5. Breast cancer is the commonest of all cancers in
women.
Worldwide, it comprises 22.9% of invasive
cancers in females.
One woman in nine will develop breast cancer
during her lifetime, making it the leading cause
of death from cancer after lung cancer I n
Western women.
6. 25% of all breast cancers occur in women of
childbearing age.
Only five percent of patients with breast cancer
are less than 40 year old and 1.8% less than 35
years
9. Risk Factors
Age : Over 75% of cases in women above 50 years old
Family History
Proliferative breast diseases : especially when
associated with atypia
Enviromental factors:exposure to ionizing radiation
especially at a young age.
Obesity: especially in post menopausal.
Paersonal history of malignancy: Breast,
endometrial, ovarian.
Dietary Factors: high fat diets
12. Definition:
Pregnancy associated breast cancer (PABC) is
defined as any breast carcinoma diagnosed
during pregnancy or during the first postpartum
year.
13. Role of pregnancy in Breast Ca. protection
There is a known solid association between parity and a
lifetime reduction in breast cancer risk.
Many theories were intoduced, one of which relate the
cause to the cellular differentiation associated with
pregnancy changes, thus epithelial cells are less liable to
proliferate and less susceptible to carcinogenic stimulus.
14. Dual effect of pregnancy
However, studies of breast cancer incidence in young
women demonstrate a clinically underrecognized
transient increase in breast cancer risk in the years
immediately following pregnancy where all parous
women have higher incidence of breast cancer
compared with nulliparous women.
This increase in risk has been shown to persist for at
least 10 and up to 15 years after birth .
15. Dual effect of pregnancy
The main contributers to this risk are:
1- Maternal age at 1st full term pregnancy:
25
30
35
40
45
full-termpregnancy
offers women some
degree of protection
pregnancy is assocIat
-ed with a permanent
increase in breast
cancer risk.
16. Dual effect of pregnancy
2- Total number of pregnancies:
Age and parity appear to act synergistically: with
high parity [≥5] and young age [≤20] at first birth associated
with the greatest ultimate reduction in lifetime breast
cancer risk
17. Dual effect of pregnancy
3- Family history:
advanced maternal age and family history act
synergistically to increase risk. Women 30 years of age or
older at first birth with a family history have a three-fold
increased risk over those with no family history, and this risk
persists longer, for 20–30 years post-partum.
18. Epidemiology of PABC :
The incidence of PABC is estimated to be about 1 in 3000
pregnancies.
up to 3% of breast cancers are diagnosed in pregnant or
lactating women.
10% of women under the age of 40 who develop breast
cancer are pregnant when it is diagnosed.
At present, breast cancer is the second most common
malignancy in pregnancy (after cervical cancer).
Once thought to be rare,it is expected to increase in
frequency as women delay childbearing until later in life .
19.
20. History
PABC usually come with an average delay
of 5-7 months as breast changes are
mistakenly related to pregnancy.
The average age of patients with breast
carcinoma in pregnancy is between 35 and
38 years
21. Clinical presentation
Most women diagnosed with
pregnancy-associated breast cancer will
present with a painless mass in the
breast .
80% of breast masses presenting
during pregnancy are benign.
22. Imaging
Two categories of radiation related effects in
humans:
Deterministic effects
Stochastic effects
23. Imaging
In general, a fetal exposure of less than 100
mGy is considered to provoke no
deterministic effects and has an associated
risk of stochastical effects of <1% which
does not justify termination of pregnancy,
according to the recommendations of the
International Commission on Radiological
Protection (ICRP-84) .
24. Imaging
Ultrasonography
Is the standard method for the evaluation of
a palpable breast mass during pregnancy.
25. Imaging
Ultrasonography
can usually distinguish cystic lesions from
solid lesions, and it is used to guide core
biopsy or fine needle aspiration of
suspicious breast lesions.
27. Imaging
Mammography
With adequate abdominal shielding, a
mammography presents little risk to the
fetus all during the tree trimesters .
