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Pregnancy-associatedBreast Cancer

SRIVIDYA VISWANATHAN, MDand BHUVANESWARI RAMASWAMY, MD, MRCP

Division of Medical Oncology, Arthur G. James Cancer Hospital,Richard J. Solove Research Institute, The Ohio State University,Columbus, Ohio

Abstract: As women delay childbirth, the incidence ofpregnancy-associated breast cancer is expected toincrease. A high degree of suspicion is necessary toensure timely investigation and diagnosis of breastcancer in a pregnant woman with a suspicious breastlump. Surgery as an initial approach is more suitablewhen diagnosis is made in the first trimester andsystemic therapy can be delayed to second trimester.Diagnosis of breast cancer in the later stages ofpregnancy can be managed with primary chemother-apy or surgery. A multidisciplinary approach invol-ving medical and surgical oncologists, high-riskobstetric care, genetic counselors, pharmacists, radia-tion oncologists, and neonatologist is highly recom-mended for the successful management of cancer andpregnancy.Key words: breast cancer, pregnancy, epidemiology

IntroductionPregnancy-associated breast cancer(PABC) is defined as breast cancer occur-ring anytime during gestation, lactation,or within 1 year after delivery. The man-agement of PABC is challenging in many

respects; the breast undergoes multiplephysiological changes during pregnancymaking the diagnosis and the follow-up ofa lump clinically difficult, the diagnosticand staging work up should not affect thedevelopment of the fetus or the offspringand yet be effective, and finally, the man-agement should take into account theeffects of therapy and timing of deliveryon development of the fetus or offspringwhile ensuring the optimal growth andpulmonary maturity of the fetus. Thus,the diagnosis of cancer during pregnancyadds complexity to both the managementof the pregnancy and cancer. However,current available data demonstrate thatthe pregnant cancer patient can receiveoptimal treatment with a multidisciplin-ary approach incorporating a medicaloncologist, surgical oncologist, radiationoncologist, radiologist, andmaternal fetalmedicine specialist. Early termination ofpregnancy does not improve the outcomeof PABC. Hence, an informed decisionwith the best interest of the mother anddeveloping fetus inmind has to bemade ina multidisciplinary manner with activeinvolvement of the patient all along theprocess. The goals of therapy are to max-imize the potential for cure for the cancer

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The authors declare that they have nothing to disclose.

Correspondence: Bhuvaneswari Ramaswamy, MD,MRCP, Division of Medical Oncology, Arthur G.James Cancer Hospital, Richard J. Solove ResearchInstitute, The Ohio State University, B406 Starling-LovingHall, OH . E-mail: [email protected].

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 54 / NUMBER 4 / DECEMBER 2011

CLINICAL OBSTETRICS AND GYNECOLOGYVolume 54, Number 4, 546–555r 2011, Lippincott Williams & Wilkins

whileminimizing the risk to the fetus fromcancer treatment.

EpidemiologyBreast cancer is the second most commonmalignancy diagnosed in pregnancy (aftercervical cancer). The incidence is between1 in 3000 and 1 in 10,000 pregnancies andcomprises about 0.2% to 3.8% of allbreast cancers diagnosed in women underthe age of 50 years. Alternatively, 10% to20% of breast cancers diagnosed in wo-men 30 years or younger are associatedwith pregnancy or postpartum. The Sur-veillance Epidemiology and End Resultsprogram estimates the rate of breast can-cer diagnosed in women less than 44 yearsat 215.8 per 100,000. As women tend todelay childbearing into their third andfourth decades, the incidence of PABC isexpected to increase.

Clinical Presentation andDiagnosisThe clinical presentation of breast canceras a painless lump in the breast is similarin both pregnant and nonpregnantwomen. Occasionally, the refusal by aninfant to nurse from a lactating breastmay be a sign of an underlying occultcarcinoma and is described as the milkrejection sign.

