Clinical features and survival of pregnancy-associated breast cancer: a retrospective study of 203 cases in China

Individualized treatment of pregnancy-associated breast cancer: a report of two cases and literature review

Background

Pregnancy-associated breast cancer (PABC) occurs during the special physiological period of female pregnancy, requiring a clinical approach that considers both the effectiveness of maternal treatment and the safety of the baby, creating a clinical challenge. This article discusses the diagnosis and treatment of two PABC cases and provides a thorough review of existing literature to offer insights for clinical practice.

Case Description

Patient A, a 41-year-old female at 30 weeks and 2 days of gestation, was diagnosed with left breast invasive carcinoma. Following one cycle of AC regimen chemotherapy, she successfully delivered a female infant at 35 weeks and 5 days of gestation. Subsequently, she received 5 cycles of THP regimen neoadjuvant therapy after childbirth. Then, she underwent left breast-conserving surgery and left axillary lymph node dissection. Postoperative pathology indicated pathologic complete response. Post-surgery, she received radiotherapy and targeted therapy. Patient B, a 33-year-old female at 27 weeks and 1 day of gestation, was diagnosed with left breast ductal carcinoma in situ (DCIS). She underwent left total mastectomy with left sentinel lymph node biopsy. Pathology post-surgery revealed intermediate-grade DCIS of the left breast concomitant with locally non-special type invasive carcinoma. No tumour metastasis was identified in the left sentinel lymph node. At 36 weeks of pregnancy, she delivered a male infant and subsequently received 4 cycles of AC regimen chemotherapy. After completing the chemotherapy, a newly formed mass was discovered in her right breast. Right breast mass mastectomy with vacuum assisted biopsy system was performed. Intraoperative pathology indicated intermediate-grade intraductal papillary carcinoma. During surgery, she underwent right total mastectomy and sentinel lymph node biopsy. Intraoperative frozen section analysis revealed the absence of tumour spread in the sentinel lymph nodes (0/8). Postoperatively, she received systematic endocrine therapy.

Conclusions

Both patients had successful outcomes for the unborn babies following delivery. By prioritizing the safety of both the mother and the child, tailored breast cancer treatments were given to the two individuals, leading to effective therapy. Clinicians should increase their awareness and knowledge of PABC to avoid misdiagnosis or overlooking diagnoses.

Systematic Review of Survival Outcomes of Pregnancy-Associated Breast Cancer in Asian Countries

Pregnancy-associated breast cancer (PABC) is a rare type of gestational cancer. It poses a significant challenge in diagnosis and management, especially in Asian countries with limited resources. We carried out a systematic literature review and narrative synthesis to identify survival outcomes for women with PABC in Asia. We searched MEDLINE, PubMed, Cochrane Library and the reference lists of the included English language articles for those conducted between January 2010 and August 2022. The search terms were pregnancy-associated breast cancer, breast cancer AND pregnancy, survival of PABC and prognosis of PABC patients. PABC is defined as breast cancer diagnosed either during pregnancy or 1 year-5 years postpartum. This review included observational studies conducted in Asian countries. The final 11 articles met the selection criteria and were analysed. Five of the studies had high quality methods as assessed using the Joanna Briggs Institute (JBI) checklist. We reported study design, year of diagnosis, country, definition of PABC, control group, age of participants, median follow-up time, survival outcomes and pregnancy as prognostic factors. Only five studies reported that PABC patients had a poor overall or disease-free survival rate compared to the control. Pregnancy was a significant independent prognostic factor of breast cancer in only two studies. This review highlights that pregnancy has an unconfirmed association with breast cancer survival in Asia. Most studies that found a non-significant association had small samples, thus there is a need for large-scale multinational epidemiological studies in Asia to establish the survival outcomes in PABC patients.

Survival probabilities and prognostic factors of pregnancy-associated breast cancer in Malaysian women

OBJECTIVE

Pregnancy-associated breast cancer (PABC) is a rare cancer. This study aimed to determine the survival probabilities and prognostic factors in patients with PABC.

METHODS

A retrospective cohort study was conducted in two tertiary care hospitals in Kota Bharu. We included all patients with breast cancer who were diagnosed by histopathology while pregnant or within 2 years post-partum from 2001 through 2020. We matched patients with PABC to non-pregnant patients with breast cancer by age and year of diagnosis. The data were analyzed using Cox proportional hazard regression.

