Breast Cancer During Pregnancy: Symptoms And Treatment

It is possible to experience breast cancer when pregnant, and the condition is referred to as pregnancy-associated breast cancer or PABC. Studies suggest that it is the second most common type of cancer to occur in pregnant women, affecting one in 3000 pregnant women (1).

The risk of breast cancer increases with age, and women who conceive at an older age than usual may be at a higher risk of PABC. Breast cancer is treatable when diagnosed early. Timely diagnosis may also help you avoid complications that could affect maternal and fetal health. Read this post to know the symptoms, tests, treatments, and fetal outcomes in breast cancer in pregnancy.

What Are The Signs And Symptoms Of Breast Cancer?

Breast cancer symptoms may vary in each woman. Some may not develop any symptoms. However, no breast is typical. What is normal for a woman can be abnormal for other women. Pregnancy, certain medications, weight gain, etc., can cause breast changes in many women.

Signs and symptoms of breast cancer may include (2):

• Lump in the breast or underarm
• Swelling or thickening of the part of the breast
• Irritation of the breast skin
• Flaky or red skin in the nipples or breast
• Dimpling of the breast skin
• Pain in the nipple area or part of the breast
• Inversion or pulling in of the nipple
• Nipple discharge such as blood or fluids other than breast milk
• Change in breast size and shape can also be normal in pregnancy

These symptoms can be due to other conditions that are not cancer or pregnancy changes. You may seek medical care to identify the cause of breast changes.

Is It Safe To Test Breast Cancer During Pregnancy?

Some breast cancer tests can be safe during pregnancy. Tests involving ionizing radiation to the abdomen and pelvis can harm the fetus. However, tests with minimal radiation on the breasts may not affect the fetus.

The following procedures and tests are ordered to diagnose breast cancer (3):

• Physical examination helps to identify general health, signs of diseases, breast appearance, etc. This information can help the doctor to determine the next best procedures or tests.

• Health history helps the doctor understand certain risk factors, health habits, previous illnesses, and treatments.

• Clinical breast exams (CBE) help the health care provider to understand breast texture, lumps, or other unusual changes.

• Ultrasound examination (sonography) of the breast is often ordered in pregnant women since these tests use high-energy sound waves that do not harm the

• Mammogram is an X-ray of the breasts that uses minimal radiation focussing on the breasts. The risks to the fetus are minimal. However, there is a risk for false-negative mammogram results during pregnancy.

• Biopsy helps to confirm breast cancer. Cells or tissues are collected using special needles from suspected areas of the breasts. Core biopsy is a type of biopsy using a wide needle to collect tissue samples. Whereas fine needle aspiration (FNA) biopsy uses a thin needle to collect tissue and fluid samples. Some may undergo excisional biopsy, which is performed after removal of the entire breast lump. These samples are then examined under a microscope by a pathologist to identify the presence of cancer cells.

A biopsy may involve some risk since it is usually performed under anesthesia (local or general), and the procedure may affect the milk ducts. If the breast cancer is confirmed on the biopsy, doctors may order further tests such as a bone scan, magnetic resonance imaging (MRI), ultrasounds, and chest X-ray to determine the stage of cancer. Staging is done based on the size of the growth, how far it is spread to nearby tissues, and distinct locations (metastasis). The treatment and outcomes may vary in each stage.

Doctors may also order the following tests to study the characteristics of the cancer cell (3):

• Estrogen and progesterone receptor tests measure the amount of estrogen and progesterone receptors in the cancer tissue. More hormone receptors can result in the rapid growth of

• Human epidermal growth factor type 2 receptor (HER2/neu) tests determine the amount of HER/neu genes in the sample tissue. These genes can cause rapid growth and the spread of cancer.

• Multigene tests look for the activity of many genes. This may help to understand the spread and chance of recurrence (come back) of MammaPrint is a lab test looking for 70 different genes related to breast cancer. Some tests, such as Oncotype DX, also help predict the score of recurrence and spread.

In addition to these cancer tests, fetal biophysical profile, growth, weeks of pregnancy, and maternal health status are also evaluated to plan treatment.

Are Breast Cancer Treatments Safe During Pregnancy?

Some breast cancer treatments such as surgery and chemotherapy are relatively safe during pregnancy. Cancer treatment in pregnancy aims to control and cure cancer while protecting the growing baby from harmful effects. Treatment options may vary depending on the tumor size, type, location, gestational age, and overall health status of the mother and fetus.

The cancer care team, including the obstetricians and gynecologists, may recommend the following breast cancer treatments in pregnancy (4):

1. Breast cancer surgery

Surgical removal of the cancer is generally safe in all trimesters of pregnancy. Anesthesia given for surgeries can pose little risk to the fetus, so the anesthesia medications are carefully opted by a specialist, and the fetus is continuously monitored.

Breast cancer surgery can be of the following types:

• Mastectomy is the complete removal of the affected breast.

• Radical mastectomy is a surgery involving the removal of underlying chest muscles, nearby lymph nodes along the breast to prevent cancer spread.

