Tuesday, September 15, 2020

GTG # 12 Pregnancy & Breast Cancer

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!!


GTG 12 Breast Cancer Pregnancy


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
    • Gadolinium enhanced MRI
    • Tumour marker CA125, CEA & CA15-3
    • Bone scanning & Pelvic X-ray, CT
  • 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 mastectomyOK
    • 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

  • Mostwait for 2 years
  • Individualised Advice (size, grade, nodal status, hormone receptor positivity & HER2 status)
  • Rate of recurrencehighest 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

  • Pregnancyjointly 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

You may also like :


GTG 26 Assisted Vaginal Birth

GTG 73 PPROM from 24+0 weeks

GTG 72 Obesity in Pregnancy

GTG All green top Guidelines


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