RESULTS

A total of 35 cases of PABC and 70 non-PABC controls were recruited. The 3-year, 5-year, and 10-year survival probabilities for patients with PABC were 58.6%, 47.54%, and 38.03%, respectively. The patients with PABC had a non-significant difference in survival probabilities compared with non-PABC patients. The significant prognostic factors of PABC were age (adjusted hazard ratio [aHR], 0.91; 95% confidence interval [CI], 0.86-0.96; P=0.001), advanced stage of cancer (aHR, 9.97; 95% CI, 3.96-25.2; P<0.001), and no surgery (aHR, 3.16; 95% CI, 1.01-9.85; P=0.047). Pregnancy was not found to be an independent factor in the prognosis of PABC (aHR, 0.72; 95% CI, 0.39-1.28; P=0.266).

CONCLUSION

Women diagnosed with PABC had similar survival probabilities compared with non-PABC patients. Pregnancy was not an independent prognostic factor for breast cancer. This information can be useful when women with breast cancer are counseled and supported with the option of beginning treatment with pregnancy continuation.

Gestational Breast Cancer - a Review of Outcomes, Pathophysiology, and Model Systems

The onset of pregnancy marks the start of offspring development, and represents the key physiological event that induces re-organization and specialization of breast tissue. Such drastic tissue remodeling has also been linked to epithelial cell transformation and the establishment of breast cancer (BC). While patient outcomes for BC overall continue to improve across subtypes, prognosis remains dismal for patients with gestational breast cancer (GBC) and post-partum breast cancer (PPBC), as pregnancy and lactation pose additional complications and barriers to several gold standard clinical approaches. Moreover, delayed diagnosis and treatment, coupled with the aggressive time-scale in which GBC metastasizes, inevitably contributes to the higher incidence of disease recurrence and patient mortality. Therefore, there is an urgent and evident need to better understand the factors contributing to the establishment and spreading of BC during pregnancy. In this review, we provide a literature-based overview of the diagnostics and treatments available to patients with BC more broadly, and highlight the treatment deficit patients face due to gestational status. Further, we review the current understanding of the molecular and cellular mechanisms driving GBC, and discuss recent advances in model systems that may support the identification of targetable approaches to block BC development and dissemination during pregnancy. Our goal is to provide an updated perspective on GBC, and to inform critical areas needing further exploration to improve disease outcome.

Breast Carcinogenesis during Pregnancy: Molecular Mechanisms, Maternal and Fetal Adverse Outcomes

Breast cancer is a common type of cancer diagnosed during pregnancy, with increasing incidence over the last years, as more women choose to delay childbearing. Compared to breast cancer in general population, pregnancy-associated breast cancer (PABC) is significantly different in its terms of epidemiology, diagnostic and therapeutic management, while it exhibits particularly aggressive behavior, deriving from its unique molecular and biological profile. Although not fully elucidated, the pathophysiological basis of PABC can be traced back to a combination of hormonal and immune changes during pregnancy, breast involution and altered gene expression. There is considerable controversy in the existing literature about the influence of PABC on pregnancy outcomes, regarding both short- and long-term effects on maternal and fetal/neonatal health. The majority of PABC patients have advanced-stage disease at initial diagnosis and face a significantly poorer prognosis, with decreased survival rates. The most commonly reported adverse obstetrical–fetal events are preterm delivery and prematurity-associated neonatal morbidity, while other neonatal treatment-associated complications might also occur, even when safe therapeutic options are applied during pregnancy. The objective of the present comprehensive review was to summarize current knowledge and up-to-date evidence about the pathophysiological, molecular and biological basis of PABC, as well as its association with adverse maternal, obstetrical, fetal and neonatal outcomes.

Pregnancy-associated breast cancer: a multicenter study comparing clinicopathological factors, diagnosis and treatment outcomes with non-pregnant patients

PURPOSE

Pregnancy-associated breast cancer (PABC), defined as breast carcinoma diagnosed during pregnancy or in the first post-partum year, is one of the most common gestation-related malignancies with reported differences in tumor characteristics and outcomes. This multicenter study aims to review cases of PABC in Singapore, including their clinicopathological features, treatment, and clinical outcomes compared to non-PABC patients.

