Right and timely treatment can keep both mother and baby safe. Dr D.G. Vijay, Breast Cancer Specialist recalls a case of gestational breast cancer.
Mrs. AK was overjoyed when her obstetrician told her that she was pregnant. She had been undergoing infertility treatment for a long time with no success. Only a few years ago, her mother had been diagnosed with breast cancer and she wished to see her grandchild before anything happened to her. But Mrs AK’s joy was short- lived as she began to sense a strange lump in her right breast. She was 20 weeks pregnant at the time. She thought that it was due to her milk-engorged breast. Her obstetrician reassured her that there was nothing to fear.
But the lump seemed to be growing in size as the months passed. It was at this time that she took a flight from Mombasa, Africa, to Ahmedabad to consult me.
When I saw her, my worst fears were confirmed. We did an ultrasound of the breasts and a guided biopsy of the lump, which by that time had grown to 7cm in size. Biopsy confirmed ductal carcinoma, which is the common variant seen in breast malignancy.
A multi-disciplinary team reviewed her reports and decided to start neoadjuvant chemotherapy. Drugs had to be chosen keeping the fetal wellbeing in mind. She underwent 6 cycles of chemotherapy with good response.
She underwent Caesarean section for the baby followed by mastectomy after a fortnight. At present, both the mother and baby are doing well. This will be followed by radiotherapy and hormone therapy.
Take home messages:
- Gestational or pregnancy associated breast cancer is defined as breast cancer that is either diagnosed during pregnancy or within 1 year postpartum.
- The treatment of breast cancer during pregnancy should include a multidisciplinary team with active communication among the patient, obstetrician, medical, surgical, pathologist, radiologist and oncology counsellor.
- The obstetrician should have a high index of suspicion when a pregnant lady presents with a breast lump and investigate appropriately.
- As women get pregnant at a later age, which could also be the age when they could be at risk for breast cancer.
- Genetic counselling should be considered for all women who have a family history and develop breast cancer at a young age (<40 years). In patients with deleterious BRCA1 or BRCA2 genes, pregnancy does not provide the same protection as in those without mutations. In fact, recent parity may increase the risk of developing breast cancer more notably in BRCA2 mutation carriers.
- Breast imaging should include mammography (with fetal protection) and breast ultrasound.
- Staging should include non-gadolinium MRI and ultrasound based imaging.
- Biopsy should be established by FNAC (fine needle aspiration cytology) or core biopsy preferably.
- Surgery could be breast conservation or mastectomy.
- Breast reconstruction should be delayed till involution (shrinkage in the size of the breast to pre-pregnancy state) after cessation of breastfeeding.
- Drugs should be chosen keeping fetal safety in mind.
- Drugs such as doxorubicin can be safely administered after the first trimester and before the 35th pregnancy. Taxanes can be considered on a case-by-case basis. Trastuzumab should be avoided.
- Radiation therapy should be completed after delivery as per guidelines.
- A multidisciplinary and coordinated approach is very important for best results – maternal and fetal safety and wellbeing.
