Breast cancer in pregnancy
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Diagnosis of breast cancer during pregnancy is rare. However, risk of breast cancer increases with age, so more cases are occurring as many women are having children at an older age compared to previous generations. Breasts undergo significant changes when you become pregnant as they develop milk ducts for breast feeding and grow in size. These changes can make it difficult to diagnose breast cancer. Most lumps in the breast found during pregnancy are not cancer, but you should get them checked out by your doctor as soon as possible.

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Breast Cancer

Information Patients and the Public (7 links)


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Latest Research Publications

This list of publications is regularly updated (Source: PubMed).

Colfry AJ
Miscellaneous syndromes and their management: occult breast cancer, breast cancer in pregnancy, male breast cancer, surgery in stage IV disease.
Surg Clin North Am. 2013; 93(2):519-31 [PubMed]
Surgical therapy for occult breast cancer has traditionally centered on mastectomy; however, breast conservation with whole breast radiotherapy followed by axillary lymph node dissection has shown equivalent results. Patients with breast cancer in pregnancy can be safely and effectively treated; given a patient's pregnancy trimester and stage of breast cancer, a clinician must be able to guide therapy accordingly. Male breast cancer risk factors show strong association with BRCA2 mutations, as well as Klinefelter syndrome. Several retrospective trials of surgical therapy in stage IV breast cancer have associated a survival advantage with primary site tumor extirpation.


Vashi R, Hooley R, Butler R, et al.
Breast imaging of the pregnant and lactating patient: imaging modalities and pregnancy-associated breast cancer.
AJR Am J Roentgenol. 2013; 200(2):321-8 [PubMed]
OBJECTIVE: The purpose of this article is to review key clinical, histologic, and imaging features of pregnancy-associated breast cancer. A discussion of imaging modalities, including mammography, ultrasound, and MRI, and imaging-based interventions available for evaluating this population is provided.
CONCLUSION: Successful detection of pregnancy-associated breast cancer requires knowledge of key clinical and imaging features of pregnancy-associated breast carcinoma and selection of the appropriate imaging workup and intervention.


Berretta M, Di Francia R, Lleshi A, et al.
Antiblastic treatment, for solid tumors, during pregnancy: a crucial decision.
Int J Immunopathol Pharmacol. 2012 Apr-Jun; 25(2 Suppl):1S-19S [PubMed]
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.


Pistilli B, Bellettini G, Giovannetti E, et al.
Chemotherapy, targeted agents, antiemetics and growth-factors in human milk: how should we counsel cancer patients about breastfeeding?
Cancer Treat Rev. 2013; 39(3):207-11 [PubMed]
An increasing number of women are diagnosed with cancer during pregnancy and lactation. Women are usually advised to interrupt breastfeeding during systemic anticancer treatment for fear of serious adverse effects to the nursed infant. However, the issue is poorly addressed in the literature and very few studies have evaluated the safety of breastfeeding during or after cytotoxic drugs or target agents administration. In this review we will analyze the available evidence that addresses the issue of anticancer drugs, targeted agents, antiemetics and growth-factors excretion in human milk. This could serve as a unique resource that may aid physicians in the management of breastfeeding cancer patients interested in maintaining lactation during treatment.


