Treatment (con’t) No longer a role for termination of pregnancy Goals are to achieve control of disease and prevent distant metastasis Fetal protective modifications Multi-disciplinary team –Medical oncology, surgical oncology, high-risk obstetrics, genetic counseling, psychological support
Treatment (con’t) Surgery –Lumpectomy –Mastectomy –Axillary dissection –Sentinel node biopsy *Breast conservation is the standard of care when appropriate in a non-pregnant patient
Treatment (con’t) NSABP trials –B06 - established the safety of breast conserving surgery for early stage breast cancer and demonstrated the importance of adjuvant breast radiation to minimize risk of in-breast recurrence.
Treatment (con’t) Surgery –Try to wait until the 12 th week –Breast conservation - i.e.. Lumpectomy –Need to consider need for XRT Don’t give during pregnancy –Consider neo-adjuvant chemotherapy
Treatment (con’t) Axillary Surgery – – Veronessi demonstrated that sentinel lymph node biopsy was accurate and reliable. –B32 – sentinel lymph node biopsy is safe and relaible * ~8-10% false negative rate
Treatment (con’t) Axillary surgery –Blue dye –Radioisotope –Filtered vs. unfiltered –Injection site –Timing
Treatment Axillary Surgery –Increased incidence of nodal involvement –Consider neo-adjuvant treatment –UTZ and FNA –Sentinel node biopsy has problems Isosulfan blue Radiocolloid –Consider axillary dissection
Sentinel Lymph Node
Treatment (con’t) Radiation Treatment –Risks are highest during first trimester –Decrease gradually –Try to avoid during pregnancy –Risks may be overstated
Treatment (con’t) Chemotherapy –Important role –Advanced disease often –Teratogenic effects –Long term safety profile Preterm delivery Low birth weight Transient leukopenia IUGR
Treatment (con’t) Chemotherapy –MD Anderson study –Anthracyclines –methotrexate
Treatment (con’t) Endocrine therapy –Contraindicated during pregnancy
Prognosis Use TNM staging Most women have stage II or III disease Same prognosis stage for stage Delay in diagnosis has impact % - 5 year survival 31-52% - 10 year survival
Pregnancy after Treatment Conflicting data 2 years 5 years Ever?
Conclusion Due to lack of prospective randomized clinical studies, both ongoing studies and future evidence are expected to solve problems related to breast cancer management during pregnancy. Must balance aggressive maternal care with appropriate modifications that will ensure fetal protection.