UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Gestational breast cancer: Treatment

Authors
Jennifer K Litton, MD
Richard Theriault, DO, MBA
Section Editors
Harold Burstein, MD, PhD
Charles J Lockwood, MD, MHCM
Deputy Editor
Sadhna R Vora, MD

INTRODUCTION

Gestational breast cancer (or pregnancy-associated breast cancer) is defined as breast cancer that is diagnosed during pregnancy, in the first postpartum year, or any time during lactation. Gestational breast cancer presents a challenging clinical situation, since the welfare of both the mother and the fetus must be taken into account. There are limited prospective data about diagnosis, treatment, and outcome of breast cancer during pregnancy; much of the clinical evidence is limited to retrospective case series and case reports.

The treatment and prognosis of gestational breast cancer will be reviewed here. The epidemiology and diagnosis of gestational breast cancer is discussed separately. (See "Gestational breast cancer: Epidemiology and diagnosis".)

TREATMENT

In general, pregnant women with breast cancer should be treated according to guidelines for nonpregnant patients, with some modifications to protect the fetus. However, the treatment should be approached with curative intent. Therefore, treatment of gestational breast cancer should not be unnecessarily delayed because of pregnancy. Informed consent is a critical component of choosing appropriate therapy. Although pregnancy termination may be considered during treatment planning, pregnancy termination has not been demonstrated to improve outcomes in gestational breast cancer. (See 'Elective termination of pregnancy' below.)

Importantly, all patients with gestational breast cancer should be evaluated for distant metastatic disease according to guidelines in nonpregnant patients with breast cancer. In order to protect the fetus, this can be attenuated to include: chest radiograph with fetal shielding, ultrasound of the liver, and magnetic resonance imaging (MRI) of the spine without contrast to evaluate for bone metastases [1,2]. (See "Gestational breast cancer: Epidemiology and diagnosis", section on 'Diagnosis and staging' and "Clinical features, diagnosis, and staging of newly diagnosed breast cancer", section on 'Post-diagnosis evaluation'.)

Locoregional treatment — The same local treatment options that are available for nonpregnant patients should be considered in pregnant women, with the exception of radiation therapy (RT). As in nonpregnant women, surgery is the definitive local treatment for gestational breast cancer. Breast and axillary lymph node surgery during any trimester of pregnancy appears to be associated with minimal fetal risk [3-8]. (See "Management of the pregnant patient undergoing nonobstetric surgery".)

                           