Azim HA, Kroman N, Paesmans M, et al.
Prognostic impact of pregnancy after breast cancer according to estrogen receptor status: a multicenter retrospective study.
J Clin Oncol. 2013; 31(1):73-9 [PubMed] Article available free on PMC after 01/01/2014
PURPOSE: We questioned the impact of pregnancy on disease-free survival (DFS) in women with history of breast cancer (BC) according to estrogen receptor (ER) status.
PATIENTS AND METHODS: A multicenter, retrospective cohort study in which patients who became pregnant any time after BC were matched (1:3) to patients with BC with similar ER, nodal status, adjuvant therapy, age, and year of diagnosis. To adjust for guaranteed time bias, each nonpregnant patient had to have a disease-free interval at least equal to the time elapsing between BC diagnosis and date of conception of the matched pregnant one. The primary objective was DFS in patients with ER-positive BC. DFS in the ER-negative cohort, whole population, and overall survival (OS) were secondary objectives. Subgroup analyses included DFS according to pregnancy outcome and BC-pregnancy interval. With a two-sided α = 5% and β = 20%, 645 ER-positive patients were required to detect a hazard ratio (HR) = 0.65.
RESULTS: A total of 333 pregnant patients and 874 matched nonpregnant patients were analyzed, of whom 686 patients had an ER-positive disease. No difference in DFS was observed between pregnant and nonpregnant patients in the ER-positive (HR = 0.91; 95% CI, 0.67 to 1.24, P = .55) or the ER-negative (HR = 0.75; 95% CI, 0.51 to 1.08, P = .12) cohorts. However, the pregnant group had better OS (HR = 0.72; 95% CI, 0.54 to 0.97, P = .03), with no interaction according to ER status (P = .11). Pregnancy outcome and BC-pregnancy interval did not seem to impact the risk of relapse.
CONCLUSION: Pregnancy after ER-positive BC does not seem to reduce the risk of BC recurrence.


Cardonick E, Gilmandyar D, Somer RA
Maternal and neonatal outcomes of dose-dense chemotherapy for breast cancer in pregnancy.
Obstet Gynecol. 2012; 120(6):1267-72 [PubMed]
OBJECTIVE: To estimate the effect of dose-dense chemotherapy during pregnancy on maternal and neonatal outcomes.
METHODS: This is a retrospective cohort study in which women were identified from the international Cancer and Pregnancy Registry at Cooper Medical School at Rowan University in Camden, New Jersey. A chart analysis was completed and Fisher's exact test and independent t test were used in comparing patient outcomes.
RESULTS: Ten women received dose-dense chemotherapy, received every 2 weeks, and 99 women received conventional chemotherapy, received with at least 3-week intervals, for breast cancer during pregnancy. Birth weight, gestational age at delivery, rate of growth restriction, congenital anomalies, and incidence of maternal and neonatal neutropenia were not statistically different between the two groups.
CONCLUSION: In the small cohort of women in our registry, dose-dense chemotherapy does not appear to increase the risk of fetal or maternal complications.


Abenhaim HA, Azoulay L, Holcroft CA, et al.
Incidence, risk factors, and obstetrical outcomes of women with breast cancer in pregnancy.
Breast J. 2012 Nov-Dec; 18(6):564-8 [PubMed]
Breast cancer in pregnancy is a rare condition. The objective of our study was to describe the incidence, risk factors, and obstetrical outcomes of breast cancer in pregnancy. We conducted a population-based cohort study on 8.8 million births using data from the Healthcare Cost and Utilization Project - Nationwide Inpatient Sample from 1999-2008. The incidence of breast cancer was calculated and logistic regression analysis was used to evaluate the independent effects of demographic determinants on the diagnosis of breast cancer and to estimate the adjusted effect of breast cancer on obstetrical outcomes. There were 8,826,137 births in our cohort of which 573 cases of breast cancer were identified for an overall 10-year incidence of 6.5 cases per 100,000 births with the incidence slightly increasing over the 10-year period. Breast cancer appeared to be more common among women >35 years of age, odds ratio (OR)=3.36 (2.84-3.97); women with private insurance plans, OR=1.39 (1.10-1.76); and women who delivered in an urban teaching hospital, OR=2.10 (1.44-3.06). After adjusting for baseline characteristics, women with pregnancy-associated breast cancer were more likely to have an induction of labor, OR=2.25 (1.88, 2.70), but similar rates of gestational diabetes, preeclampsia, instrumental deliveries, and placental abruption. The incidence of breast cancer in pregnancy appears higher than previously reported with women over 35 being at greatest risk. Aside from an increased risk for induction of labor, women with breast cancer in pregnancy have similar obstetrical outcomes.