METHODS

Demographic, histopathologic and clinical outcomes of 93 PABC patients obtained from our database were compared to 1424 non-PABC patients.

RESULTS

PABC patients presented at a younger age. They had higher tumor and nodal stages, higher tumor grade, were more likely to be hormone receptor negative and had a higher incidence of multicentric and multifocal tumors. Histological examination after definitive surgery showed no significant difference in tumor size and number of positive lymph nodes suggesting similar neoadjuvant treatment effects. Despite this, PABC patients had worse outcomes with poorer overall survival and disease-free survival, OS (P < 0.0001) and DFS (P < 0.0001). Termination of pregnancy did not improve survival.

CONCLUSION

Patients with PABC present at a higher stage with more aggressive disease and have poorer outcomes compared to non-PABC patients. Reducing delay in diagnosis and treatment may help improve survival.

Breast cancer during pregnancy: epidemiology, phenotypes, presentation during pregnancy and therapeutic modalities

Although it is uncommon in general, breast cancer is the most commonly diagnosed cancer during pregnancy. While treatment for pregnant patients should adhere to treatment guidelines for non-pregnant patients, there exist specific considerations concerning diagnosis, staging, oncological treatment, and obstetrical care. Imaging and staging are preferably performed using breast ultrasound and mammography. Other ionizing radiation imaging modalities, including computed tomography (CT) and Positron Emission Tomography/ Computed Tomography (PET/CT), can be selectively performed when the estimated benefit for the mother outweighs the risks to the foetus, e.g., when the results will change clinical management. MRI is appropriate to stage for distant disease on the indication. Breast cancer during pregnancy is less often hormone receptor-positive and more frequently triple-negative breast cancer compared to age-matched controls. The basic principle is that women should receive state-of-the-art oncological treatment without delay if possible and that the pregnancy should be maintained as long as possible. Treatment strategy should be multidisciplinary defined, carefully weighing the selection, sequence, and timing of treatment modalities depending on patient-, tumour-, and pregnancy-related characteristics, as well as patient preferences. Initiating cancer treatment during pregnancy often decreases the risks of early delivery and prematurity. Breast cancer surgery is possible during all trimesters. Radiotherapy is possible during pregnancy in the first half of pregnancy. Chemotherapy can be safely administered starting from 12 weeks of gestational age, but endocrine and HER2 targeted therapy are contraindicated throughout the whole pregnancy. Importantly, foetal growth should be monitored and long-term follow-up of the children is encouraged in dedicated centres.

Clinical characteristics, pregnancy outcomes and ovarian function of pregnancy-associated breast cancer patients: a retrospective age-matched study

Background

Pregnancy-associated breast cancer (PABC) is a rare disease with increasing incidence. The prognosis, pregnancy outcomes and subsequent ovarian function of PABC patients are attracting attention.

Methods

Sixty-three PABC patients and 126 age-matched non-PABC patients were obtained in Tongji Hospital from January 2011 to September 2019. The clinical characteristics and ovarian function of PABC patients were compared with those of non-PABC patients. The pregnancy outcomes and neonatal outcomes of patients with breast cancer diagnosed during pregnancy (BCP) were described. Nonparametric tests, the χ2-test Kaplan–Meier, Cox regression and binomial logistic regression were used for analysis.

