Impact of pregnancy on non-metastatic breast cancer: a case control study

Survival in Women Diagnosed With Breast Cancer During Pregnancy

INTRODUCTION

Pregnancy rarely coincides with breast cancer, but when it does, uncertainties remain about how survival is affected. In a nation-wide study, we investigated survival in women diagnosed with breast cancer during pregnancy.

MATERIALS AND METHODS

Through health registries, we identified women with breast cancer at ages 15-44 years from 1973-2016 in Denmark and included 156 who were pregnant at diagnosis and 11,110 who were not. We compared overall mortality in pregnant and non-pregnant women using multivariate Cox regression stratified by time since cancer: <2 and ≥2 years.

RESULTS

During the first 2 years after diagnosis, the hazard ratio of overall death was 2.28 (95% CI: 1.48-3.52) for pregnant versus non-pregnant breast cancer patients after adjustment for age and calendar period and 1.62 (95% CI: 1.05-2.50) after further adjustment for extent of disease. Adjusting for additional tumor characteristics, the hazard ratio was still significantly increased. Beyond the first 2 years, there was no excess mortality.

CONCLUSION

Our study identifies the early period after breast cancer as a period of particular interest in future studies on survival after breast cancer in pregnancy. We found no evidence that survival is affected by pregnancy when 2 or more years have passed since diagnosis.

Receptor status of breast cancer diagnosed during pregnancy: A literature review

The definition of PABC is inconsistently given as either breast cancer diagnosed exclusively during pregnancy, or combined with breast cancer diagnosed within six months to five years after delivery, and sometimes even longer. The longer away from the delivery date breast cancer is diagnosed, the less clear this association with pregnancy may become. Therefore, breast cancer diagnosed during pregnancy (BCdP) may not necessarily be the same disease entity as PABC. This review aims to provide an overview of BCdP receptor status, as this has not been assessed before. BCdP tumors were predominantly ER negative (56.6 %), PR negative (57.2 %) or both ER and PR negative (47.9 %). Moreover, HER2-overexpression was seen in 33.2 % of BCdP patients and 27.6 % had triple negative disease. This predominantly ER and PR negative profile with more often HER2 overexpression is aggressive and distinct from non-pregnant similar-aged patients, warranting future comparative research.

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.

Cancer in Pregnancy

Cancer in pregnancy may be increasing in incidence with advancing maternal age and higher rates of obesity. The diagnosis of cancer in pregnancy provokes complex management issues balancing short- and long-term risks for both mother and baby. Every case needs to be individualized, with a multidisciplinary team of midwives, obstetricians, oncologists, surgeons, radiation oncologists, and neonatologists assisting the family to make informed decisions regarding the best treatment course for the mother and baby. The present article reviews the evidence regarding the safety of diagnostic imaging, procedures and treatment modalities for cancer for the pregnant woman and fetus. The efficacy of novel anticancer therapies highlight the need for International Registries to accumulate safety data for these agents in pregnancy as expeditiously as possible.

Outcome of patients with pregnancy during or after breast cancer: a review of the recent literature

BACKGROUND

An increasing number of young women are delaying childbearing; hence, more are diagnosed with breast cancer (bca) before having a family. No clear recommendations are currently available for counselling such a population on the safety of carrying a pregnancy during bca or becoming pregnant after treatment for bca.

METHODS

Using a Web-based search of PubMed we reviewed the recent literature about bca and pregnancy. Our objective was to report outcomes for patients diagnosed with bca during pregnancy, comparing them with outcomes for non-pregnant women, and to evaluate prognosis in women diagnosed with and treated for bca who subsequently became pregnant.

RESULTS

"Pregnancy and bca" should be divided into two entities. Pregnancy-associated bca tends to be more aggressive and advanced in stage at diagnosis than bca in control groups; hence, it has a poorer prognosis. With respect to pregnancy after bca, there is, despite the bias in reported studies and meta-analyses, no clear evidence for a different or worse disease outcome in bca patients who become pregnant after treatment compared with those who do not.