Czaplicki KL
Two lives intertwined: pregnancy-associated breast cancer.
Clin J Oncol Nurs. 2012; 16(5):E183-9 [PubMed]
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.


Cheung WL, Smoller BR
Dermatopathology updates on melanocytic lesions.
Dermatol Clin. 2012; 30(4):617-22, vi [PubMed]
This article provides an update on histopathologic studies of different types of melanocytic lesions, such as site-specific nevi, "Spark's" nevi, nevi during pregnancy, and atypical dermal melanocytic proliferation, including pigmented epithelioid melanocytoma, proliferating nodules, and atypical Spitzoid tumor. Special-site nevi, such as those appearing on the breast and genital region, generally have more cytologic and architectural atypia. Melanocytic proliferations generally do not change during pregnancy, contrary to earlier observations. Atypical dermal melanocytic proliferations are difficult to diagnose and usually have a better outcome after adequate treatment, including wide local skin excision with or without sentinel lymph node resection.


Christinat A, Pagani O
Fertility after breast cancer.
Maturitas. 2012; 73(3):191-6 [PubMed]
Breast cancer is the most common tumor in childbearing women. In the last decades, considerable improvement in breast cancer-related death has been achieved with adjuvant therapies (chemotherapy, endocrine and targeted therapies, radiotherapy) but at cost of significant long-term sequels, including infertility. Reproductive issues are of great importance to young women, in particular for those who did not complete their families before breast cancer diagnosis: patients should be adequately informed at the time of diagnosis about the risk of infertility and the available methods for fertility preservation. This review will focus on incidence and impact of infertility secondary to breast cancer treatment, the available options for ovarian function preservation, including embryo and oocyte cryopreservation, ovarian tissue cryopreservation, and ovarian suppression with gonadotropin-releasing hormone agonists. We will also discuss the optimal time of subsequent pregnancy, the potential risks for the mother and the fetus, and the impact of therapies on breastfeeding.


Patel KM, Basci D, Nahabedian MY
Multiple pregnancies following deep inferior epigastric perforator (DIEP) flap breast reconstruction.
J Plast Reconstr Aesthet Surg. 2013; 66(3):434-6 [PubMed]
Pregnancy following abdominal flap-based breast reconstruction may cause stress to the abdominal wall. These changes may result in weakness and hernia or bulge. We present two patients who previously underwent unilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction and became pregnant twice. Both patients maintained abdominal contour without bulges or hernias. Subjectively, patients reported minor changes to abdominal strength. Therefore, these two patients had minimal abdominal morbidity following pregnancy after unilateral DIEP flap reconstruction.


Han SN, Lotgerink A, Gziri MM, et al.
Physiologic variations of serum tumor markers in gynecological malignancies during pregnancy: a systematic review.
BMC Med. 2012; 10:86 [PubMed] Article available free on PMC after 01/01/2014
BACKGROUND: Recent insights provide support for the treatment of cancer during pregnancy, a coincidence that poses both mother and fetus at risk. Our aim was to critically review studies on the physiologic variations during pregnancy, the most common tumor markers used in diagnosis and follow-up of gynecological cancers.
METHODS: We conducted a systematic review of six tumor markers during normal pregnancy: carbohydrate antigen (CA) 15-3 (breast cancer); squamous cell carcinoma antigen (cervical cancer); and CA 125, anti-Müllerian hormone, inhibin B and lactate dehydrogenase (ovarian cancer).
RESULTS: For CA 15-3, 3.3% to 20.0% of all measurements were above the cut-off (maximum 56 U/mL in the third trimester). Squamous cell carcinoma antigen values were above cut-off in 3.1% and 10.5% of the measurements (maximum 4.3 µg/L in the third trimester). Up to 35% of CA 125 levels were above cut-off: levels were highest in the first trimester, with a maximum value up to 550 U/mL. Inhibin B, anti-Müllerian hormone and lactate dehydrogenase levels were not elevated in maternal serum during normal pregnancy.
CONCLUSION: During normal pregnancy, tumor markers including CA 15.3, squamous cell carcinoma antigen and CA 125 can be elevated; inhibin B, anti-Müllerian hormone and lactate dehydrogenase levels remain below normal cut-off values. Knowledge of physiological variations during pregnancy can be clinically important when managing gynecological cancers in pregnant patients.