The challenge in diagnosing PABC isrelated to the fact that the breast under-goes several physiological changes includ-ing increased glandular changes, size, anddensity during gestation and lactation.Any lump that is persistent in a pregnantpatient beyond 2 to 4 weeks needs furtherwork up. A high degree of suspicion isrequired to diagnose these cancers with-out significant delay. Most recent studiesindicate that most PABCs are diagnosedafter a delay of 1 to 2 months.1 In amathematical model assessing tumor pro-gression over time, a 1-month delay in the

treatment of primary tumor increased therisk of axillary metastases by 0.9% to1.8%.2 This perhaps contributes to thehigher percentage of pregnant womenbeing diagnosed with larger tumors andnode-positive breast cancer. A list of dif-ferential diagnosis for breast lumps inpregnancy is outlined in Table 1.

Breast ultrasonography is the ideal firststep toward investigating a suspiciousbreast lump in a pregnant woman. Anultrasound can distinguish between asolid and cystic lesion without the risk ofradiation exposure to the fetus. In addi-tion, the axillary basin can be evaluatedfor any suspicious lymph nodes. If palp-able or suspicious lymph nodes are pre-sent, these can be biopsied by fine needleaspiration (FNA) biopsy under ultra-sound guidance.

Mammography is associated with ahigh false-negative rate during pregnancy,with sensitivity rates ranging from 63% to78%, with the higher percentages re-ported in some of the most recent stu-dies.3,4 The changes in the breast thatresult in the high false-negative rate arethe increased water content and change inthe distribution of fat. Mammographywith abdominal shielding is consideredsafe during pregnancy as the averageglandular dose of 0.02 to 0.04Gy resultsin a very negligible radiation dose of only0.00004Gy to the fetus. Hence, mammo-graphy is still a useful and safe tool duringpregnancy and bilateral mammogram isoften performed if ultrasound is sugges-tive of malignancy.

No published data currently exists re-garding the use of breast magnetic reso-nance imaging (MRI) during pregnancy.Although gadolinium-enhanced MRI ismore sensitive than mammography fordetecting invasive breast cancer, severaldisadvantages limits its use in pregnantwomen. Gadolinium crosses the placentaand is associated with fetal abnormalitiesin rats. Hence MRI is not recommendedfor diagnosis of breast cancer during

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pregnancy; MRI with gadolinium may beperformed during the postpartum periodif necessary.

Definitive diagnosis of any breast lumpis achieved by tissue biopsy and should beperformed for any clinically suspiciouslump. This can be safely performed bycore needle biopsy, under local anes-thesia. Alternatively, FNA can be per-formed; however, it may pose a diagnosticchallenge for the pathologist secondary tothe pregnancy-associated changes in thebreast architecture. The pathologistshould be made aware that the specimenis from a pregnant woman. Complica-tions resulting from a biopsy for a sus-pected PABC include formation of a milkfistula in a lactating women and a slightincreased risk of bleeding. Stoppingbreast feeding or medical suppression oflactation will reduce the risk of develop-ment of milk fistula. Excisional biopsycan be performed for benign breastlumps. Immunohistochemical stains forthe estrogen receptors (ER), progesteronereceptors (PR), and Her2 should be per-formed on biopsied tissue from PABCs.

StagingThe tumor, node, and metastasis stagingsystem of the American Joint Committeeon Cancer is appropriate for pregnantwomen with breast cancer. Women withPABC often present with a more

advanced stage because of the diagnosticchallenges that lead to delayed diagnosis.It is essential to begin with a thoroughhistory to evaluate for any possible symp-toms attributable to underlying malig-nancy or metastasis. A completephysical examination should be per-formed to clinically assess for the extentof the primary disease and for possiblemetastasis, in particular axillary nodalmetastasis.

Women with PABC who are asympto-matic and clinically node negative do notrequire further staging work up for detec-tion of distant metastasis. In women withsymptoms andwith larger tumors (such asT3 and T4 lesions and clinically palpablenodes), a complete radiologic staging eva-luation is warranted. Clinically palpablelymph nodes should be assessed furtherby ultrasound-guided FNA. In womenwith nonpalpable axillary nodes, sentinellymphnode biopsymay be performed andis discussed in the section below.

