Lost in the pregnant breast cancer jungle

If you find yourself in the pregnant breast cancer jungle, Prof Carol-Ann Benn advises you choose the right boat (a specialist unit) to get you and baby both safe to cover.

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For many women the excitement of finding out they are pregnant is much like an amazing cruise down the Amazon River; a-once-in-your-life experience. Lots of exotic experiences: scans, cravings, gender reveal parties, baby showers, and choosing names. 

During all the antenatal check-ups (your map), don’t forget to insist that you have a breast examination. Why? Because breast cancer in pregnancy is the most common malignancy diagnosed in pregnancy. In fact, by definition, any breast cancer diagnosed up to two years post-delivery and whilst breastfeeding is collectively named pregnancy-associated breast cancer (PABC). Note the word associated; this means breast cancer isn’t caused by the pregnancy but rather occurs at a slightly higher incidence in pregnant women. Most commonly between ages 32 and 38. 

During pregnancy, besides the growing bump, the breasts become fuller, more sensitive, and tender due to increasing levels of oestrogen, progesterone, prolactin, and chorionic gonadotropin. 

The breasts become a fertilised rainforest, with increased blood flow and engorged vessels much like the Amazon River tributaries. The resultant lobular alveolar growth that will produce milk later means many lumps and bumps are felt and it’s often difficult to work out the difference between a concerning mass and a pregnancy-induced change. Though, not all breast problems found in pregnant and breastfeeding women are cancer; most aren’t.

This is why if your pregnancy is planned, when you take your pre-pregnancy vitamins, go to a reputable radiologist for a breast ultrasound as well as your 3/12 scan. Your friendly gynae and antenatal team should play a major role, particularly if you’re older and considering pregnancy. 

If requiring fertility treatment to assist with conception, a preconception mammogram and ultrasound are advised as well as serial sonars during all the stimulating hormones.

The common jungle predators

During pregnancy, this extremely fertile breast tissue means it’s more difficult for the ultrasound (binoculars) to look for predators, so if worried insist on repeated ultrasounds. 

Sadly, the diagnosis of breast cancer in a pregnancy is often delayed partly because it’s not recognised as a mass by the mom-to-be, or worse not assessed as a potential predator by the doctor. 

Don’t miss the big jungle predators. The red-hot breast, often mistaken as a mastitis; this can be an inflammatory breast cancer. A good trick is to ultrasound the armpit and look for glands or lymph nodes. 

During pregnancy, the weight of the breast can cause red breast syndrome. This presents with a red-looking painful breast that gets less red when you lie down, and redder when you stand. Breast hygiene in pregnancy is essential; this means good supportive bras day and night.

Both during pregnancy and breastfeeding, a red inflamed area usually involving one of the outer areas of the breast can herald a mastitis. This is treated with antibiotics that are safe in pregnancy (amoxicillin and clindamycin). Never forgot the great mimic TB.

Another missed predator is Paget’s disease that presents with a scab or bleeding on the nipple. The breast ultrasound may be normal, and the diagnosis is made with a small skin biopsy of the nipple. 

Eczema of the areolar is also seen and is managed with topical steroids, washed-off with water before a feed.

A rare and large pregnancy-related predator that isn’t a breast cancer is gigantomastia. This is where the breasts get bigger and bigger. The largest breasts I’ve seen weighed 7,5kg each and the skin of the breast can die. This giant predator is one of the few emergencies related to pregnancy. 

Safe diagnostic tests

For many years there was a misconception that PABC had a worse prognosis than other breast cancers. This was purely because of delays in diagnosis and mom-to-be and doc missing the signs, resulting in an advanced stage at the time of diagnosis.

Most pregnancies occur before age 35 therefore fall under the age for recommended mammograms. Mammograms can be performed in younger women, as well as in pregnant women with little risk to baby.

The main problem with mammograms in young women is the increased density of breast tissue, resulting in decreased accuracy (harder to see predators). 

Breast ultrasound is safe, accurate, and provides a rapid and safe way to see if a mass is cystic or solid. Not all masses felt or seen in pregnant breasts are cancers. However, if a mass is new or concerning, a core needle biopsy can safely be performed with little risk to all, and most definitely doesn’t cause a milk leak. Avoid unnecessary surgeries during pregnancy. The goal in pregnant women with breast concern is to make the diagnosis accurately with the least invasive technique possible. Core biopsy is highly accurate with minimal risk. 

Facts, myths, and misinformation

Having a first pregnancy is supposed to confer protection against breast cancer. This is if you have your pregnancy under age 18 and we aren’t encouraging teen pregnancies. 

Remember, most women with breast cancer (65%) have no significant risk factors. Having a first pregnancy over 35 is supposed to increase risk. A recent study shows for 10 years post-pregnancy, women are at an increased risk of breast cancer. 

For a long time, women with BRCA 1 and 2 mutations were encouraged to have their pregnancies at a young age as this was thought to be protective (no comprehensive data). It was also thought that the incidence of PABC is higher in BRCA 1 mutations than BRCA 2. Though, an allelic deletion at the BRCA 2 locus is seen in 88% of PABC, suggesting a BRCA 2 involvement as well. Remember anyone is at risk.

A study from the 16^th century showed that the breast the baby feeds from the least (the milk reject sign) is more likely to be the one that gets cancer. There are no recent studies suggesting this.

