This blogpost is a summary of GTG 12 Pregnancy and Breast Cancer. This is an old guideline which was last updated in 2011 but it is one of an important guidelines which is repeatedly tested in exam. This summary is from my personal notes which I prepared for the exam. My purpose to share these notes is to give you an idea “how to summarise a guideline without missing out important information”.
I hope it is helpful. To download full guideline : Click Here
Best wishes as always!!
Background
- Most common cancer in females
- Lifetime risk 1:9 in UK
- Leading cause of death aged 35-54yrs
- 15%→ dx before 45 yrs
- Almost 5000 women affected in reproductive age group in UK annually
- B/w 1991-1997→ 1.3-2.4 cases per 10 000 live births
- If diagnosed ≤30 yrs→ 10-20% may be associated with pregnancy + up to 1 yr postpartum
- Prognosis→ improving
- 5-yr survival→ 80% for under 50 yrs (survival rate may be lower in very young)
- Fewer than 10% diagnosed will become pregnant
- Number of women seeking pregnancy after t/m is increasing
What is optimal management if diagnosed during pregnancy?
Prognosis
- Pregnancy itself doesn’t worsen the prognosis
- As pregnancy associated cancer occurs in younger→ so may have poor prognosis
Diagnosis
- Breast lump + pregnancy→ Refer to breast specialist team
- Any imaging or further tests must be in conjunction with MDT
- USG is used first for discrete lump but if cancer is confirmed, Mammography is necessary to assess extent of disease & contralateral breast
- Tissue diagnosis→ USG-guided biopsy for histology (*not cytology)
- Histology → similar to age-matched non-pregnant. Grade, receptor status & HER2 → for t/m planning
- Staging for metastasis→ only done if high clinical suspicion. Includes→ CXR + liver USG
- Not Recommended
- If concerns about bone involvement→ plain film of relevant area/ MRI
Termination Of Pregnancy Considerations
- Decision to continue pregnancy→ based on discussion of prognosis, t/m & future fertility wishes with woman, partner & MDT
Treatment During Pregnancy
- MDT review → forward to obstetrical team & family doctor
- Surgical
- Can be taken in ALL trimesters.
- Breast conserving or mastectomy→OK
- Reconstruction should be delayed
- Sentinel node assessment→ OK But do not use blue dye
- Sentinel node biopsy→ indicated in negative pre-operative axillary USG & needle biopsy.
- If axilla positive→ do clearance
- Radiotherapy
- Contraindicated till delivery. Unless life saving or preserve organ function. Do consider fetal shielding or early delivery depending on gestation
- Systemic Chemotherapy
- Contraindicated in 1st trimester Safe from 2nd trimester
- Anthracycline Regimens→ Safe Taxanes→ for High Risk
- Standard anti-emetics→ 5HT serotonin antagonist + dexamethasone→ OK to use
- Neo-adjuvant chemo→ before surgery for down-staging
- Tamoxfen & Trastuzumab→ Contraindicated
- Hemopoietic growth factors→ used to reduce neutropenia associated with chemo
Timing Of Delivery
- Birth timed after discussion with woman & MDT
- Most reach full term & deliver If early → give steroids
- Birth at least 2-3 weeks after last session of chemo
Lactation
- Do not breast feed if taking→ tamoxifen or trastuzumab
- Interval of at least 14 days after last chemo session
Contraceptive choices after t/m of breast cancer
- Non hormonal methods→ Recommended
- Seek specialist contraceptive advised
- Hormonal methods→ contraindicated with Current or Recent breast cancer
- Hormonal may be considered after 5 yrs free of recurrence
- LNG-IUS→ no overall ↑ in recurrence. May ↓ risk of endometrial abnormalities
Advice to women planning pregnancy after breast cancer
- Consult→ Oncologist, Breast Surgeon & Obstetrician
- Stop Tamoxifen→ 3 MONTHS before trying to conceive
- Avoid pregnancy→ in metastatic disease (*↓ life expectancy)
Impact of pregnancy on risk of recurrence
- Long term survival→ not adversely affected
- Good prognosis in subsequent pregnancy after early-stage cancer