Results

PABC patients were diagnosed with a more advanced tumour stage (II: 47.6% vs. 45.2%, III: 33.3% vs. 19.8%, IV 3.2% vs. 0%, p = 0.003), which caused worse progression-free survival (PFS) (log-rank p = 0.0138) and breast cancer-specific survival (CSS) (log-rank p = 0.0076) than non-PABC patients. Tumour stage (III/IV vs. 0/I/II) (HR 16.017, 95% CI 5.830 ~ 44.006, p < 0.001) and endocrine therapy (HR 0.254, 95% CI 0.099 ~ 0.653, p = 0.004) were predictors of PFS. Tumour stage (III/IV vs. 0/I/II) (HR 30.875, 95% CI 7.232 ~ 131.820, p < 0.001), endocrine therapy (HR 0.200, 95% CI 0.049 ~ 0.818, p = 0.025) and targeted therapy (HR 0.143, 95% CI 0.028 ~ 0.743, p = 0.021) were predictors for breast CSS. Among the 15 BCP patients, 11 patients voluntarily continued their pregnancy, and the newborns had no obvious birth defects, either in 5 patients who received chemotherapy or in 6 patients who did not receive chemotherapy during pregnancy. Among the patients who received chemotherapy and did not receive endocrine therapy, 24 PABC patients and 48 non-PABC patients experienced chemotherapy-induced amenorrhea. There was no significant difference in resumption of menstruation between the two groups at 6 months and 12 months after the end of chemotherapy. No potential factors affecting resumption of menstruation were found.

Conclusion

Pregnancy at diagnosis or within 1 year after delivery was not a risk factor for a worse prognosis in PABC patients. Compared with non-PABC patients, patients with PABC presented more aggressive tumour characteristics, which could mostly explain the worse prognosis observed in PABC patients. Receiving the appropriate regimen of chemotherapy in the second and third trimesters did not affect the maternal outcomes or neonatal outcomes of BCP patients. The special physiological state during pregnancy and lactation did not interfere with the damage of chemotherapy to ovarian function.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09260-6.

Breast Cancer During Pregnancy: A Marked Propensity to Triple-Negative Phenotype

Breast and cervical cancers comprise 50% of all cancers during pregnancy. In particular, gestational breast cancer is considered one of the most aggressive types of cancers, which is a rare but fatal disease. However, the incidence of this type of cancer is increasing over the years and its prevalence is expected to rise further as more women delay childbearing. Breast cancer occurring after pregnancy is generally triple negative with specific characterizations of a poorer prognosis and outcome. On the other hand, it has been pointed out that this cancer is associated with a specific group of genes which can be used as precise targets to manage this deadly disease. Indeed, combination therapies consisting of gene-based agents with other cancer therapeutics is presently under consideration. We herein review recent progress in understanding the development of breast cancer during pregnancy and their unique subtype of triple negative which is the hallmark of this type of breast cancer.

Diagnosis and treatment of advanced HER2-positive breast cancer in young pregnant female: A case report

RATIONALE

The incidence of pregnancy-associated breast cancer (PABC) is increasing nowadays, and its diagnosis and treatment remain complicated due to the consideration of the fetus. The available data on PABC are primarily derived from case reports since there are ethical restrictions on conducting randomized clinical trials. In the present work, we reported a case of the human epidermal growth factor receptor 2 (HER2)-positive PABC and described the diagnosis and treatment for such type of breast cancer.

PATIENT CONCERNS

A 27-year-old patient was admitted to our hospital with the complaints of right breast mass for 3 days, and she was a first-time pregnant woman with a single live intrauterine fetus at 26 + 3 weeks of gestation. Physical examination of the right breast revealed a palpable and hard mass with obscure boundaries (5.0 cm × 4.0 cm) in the upper outer quadrant. Significant axillary lymph nodes (2.0 cm) were also present.

DIAGNOSIS

PABC.

INTERVENTION

To protect the fetus, breast ultrasonography was used to test her breast mass, a core needle biopsy was adopted to confirm the diagnosis, and abdominal ultrasound and chest X-ray were used to evaluate the metastasis. The patient was scheduled for neoadjuvant therapy using bi-weekly pirarubicin in combination with cyclophosphamide (AC) without anti-HER2 therapy for consideration of the fetus's safety. After 4 cycles of AC, the patient delivered a healthy male infant. After the delivery, all the treatments were carried out according to the standard recommendation for HER2 + breast cancer as non-pregnant patients.

OUTCOMES

After the surgery, the disease-free survival for the patient was 12 months until brain metastasis was diagnosed. She was still undergoing second-line anti-HER2 therapy and currently in a stable situation. Besides, the child was also healthy so far.

LESSONS

The methods for the diagnosis and treatment of PABC that result in teratogenesis should be avoided to protect the fetus. Mammogram and chest X-ray were safe approaches for the fetus. Moreover, chemotherapy-based on pirarubicin in combination with cyclophosphamide had no risk to the fetus.