Breast cancer most commonly meta-stasizes to the distant organs such as bone,liver, lung, and lymph nodes. Thus, inde-pendent of pregnancy, axial imaging suchas computed tomography (CT) is oftenused for radiographic staging of the dis-ease. CT scans are generally avoided inpregnancy because of the large cumula-tive radiation dose because of repeatedimaging. Chest radiograph can be safelyperformed in pregnancy with abdominalshielding. If further evaluation of thechest is required, MRI without gadoli-nium can be performed as the safety ofgadolinium (category B) in pregnancy isyet not established. Although less sensi-tive thanCT scans, abdominal ultrasoundis a safe method to evaluate for livermetastases in pregnancy. MRI withoutcontrast of the liver can be performed iffurther assessment is required.

To assess the skeleton for metastasisduring pregnancy, low-dose bone scan orthoracic and lumbar spine MRI withoutcontrast is recommended. Low-dose bone

TABLE 1. Differential Diagnosis of aBreast Mass in a Pregnant orLactating Woman

Invasive breast cancerLactating adenomaFibroadenomaFibrocystic diseaseMilk retention cystAbscessLipomaHamartomaLobular hyperplasiaPhyllodes tumorsSarcoma

548 Viswanathan and Ramaswamy


scans expose the fetus to 0.08 rad (ascompared with 0.19 rad with a conven-tional bone scan).5 When bone scans areperformed, good maternal hydration andfrequent voiding is recommended tomini-mize the fetal exposure to radionuclide.Plain x-rays of the symptomatic bony sitescan also be used to assess for metastaticdisease. Any suspicious lesion on theabove imaging which needs further workup should be considered for a biopsy.MRI of the brain, if indicated is per-formed without contrast.

PathologyMajority of breast cancers in pregnancyare infiltrating ductal carcinomas that arepoorly differentiated. Most studies havereported a lower percentage of PABCsexpressing ER or PR (approximately25%) than the 55% to 60% reported innonpregnant premenopausal women.Many of the older studies reporting theincidence of ER/PR-positive tumors inPABC used the ligand-binding assay butsome of the more recent studies usingimmunohistochemical staining for ER/PR still report a lower incidence of ER/PR positivity in PABCs. The high circu-lating levels of estrogen and progesteroneduring pregnancy down-regulate the ERlevels and contribute to this low ER-po-sitive status is a potential explanation forthis finding.

Her2 is a tyrosine kinase belonging tothe epidermal growth factor receptorfamily and approximately 20% to 25%of breast tumors have amplification ofthis gene resulting in over expression ofthe protein (which is detected by immu-nohistochemistry). Her2 over-expressingtumors are typically more aggressive andassociated with a poor prognosis. Theprevalence of Her2 over expression inPABC is slightly higher than that seenindependent of pregnancy, with rates re-ported between 28% and 58%.

In addition, among women withPABC, there is a higher incidence ofaggressive inflammatory breast cancers,which are 2.5 times more likely to havedistant metastatic disease at diagnosis.

TreatmentBreast cancer occurring in the postpartumperiod is treated in the same way as breastcancer occurring in the nonpregnantwoman. Breast feeding is contraindicatedin patients receiving systemic therapy.Treatment of breast cancer during preg-nancy follows the same principles as themanagement of breast cancer in nonpreg-nant patients with some key exceptions.The goal of treatment is directed at pro-viding the best curative treatment for thecancer with minimal or no harm to thefetus and to maximize the gestationalperiod and ensure safe delivery of thefetus. Although medical termination ofpregnancy should be discussed if a diag-nosis of PABC is made early in the preg-nancy, this has not been shown toimprove the overall outcome of the can-cer. A treatment algorithm is outlinedin Figure 1.