• Lumpectomy or breast-conserving surgery (BCS) is the removal of cancer tissue and the rim of normal tissue around it.

Breast cancers in pregnancy are often treated with radical mastectomy, especially if the cancer is aggressive or rapidly growing. Usually, after BCS, radiation therapy is needed to prevent spread and recurrence. Radiation is unsafe in pregnancy, so considering the baby’s wellbeing, doctors may recommend a mastectomy.

2. Chemotherapy

Chemotherapy uses medications to destroy or control the growth of cancer cells. This can also be provided as an adjuvant treatment (treatment after surgery) for some cancers. Chemo medications used in the later trimesters do not cause birth defects such as heart problems and stillbirth.

These treatments are recommended based on the weeks of pregnancy to protect the fetus. The treatments options in each trimester may include (5):

• First trimester

Radical mastectomy is the common breast cancer treatment recommended during the first 12 weeks of pregnancy. If possible, doctors may delay the procedure and treatments to the second trimester. Chemotherapy is not done in the first trimester due to the increased risk for birth defects since the baby’s organs are forming at this time. Pregnancy loss (miscarriage) can also occur if chemo is done in the first trimester. Adjuvant chemotherapy can be delayed for other trimesters.

• Second trimester

Surgery and adjuvant chemotherapy can be safe during the second trimester (13-27 weeks of pregnancy). The organs are formed during this time, and the treatment does not cause birth defects. If favorable, doctors may recommend breast-conserving surgery.

• Third trimester

Breast-conserving surgery is often done in the third trimester (28 weeks until delivery) treatment since radiation can be given after delivery. However, the decision may vary depending on the type of cancer and its stage. Some cancers require surgical removal of the breast and nearby tissues to prevent recurrence at any time of pregnancy or even in nonpregnant women.

Chemo is provided after surgery in the early weeks of the third trimester. However, chemotherapy is not recommended in later weeks, especially after 35 weeks of gestation and within three weeks of delivery, since low blood cell counts can increase the risk of bleeding.

Which Breast Cancer Treatments Are Delayed Until Delivery?

Doctors may consider the risk and benefits of the cancer treatment and its effects on pregnancy and the fetus before initiating cancer treatments during pregnancy. Some breast cancer treatments can harm the baby during any time of pregnancy. They are unsafe during pregnancy, are scheduled after delivery if needed, and other treatment modalities with little or no risk to the fetus are opted during pregnancy.

The following treatment modalities are typically on hold until after delivery (4):

• Radiation therapy is not safe anytime during pregnancy. Usually, radiation to the breasts is given after lumpectomy can harm the This may cause slow growth, birth defects, childhood cancers, or pregnancy loss. Doctors may do the surgery during pregnancy and delay the radiation therapy until delivery to avoid these effects.

• Targeted therapy uses medications such as Herceptin (trastuzumab), Perjeta (pertuzumab), Tykerb (lapatinib), etc., to target HER2 positive breast cancer. None of the medications used in targeted therapy are known to be safe during pregnancy.

• Hormone therapy is not recommended for pregnant women with breast cancer. This is often given for advanced cancers or as a treatment after surgery for women with hormone (estrogen or progesterone) receptor-positive breast cancers. Hormone therapy drugs such as tamoxifen, anastrozole, exemestane, and letrozole can harm the growing So, treatment with these drugs is delayed until after childbirth.

Breast reconstruction in pregnant women is often done after delivery. Immediate reconstruction after a mastectomy is not recommended in pregnancy to reduce the time under general anesthesia and other risks such as bleeding.

Does Breast Cancer During Pregnancy Affect The Baby?

There are no cases of metastasis (spread) of breast cancer to the fetus. However, few cases of breast cancer metastasis to the placenta have been reported. Therefore, the placenta of women with breast cancer during pregnancy is usually examined after delivery. There is no evidence that the child can develop cancers in later life due to breast cancer during pregnancy (1).

Although there is no direct risk from breast cancer, in-utero exposure to certain cancer treatments such as chemotherapy can be associated with the following problems in the growing baby (1):

• Intrauterine growth restriction (IUGR)
• Preterm birth
• Low birth weight
• Transient leukopenia

Maternal chemotherapy during pregnancy is not shown to cause neurological, psychological, and congenital abnormalities in babies. More frequent growth scans, often every month, and detailed anatomy scans are done if the chemotherapy was done in the first trimester. Nonstress testing or biophysical profile, amniotic fluid evaluation, and growth scans are done in short intervals if slow growth is observed.

You may seek emotional and financial support from various support groups, counselors, and social agencies while managing breast cancer during pregnancy. Breast cancer treatment may vary in each woman depending on the type of tumor, gestational age, and individual factors. It is recommended to continue the pregnancy and treat breast cancer in pregnant women.

Speak to your doctor to understand the correct way of self-breast examination, which is simple, can be done at home, and can help identify any abnormal breast lump or nodule. A breast examination should be a routine measure during pregnancy and could help you detect the condition on time.

References

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