1. BREAST CANCER IN PREGNANCY

2. Incidence 2nd most common cancer in pregnancy (after cervical cancer)
Accounts for 3% of total Ca breast in women
Exact incidence- difficult to estimate
Recorded incidence- 1: :50,000 (Smith et al, 2003)
Recent studies- Incidence is 1:3000
Pregnancy associated breast Ca (PABC)- Ca diagnosed primarily during pregnancy or 1 year after it’s termination
Causes of increased incidence
Child bearing at late age
Life style changes

3. Effect of Pregnancy on Breast Cancer
Not simply explained by high dose of estrogen
Increased AFP and hCG are protective
PABC are more likely to be advanced/ metastatic (due to increased blood/ lymphatic supply)
Microscopic lymph node involvement more likely in pregnancy (60%)
Stage I- 30%, Stage II- 30%, Stage III & IV- 40%
Higher incidence of Inflammatory Cancers
80% lesions are ER/PR negative
Interruption of pregnancy does not alter the prognosis

4. Does Pregnancy Affect The Prognosis?
Slight delay in diagnosis- mean delay 1-2 months
6 month delay increases chance of nodal involvement by 10%
Post-pregnancy breast remodeling may favour tumour cell dissemination
Breast cancer is always more aggressive in young women (so more common at advanced stage)
NO difference in 5 year survival between pregnant and non-pregnant women when matched with age and stage (Bladstrom et al, 2003; Beadle et al, 2009)

5. Effect of Breast Cancer on Pregnancy
Disease itself- very little effect, if any
Adverse effects due to
Anaesthetic drugs
Radiation
Chemotherapy
Hormonal agents
Placental metastasis
Seen occasionally in inter-villus space
No transmission to the fetus due to immune rejection by the trophoblasts

6. Diagnosis Clinical Imaging
Any suspicious breast mass must be evaluated
Physiological changes, especially in lactation makes diagnosis difficult
Friction-free examination may help
Imaging
USG- Irregular borders with shadowing is highly suspicious
Mammography
Fetal exposure only 0.04 cGy
False negative result 35-40% in pregnancy
MRI
More sensitive
No ionizing radiation
More false positive in pregnancy

7. Diagnosis (Contd.) Normal Pregnancy Invasive Cancer Tissue Diagnosis
If the mass is suspicious/ non-diagnostic in imaging
Lactation should be suppressed to decrease vascularity and chance of milk-fistula
Needs expert pathologist
FNAC
High rate of insufficient samples
Pregnancy induced changes (lobular hyperplasia, galactostasis)
Core biopsy
Standard of diagnosis
Normal Pregnancy
Invasive Cancer

8. Metastatic Workup Chest X-ray- Alkaline Phosphatase- CT scan abdomen
Should be done (fetal exposure 0.08 cGy)
Alkaline Phosphatase-
Unreliable
CT scan abdomen
Usually avoided (fetal exposure <2 cGy)
Bone scan
Yield is low, selective use (fetal exposure 0.4 cGy)
MRI abdomen-
Safer alternative, when indicated clinicaly

9. Differential Diagnosis
Associated with pregnancy
May undergo H/P changes due to hormonal stimulation
Fibroadenoma
Lipoma
Papilloma
Fibrocystic disease
Peculiar to pregnancy
Lactating adenoma
Galactocele
Mastitis
Breast abscess (Wall should be biopsied)
Bloody nipple discharge
Cytology is always warranted
Not a contraindication to breast-feeding
Physiological
Infection
Duct papiloma
Carcinoma

10. Management Multidisciplinary approach Respect patient’s wishes
Obstetricians
Surgeons
Neonatologists
Medical Oncologists
Anaesthetists
Psychiatric Counselors
Respect patient’s wishes
If diagnosed post-partum- lactation to be suppressed and immediate treatment to be started

11. Surgery Treatment of choice for non-metastatic disease
Peri-operative hazards- position, anaesthesia, risk of preterm labour
Modified radical mastectomy (MRM) with axillary clearance- done in most cases
Breast Conserving Surgery (BCT)
Lumpectomy/ Quadranectomy + Axillary Clearance
Needs adjuvant RT after delivery (<8 weeks)
Only for localized Tx diagnosed in 3rd trimester
Sentinel LN biopsy
Tc99sulphur colloid- NOT detrimental (fetal exposure 0.5 cGy)

12. Chemotherapy Indications- Axillary LN +ve, growth >1 cm, aneuploidy
Early pregnancy- Teratogenic (3-8 weeks of embryonic age) → needs MTP
Late pregnancy- Can be given in late 2nd and 3rd trimester
Breast feeding should be avoided during chemo
CAF (Cyclophophamide, Adriamycin, 5-FU) is the preferred regime
CMF-
Methotrexate (Mtx) instead of Adriamycin-
Controversial as Mtx can kill the trophoblasts

13. Other Therapies Radiotherapy Contraindicated- deferred till delivery
Maternal dose of 5000 cGy exposes the fetus to cGy
Immunotherapy
Trustuzumab-Herceptin (monoclonal Ab against HER2/neu)
Limited experience in pregnancy
May cause oligohydramnios (Shrim et al, 2008; Sekar and Stone, 2007)
Hormonal therapy
Tamoxifen is teratogenic (Cat D drug)
Aromatase inhibitors- may cause ambiguous genitalia
Oophorectomy- little help

14. Future Pregnancy
ER/PR +ve breast Ca may be theoretically aggravated by future pregnancy (no evidence)
Most of the recurrence- within 2-3 years
Better to plan next pregnancy after 2-3 years of completion of therapy
Chemo may cause POF
No adverse effect on future obst outcome
Survival is even BETTER! than those who don’t conceive
Breast feeding possible even from the affected breast after BCT & RT

15. THANK YOU
Thank You