancies were synchronous in 23 cases and 13 were diagnosed in the following 12 months after birth. Mean gestational age of the product was of 37.4 weeks, resulting in 15 deliveries with healthy products, four abortions, and four deaths. The majority of patients had advanced clinical stages. Overall survival was 36.4%.

DISCUSSION

Cancer during pregnancy appears to have a worse outcome when compared to the results reported in the literature of non-pregnant women with the same conditions. This may be related to the advanced clinical stages we found. Cancer during pregnancy requires specialized attention to improve both fetal and maternal outcomes.