Azim HA, Santoro L, Russell-Edu W, et al.
Prognosis of pregnancy-associated breast cancer: a meta-analysis of 30 studies.
Cancer Treat Rev. 2012; 38(7):834-42 [PubMed]
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.


Genin AS, Lesieur B, Gligorov J, et al.
Pregnancy-associated breast cancers: do they differ from other breast cancers in young women?
Breast. 2012; 21(4):550-5 [PubMed]
The impact of pregnancy in the physiopathology of pregnancy-associated breast cancer (PABC) is still unclear. We compared the characteristics of PABCs and breast cancers not associated with pregnancy (non-PABCs) in terms of their loco-regional invasion and histological phenotype. We conducted a retrospective chart review on women less than 43 years of age treated for breast cancer from January 1, 2004 to December 31, 2010. We compared age at diagnosis, loco-regional invasion and histological data. We recorded 282 breast cancers in 276 patients. Forty-one tumors (14.5%) were PABCs. PABC patients were significantly younger than non-PABC patients. Compared with the non-PABCs, PABCs were twice more frequent advanced tumors (T3-4) and have twice more frequent HER2 over-expression and hormone negative status. The more aggressive histological profile observed in the PABCs, especially in post-partum tumors and women older than 35 years of age, seems to be a direct consequence of the association with pregnancy.


Al-Salam S, Balalaa N, Faour I, et al.
HIF-1α, VEGF and WT-1 are protagonists in bilateral primary angiosarcoma of breast: a case report and review of literature.
Int J Clin Exp Pathol. 2012; 5(3):247-53 [PubMed] Article available free on PMC after 01/01/2014
Bilateral primary angiosarcoma of breast is an extremely rare disease. Only 4 cases had been described in the literature. Hypoxia inducible factor- 1 α (HIF-1α) is a transcription factor that binds to hypoxia response elements in the promoters of target genes. Vascular endothelial growth factor (VEGF) is an important signaling protein involved in angiogenesis. Wilms tumor -1 protein (WT-1) is a transcription factor that plays an important role in angiogenesis. We present a 29-year old female with bilateral primary angiosarcoma of breast. Five-μm sections were stained with CD31, FLI-1, HIF-1α, WT-1, VEGF, VEGF-R, D2-40, estrogen receptor, and progesterone receptor. The neoplastic cells show diffuse immunoreactivity to CD31, FLI-1, HIF- 1α, VEGF, VEGFR, and WT-1 protein. The neoplastic cells show no immunoreactivity to estrogen receptor, progesterone receptor and D2-40. In conclusion, HIF- 1α, WT-1 and VEGF are possible protagonists in the development of bilateral primary angiosarcoma of breast. The neoplastic process involves endothelial cell of blood vessels lineage rather than lymphatic lineage. Painless breast tumors in young women that are highly vascular at the time of biopsy should be considered as malignant until proven otherwise. Tissue biopsy is the gold standard in the diagnosis of primary angiosarcoma of breast.