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Fri Nov 20 00:00:00 GMT 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Amant F, Deckers S, Van Calsteren K, et al. Breast cancer in pregnancy: recommendations of an international consensus meeting. Eur J Cancer 2010; 46:3158.
  2. Hahn KM, Johnson PH, Gordon N, et al. Treatment of pregnant breast cancer patients and outcomes of children exposed to chemotherapy in utero. Cancer 2006; 107:1219.
  3. Woo JC, Yu T, Hurd TC. Breast cancer in pregnancy: a literature review. Arch Surg 2003; 138:91.
  4. BYRD BF Jr, BAYER DS, ROBERTSON JC, STEPHENSON SE Jr. Treatment of breast tumors associated with pregnancy and lactation. Ann Surg 1962; 155:940.
  5. Mazze RI, Källén B. Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. Am J Obstet Gynecol 1989; 161:1178.
  6. Gianopoulos JG. Establishing the criteria for anesthesia and other precautions for surgery during pregnancy. Surg Clin North Am 1995; 75:33.
  7. Duncan PG, Pope WD, Cohen MM, Greer N. Fetal risk of anesthesia and surgery during pregnancy. Anesthesiology 1986; 64:790.
  8. Barron WM. The pregnant surgical patient: medical evaluation and management. Ann Intern Med 1984; 101:683.
  9. Berry DL, Theriault RL, Holmes FA, et al. Management of breast cancer during pregnancy using a standardized protocol. J Clin Oncol 1999; 17:855.
  10. Kuerer HM, Gwyn K, Ames FC, Theriault RL. Conservative surgery and chemotherapy for breast carcinoma during pregnancy. Surgery 2002; 131:108.
  11. Kuerer HM, Cunningham JD, Bleiweiss IJ, et al. Conservative surgery for breast carcinoma associated with pregnancy. Breast J 1998; 4:171.
  12. Annane K, Bellocq JP, Brettes JP, Mathelin C. Infiltrative breast cancer during pregnancy and conservative surgery. Fetal Diagn Ther 2005; 20:442.
  13. Dominici LS, Kuerer HM, Babiera G, et al. Wound complications from surgery in pregnancy-associated breast cancer (PABC). Breast Dis 2010; 31:1.
  14. Kal HB, Struikmans H. Radiotherapy during pregnancy: fact and fiction. Lancet Oncol 2005; 6:328.
  15. Greskovich JF Jr, Macklis RM. Radiation therapy in pregnancy: risk calculation and risk minimization. Semin Oncol 2000; 27:633.
  16. Petrek JA. Breast cancer during pregnancy. Cancer 1994; 74:518.
  17. Antypas C, Sandilos P, Kouvaris J, et al. Fetal dose evaluation during breast cancer radiotherapy. Int J Radiat Oncol Biol Phys 1998; 40:995.
  18. Gemignani ML, Petrek JA, Borgen PI. Breast cancer and pregnancy. Surg Clin North Am 1999; 79:1157.
  19. www.bt.cdc.gov/radiation/prenatalphysician.asp (Accessed on July 09, 2012).
  20. Schwartz GF, Giuliano AE, Veronesi U, Consensus Conference Committee. Proceedings of the consensus conference on the role of sentinel lymph node biopsy in carcinoma of the breast, April 19-22, 2001, Philadelphia, Pennsylvania. Cancer 2002; 94:2542.
  21. Lyman GH, Giuliano AE, Somerfield MR, et al. American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol 2005; 23:7703.
  22. Filippakis GM, Zografos G. Contraindications of sentinel lymph node biopsy: are there any really? World J Surg Oncol 2007; 5:10.
  23. Nicklas AH, Baker ME. Imaging strategies in the pregnant cancer patient. Semin Oncol 2000; 27:623.
  24. Morita ET, Chang J, Leong SP. Principles and controversies in lymphoscintigraphy with emphasis on breast cancer. Surg Clin North Am 2000; 80:1721.
  25. Keleher A, Wendt R 3rd, Delpassand E, et al. The safety of lymphatic mapping in pregnant breast cancer patients using Tc-99m sulfur colloid. Breast J 2004; 10:492.
  26. Gentilini O, Cremonesi M, Trifirò G, et al. Safety of sentinel node biopsy in pregnant patients with breast cancer. Ann Oncol 2004; 15:1348.
  27. Mondi MM, Cuenca RE, Ollila DW, et al. Sentinel lymph node biopsy during pregnancy: initial clinical experience. Ann Surg Oncol 2007; 14:218.
  28. Khera SY, Kiluk JV, Hasson DM, et al. Pregnancy-associated breast cancer patients can safely undergo lymphatic mapping. Breast J 2008; 14:250.
  29. Amant F, Vandenbroucke T, Verheecke M, et al. Pediatric Outcome after Maternal Cancer Diagnosed during Pregnancy. N Engl J Med 2015; 373:1824.
  30. Ring AE, Smith IE, Jones A, et al. Chemotherapy for breast cancer during pregnancy: an 18-year experience from five London teaching hospitals. J Clin Oncol 2005; 23:4192.
  31. Giacalone PL, Laffargue F, Bénos P. Chemotherapy for breast carcinoma during pregnancy: A French national survey. Cancer 1999; 86:2266.