EARLY BREAST CANCER

Loco-regional TherapySurgery is the definitive treatment forlocalized breast cancer. Surgery and theuse of general anesthesia are currentlyconsidered to be safe during any trimesterof the pregnancy. Mastectomy andbreast-conserving therapy followed byradiation are the 2 options for definitivesurgery. Mastectomy eliminates the needfor breast irradiation and hence elimi-nates the fetal risks associated with radia-tion. However, if cancer is diagnosed latein the second or third trimester, lumpect-omy can be performedwith plan for radia-tion after delivery. Breast reconstruction, if



desired is usually delayed until afterdelivery.

Axillary staging is a very importantaspect of therapy as the nodal statusaffects locoregional therapy and choiceof adjuvant therapy. The standard of carefor axillary staging in clinically node ne-gative, nonpregnant women is sentinellymph node biopsy. Although some re-cent studies illustrate the potential safetyof this approach in pregnant women,several concerns still exist. Supravitaldyes such as isosulfan blue dye shouldnot be used in pregnancy because of po-tential anaphylactic reactions resulting infetal loss. Small studies demonstrate thatwith the use of double filtered technetiumsulfur colloid, sentinel lymph node biopsycan be safely performed in pregnantwomen.6 However, until further data areavailable, sentinel lymph node biopsy

should only be recommended to pregnantwomen in the context of a clinical trial.

In summary, mastectomy with axillarylymph node dissection remains the stan-dard of care for women with early stage,operable breast cancer diagnosed in thefirst and early second trimester. Breastconservation surgery with lumpectomyand axillary lymph node dissection is anoption for women diagnosed in the latesecond or third trimester when radiationtherapy can be pursued after delivery.Decisions regarding timing and type ofsurgery should take into consideration theneed for adjuvant chemotherapy and ra-diation therapy and avoiding delays be-yond 6 months from the time of definitivesurgery in initiating adjuvant radiation.

Adjuvant radiation therapy improveslocal control and survival in breast cancer.However, the increased risk to the fetus in

PREGNANCY ASSOCIATED BREASTCANCER

< 12-14 weeks 14-34 weeks

Operable Inoperable

Surgery-Mastectomy preferredAdjuvant CT after 1st trimester

Operable Inoperable

Wait until 2nd trimesterNeoadjuvant CTSurgery before or after delivery

Surgery-Mastectomy or BCSAdjuvant CTPlan surgery 2-4 weeks after CT

Neoadjuvant CTSurgery after deliveryConsider delivery at 35 weeks

Postpartum:Adjuvant radiation therapy if indicatedAdjuvant hormone therapy with tamoxifen if indicated

FIGURE1. Treatment algorithm formanagement of pregnancy-associated breast cancer. BCSindicates breast-conserving surgery; CT, chemotherapy.



the form of teratogenicity, induction ofchildhood malignancies, and hemato-logical disorders preclude the use of radia-tion therapy in the management of breastcancer during pregnancy. The excess can-cer risk to a fetus receiving radiation is 6.57cases per 10,000 children per rad per year.Typical external beam radiation dose tothe breast range from 45 to 60Gy, whichcould result in a fetal radiation exposure of3.9 to 15 rad in the first trimester to asmuch as 200 rad in late third trimester.7

Despite several anecdotal reports of nor-mal infants born to mothers exposed toradiation, radiation therapy is not recom-mended during pregnancy as absence ofrisk to the fetus cannot be guaranteed.

Systemic TherapyWomen with PABC are often candidatesfor systemic chemotherapy as they tend topresent with higher stage disease and havetumors that are more commonly ER ne-gative, consistent with guidelines used totreat similar stage cancers diagnosed in-dependent of pregnancy. In patients withlocally advanced (T3 or clinically node-positive) breast cancer, systemic che-motherapy may be given before definitivesurgery (neoadjuvant chemotherapy) fordownstaging of the tumors and to obtainbetter surgical outcomes. Neoadjuvantchemotherapy can also be administeredin pregnant women who want to avoidmastetomy. This approach provides sys-temic therapy first and the surgery can bedelayed close to or after delivery andradiation therapy can be done subse-quently after delivery.