28. Imaging
Mammography
The increased water content, higher density
and loss of contrasting fat in the
proliferating mammary glands of young
pregnant women may make mammographic
diagnosis difficult (sensitivity less than 70%)
29. Imaging
Mammography
Digital mammography (DM) is as safe as
film-screen mamorgraphy (FM) but more
accurate in detecting breast cancer in
women aged under 50 years , those who are
pre- or perimenopausal, and those with
heterogeneously dense.
30. Imaging
MRI
MRI is not recommended during the first
trimester because the developing embryo is
susceptible to injury from various physical
agents
31. Imaging
Chest X-ray
Chest radiography is used mainly in staging
work up.
It can be carried out safely during pregnancy
with proper using of abdominal shielding.
32. Imaging
Computed Tomography
CT of the abdomen and pelvis are by far the
examinations with the highest radiation
exposure to the fetus.
CT is used only in staging , however where
possible, it should be replaced by
ultrasound or MRI.
33.
34. Approximate fetal doses from common radiological
diagnostic procedures in the United Kingdom
35. Pathology
Biopsy of a suspicious mass is the gold
standard for the diagnosis of breast cancer.
A core needle biopsy is the technique of
choice. The sensitivity of core needle biopsy
is around 90%.
Fine Needle aspiration cytology (FNAC) may
be misleading and should not be performed
during pregnancy.
36. Pathology
Breast cancers in pregnant women are
histologically similar to those in non-pregnant
women, with 75% to 90% being
ductal cancers.
The incidence of inflammatory tumors
probably lies between 1.5% and 4%.
37. Pathology
High grade
pathological lymph node involvement (56–67%)
ER –PR negative tumors :54% and 80%
HER-2/Neu overexpression 36% to 58%
Lymphovascular invasion
38. Staging
The following points should be taken into
consideration:
Staging of PABC is the same as TNM staging of
breast caner
If this risk is low, distance disease staging should be
postponed to after delivery.
Chest radiography with abdominal shielding to detect
pulmonary metastasis .
Ultrasound is the best to detect liver metastasis.
MRI is preferred to detect bone metastasis .
Bone scan is only recommended in cases of uncertain
MRI findings, or when MRI is unavailable.
39. Staging
Alkaline phosphatase levels may be falsely elevated.
Ultrasound is the best to detect liver metastasis.
Echocardiogram prior to anthracycline- based
regiments , and is safe.
Sites concerning for metastatic disease should be
biopsied whenever possible and safe
40.
41. Cancer during pregnancy puts the mother
in a difficult situation. A new life is
growing inside her and at the same time
her own life is threatened.
Also, for the medical team it is a complex
setting, because two individuals are
involved: the mother and her unborn
child.
43. Breaking bad news
Should be performed by persons skilled in
communication skills.
The whole situation should be clear:
diagnosis , prognosis , risks and options of
treatment.
The information should be given in pieces
at several different appointments in a
simple , clear and not a blunt language.
44. Communicating risks and shared decision-making
Communicating risk means confrontation
with important uncertainties.
Shared decision-making means that
patient with another person ; eg the
partener, share in decision making based
on the information they gained. It seems
to be of benefits like improved patient
satisfaction and clinical outcome .
45. Understanding the ethical framework
As physicians, we have legal obligations , and
moral obligations.
This creates a conflict between what we have to
do according to medicine rules and the patient
autonomy that takes into consideration her
opinion and her fears respect.
It is a matter of balance and the art of tailoring.
46. Bio- psychosocial care
The patients should feel. that all medical stuff
are caring for the mother–baby unit as a whole,
the problem shouldn’t be considered as a matter
of a breast and a uterus.
Inevitably, there will be phases of crisis during
the pregnancy, which have to be responded to
by psychologically trained members of staff
47.
48. The protocol of treatment should be
as close as possible to that offered to
non-pregnant women.