  32. Cardonick E, Gilmandyar D, Somer RA. Maternal and neonatal outcomes of dose-dense chemotherapy for breast cancer in pregnancy. Obstet Gynecol 2012; 120:1267.
  33. Cardonick E, Iacobucci A. Use of chemotherapy during human pregnancy. Lancet Oncol 2004; 5:283.
  34. Wiebe VJ, Sipila PE. Pharmacology of antineoplastic agents in pregnancy. Crit Rev Oncol Hematol 1994; 16:75.
  35. Doll DC, Ringenberg QS, Yarbro JW. Antineoplastic agents and pregnancy. Semin Oncol 1989; 16:337.
  36. Stevenson J, Giantonio B, Boyd RL, Bruner JA. Adjuvant chemotherapy for breast cancer in pregnancy: can recommendations be made with confidence. Semin Oncol 1997; 24:xxv.
  37. van Kalken CK, Giaccone G, van der Valk P, et al. Multidrug resistance gene (P-glycoprotein) expression in the human fetus. Am J Pathol 1992; 141:1063.
  38. Germann N, Goffinet F, Goldwasser F. Anthracyclines during pregnancy: embryo-fetal outcome in 160 patients. Ann Oncol 2004; 15:146.
  39. Ebert U, Löffler H, Kirch W. Cytotoxic therapy and pregnancy. Pharmacol Ther 1997; 74:207.
  40. Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, 8th ed, Lippincott Williams & Wilkins, Philadelphia, PA 2008.
  41. Mulvihill JJ, McKeen EA, Rosner F, Zarrabi MH. Pregnancy outcome in cancer patients. Experience in a large cooperative group. Cancer 1987; 60:1143.
  42. Garcia V, Miguel JS, Borrasca AL. Doxorubicin in the first trimester of pregnancy. Ann Intern Med 1981; 94:547.
  43. Stephens JD, Golbus MS, Miller TR, et al. Multiple congenital anomalies in a fetus exposed to 5-fluorouracil during the first trimester. Am J Obstet Gynecol 1980; 137:747.
  44. Zemlickis D, Lishner M, Degendorfer P, et al. Maternal and fetal outcome after breast cancer in pregnancy. Am J Obstet Gynecol 1992; 166:781.
  45. Buzdar AU, Smith TL, Powell KC, et al. Effect of timing of initiation of adjuvant chemotherapy on disease-free survival in breast cancer. Breast Cancer Res Treat 1982; 2:163.
  46. Nettleton J, Long J, Kuban D, et al. Breast cancer during pregnancy: quantifying the risk of treatment delay. Obstet Gynecol 1996; 87:414.
  47. Durodola JI. Administration of cyclophosphamide during late pregnancy and early lactation: a case report. J Natl Med Assoc 1979; 71:165.
  48. Turchi JJ, Villasis C. Anthracyclines in the treatment of malignancy in pregnancy. Cancer 1988; 61:435.
  49. Murray CL, Reichert JA, Anderson J, Twiggs LB. Multimodal cancer therapy for breast cancer in the first trimester of pregnancy. A case report. JAMA 1984; 252:2607.
  50. Zemlickis D, Lishner M, Degendorfer P, et al. Fetal outcome after in utero exposure to cancer chemotherapy. Arch Intern Med 1992; 152:573.
  51. Meyer-Wittkopf M, Barth H, Emons G, Schmidt S. Fetal cardiac effects of doxorubicin therapy for carcinoma of the breast during pregnancy: case report and review of the literature. Ultrasound Obstet Gynecol 2001; 18:62.
  52. Siu BL, Alonzo MR, Vargo TA, Fenrich AL. Transient dilated cardiomyopathy in a newborn exposed to idarubicin and all-trans-retinoic acid (ATRA) early in the second trimester of pregnancy. Int J Gynecol Cancer 2002; 12:399.
  53. Achtari C, Hohlfeld P. Cardiotoxic transplacental effect of idarubicin administered during the second trimester of pregnancy. Am J Obstet Gynecol 2000; 183:511.
  54. Reynoso EE, Huerta F. Acute leukemia and pregnancy--fatal fetal outcome after exposure to idarubicin during the second trimester. Acta Oncol 1994; 33:709.
  55. Peres RM, Sanseverino MT, Guimarães JL, et al. Assessment of fetal risk associated with exposure to cancer chemotherapy during pregnancy: a multicenter study. Braz J Med Biol Res 2001; 34:1551.
  56. Mir O, Berveiller P, Goffinet F, et al. Taxanes for breast cancer during pregnancy: a systematic review. Ann Oncol 2010; 21:425.
  57. HERCEPTIN® (trastuzumab) Prescribing Information http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/103792s5256lbl.pdf.
  58. Zagouri F, Sergentanis TN, Chrysikos D, et al. Trastuzumab administration during pregnancy: a systematic review and meta-analysis. Breast Cancer Res Treat 2013; 137:349.
  59. Kelly H, Graham M, Humes E, et al. Delivery of a healthy baby after first-trimester maternal exposure to lapatinib. Clin Breast Cancer 2006; 7:339.
  60. Zemlickis D, Klein J, Moselhy G, Koren G. Cisplatin protein binding in pregnancy and the neonatal period. Med Pediatr Oncol 1994; 23:476.
