Tn the past, cancer of the breast during pregnancy was thought to be an ominous disease. As Dr Haagensen suggested in 1943, “Carcinoma of the breast developed during pregnancy or lactation is so malignant that surgery cannot cure it often enough to justify this method of treatment. We pre fer to classify these patients as categorically inoperable and to treat them palliatively with radiation.” This has been shown to be untrue and patients matched age for age and stage of disease for stage of disease. the outcome has been found to be the same regardless of pregnancy
Breast cancer remains the most common cancer of American women, but due to the growing popularity of smoking among young women, lung cancer is the most common cause of death. Still, breast cancer is among the most common malignancies and causes of death in American women. Breast cancer in pregnancy, however, is rare, making up only 1% to 25% of all female breast cancers. It is thought to com plicate only 1 in 3,500 deliveries.
A probable reason breast cancer in pregnancy was thought to be so malignant is that the diagnosis was difficult to make, primarily because the breast is engorged and more nodular and tender during pregnancy and lactation, which makes it difficult for the woman and her physician to find an abnormal mass. Therefore, it is common to have a delay in the diagnosis which gives the cancer a longer period of time to divide, grow and possibly metastasize to distant sites. When this occurs, efforts to control the cancer are generally less effective. But delay in diagnosis and treatment does not have to be the rule.
Traditional mammography is typically not helpful in the pregnant and young patient because of the increased density of the breast, as well as the fact that some women cannot tolerate the examination due to tenderness Ultrasonography. however, can be safely utilized to differentiate cystic lesions which are generally not cancerous from solid lesions which may be cancerous, but this test is often not necessary and ultimately does not help make the diagnosis. Some physicians routinely obtain a chest X-ray to rule out distant metastasis, perhaps to bene or lung, and this can be safely done with appropriate uterine shielding However, a chest X-ray does not definitively diagnose breast cancer. In some non-pregnant women, a liver-spleen scan or a bone scan are ordered to determine whether or not the cancer has spread to these organs, but these tests should be avoided in the pregnant women because of the risk of radiation exposure to the fetus
So how is the diagnosis made The diagnosis is made just as it is in the non-pregnant woman. And that is by monthly breast self-examinations by the patient after her period before she becomes pregnant, and monthly during the pregnancy, and by her physician on a regular basis. Any suspicious lesions can then be safely biopsied under local anesthesia which will have no impact on the gravid uterus. Some physicians perform needle aspiration which consists of a skinny, thin gauged needle placed into the mass and the aspirate is sent to the pathologist for evaluation. This cannot give a tissue diagnosis because only single cells. are obtained for microscopic examination but can differentiate cancer cells from normal ones. More tissue can be obtained by the Turcot biopsy technique which is essentially a large needle that removes a small core of tissue and is as good as an open surgical biopsy if the cancerous part is sampled. This procedure can be done in the office with local anesthesia and results can be obtained within an hour in some institutions. A negative or equivocal result by either of these methods means that an open biopsy must be performed to get the proper tissue diagnosis. Again this can be done under local anesthesia and even general in the second and third trimesters. The pregnant or lactating breast is usually more difficult to biopsy than a non-pregnant breast because of increased vascularity. The lactating breast is also an ideal culture medium for bacteria especially if blood is mixed and increases the risk of infection. But with meticulous techniques these complications are rare.
I am often asked if the pregnancy should be terminated when breast cancer is discovered in the pregnant woman. Most breast cancers in pregnancy do not have the so-called estrogen receptor that would benefit from treatments aimed at eliminating estrogen (found in high concentration during pregnancy) and there fore there is no reason to terminate the pregnancy on that basis. In addition, there appears to be no adverse effect on overall survival attributed by these hormones found in pregnancy. There are, however, reasons to terminate a pregnancy such as in patients where chemotherapeutic agents must be employed that would be teratogenic to the fetus. Although there are new drugs being developed almost yearly that may be safely given without harm to the fetus, one must remember that new drugs have short follow-up and may subsequently be found to be harmful over the long term. One must also remember that radiation is teratogenic to the embryo and can cause leukemia to the fetus in those patients that elect radiation when proper shielding cannot be assured. Also, there are personal reasons patients may elect to terminate their pregnancies when they are found to have cancer. If the breast cancer is caught early and treated they have the same chance of survival as a non-pregnant woman of the same age and tumor size. Younger patients (with breast cancer) confer an unfavorable prognosis presumably due to more aggressive tumors or heightened virulence of breast cancer in young women, but not because of the pregnancy itself. In a woman who desires to have another child, I advise to proceed just as if she developed breast cancer while not pregnant because the patient’s risk for recurrent disease and the disease-free survival and overall survival is no different than in her non-pregnant counterparts. Whether or not she should subsequently become pregnant is more a personal decision than a medical necessity. It should be emphasized, however, that the diagnosis during pregnancy is more difficult and for this reason many breast surgeons recommend waiting 2 to 3 years to allow aggressive disease to manifest itself before starting a new pregnancy.
Lawrence J. Goldstein, M.D.
UC Davis-East Bay Department of Surgery Highland Hospital