CONCLUSIONS

Pregnancy-associated bca should be treated as aggressively as and according to the standards applicable in nonpregnant women; pregnancy after bca does not jeopardize outcome. The guidelines addressing risks connected to pregnancy and bca lack a high level of evidence for better counselling young women about pregnancy considerations and preventing unnecessary abortions. Ideally, evidence from large prospective randomized trials would set better guidelines, and yet the complexity of such studies limits their feasibility.

Does pregnancy-associated breast cancer imply a worse prognosis? A matched case-case study

BACKGROUND

Significant controversy exists in the literature regarding the role of pregnancy in the prognosis of breast cancer. We designed a matched case-case study, matching pregnancy-associated breast cancer (PABC) cases with breast cancer cases for stage, age, and year of diagnosis.

PATIENTS AND METHODS

39 consecutive cases of PABC were matched with 39 premenopausal cases of breast cancer. Univariate and multivariate survival analyses followed by adjustment for stage, grade, estrogen receptor status, and age at diagnosis, were performed.

RESULTS

Regarding overall survival (OS), univariate analysis pointed to longer OS in non-PABC cases vs. PABC cases. Accordingly, a more advanced stage predicted shorter survival. In the multivariate analysis, the independent aggravating effect mediated by pregnancy persisted. Interestingly, a post hoc nested analysis within PABC cases indicated that the 3rd trimester pointed to shorter OS. The aforementioned results on OS were also replicated during the examination of relapse-free survival.

CONCLUSION

Implementing a matched case-case design, the present study points to pregnancy as a poor prognostic factor for breast cancer.

Challenges in managing breast cancer during pregnancy

Pregnancy-associated breast cancer (PABC) is defined as breast cancer occurring anytime during gestation, lactation or within one year after delivery. The optimal management of pregnant women with breast cancer is challenging and not well established; the main concern is the effect of the drugs on the developing fetus and long-term complications after in utero exposure to anti-cancer drugs. Surgical resection is the mainstay of treatment for early breast cancer diagnosed during pregnancy. Modified radical mastectomy is standard of care in first trimester, whereas breast-conserving surgery (lumpectomy with lymph node dissection) can be performed preferably in the second and third trimester. Of note, breast-conserving surgery is not contraindicated per se during the first trimester, but owing to the potential impact of delaying radiotherapy. Radiation therapy is not favored during pregnancy. Moreover, tamoxifen is contraindicated during pregnancy; the agent has been associated with birth defects in up to 20% of exposures. Chemotherapy is generally contraindicated during the first trimester because of the possible damage to organogenesis. Anthracyclines-based regimens are the most widely used is breast cancer treatment and were been shown to be associated with favourable safety profile when administered during pregnancy. As for taxanes, more limited data is available. The use of trastuzumab is contraindicated during pregnancy, given the apparent risk of oligo- and/or anhydramnios as well as the unknown long-term sequelae on the fetus. It is obvious that, diagnosis of breast cancer during pregnancy adds complexity to cancer treatment recommendations. In all cases, a multidisciplinary therapeutic approach among obstetricians, gynaecologists, surgical oncologists, radiation oncologists, medical oncologists, pediatricians and hematologists is clearly warranted.

Prognosis of women with primary breast cancer diagnosed during pregnancy: results from an international collaborative study

PURPOSE

We aimed to determine the prognosis of patients with breast cancer diagnosed during pregnancy (BCP).

PATIENTS AND METHODS

In this cohort study, a multicentric registry of patients with BCP (from Cancer in Pregnancy, Leuven, Belgium, and GBG 29/BIG 02-03) compiled pro- and retrospectively between 2003 and 2011 was compared with patients who did not have associated pregnancies, using an age limit of 45 years. Patients with a diagnosis postpartum were excluded. The main analysis was performed using Cox proportional hazards regression of disease-free survival (DFS) and overall survival (OS) on exposure (pregnant or not), adjusting for age, stage, grade, hormone receptor status, human epidermal growth factor 2 status, histology, type of chemotherapy, use of trastuzumab, radiotherapy, and hormone therapy.