  61. Cullins SL, Pridjian G, Sutherland CM. Goldenhar's syndrome associated with tamoxifen given to the mother during gestation. JAMA 1994; 271:1905.
  62. Tewari K, Bonebrake RG, Asrat T, Shanberg AM. Ambiguous genitalia in infant exposed to tamoxifen in utero. Lancet 1997; 350:183.
  63. Isaacs RJ, Hunter W, Clark K. Tamoxifen as systemic treatment of advanced breast cancer during pregnancy--case report and literature review. Gynecol Oncol 2001; 80:405.
  64. National Library of Medicine drug and lactation database, LactMed. http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT (Accessed on July 09, 2012).
  65. Bilgin K, Yaramiş A, Haspolat K, et al. A randomized trial of granulocyte-macrophage colony-stimulating factor in neonates with sepsis and neutropenia. Pediatrics 2001; 107:36.
  66. Schibler KR, Osborne KA, Leung LY, et al. A randomized, placebo-controlled trial of granulocyte colony-stimulating factor administration to newborn infants with neutropenia and clinical signs of early-onset sepsis. Pediatrics 1998; 102:6.
  67. Nugent P, O'Connell TX. Breast cancer and pregnancy. Arch Surg 1985; 120:1221.
  68. Clark RM, Chua T. Breast cancer and pregnancy: the ultimate challenge. Clin Oncol (R Coll Radiol) 1989; 1:11.
  69. Amant F, von Minckwitz G, Han SN, et al. Prognosis of women with primary breast cancer diagnosed during pregnancy: results from an international collaborative study. J Clin Oncol 2013; 31:2532.
  70. Litton JK, Warneke CL, Hahn KM, et al. Case control study of women treated with chemotherapy for breast cancer during pregnancy as compared with nonpregnant patients with breast cancer. Oncologist 2013; 18:369.
  71. Azim HA Jr, Santoro L, Russell-Edu W, et al. Prognosis of pregnancy-associated breast cancer: a meta-analysis of 30 studies. Cancer Treat Rev 2012; 38:834.
  72. Murthy RK, Theriault RL, Barnett CM, et al. Outcomes of children exposed in utero to chemotherapy for breast cancer. Breast Cancer Res 2014; 16:500.
  73. Dessolle L, Dalmon C, Roche B, Daraï E. [Placental metastases from maternal malignancies: review of the literature]. J Gynecol Obstet Biol Reprod (Paris) 2007; 36:344.
  74. Al-Adnani M, Kiho L, Scheimberg I. Maternal pancreatic carcinoma metastatic to the placenta: a case report and literature review. Pediatr Dev Pathol 2007; 10:61.
  75. Azim HA, Bellettini G, Liptrott SJ, et al. Breastfeeding in breast cancer survivors: pattern, behavior and effect on breast cancer outcome. Ann Oncol 2010; 21 (suppl 8):viii89 (abstr 251P).
  76. Higgins S, Haffty BG. Pregnancy and lactation after breast-conserving therapy for early stage breast cancer. Cancer 1994; 73:2175.
  77. Moran MS, Colasanto JM, Haffty BG, et al. Effects of breast-conserving therapy on lactation after pregnancy. Cancer J 2005; 11:399.
  78. Wobbes T. Effect of a breast saving procedure on lactation. Eur J Surg 1996; 162:419.
  79. Findlay PA, Gorrell CR, d'Angelo T, Glatstein E. Lactation after breast radiation. Int J Radiat Oncol Biol Phys 1988; 15:511.
  80. Hassey KM. Pregnancy and parenthood after treatment for breast cancer. Oncol Nurs Forum 1988; 15:439.
  81. Mueller BA, Simon MS, Deapen D, et al. Childbearing and survival after breast carcinoma in young women. Cancer 2003; 98:1131.
  82. Blakely LJ, Buzdar AU, Lozada JA, et al. Effects of pregnancy after treatment for breast carcinoma on survival and risk of recurrence. Cancer 2004; 100:465.
  83. Rosenberg L, Thalib L, Adami HO, Hall P. Childbirth and breast cancer prognosis. Int J Cancer 2004; 111:772.
  84. Kroman N, Jensen MB, Wohlfahrt J, et al. Pregnancy after treatment of breast cancer--a population-based study on behalf of Danish Breast Cancer Cooperative Group. Acta Oncol 2008; 47:545.
  85. de Bree E, Makrigiannakis A, Askoxylakis J, et al. Pregnancy after breast cancer. A comprehensive review. J Surg Oncol 2010; 101:534.
  86. Azim HA Jr, Santoro L, Pavlidis N, et al. Safety of pregnancy following breast cancer diagnosis: a meta-analysis of 14 studies. Eur J Cancer 2011; 47:74.
  87. Largillier R, Savignoni A, Gligorov J, et al. Prognostic role of pregnancy occurring before or after treatment of early breast cancer patients aged <35 years: a GET(N)A Working Group analysis. Cancer 2009; 115:5155.
  88. Helewa M, Lévesque P, Provencher D, et al. Breast cancer, pregnancy, and breastfeeding. J Obstet Gynaecol Can 2002; 24:164.