Jiang AR, Gao CM, Ding JH, et al.
Abortions and breast cancer risk in premenopausal and postmenopausal women in Jiangsu Province of China.
Asian Pac J Cancer Prev. 2012; 13(1):33-5 [PubMed]
To evaluate the relationship between abortions and risk of breast cancer, we conducted a case-control study with 669 cases and 682 population-based controls in Jiangsu Province of China. A structured questionnaire was used to elicit detailed information. Unconditional logistic regression analysis was performed to calculate odds ratios (ORs) and 95% confidence intervals (CIs). The results have revealed that induced abortion was related to increased risk of breast cancer. Premenopausal women who had ≥ 3 times of induced abortion were at increased crude OR (2.41, 95%CI: 1.09-5.42) and adjusted-OR (1.55, 95%CI: 1.15-5.68). Postmenopausal women with a previous induced abortion were at increased crude OR (2.04, 95%CI: 1.48-2.81) and adjusted-OR (1.82, 95%CI: 1.30-2.54), and there was a significant increase trend in OR with number of induced abortions (p for trend: 0.0001). Overall, spontaneous abortion did not significantly alter the risk of breast cancer, but postmenopausal women who had history of spontaneous abortion were at increased OR. These results suggested that relationship between breast cancer and abortions may depend on menopausal status and induced abortion may played an important role in the development of breast cancer in Jiangsu' women of China.


Hsieh TC, Wu YC, Sun SS, et al.
FDG PET/CT of a late-term pregnant woman with breast cancer.
Clin Nucl Med. 2012; 37(5):489-91 [PubMed]
A 38-year-old pregnant woman at 26-week gestation with left breast cancer requested an FDG PET/CT scan for more detailed staging of her breast cancer before treatment. After discussing the potential radiation-related risk and estimating possible absorbed dose to fetus, she consented for examination. By using a low-radiation-dose CT protocol and administration of routine 370-MBq FDG without diuresis, the resultant calculated (using existing models to predict fetal radiation exposure) fetal dose from CT and FDG would be 3.60 mGy and 6.29 mGy, respectively. In contrast to the existing few literatures, our case also demonstrated previously unreported uptake in the fetal kidneys.


Abdel-Hady el-S, Hemida RA, Gamal A, et al.
Cancer during pregnancy: perinatal outcome after in utero exposure to chemotherapy.
Arch Gynecol Obstet. 2012; 286(2):283-6 [PubMed]
OBJECTIVES: To study the outcome of pregnancies complicated by malignant disease, in particular neonatal morbidity and mortality after in utero exposure to chemotherapy.
METHODS: This prospective study included 118 patients diagnosed with malignant disease for the first time during pregnancy over an 8-year period (March 2003-March 2011). Outcome of neonates born to mothers who received chemotherapy during pregnancy was studied and compared with a control group.
RESULTS: The commonest cancer type diagnosed during pregnancy (56/118 = 47.45 %) was breast carcinoma followed by lymphoma/leukemia (32 = 27.12 %). Gynecological tumors (all ovarian) represented 10.16 %, soft tissue tumors 5.08 %, colorectal 4.23 %, thyroid 2.54 % and others 3.38 %. Sixty-one (51.64 %) women received chemotherapy (average 3 ± 2 cycles) during the second and third trimesters. The incidence of neonatal survival, preterm birth, small for gestational age and congenital malformations was not significantly different between women who received chemotherapy during pregnancy and the control group. Five (4.23 %) women with advanced disease died during or shortly after termination of pregnancy.
CONCLUSION: In utero exposure to chemotherapy during the second and third trimesters of pregnancy carries minimal morbidity to the unborn fetus.


Massey Skatulla L, Loibl S, Schauf B, Müller T
Pre-eclampsia following chemotherapy for breast cancer during pregnancy: case report and review of the literature.
Arch Gynecol Obstet. 2012; 286(1):89-92 [PubMed]
PURPOSE: There has been some discussion about the effect of antineoplastic agents on the trophoblast, and whether this is associated with abnormal placental function such as an increased risk of pre-eclampsia/eclampsia. We discuss a possible causal relationship between chemotherapy for breast cancer during pregnancy and the development of pre-eclampsia based on the occurrence of both in a recent pregnancy.
METHODS: We report the case of a 34-year-old gravida 4, para 1 with unilateral ductal invasive breast cancer, treated by surgery and subsequent chemotherapy during pregnancy. At 36 + 2 weeks of gestation a growth restricted male infant (1,680 g, <5th percentile) was born by urgent caesarean section because of acute pre-eclampsia, pathologic CTG and umbilical end-diastolic reverse flow. This case is reported in detail, and literature and databases reviewed.
RESULTS: So far there have been no reports suggesting an increased risk of pre-eclampsia following chemotherapy for breast cancer in pregnancy from the second trimester onwards, and the most probable is an accidental occurrence from pre-eclampsia and chemotherapy.
CONCLUSIONS: Whenever possible, pregnant patients with breast cancer should receive the same treatment as those who are not pregnant. Should chemotherapy for breast cancer be indicated in pregnancy from the second trimester onwards only, contraindications would be other risks for pre-eclampsia and intrauterine growth restriction, such as smoking and gestational diabetes.