RESULTS

The registry contained 447 women with BCP, mainly originating from Germany and Belgium, of whom 311 (69.6%) were eligible for analysis. The nonpregnant group consisted of 865 women. Median age was 33 years for the pregnant and 41 years for the nonpregnant patients. Median follow-up was 61 months. The hazard ratio of pregnancy was 1.34 (95% CI, 0.93 to 1.91; P = .14) for DFS and 1.19 (95% CI, 0.73 to 1.93; P = .51) for OS. Cox regression estimated that the 5-year DFS rate for pregnant patients would have increased from 65% to 71% if these patients had not been pregnant. Likewise, the 5-year OS rate would have increased from 78% to 81%.

CONCLUSION

The results show similar OS for patients diagnosed with BCP compared with nonpregnant patients. This information is important when patients are counseled and supports the option to start treatment with continuation of pregnancy.

Antiblastic treatment, for solid tumors, during pregnancy: a crucial decision

Cancer is the second leading cause of death during the reproductive years complicating between 0.02 percent and 0.1 percent of pregnancies. The incidence is expected to rise with the increase in age of childbearing. The most common types of pregnancy-associated cancers are: cervical cancer, breast cancer, malignant melanoma, Hodgkin's lymphoma, non-Hodgkin's lymphoma and ovarian cancer. The relatively rare occurrence of pregnancy-associated cancer precludes conducting large, prospective studies to examine diagnostic, management and outcome issues. The treatment of pregnancy-associated cancer is complex since it may be associated with adverse fatal effects. In pregnant patients diagnosed with cancer during the first trimester, treatment with multidrug anti-cancer chemotherapy is associated with an increased risk of congenital malformations, spontaneous abortions or fetal death, and therefore, should follow a strong recommendation for pregnancy termination. Second and third trimester exposure is not associated with teratogenic effect but increases the risk of intrauterine growth retardation and low birth weight. There are no sufficient data regarding the teratogenicity of most cytotoxic drugs. Almost all chemotherapeutic agents were found to be teratogenic in animals and for some drugs only experimental data exist. Moreover, no pharmacokinetic studies have been conducted in pregnant women receiving chemotherapy in order to understand whether pregnant women should be treated with different doses of chemotherapy. This article reviews the available data regarding the different aspects of the treatment of cancer during pregnancy.

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.

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.

Chemotherapy for breast cancer in pregnancy: evidence and guidance for oncologists

It has been estimated that up to 3.8% of breast cancers may be diagnosed in women who are pregnant, with an estimated 1 in 3000-3500 deliveries occurring in women with breast cancer. Owing to the lack of large randomized trials available to guide our clinical practice, our decisions regarding adjuvant systemic management are based on retrospective analyses, case reports and a small number of prospective studies. A tailored approach to treatment is required with careful consideration given at all stages to the needs of the mother and risks to the foetus. Management is critically influenced by the stage of pregnancy, especially the first trimester. Anthracycline-based chemotherapy may be administered during the second and third trimesters, with apparently few short-term implications. Limited data shows the taxanes may also be given with few adverse events at these stages. Weekly fractionation regimens may allow closer monitoring of pregnancy with prompt termination of agents, if necessary. Data concerning the long-term risks of systemic anticancer treatment are limited. All stages of patient management should be discussed within a multidisciplinary team and a clear consensus of treatment options communicated to the mother. Delaying chemotherapy until after delivery may be reasonable in some cases, but where the delay is likely to be prolonged, a decision must be made on the basis of risks versus benefits.