Multidisciplinary approach is essential
49. Termination of pregnanacy
Termination of pregnancy is indicated in:
Advanced disease with dismal prognosis.
Poor general patient condition.
fetal exposure to more than 100 mGy during
the first trimester.
Reluctancy of the parents to accept the risks.
50. Surgery:
Breast surgery can be offered safely
during pregnancy.
The question is: or
51. surgery:
The answer depends mainly on “when the
diagnosis is made”
Is write option at any time of pregnancy .
Here , radiotherapy can be delayed after delivery
At the end of second and at
the third trimester . Radiotherapy again is delayed
until after childbirth.
52. So it seems that radiotherapy derives the choice
of the type of surgery
Is there a role for radiotherapy in PABC ?
53. Radiotherapy
Definitly , radiotherapy is contraindicated in
pregnancy
Radiation doses used in cancer therapy are usually
within the range of 4000–7000 cGy which is more
than 1000-fold the level in diagnostic radiology.
Fetal exposure > 100 mGy can result in abortion or
major fetal malformation in the 1st trimester.
while exposur to > 250 m Gy in late pregnancy
increase incidence of childhood cancer.
54. Radiotherapy
The only role for RT is in a woman who has a diagnosis
of breast cancer made during the first, or early in the
second trimester, and insist on preserving her breast.
Here , radiotherapy option should be well discusssed
with the patient and her family. RT is given in the 1st
or early 2nd trimester with peoper shielding.
55. Chemotherapy
Due to their relatively low molecular
weight, most cytotoxic agents can
cross the placenta.
In pregnancy, most chemotherapy
are classified as a class D category.
56. Chemotherapy
Anthracyclines-based regimens are the most
widely used In PABC and has been shown to
be associated with favorable safety profile
In the metastatic setting, anthracycline-based
regimens remain the best choice as well. For
patients who are not good candidates for
anthracycline-based regimens, single agent
taxane would be a preferred option.
57. Chemotherapy
Chemotherapy is contraindicated during the
first trimester “period of organogenesis”, and
should be postponed till the second and third
trimester.
Chemotherapy should not be given after 34-35
weeks of gestation as spontaneous delivery
can occur before bone marrow recovery and
before the baby eleminates the chemotherapt
by the placenta.
58. Prognosis..
PABC is definitly associated with poor
prognosis
Delayed diagnosis
Late stage
Young age
59. Prognosis..
TUMOR PABC Non PABC
LN Metastases 56–89% 38–54%
Tumor size 3.5 cm 2 cm
Diagnosis. at II
and III stage
Diagnosed as 65–90% 45–66%
metastatic
The pregnant women had a 2.5-
fold higher risk
60. Prognosis..
However, many studies were done to investigate
the role of pregnancy itself as an independent
predictor of worse survival.
These studies suggesting a similar stage-for-stage
prognosis as breast cancer in age matched non-pregnant
women.
Therefore, pregnancy itself should not be regarded
as a poor prognostic indicator
64. women undergoing active chemotherapy
should not breastfeed. Cytotoxic agents
can be detected in small quantities in breast
milk and are potentially toxic for the baby.
There should be a time interval of 14 days
or more from the last chemotherapy session
to resume breastfeeding.
67. YES
Breast cancer survivors who become
pregnant should be encouraged
to breastfeed.
68. A history of breast surgery and radiation
may affect milk supply.
Mothers who have undergone mastectomy
but no radiation to the remaining breast
can often develop a full supply for one infant
Some researchers believe that breastfeeding
after breast cancer will have a protective
effect on the contralateral breast
70. Amenorrhea is a common problem
following adjuvant chemotherapy given to
premenopausal women with breast cancer.
Regiments containing Cylophosphamide or
taxanes are associated with high level of
ovarian failure.
72. Patients are generally advised to wait at
least two years after diagnosis before
becoming pregnant.
For women receiving TAM it is better to
wait untill the end of the 5 year treatment
time before getting a pregnancy.