El-Safadi S, Wuesten O, Muenstedt K
Primary diagnosis of metastatic breast cancer in the third trimester of pregnancy: a case report and review of the literature.
J Obstet Gynaecol Res. 2012; 38(3):589-92 [PubMed]
To the best of our knowledge, we are presenting the first documented primary diagnosis of a 32-year-old pregnant patient at 29 + 4 weeks' gestation with poorly differentiated, metastatic scirrhous breast cancer, with negative hormone receptors, HER-2/neu receptor overexpression and metastases in the lumbar spine. The patient was administered neoadjuvant chemotherapy with vinorelbine and trastuzumab, and received ibandronate for the bone metastases. The tumor responded well to treatment; however, treatment was associated with anhydramnios, probably related to the trastuzumab treatment. Delivery was planned for 33 + 5 weeks' gestation by cesarean section due to concurrent breech presentation and anhydramnios, and the infant is in good health. After delivery, the patient underwent a mastectomy. Following completion of six courses of vinorelbine and ongoing treatment with trastuzumab and ibandronate, the patient's tumor went into regression and currently the patient does not present with any clinical evidence of disease.


Azim HA, Metzger-Filho O, de Azambuja E, et al.
Pregnancy occurring during or following adjuvant trastuzumab in patients enrolled in the HERA trial (BIG 01-01).
Breast Cancer Res Treat. 2012; 133(1):387-91 [PubMed]
Only few case reports describe the pregnancy course and outcome of breast cancer patients, who were under treatment with trastuzumab at the time of conception or who have completed trastuzumab therapy before becoming pregnant. The HERA trial is a large phase III randomized clinical trial in which patients with early HER2-positive breast cancer were randomized to receive 1 or 2 years of trastuzumab or observation following completion of primary chemotherapy. To examine the effect of trastuzumab on pregnancy outcome, we report all pregnancy events that occurred until March 2010 in patients enrolled in the study. For the sake of this analysis, patients were assigned to three groups: (1) pregnancy occurring during and up to 3 months after trastuzumab exposure (group 1); (2) pregnancy occurring >3 months of last trastuzumab dose (group 2); and (3) pregnancy occurring in patients without prior exposure to trastuzumab (group 3). Sixteen, 45 and 9 pregnancies took place in groups 1, 2, and 3, respectively. 25 and 16% of patients in groups 1 and 2 experienced spontaneous abortion, the former being higher than figures reported in the general population. However, short-term fetal outcome appeared normal across the three groups. Only 2 congenital anomalies were reported, one in group 2 and one in group 3. No congenital anomalies were reported in those exposed to trastuzumab in utero. This is the first report from a large randomized trial assessing the effect of trastuzumab on pregnancy course and outcome. Based on our results, trastuzumab does not appear to affect fetal outcome in patients who manage to complete their pregnancy. We are currently initiating a collaboration to collect similar data from the other large adjuvant trastuzumab trials to confirm these findings.


Ali SA, Gupta S, Sehgal R, Vogel V
Survival outcomes in pregnancy associated breast cancer: a retrospective case control study.
Breast J. 2012 Mar-Apr; 18(2):139-44 [PubMed]
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.