- Pregnancy impact→ not modified by tumour characteristics
- BRCA gene mutation risk associated→ uncertain
Time interval before pregnancy
- Most→wait for 2 years
- Individualised Advice (size, grade, nodal status, hormone receptor positivity & HER2 status)
- Rate of recurrence→highest in first 3 yrs after diagnosis
- Late relapses→ up to 10 yrs
- With oestrogen receptor + disease→ Need tamoxifen t/m for 5yrs
Outcome of pregnancy
- Majority→ proceed to live birth May be ↑ miscarriage rate
- Study Findings
51% FTP births 8% Spontaneous Miscarriage 41% Induced TOP
- Women can be reassured concerning risk of malformations in offspring
- Some with BRCA +ve→ may want PIGD
Optimal management of pregnancy after breast cancer t/m
- Pregnancy→jointly supervised by obstetrician, oncologist & breast surgeon
- Echocardiography→ performed in women who are at risk to detect cardiomyopathy
- Breast treated with surgery/radiotherapy→ may not undergo hormonal change→ may require temporary prosthesis
- Slightly↑ risk of delivery complications & CS
Advice about breastfeeding after t/m of breast cancer
- Reassure they can breastfeed from unaffected breast
- No evidence that breast feeding increases recurrence
- Breast-conserving surgery→ may not inhibit lactation but Radiotherapy→ may cause fibrosis
- Chemotherapy→ does NOT effect safety of breast feeding
- Encourage women who want to breastfeed
Effect of breast cancer treatment on fertility
- Effect on fertility → discussed with ALL women of reproductive age diagnosed with breast cancer
- Provide written information. Referral to fertility specialist. Specialist counselling
- Should be fully informed of potential gonadotoxicity before t/m
- Specialist psychological support & counselling→ should be available
Effect of adjuvant chemotherapy on fertility
- May cause permanent amenorrhea with complete loss of germ cells, transient amenorrhea, menstrual irregularity & sub-fertility
- Degree of gonadotoxicity depends on→ agents used, dose, & woman age
- Premenopausal with breast cancer→ 20-70% have amenorrhea
- <5% under 30 yrs
- 50% aged 36-40yrs
- Alkylating (Cyclophosphamide)→ well-recognised gonadotoxicity
- CMF regimen→ higher incidence of amenorrhea (Cyclophosphamide, Methotrexate, 5-Fluorouracil)
- FEC regimen→ lesser amenorrhea (5-Fluorouracil, Epirubicin, Cyclophosphamide)
- Newer Taxanes→ less gonadotoxic
Effect of adjuvant hormonal therapy on fertility
Agents do not in themselves cause long-term effects on infertility
Tamoxifen:
- Menstrual irregularity & ↑ risk of endometrial pathology
- Avoid conception during use
- 2-3 months wash-out period
GnRH analogues:
- Cause amenorrhea & profound oestrogen deficiency
- Entirely Reversible
Trastuzumab:
- No evidence for fertility impairment but avoid pregnancy
Advise about pregnancy postponement
- Generally→ avoid for 2 yrs Tamoxifen may need for 5 yrs
- Age is major determent for infertility Women in 30s→ may wish to discuss
Fertility preservation before treatment
- Every breast oncology service must have designated pathways for prompt referral to fertility specialist who is able to offer ART
- NICE recommends→ universal access to sperm, egg & embryo storage for people undergoing gonadotoxic t/m
- NHS funding NOT available in all areas
GnRH analogues:
- Insufficient level 1 data to support routine use in oestrogen receptor positive.
- May↓ chemo response & ↓ risk of ovarian damage
Cryopreservation:
- Careful discussion
- Modified stimulation regimens considered in estrogen-sensitive breast cancer
Embryo cryopreservation:
- Success rate → 20% per cycle
- May be lower in women with cancer
Stimulation regimen with tamoxifen or letrozole combined with gonadotropins
- Advised, but
- Insufficient data to support ovarian tissue storage
ART after breast cancer t/m
- Limited by loss of ovarian function
- Chemotherapy induce amenorrhea → donated eggs
- Surrogacy
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