In general, adjuvant chemotherapy isconsidered for all premenopausal womenwith node-positive breast cancer ortumors that are poorly differentiated,ER negative and >1 cm, and Her2-posi-tive tumors. There are no randomizedcontrolled trials evaluating the safety ofthe various chemotherapy regimens inbreast cancer. Most of the data are ob-tained from the use of the drugs or similar

drugs in breast cancer or other cancersoccurring in pregnancy. Information re-garding the effects of chemotherapy ad-ministered during pregnancy is largelycompiled from case reports and small caseseries. Dosing of chemotherapy duringpregnancy is also complicated by the phy-siological changes in plasma volume, in-creased hepatic and renal clearance, thirdspacing of drugs in the amniotic sac fluid,changes in serum albumin, and decreasedgastric emptying. Nonetheless, the dosingof chemotherapy is the same as in non-pregnant females.

Organogenesis occurs from 10 days to12 weeks after implantation and carriesthe greatest risk for spontaneous abortionand fetal death secondary to chromosomeor congenital abnormalities. In general,chemotherapy is best avoided during thisperiod of critical organogenesis if thedelay in chemotherapy would not com-promise the health of the mother. If adiagnosis of PABC is made very early inpregnancy, medical termination of preg-nancy can be discussed with the patient.There are no studies of chemotherapy inthe first trimester other than anecdotalreports of patients becoming pregnantwhile on chemotherapy.

Chemotherapy is generally consideredto be less risky in the second and thirdtrimester. One review reported a 1.3%risk of fetal malformation in 150 womengiven chemotherapy in second or thirdtrimester compared with risk of 16% inthe first trimester chemotherapy.8 Ap-proximately 50% of infants exposed tochemotherapy in the second and thirdtrimester manifest intrauterine growth re-tardation, prematurity, and low birthweight.

Anthracyclines and taxanes are consid-ered standard of care in the managementof node-positive breast cancer in nonpreg-nant women. Anthracycline (doxorubicinand cyclophosphamide)-based therapywith or without fluorouracil/adriamycin/cyclophosphamide (FAC) are the most



common regimens used in women withPABC. In the largest prospective study of57 pregnant women treated with FACregimen administered either as adjuvant(n=32) or neoadjuvant (n=25) therapyin the second or third trimester, therewereno reported stillbirths, miscarriages, orperinatal deaths. The median number ofFAC cycles given in this study was 4(range, 1 to 6). The mean gestational ageat delivery was 37 weeks. Patients on thisstudy were then followed by mail or tele-phone to determine the long-term out-come of the children exposed tochemotherapy in utero. Three childrenhad congenital abnormalities: one eachwith Down syndrome, ureteral reflux,and club foot. The other children werefound to have normal developmentalmilestones during the follow-up rangingfrom 2 to 157 months.9 Of the 25 patientswho received neoadjuvant chemotherapywith FAC, 6 had a complete pathologicresponse, whereas 4 had no tumor re-sponse to chemotherapy and eventuallydied from their disease. PABC is reportedto be as chemosensitive as non-PABC inthe neoadjuvant setting.10

Another group reported results from astudy of 20 patients with PABCwith singleagent epirubicin (E) administeredweekly.11

Weekly E was well tolerated and no con-genital anomalies other than 1 child withpolycystic kidney disease. However, singleagent E is not considered a standard treat-ment option for adjuvant therapy. Othersmaller case series have been reportedwith use of abdominal circumference,FEC, and epirubicin/cyclophosphamidein pregnancy. Methotrexate should beavoided in all stages of pregnancy becauseof the possibility of third spacing in theamniotic fluid as well as its abortifacientand teratogenic effects in early pregnancy.Currently, there are no reports of use ofdose dense regimens for PABC.