If diagnosed with breast cancer during pregnancy, ensure that you’re seen at a specialist unit. A robust multi-disciplinary approach (having the correct boat) with many specialists being the team to help you on your cruise. This is about choosing the right guides for your jungle adventure.

Treating breast cancer while pregnant 

Once diagnosed by ultrasound and core biopsy, both mammogram and MRI of the breast can be performed safely, with special T&Cs applied to protect the baby.

There are many treatment options. Treatment usually starts in the second trimester. The principles are identical to that of a non-pregnant woman with the understanding that there are two lives to monitor and look after. The treatment shouldn’t be delayed because of the pregnancy (most women are usually five weeks pregnant when they realise they are pregnant). 

Part of the multi-disciplinary team’s role is to discuss options with you and your family. Informed consent is important about the risk to mother and baby. 

PABC is a complicated psychosocial issue that often involves adult partners if there are two, mom-to-be and baby-to-be, and often an extended family. A professional team is needed to ensure best decisions for all involved. 

The specialist jungle safari team’s main goal is to plan the journey together and have the right team members to watch out for crocs, piranhas, and jaguars. Although the jungle sounds scary, please enjoy the exotic birds and other sights. 

Abortion is usually not recommended and has no bearing on a woman’s survival. Some studies have found that women who terminate may have a worse outcome. These factors should be discussed before termination is considered. Huge strides have been made to ensure long disease-free intervals for women with breast cancer in pregnancy.

The reality of the situation

The ability to cope with a new infant, the effect of treatment on mom and baby, and the possible consequences of foetal death, particularly if treatment is started in the first 12 weeks needs to be addressed. This is an Amazon River safari at its most complex. 

The journey map is regular prenatal monitoring during therapy (foetal ultrasounds), doctor check-ups for mom and baby, and open communication with the team. Your compass (primary treating physician) and binoculars (ultrasound) are there to ensure that you and baby are safe. Close attention should be paid to gestational age and baby monitoring in utero. Specialists in high-risk obstetrics are available as part of the treating team. This is like having The Rock (Dwayne Johnson) on your team.

Remember breast cancer treatment is based on biology of the cancer today and less on stage.

Surgery

Breast and axillary surgery can be performed during any trimester of pregnancy as long as specialist physicians and anaesthetists are monitoring for the physiological changes in pregnancy. The old adage that the surgery of choice is a modified radical mastectomy as it avoids the inherent risk of radiation exposure associated with breast-conserving surgery is really not necessary. No rushed surgeries please. 

Breast conservation can be done whilst delaying radiation to post-delivery. Breast reconstruction can be done at the time of breast surgery and usually smaller surgeries are advised with small movement and closure of the breast tissue. 

All these patients should be managed in units having a special interest in PABC that routinely offer immediate reconstruction, pathologists in theatre as well as all monitoring bells and whistles. 

A direct implant reconstruction (with nipple saving) or a tissue expander may be inserted at time of mastectomy. However, breast-saving surgery is always first prize during a pregnancy. Less is more and always safer. 

Important treatment facts

Radiation is still contraindicated during pregnancy although isolated studies have used radiation during pregnancy (particular interest is currently in intra-operative radiation). 

Neo-adjuvant therapy (primary chemotherapy) can be given during the second trimester. Sentinel lymph node biopsy and targeted axillary surgery (not full axillary dissection) may be undertaken with cautious care as to what techniques are used to detect the sentinel (dye or Magtrace or isotope). 

Chemotherapy is generally not given in the first trimester as this is when the baby’s organs develop. Waiting a few weeks after diagnosis to start treatment in the second trimester is safe. Taking a few weeks to assess all options and go for second opinions is recommended. 

Chemotherapies can be used during pregnancy but have to be carefully selected and doses watched, so as to avoid harm to the foetus. In our unit, the oncologist has treated many women with PABC with safe outcomes to both mother and child. Chemotherapy should be avoided for two weeks prior to delivery. 

Delivery dates and chemo treatment dates are fine-tuned in case medicines are needed to mature a baby’s lungs or to improve mom’s white cell count. Delivery need not be a C-section but sometimes inductions and caesareans are advised as it’s often all about timing. 

Specialist obstetric units should treat these women and be involved in the delivery options and safety. 

Studies have confirmed minimal chemotherapy long-term effects to these children, with the commonest effects being babies born “small for gestational size.” 

Treatment with endocrine therapy (tamoxifen or aromatase inhibitors) should be delayed until the completion of pregnancy with care taken to avoid deep vein thrombosis risk post-pregnancy.

Breastfeeding post-delivery while still on cancer treatment isn’t advised, and we’ll often advise drying up your milk. Breastfeeding a subsequent baby, or a first baby after breast cancer treatment is possible from the non-radiated breast (as long as not on cancer treatment). 

The outdated assumption that PABC patients do poorly has been attributed to late presentation but the prognosis is identical to that of the non-pregnant woman. 

Having babies after treatment

Having breast cancer during a pregnancy doesn’t put you at higher risk of another cancer in pregnancy. 

The recommendation is to wait two years between ending treatmentand future pregnancies. This prudent recommendation is purely because of a higher rate of relapse and recurrence during the first two years post-diagnosis for all women with breast cancer. 

Subsequent pregnancies don’t negatively affect prognosis of early breast cancers although the concerns and difficulties of conception due to cytotoxic agents must be addressed.

So, whilst no one wants a trip through the jungle. If you have found yourself there, I suggest a boat, a compass, binoculars to see the exotic birds, and friendly company. Take pics and make memories.

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