Impact of MRI surveillance and breast cancer detection in young women with BRCA mutations

Based on several observational studies that have yielded consistent results, the combination of annual magnetic resonance imaging (MRI) plus mammography is now the standard of care for screening women with BRCA mutations who decline risk-reducing mastectomy. However, many of these women will develop breast cancer at a young age and, while most of these cancers will be very early stage, oncologists need to be aware of the unique issues faced by women in this age group due to the diagnosis and treatment. Fear of death, loss of fertility, premature menopause, relationship stress, career disruption and financial losses are only some of the problems that are either unique to young women or much more pronounced in this age group. Urgent referral to a fertility specialist of any woman who has not yet completed her family should be made as soon as the possible need for systemic treatment is recognized. The oncologist should also have a low threshold for referring young women to professionals experienced in navigating young women and their families through the psychosocial trauma of a breast cancer diagnosis.

Breast cancer and pregnancy: current concepts in diagnosis and treatment

The treatment of breast cancer diagnosed during pregnancy presents a challenging situation for the patient, family, and caregivers. Case series have demonstrated the efficacy and safety of using anthracycline-based chemotherapy during the second and third trimesters. Additionally, patients should be seen, evaluated, and treated in a multidisciplinary setting with facilitated communication among the medical oncologist, surgical oncologist, obstetrician, radiation oncologist, pathologist, and radiologist. This review details the available data regarding the diagnosis and management of the pregnant breast cancer patient.

Comparison of Locoregional Recurrence with Mastectomy vs. Breast Conserving Surgery in Pregnancy Associated Breast Cancer (PABC)

We have compared outcomes, including the locoregional recurrence, between mastectomy and breast conserving therapy in PABC. Patients were divided into those who were treated with mastectomies (group 1) and those with breast conserving surgery (group 2). The groups were comparable except for lower mean age in group 2 and more patients with stage III disease and higher number of nodes positive in the group 1. Five-year actuarial LRR, distant metastases free survival and overall survival in group 1 vs. 2 were 10% vs. 37%, 73% vs. 81% and 57% vs. 59% respectively. The patients with PABC treated with breast conserving therapy, despite having lower stage disease, have a higher risk of local regional recurrence in comparison with those treated with mastectomy.

Pregnancy and breast cancer: when they collide

Women of childbearing age experience an increased breast cancer risk associated with a completed pregnancy. For younger women, this increase in breast cancer risk is transient and within a decade after parturition a cross over effect results in an ultimate protective benefit. The post-partum peak of increased risk is greater in women with advanced maternal age. Further, their lifetime risk for developing breast cancer remains elevated for many years, with the cross over to protection occurring decades later or not at all. Breast cancers diagnosed during pregnancy and within a number of years post-partum are termed pregnancy-associated or PABC. Contrary to popular belief, PABC is not a rare disease and could affect up to 40,000 women in 2009. The collision between pregnancy and breast cancer puts women in a fear-invoking paradox of their own health, their pregnancy, and the outcomes for both. We propose two distinct subtypes of PABC: breast cancer diagnosed during pregnancy and breast cancer diagnosed post-partum. This distinction is important because emerging epidemiologic data highlights worsened outcomes specific to post-partum cases. We reported that post-partum breast involution may be responsible for the increased metastatic potential of post-partum PABC. Increased awareness and detection, rationally aggressive treatment, and enhanced understanding of the mechanisms are imperative steps toward improving the prognosis for PABC. If we determine the mechanisms by which involution promotes metastasis of PABC, the post-partum period can be a window of opportunity for intervention strategies.

The impact of pregnancy on breast cancer outcomes in women<or=35 years

BACKGROUND

Some evidence suggests that women with pregnancy-associated breast cancers (PABC) have a worse outcome compared with historical controls. However, young age is a worse prognostic factor independently, and women with PABC tend to be young. The purpose of the current study was to compare locoregional recurrence (LRR), distant metastases (DM), and overall survival (OS) in young patients with PABC and non-PABC.

METHODS

Data for 668 breast cancers in 652 patients aged<or=35 years were retrospectively reviewed. One hundred four breast cancers (15.6%) were pregnancy-associated; 51 cancers developed during pregnancy and 53 within 1 year after pregnancy.