There is not an extensive experiencewith taxanes in the gestational patient. Inbreast cancer patients, often the taxane

therapy is done after delivery. In a recentreviewof 40 pregnantwomenwho receivedtaxanes, therewas no report of intrauterinedeaths or congenital malformations otherthan 1 infant with pyloric stenosis.12 An-other concern regarding the taxanes is thepotential for lowered serum concentra-tions in pregnancy because of the activa-tion of the P-450 system in pregnancyresulting in increased drug metabolism.13

Chemotherapy in general should beavoided for 3 to 4 weeks before antici-pated time of delivery to reduce myelo-suppression and potential for peripartumcomplications.

TrastuzumabIncorporation of trastuzumab therapy forHER-2/neu-positive disease is the stan-dard of care in the adjuvant and meta-static setting. There have been 13 casereports of the use of trastuzumab in preg-nancy. Of the 13 patients, 1 patient electedto have abortion and was found to havean ectopic pregnancy. Eight of the other12 patients developed oligohydramnios.Four neonatal deaths were reported afterexposure to trastuzumab secondary to res-piratory and renal failure. The increasedrisk of oligohydramnios is thought to bedue to trastuzumab down-regulating thestrong expression of Her2 on the renalepithelium. Surprisingly, there have beenno reports of serious fetal cardiac effects.There is a case report of significant dete-rioration in maternal cardiac functionwhen trastuzumab was administered dur-ing pregnancy. Currently, trastuzumabhas a black box warning for use in preg-nancy and treatment with trastuzumabshould be delayed after delivery.

TamoxifenFor women who have hormone receptor-positive disease, therapy with tamoxifenis best deferred until after delivery. Pre-clinical models have shown that in uteroexposure to tamoxifen increased theincidence of genital abnormalities.



Treatment with tamoxifen has been asso-ciated with vaginal bleeding, spontaneousabortion, birth defects, and fetal death. Inaddition, the long-term effects of tamo-xifen on the female offspring are unknown.

METASTATIC BREAST CANCER

Reports ofmetastatic PABCare generallysingle case reports describing patientswho were incidentally found to bepregnant while being treated for theirmetastatic disease. Evidence-based re-commendations for the management ofmetastatic breast cancer in pregnantwomen are very limited compared withthose in early breast cancer. Anthracy-cline-based regimens are considered safein second and third trimester and therehave been 3 case reports of docetaxelbeing used without much consequence.However, patients may not have a pro-longed response to a single agent (lasting 2trimesters) and may need to switch toother agents. Delaying therapy for longperiods of time may adversely affect thewelfare of the mother. Hence, it is reason-able to discuss medical termination ofpregnancy in a patient with metastaticbreast cancer. Bisphosphonates are com-monly used to reduce skeletal-relatedevents in breast cancer patients with bonemetastases. Reports of use of bisphospho-nates in 51 pregnant patients for differentindications did not reveal any increase inmaternal or fetal morbidity.14 A morerecent report in 21 patients treated forosteoporosis did not reveal any increasein adverse effects on the fetus or thepregnancy.15Zoledronicacidandpamidro-nic acid, the 2most commonly used bispho-sphonates in metastatic breast cancer arecategorized as pregnancy category D andthe risksmust be weighed against the poten-tial benefits in an individual situation.

Supportive CareUse of antiemetics such as the 5HTantagonists, steroids, or antihistamines

is not contraindicated in pregnancy.Granulocyte-stimulating factors areconsidered pregnancy category C andthe use should be guided by the clinicalnecessity.

Monitoring of Pregnancy and DeliveryPregnant women with breast cancershould be managed in a high-risk preg-nancy clinic in collaboration with an on-cologist. Gestational age should beaccurately determined to aid in planningtreatment and timing of delivery. Fre-quent clinical examinations and fetal ul-trasound examination should beperformed to monitor the fetal growthappropriately. An imaging study likeechocardiogram of the heart to assessthe cardiac function is recommended ifan anthracycline-based chemotherapyregimen is to be administered to themother.

