Cancer in pregnancy Flashcards
Characteristics of breast ca in pregnancy
Typically more advanced:
- larger tumour
- node positive
- poorer outcomes
Likely due to delayed diagnosis as:
- Symptoms less noticable (to pt and physician) due to physiological changes of breast in pregnancy (therefore skin change, mass, abnormal discharge may be thought to be normal)
Investigations for breast ca in pregnancy
- History and examination by specialist
- Breast USS first line
- mammography to check for bilateral/multifocal disease
- Core biopsy of breast lump (FNA has high risk of false pos and false neg due to proliferative breast changes in pregnancy)
- Try to minimise unnecessary fetal radiation exposure
- Staging: CXR, liver USS, MRI bones
- (or radionucear bone scan with IDC and IVF to minimise accumulation of contrast, if MRI unavailable or further info needed)
All women should have genetic testing due to young age at diagnosis
Obstetric considerations in management of breast ca pregnancy
- No evidence for better outcomes with TOP - personal choice based on woman’s situation
- May be more likely to consider TOP if <10/40
- Chemotherapy shouldn’t start until >14/40 (after 10/40 when organogenesis complete then wait 4 weeks after)
- Detailed anatomy scan prior to treatment to ensure no prior congenital abnormalities
- Growth scans due to increased risk of FGR
- Steroids can be given for obstetric indications
- May require early delivery 35-37 weeks to allow completion of therapy postpartum
Pregnancy related risks if breast ca
Increased risk of:
- FGR
- Preterm birth
Surgical management of breast ca in pregnancy
- Surgery safe
- Anaesthesia- be mindful of risk of preterm labour
- Consider FHR monitoring intraoperatively or after and monitor for contractions that may be masked by analgesia
- Optimise analgesia as pain may stimulate PTB
Anaesthesia/surgical team aim to minimise risk of:
- hypoxia,
- hypotension,
- hypoglycaemia,
- fever,
- pain,
- infections,
- thrombosis
Chemotherapy options in breast ca
- Avoid MXT, trastuzumab and tamoxifen
- Recommended regime:
—– fluorouracil and epirubicin
—–doxorubicin plus cyclophosphamide
—–epirubicin or doxorubicin plus cyclophosphamide and taxanes (paclitaxel weekly to
every 3 weeks or docetaxel every 3 weeks)
Evidence re chemotherapy in pregnancy after 1st trimester suggests a higher rate of FGR, preterm birth, haemopoietic suppression and possible fetal/neonatal death but outcomes thought to be better for chemotherapy agents used in breast ca.
Minimal evidence re long term outcomes doesn’t suggest any long term physical/congential/emotional/behavioural adverse effects from chemo for breast ca
Risks of prematurity thought to outweigh risks of chemotherapy
Timing of delivery of a woman with breast ca
If preterm, can treat whilst pregnant- outcomes likely to be better as PTB increases likelihood of complications related to prematurity
If 35/40 at time of diagnosis then deliver and arrange staging and treatment following delivery
Overall aim of delivery 35-37/40
Ideally don’t perform chemo within 3 weeks of delivery due to fetal risk of neutropenia at birth
Mode of delivery with breast ca and pregnancy
Can have NVD- if NVD achieved can restart chemo the next day
If CS- can start chemo usually 1/52 later
Radiotherapy for breast ca in pregnancy?
Individualised decision with rad onc physician due to fetal risks of radiation exposure
Risks aren’t clear - likely a small increased risk of long term adverse health outcomes including malignancies
Ideally wait till after delivery
If needed
- shield fetus
- minimise field of exposure
- Increase distance of beam from field of exposure
Most common type of breast ca in pregnancy
infiltrating ductal adenocarcinoma
Factors to take into consideration when deciding on treatment for breast ca in pregnancy
- Tumour biology
- Tumour stage
- Gestational age
- Patient and family’s wishes- including ethical/psychlogical/religious issues
Who should be involved in the MDT for treatment of women with breast ca in pregnancy?
Breast surgeons Med Oncology Rad Oncology Obstetrics Neonatologist Radiologist Pathologist
What is the broad approach to management of breast cancer outside pregnancy?
- Surgery first-line at most stages unless palliation recommended; in advanced stage cancer neoadjuvant chemo may be given prior to surgery
- Breast conserving surgery OR mastectomy AND SNLB/axillary node clearance
- Adjuvant radiotherapy (for all BCS, advanced grade/stage and LN involvement)
- Adjuvant chemotherapy (if tumour >1cm, receptor neg, high stage or other poor prognostic criteria)
- Adjuvant Tamoxifen / letrozole for 5 years (if ER/PR pos)
- Adjuvant Trastazumab (herceptin) for 1 year (if HER2 receptor positive)
Treatment of locally advanced breast ca in pregnancy?
Neoadjuvant chemotherapy with or without surgery
until fetal maturity
Delivery 35-37/40
Completion of treatment
Treatment options for breast cancer if <12 weeks gestation.
If locally advanced:
- Consider termination, and then standard treatment
If not locally advanced:
- Breast conserving surgery or mastectomy + SLND or axillary node clearance
- Adjuvant chemotherapy AFTER 14 weeks
- No radiotherapy
- Aim delivery ≥35-37 weeks
- Complete treatment pos partum with radiotherapy and other adjuvant treatments e.g. tamoxifen/herceptin as required
Treatment of breast ca that ISN’T locally advanced in pregnancy?
Breast-conserving surgery or mastectomy, sentinel
node procedure or axillary node dissection
Adjuvant chemotherapy until fetal maturity, with
approved cytotoxic drugs (not if >35/40- in this case deliver)
Radiotherapy is not considered after surgery and
before chemotherapy to reduce treatment methods
during pregnancy
Delivery 35-37/40
completion of treatment after delivery
Specific surgical considerations for breast cancer in pregnancy.
- Avoid adjuvant radiotherapy - therefore consider less breast conserving surgery
- For SNLB - technetium radioisotope is safe, but avoid blue dye due to risk of hypersensitivity reaction
- Avoid autologous breast reconstruction surgery whilst pregnant, due to physiological changes during pregnancy
- Ensure has LMWH VTE prophylaxis postpartum due to triple risk (pregnancy, cancer, post-op)
Postpartum considerations for pts with breast ca
Examine placenta for evidence of metastasis
Can start chemo: 1/7 after NVD, 1/52 after CS
Breastfeeding can be done if physologically possible but not if having chemo
Why shouldn’t trastuzumab or tamoxifen be given during pregnancy?
trastuzumab
- HER2 receptors expressed on fetal kidneys therefore can cause fetal renal failure/renal consequences and oligo/anhydramnios
Tamoxifen
- causes craniofacial abnormalities and ambiguous genitalia, and fetal death