Amant F, Loibl S, Neven P, Van Calsteren K
Breast cancer in pregnancy.
Lancet. 2012; 379(9815):570-9 [PubMed]
Breast cancer staging and treatment are possible during pregnancy, and should be defined in a multidisciplinary setting. Tumour biology, tumour stage, and gestational stage at diagnosis determine the appropriate approach. Surgery for breast cancer is possible during all trimesters of pregnancy. Radiotherapy is possible during pregnancy but, dependent on the fetal dose received, can result in poor fetal outcomes. The decision to give radiotherapy should be made on an individual basis. Evidence increasingly supports administration of chemotherapy from 14 weeks' gestation onwards. New breast cancer treatments might be applicable to pregnant patients, but tamoxifen and trastuzumab are contraindicated during pregnancy. Cancer treatment during pregnancy will decrease the need for early delivery and thus prematurity, which is a major concern in management of breast cancer in pregnancy.


Nye L, Huyck TK, Gradishar WJ
Diagnostic and treatment considerations when newly diagnosed breast cancer coincides with pregnancy: a case report and review of literature.
J Natl Compr Canc Netw. 2012; 10(2):145-8 [PubMed]
Breast cancer is the most common malignancy associated with pregnancy and is a rare but well-recognized complication. It is hypothesized that as more women continue to delay childbearing, the incidence of breast cancer in pregnancy will increase. Because of the lack of clinical experience with breast cancer in the setting of pregnancy, given its relative infrequency, many patients and physicians believe the diagnosis puts the life of the mother at odds with that of the fetus, but available data suggest that termination of the pregnancy does not improve the outcome for pregnant women with breast cancer. Often diagnosis is delayed because neither patient nor physician suspects malignancy. This report presents a recent case of a young primigravid woman with a newly appreciated breast mass seen at Northwestern University Feinberg School of Medicine as a means of discussing diagnostic considerations, therapeutic options, and supportive care available to the practitioner when managing a pregnant patient with breast cancer.


Blumenfeld Z
Chemotherapy and fertility.
Best Pract Res Clin Obstet Gynaecol. 2012; 26(3):379-90 [PubMed]
The overall increase in cancer prevalence and the significant increase in long-term survival have generated worldwide interest in preserving fertility in young women exposed to gonadotoxic chemo- and radiotherapy. Infertility represents one of the main long-term consequences of combination chemotherapy given for lymphoma, leukaemia and other malignancies in young women. The gonadotoxic effect of various chemotherapeutic agents is diverse, may involve a variety of pathophysiologic mechanisms, and is not unequivocally understood. Proliferating cells, such as in tissues with high turnover (i.e. bone marrow, gastrointestinal tract and growing ovarian follicles) are more vulnerable to the toxic effect of alkylating agents. These agents may also be cytotoxic to cells at rest, as they are not cell-cycle specific. Alkylating agents, the most gonadotoxic chemotherapeutic medications, cause dose-dependent, direct destruction of oocytes and follicular depletion, and may bring about cortical fibrosis and ovarian blood-vessel damage. The reported rate of premature ovarian failure after various diseases and chemotherapeutic protocols differ enormously, and depend mainly on the chemotherapeutic protocol used and age range of the woman. Several options have been proposed for preserving female fertility, despite gonadotoxic chemotherapy: ovarian transposition, cryopreservation of embryos, unfertilised metaphase-II oocytes and ovarian tissue, and administration of gonadotropin-releasing hormone agonistic analogs in an attempt to decrease the gonadotoxic effects of chemotherapy by simulating a prepubertal hormonal milieu. None of these methods is ideal and none guarantees future fertility in all survivors; therefore, a combination of methods is recommended for maximising women's chances of future fertility.


