1. Breast Cancer in Pregnancy
Steven Stanten MD
Rupert Horoupian MD
AltaBates Summit Medical Center
Oakland, California

2. Introduction One of the most commonly diagnosed cancers of pregnancy
More advanced stage
Poorer prognosis
Pregnancy-associated
During pregnancy
During lactation
Up to 12 months post-partum

3. Epidemiology 12.67% within their lifetime Mean age 61
12.7% between 20 and 44
Of women with breast cancer before 40, 10% will be pregnant
1/3000 pregnancies

4. Pathology Invasive ductal predominates Larger in size at presentation
Higher frequency of lymphovascular invasion
Higher nuclear grade
Higher hormonal independence
Her-2/neu – no concensus

5. Diagnosis Clinical exam Medical Imaging Usually a mass
Broad differential diagnosis
Most are benign
Medical Imaging
Mammography usually not helpful
Safety and efficacy

6. Diagnosis (con’t) Medical Imaging Screening - not when pregnant UTZ
CXR
Other staging modalities

7. Diagnosis (con’t) Cytology and Histology
Biopsy recommended if questions persist
FNA, core needle biopsy, excisional biopsy
-rare milk fistula and infection

8. Treatment Surgery Radiotherapy Chemotherapy Obstetric outcome
Endocrine therapy
Supporting agents

9. 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

10. 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

11. 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.

12. Treatment (con’t) Surgery Lumpectomy Anesthesia Wire localization
X-ray confirmation
Wide margins

13. Treatment (con’t) Surgery Try to wait until the 12th week
Breast conservation - i.e.. Lumpectomy
Need to consider need for XRT
Don’t give during pregnancy
Consider neo-adjuvant chemotherapy

14. 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

15. Treatment (con’t) Axillary surgery Blue dye Radioisotope
Filtered vs. unfiltered
Injection site
Timing

16. 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

17. Lymphoscintigraphy

18. Lymphoscintigraphy

19. Sentinel Lymph Node

20. Sentinel Lymph Node

22. Sentinel Lymph Node

23. Treatment (con’t) Radiation Treatment
Risks are highest during first trimester
Decrease gradually
Try to avoid during pregnancy
Risks may be overstated

24. Treatment (con’t) Chemotherapy Important role Advanced disease often
Teratogenic effects
Long term safety profile
Preterm delivery
Low birth weight
Transient leukopenia
IUGR

25. Treatment (con’t) Chemotherapy MD Anderson study Anthracyclines
methotrexate

26. Treatment (con’t)
Endocrine therapy
Contraindicated during pregnancy

27. Treatment (con’t)
Other agents
Trastuzumab – unknown
Taxanes - unknown

28. Prognosis Use TNM staging Most women have stage II or III disease
Same prognosis stage for stage
Delay in diagnosis has impact
60-100% - 5 year survival
31-52% - 10 year survival

29. Pregnancy after Treatment
Conflicting data
2 years
5 years
Ever?

30. 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.