Breast cancer Flashcards
What is a woman’s lifetime risk of breast cancer?
1 in 9
Of the women diagnosed with breast cancer, what % are diagnosed after age 50?
70-75%
What % of women diagnosed with breast cancer before 30 years old is associated with pregnancy or the first year postpartum?
10-20%
Outline the investigations you would organise in a woman with a breast lump during pregnancy suspicious for breast cancer:
- Breast ultrasound: to assess discrete lump
- If cancer confirmed, mammography (with fetal shielding) to assess the extent of the disease and the contra lateral breast
- Ultrasound-guided biopsy: histological grade, receptor status, HER2 status. Histology rather than cytology because the proliferative change during pregnancy renders cytology inconclusive
Staging imaging:
- CXR
- Liver ultrasound
- Consider gadolinium MRI if bone involvement suspected; limited data but no evidence of adverse outcomes for fetus.
List potential management plan for breast cancer treatment during pregnancy:
- Referral to breast cancer MDM.
- Termination of pregnancy an option after careful consideration.
- Surgical loco-regional clearance.
- Sentinel node assessment +/- axillary clearance.
- Radiotherapy: only if life-saving or to preserve organ function e.g. spinal cord compression.
- Systemic chemotherapy: contraindicated in first trimester but safe in second trimester.
- Delivery: usually full term.
What are the principles of surgical management of breast cancer in pregnancy?
- Loco-regional clearance
- Can occur in all trimesters.
- Reconstruction delayed till after pregnancy: avoid prolonged anaesthesia and allow optimal symmetrisation of breasts.
- Sentinel node assessment: radioisotope scintigraphy okay in pregnancy but avoid blue dye as effect unknown.
What are the principles of radiotherapy treatment of breast cancer in pregnancy?
- Routine breast and chest wall radiotx should be deferred till after pregnancy.
- Contraindicated unless life-saving or to preserve organ function.
- If used in pregnancy, use fetal shielding or consider early elective delivery depending on gestation.
What are the principles of chemotherapy treatment of breast cancer in pregnancy?
- Contraindicated in first trimester due to high rate of fetal anomalies.
- Safe in second trimester: athracyline regiments. No evidence of increased miscarriage, IUGR, organ dysfunction or long-term adverse outcomes.
- Not safe in pregnancy: tamoxifen and trastuzumab.
- G-CSF can be used in pregnancy to reduce neutropenia complications for mum and fetus.
When should baby be delivered when mum is receiving treatment for breast cancer?
- Majority at full term (normal or IOL).
- If early elective delivery indicated, consider antenatal corticosteroids depending on gestation.
- Wait 2-3 weeks after last chemotx to reduce neutropenic complications.
Outline the principle considerations regarding breastfeeding and chemotherapy and other treatment for breast cancer:
- Breastfeeding while on chemotherapy is not advised as baby at risk of neutropenia and infection.
- Wait 14 days or more between last chemotherapy and starting breast feeding.
- Drugs not safe while breastfeeding: tamoxifen, trastuzumab.
- A short period of breastfeeding prior to starting chemotherapy may be mentally beneficial for mother and baby.
Outline the principle considerations regarding contraception in a woman with breast cancer:
- Use non-hormonal contraceptive methods.
- Hormonal contraception may be considered after at least 5 years free of recurrence.
- Mirena may reduce risk of endometrial hyperplasia and malignancy in tamoxifen users but further evidence regarding safety in breast cancer survivors is needed.
- Discuss any choice of hormonal contraception with breast surgeon first.
Outline your discussion with a breast cancer survivor regarding future pregnancy planning:
Women should be seen by clinical oncologist, breast surgeon and obstetrician.
Advise no evidence of increased congenital malformations or stillbirth after treatment.
Women should wait 2 years after diagnosis and treatment before conceiving as risk of recurrence highest in first 2 years.
- ER positive disease: should complete 5 years of tamoxifen
If metastatic disease: advise not to become pregnant due to limited life expectancy and compromising treatment.
Preparing for conception:
- Stop tamxiofen 3 months before trying.
- Complete routine imaging.
- If BRCA positive, offer preimplantation genetic diagnosis.
What special considerations and care is needed during pregnancy following treatment of breast cancer?
- MDT care under obstetrician, oncologist and breast surgeon.
- ECHO: if had anthracycline chemotherapy (doxirubicin, epirubicin) which can cause dose-dependent left ventricular dysfunction and cardiomyopathy.
Counsel:
- Slightly increased risk of delivery complications (OR 1.5) and CS (OR 1.3).
- Can breastfeed from unaffected breast.
- Radiotherapy causes fibrosis and lactation unlikely.
Should have lactation support.
How does pregnancy impact prognosis for women diagnosed with breast cancer during pregnancy?
It does not worsen prognosis.
As pregnancy associated breast cancer occurs in a YOUNGER population who may have FEATURES that carry a higher risk of metastasis such as high grade tumours and oestrogen receptor negative tumours, these younger women may be expected to have an inferior prognosis.
In breast cancer survivors, how does pregnancy impact prognosis?
It does not worsen prognosis.
Survival at 5 years: 92%
Survival at 10 years: 86%.