RESULTS

The median follow-up for all living patients was 114 months. Patients who developed PABC had more advanced T classification, N classification, and stage group (all P<.04) compared with patients with non-PABC. Patients with PABC had no statistically significant differences in 10-year rates of LRR (23.4% vs 19.2%; P=.47), DM (45.1% vs 38.9%; P=.40), or OS (64.6% vs 64.8%; P=.60) compared with patients with non-PABC. For those patients who developed breast cancer during pregnancy, any treatment intervention during pregnancy provided a trend toward improved OS compared with delaying evaluation and treatment until after delivery (78.7% vs 44.7%; P=.068).

CONCLUSIONS

Young patients with PABC had no statistically significant differences in LRR, DM, or OS compared with those with non-PABC; however, pregnancy contributed to a delay in breast cancer diagnosis, evaluation, and treatment. Primary care and reproductive physicians should be aggressive in the workup of breast symptoms in the pregnant population to expedite diagnosis and allow multidisciplinary treatment.

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.

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.

Breast cancer and pregnancy: a diagnostic and management dilemma

BACKGROUND

The purpose of the present paper was to review the current knowledge of pregnancy concurrent with a diagnosis of breast cancer, and how best to manage this group of women and those breast cancer survivors who may subsequently conceive.

RESULTS

Pregnancy-associated breast cancer or gestational breast cancer is defined as breast cancer diagnosed during pregnancy or in the 12 months post-partum. A review of the current literature on breast cancer-related pregnancy suggests an incidence of between 0.7 and 3.9%. The prognosis is thought not to be significantly different from non-pregnancy-associated breast cancer, except in cases where a delay in diagnosis is associated with more advanced disease. The treatment is similar to non-pregnant cases, with the exception of radiotherapy, which is contraindicated throughout pregnancy; and chemotherapy, which is contraindicated during the first trimester. Few breast cancer survivors go on to conceive, but those who do have no worse breast cancer or pregnancy outcomes.

CONCLUSION

Most of the research in this field has come from small, specialized institutions and may not reflect what occurs in the wider community. Further population-based research in this area is needed, and is currently being undertaken in Western Australia.

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.

Effect of pregnancy on overall survival after the diagnosis of early-stage breast cancer

PURPOSE

To evaluate the impact of subsequent pregnancy on the prognosis of patients with early breast cancer.

PATIENTS AND METHODS

One hundred eight patients who became pregnant after diagnosis of early-stage breast cancer were identified in institutions participating in International Breast Cancer Study Group (IBCSG) studies. Fourteen had relapse of breast cancer before their first subsequent pregnancy. The remaining 94 patients (including eight who relapsed during pregnancy) formed the study group reported here. A comparison group of 188 was obtained by randomly selecting two patients, matched for nodal status, tumor size, age, and year of diagnosis from the IBCSG database, who were free of relapse for at least as long as the time between breast cancer diagnosis and completion of pregnancy for each pregnant patient. Survival comparison used Cox proportional hazards regression models.

RESULTS

Overall 5- and 10-year survival percentages (+/- SE) measured from the diagnosis of early-stage breast cancer among the 94 study group patients were 92% +/- 3% and 86% +/- 4%, respectively. For the matched comparison group survival was 85% +/- 3% at 5 years and 74% +/- 4% at 10 years (risk ratio, 0.44; 95% confidence interval, 0.21 to 0.96; P =.04).

CONCLUSION

Subsequent pregnancy does not adversely affect the prognosis of early-stage breast cancer. The superior survival seen in this and other controlled series may merely reflect a healthy patient selection bias, but is also consistent with an antitumor effect of the pregnancy.

Breast cancer and pregnancy

Pregnancy-associated breast cancer has an overall worse prognosis than nonpregnancy-associated breast cancers because a large proportion present with more advanced disease. Stage for stage, however, the prognosis is similar. The various modalities used for screening, diagnosis, and staging of breast cancer are not always applicable during pregnancy. Often, a delay in diagnosis may contribute to a more advanced stage at presentation. The management of pregnant women with breast cancer is also different because it involves assessing the possible risks to the fetus versus the maternal benefits.