Ideally, chemotherapy should be with-held for 3 to 4 weeks before anticipateddate of delivery to prevent infectious orbleeding complications secondary tomye-losuppression. Ideally, the fetus should bedelivered after confirming fetal pulmo-nary maturity or after 34 weeks of gesta-tion to prevent neonatal complications.The mode of delivery should be dictatedby the obstetrical indication.

Lactation: patients receiving che-motherapy should be cautioned againstbreast feeding as many cytotoxic drugsand supportive medications are secretedin the breast milk and can resultin exposure of the baby to thesemedications.

Termination of PregnancyElective termination of pregnancy has notbeen shown to improve outcomes inbreast cancer. Hence this is not routinelyrecommended. However, in early preg-nancy, this option should be discussedalong with the other treatment optionssince delaying definitive therapy untilafter the first trimester could adversely



affect maternal outcome. The decision toterminate the pregnancy should be indivi-dualized based on the maternal concernsand oncologic situation.

Prognosis of Breast Cancer AssociatedWith PregnancyThe prognosis of breast cancer occurringduring pregnancy has changed over theyears. Earlier reports suggest that PABChas a worse prognosis, which was perhapslargely related to the delayed diagnosisand more advanced stage at presentation.A recent report on outcome of 32 patientswith PABC when matched for age, stageand other characteristics was shown to becomparable to the outcome of non-preg-nant breast cancer patients.16 Howeversome older reports indicate decreasedsurvival in pregnant women with breastcancer.1,17

Follow-up After TreatmentWomen with breast cancer occurring dur-ing pregnancy should be monitored forrecurrence as per guidelines recom-mended by the American society of Clin-ical Oncology and the NationalComprehensive Cancer Network for allwomen with breast cancer. This includescomprehensive history and physical examevery 3 to 6 months for the first 3 yearsand every 6 to 12 months for the next 2years. Annual mammograms should beperformed. No additional imaging is ne-cessary for surveillance.

Genetic TestingGiven the younger age of the women withPABC, the risk of carrying amutation in agene (such as BRCA1 or BRCA2) respon-sible for a hereditary cancer syndrome ishigher and genetic counseling and testingshould be offered to all these women.

Pregnancy After Breast CancerThe safety of pregnancy after breast can-cer is an important issue as more youngwomen with breast cancer survive longer

with effective therapies. Several popula-tion-based studies have reported thatwomen who become pregnant after suc-cessful treatment of breast cancer do nothave adverse cancer outcomes.18,19 In factthere are data suggesting a favorable ef-fect of a subsequent pregnancy on earlybreast cancer (suggesting a possible anti-tumor effect of pregnancy). At this time,the consensus is generally to avoid preg-nancy in the immediate 2 to 3 years aftertreatment as there is a higher chance ofrecurrence in this period. However, this isbased on small patient cohort studies.Moreover, a healthy mother effect mayhave biased the selection in these studies.In a recent meta-analysis of publishedstudies corrected for this bias (so as toassess the effect of pregnancy (at least10mo after diagnosis vs. no pregnancyon overall survival), pregnancy after 10months of diagnosis of breast cancer didnot adversely affect the outcomes.20

SummaryAs women delay childbirth, incidence ofPABC is expected to rise. A high degree ofsuspicion is necessary to ensure timelyinvestigation and diagnosis of breast can-cer in a pregnantwomanwith a suspiciousbreast lump. Surgery as an initial ap-proach is more suitable when diagnosisis made in the first trimester and systemictherapy can be delayed to second trime-ster.Diagnosis of breast cancer in the laterstages of pregnancy can be managed witheither primary chemotherapy or surgery.A multidisciplinary approach involvingmedical and surgical oncologists, high-risk obstetric care, genetic counselors,pharmacists, radiation oncologists, andneonatologist is highly recommended forthe successful management of the cancerand pregnancy.

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