Fernandes AF, Santos MC, de Castro e Silva TB, Galvão CM
Prognosis of breast cancer during pregnancy: evidence for nursing care.
Rev Lat Am Enfermagem. 2011 Nov-Dec; 19(6):1453-61 [PubMed]
This integrative review analyzed evidence available in the literature concerning the prognosis of breast cancer during pregnancy. The following databases were used for selecting studies: PubMed, CINAHL and LILACS. A total of 240 primary studies were identified; 13 papers were included in the integrative review's sample after reading the titles and abstracts and according to the established inclusion and exclusion criteria. There is evidence indicating that pregnancy does not worsen the evolution of breast cancer and a poor prognosis is related to late stage tumors. Among the gaps identified in the studied theme, the need for further studies addressing nursing care provided to pregnant women with breast cancer is highlighted in order to promote improved care in the context of health care.


Azim HA, Botteri E, Renne G, et al.
The biological features and prognosis of breast cancer diagnosed during pregnancy: a case-control study.
Acta Oncol. 2012; 51(5):653-61 [PubMed]
BACKGROUND: Breast cancer during pregnancy (BCP) is relatively rare and is associated with controversies about its biology and prognosis. Hence, we designed a case-control study to examine tumor features and outcome in a series of BCP patients diagnosed and treated in a single institution.
MATERIAL AND METHODS: We identified 65 patients diagnosed with BCP and for each; we selected two non-pregnant breast cancer patients, who were matched for age, year of surgery, stage, and neoadjuvant chemotherapy. We then compared the differences in pathology, immunohistochemical features (ER, PR, HER2 and ki-67), disease-free (DFS) and overall survival (OS).
RESULTS: We did not find any significant differences in tumor characteristics between the two groups. However, at a median follow-up of four years, BCP patients had an inferior DFS (HR 2.3; 95% CI 1.3-4.2), after adjustment for possible confounding covariates. No difference in OS was observed. However, upon restricting the analysis to patients who did not receive neoadjuvant chemotherapy, patients with BCP had inferior OS as well (HR 2.6; 95% CI 1.0-6.5). No association between induction of abortion and prognosis was observed.
CONCLUSIONS: While we did not observe any differences in tumor features, BCP patients have poorer prognosis compared to age and stage-matched control. Further studies should try to elucidate reasons for such poor outcome.


Murphy CG, Mallam D, Stein S, et al.
Current or recent pregnancy is associated with adverse pathologic features but not impaired survival in early breast cancer.
Cancer. 2012; 118(13):3254-9 [PubMed]
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.


Kizer NT, Powell MA
Surgery in the pregnant patient.
Clin Obstet Gynecol. 2011; 54(4):633-41 [PubMed]
The key pregnancy-related physiological maternal and fetal changes that occur and the modifications to standard surgical approaches that can impact surgical outcomes are important to recognize. Surgery during pregnancy can be safe and effective. Laparoscopy has become an acceptable alternative to the standard laparotomy and should be considered when surgeons with appropriate skills and experience are available. Care of these patients should always involve a multidisciplinary team with the goal to optimize outcomes for both the mother and the fetus.


Brewer M, Kueck A, Runowicz CD
Chemotherapy in pregnancy.
Clin Obstet Gynecol. 2011; 54(4):602-18 [PubMed]
One in 1000 pregnancies is complicated with cancer with the most common tumors being breast cancer, cervical cancer, thyroid, leukemia, lymphoma, and ovarian cancer. It is often assumed that cancer during pregnancy necessitates sacrificing the well-being of the fetus but in most cases appropriate treatment can be offered to the mother without placing the fetus at serious risk. The care of a pregnant woman with cancer involves evaluation of competing maternal and fetal risks and benefits. Although it is rare to administer chemotherapy during pregnancy, the risks depend on the drugs used and the gestational age of the fetus. During the period of organogenesis (4 to 13 wk), administration of cytotoxic drugs carries an increased risk of fetal malformations and fetal loss. Chemotherapy in the second or third trimester is associated with intrauterine growth retardation, prematurity, and low birth weight and bone marrow toxicity in many exposed infants.


This page last updated: 22nd May 2013
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