Cancer complicate 1 / 1,000 pregnancies

1/3 maternal death during pregnancy

Commonly diagnosed cancer during pregnancy:

Breast cancer Cervical ca Melanoma Thyroid ca

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• Diagnostic delay is not rare

• The management of pregnant mother is difficult

• Concern :

Save mother’s life Protect fetus Intact reproductive system

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Tumours diagnosed during pregnancy or within one year

post partum

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• Diagnosed 1 / 3000 pregnancies

• Incidence 0.76 – 3.8 %

• Median age 33 ( 23 - 47 y)

Saunders CM,Baum M Breast cancer and pregnancy review .J R Soc Med 1993;86:162-5 7/46

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Similar to non pregnant lady

- Painless mass

- Nipple discharge

- Inflammatory breast

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Histopathology

LN Status

Receptor status

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Invasive ductal ca

Invasive lobular ca

Inflammatory breast ca

Middleton LP , et al. Breast carcinoma in pregnant women.Assissment of clinicopathologic & immunohistochemical features. Cancer 2003;98:1055-60

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Similar to non pregnant women in :

Histological frequencie

Grade

Middleton LP , et al. Cancer 2003;98:1055-6013/46

+ve ER , PR < 30 %

Her-2 / neu over expression 28-58%

p53 50 %

Elledge RM ,et al ER , PR and Her-2/neu protien in breast cancer from pregnant patients. Cancer 1993;71:2499-506

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Involved in 60 - 90 %

Similar to general population

Isaac J . Cancer of the breast in pregnancy. Surg clin North Am 1995;75:47-51

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Diagnostic delay

Average delay 8.2 months ‘ 2-15 months ‘

Advanced breast cancer ‘ 2.5 fold ‘

Moore HCF, Foster Jr Rs. Breast cancer and pregnancy Semin oncol.2000;27:646-53 17/46

FNA

Core biopsy – Cost effective

Early stage breast ca accounts 60%

Sorosky JI ,Scott-conner. Breast cancer complicating pregnancy.Obst Gynecol clin North Amer 1998;25(2):353-63

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Radiation effect

Dose dependant

Gestational age

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<0.1 Gy

<3 Gy

Dose

No effect

Fetal malformation

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Teratogenic16 w

2 w

Abortion

25 w

Sterility malignancy

Mole RH.childhood cancer after prenatal exposure to diagnostic x-ray examinations in Britain. Br J Cancer 1990;62:152-68

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Ultrasound sensitivity 93 %

Diagnostic Mammogram:

- 0.004 Gy

- sensitivity 70%

Nicklas A, Baker M. Imaging strategies in pregnant caner patients. Semin oncol 2000;27:623-32

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• Staging – CXR , Ultrasound

• Avoid CT Pvlidis NA. The oncologist 2002;7:279-87’

• MRI

- No proof of safety

Aloraini et al Ann.Saud.Med. July-Aug. 2006

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Gold standard

BCS

2nd - 3rd trimester

Axillary LN dissection

SLNB not recommended 27/46

Chemotherapy

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teratogenic

2 - 3 trimester

CAF , CMF

Giacalone PL.et al chmotherapy for breast carcinomaduring

pregnancy . Cancer 1999;86:2266-72

• Epirubicin not recommended

Peccatori F. chemotherapy during pregnancy : what is really safe?

Lancet oncol 2004;5:398

• Taxol

Eur J Cancer care 2000;9:235-7 29/46

Not offered during pregnancy

Threshold fetal dose for complication

– 10-15 rad 20 wks gestation– 25-50 rad after

Woo JC et al Breast cancer in pregnancy: a literature review. Arch Surg 2003;138:91-8

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Inadequate information

Delivery 2-3 wk after Rx

Similar survival rate among pregnant & non pregnant lady

Petrek JA et al. Prognosis of pregnancy associated breast cancer. Cancer 1991;67:869-72

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• Rate of malformation 2-3%

• Stillbirth 5-15%

• Breast feeding – not recommended

• Suppression of lactation does not improve prognosis 33/46

G-CSF:

- Reduce duration of neutopenia

- Improve overall survival

- safe ?

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• Erythropoietin Scott LL et al.Erythropoietin use I pregnancy: two cases & review

Am JP parinatol 1995;12:22-4

• Ondansteron , metochlopramide

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Recommended 1950-1960s

Abortion doesn’t prolong survival

Currently indicated in :

- Very aggressive tumor - Advanced disease with dismal prognosis

Petrek JA et al. Prognosis of pregnancy associated breast cancer. Cancer 1991;67:869-72

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Petrek JA et al. Prognosis of pregnancy associated breast cancer. Cancer 1991;67:869-72

• Chemotherapy may cause premature ovarian failure

• Depending upon the woman’s age & the Rx regimen Bonadonna and Valgussa ‘

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‘

CMF < 40 y 96% developed amenorrhoea

< 40 y 54%

Doxorubicin

< 35 y 9% permanent amenorrhea

Taxol ???40/46

• Resumption of menstruation doesn’t confirm restoration of fertility

• It seems that pregnancy after Rx for breast cancer has an increased chance

of spontaneous pregnancy loss

Bonadonna G, Valgussa P. Adjuvant systemic therapy forresectable breast cancer.J Clin Oncol 1985:3:259–75.

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• Long-term survival after breast cancer not affected by pregnancy

• five-year survival rate of 80%

• The survival of women who were node-negative was 90% at ten years

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No difference between those who had subsequent

pregnancies & who did not

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• Delay pregnancy < 33 years

• Decisions about future conception based on prognosis :

- Stage IV deferring pregnancy for 5 y

- Recurrent stage-I or -II should not contemplate conception

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It is recommended that pregnancy should be deferred for at least

2 years after treatment

Berry et al. Management of breast cancer duringpregnancy using a standardized protocol J Clin Oncol 1999

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Women planning a pregnancy after Rx for breast cancer should consult their obstetrician, breast surgeon and

clinical oncologist

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