Pregnancy associated breast cancer

IN recent years, medical professionals have seen an increase in the prevalence of pregnancy-associated breast cancer. The incidences of gestational cancer, which is noted as one of the most aggressive types of cancer, are projected to rise in the coming years as more women delay motherhood to pursue their careers and other personal goals.

“Pregnancy-associated breast cancer simply refers to the diagnosis of breast cancer either during pregnancy, within one year post-partum or during breastfeeding,” consultant obstetrician-gynaecologist Dr Leo Walker told All Woman.

The risk factors are essentially identical among both the pregnant and non-pregnant population with both modifiable and non-modifiable risk factors existing. Some risk factors include early onset of menses, late menopause, genetic predisposition, obesity, and smoking.

Dr Walker pointed out that breast cancer, which is the most common malignancy in women, affects 15 per cent of women age 45 years and below. He said that for this subset of women it is often more difficult to diagnose breast cancer because of the various changes that occur in a woman’s breasts during pregnancy and childbirth. This is why pregnancy-related breast tumours are often discovered at a more advanced stage than in non-pregnant women.

“Understandably, the diagnosis of cancer is a devastating one, but pregnant women diagnosed with cancer present quite unique challenges. Even though the prognosis is generally favourable among young women with an 80 per cent survival rate, pregnancy can often delay diagnosis because of difficulty identifying breast masses during pregnancy, and increased likelihood of more aggressive tumours,” Dr Walker explained.

Positive outcomes are on the rise because of an increase in available diagnostic procedures and treatments that are both safe for pregnant women and their unborn children. The most aggressive treatment plans, however, according to Dr Walker, are often delayed.

“Specific treatments used in the management of breast cancer such as chemotherapy, which should not be given during the first trimester, radiation and other therapies which are contraindicated in pregnancy entirely are often delayed. Also, for those who desire reconstructive surgery following mastectomy, it is often advised that this is delayed until after pregnancy, to allow for a more symmetrical reconstruction,” Dr Walker advised.

Not to be daunted by the statistics though, and the various noted obstructions to some treatments in pregnancy, Dr Walker said that many women who are diagnosed with breast cancer during pregnancy do very well, even better than non-pregnant women, and even go on to deliver healthy babies.

“On a more positive note, the evidence shows that pregnancy outcomes are rarely affected by the diagnosis of breast cancer and interestingly, all things being equal, those who choose to continue pregnancy have slightly improved outcomes versus those who choose to terminate the pregnancy,” Dr Walker shared.

Post-childbirth, breastfeeding is just one way that many women bond with their babies. Unfortunately, it is not recommended that some mothers breastfeed while they are receiving some treatments, and are instead advised to explore the formula options available for their little ones’ nutritional care.

“Women who are receiving treatment in the form of chemotherapy and/or hormonal therapy (tamoxifen & trastuzumab) are advised not to breastfeed because of the potential risk to the newborn. Chemotherapy is often scheduled such that it is completed at least three to four weeks prior to delivery, which also allows for restoration of the bone marrow. In women who were previously treated for breast cancer and have completed therapy, breastfeeding is completely safe,” Dr Walker advised.

Certainly for most women of child-bearing age who are not yet mothers and/or are interested in having more children, fertility is clearly another huge concern. It is a known fact that cancer can temporarily or permanently affect a woman’s fertility. With their lives and their fertility hanging in the balance, what options are available to these women?

“Unfortunately, many of the chemotherapeutics used in the treatment of breast cancer are also toxic to the ovaries and many women do experience a decline in fertility following treatment. Additionally, it’s often advised that women delay pregnancy until AT LEAST two years following completion of treatment due to the fact that recurrences will often occur within those initial two years. This additional delay will also present hurdles to women attempting to fulfil their fertility desires,” Dr Walker explained.

Dr Walker further reasoned that while there is growing literature on fertility preservation prior to starting chemotherapy, one of the options at present is egg freezing; in Jamaica this service may be accessed at the Hugh Wynter Fertility Management Unit.

“This process involves the extraction of a woman’s eggs (oocytes) then freezing and storing them until the woman is ready to try getting pregnant. It is important to note, however, that the time taken to harvest the eggs may delay therapy and the medication administered to stimulate the ovaries can possibly have deleterious effects on breast cancer,” Dr Walker explained.

For this reason, Dr Walker said that the decision therefore to proceed with these fertility-sparing options are individualised and may not be suitable for all patients.

Dr Leo Walker is a Maternal Foetal Fellow at the University Hospital of the West Indies. His obstetrician and gynaecology practices are at Westminster and Oxford Medical Centres.