Breast Cancer during Pregnancy-Current Paradigms, Paths to Explore

Abstract

Breast cancer is the most common form of malignancy in pregnant women. The prevalence of pregnancy-associated breast cancer (PABC) is up to 0.04% of pregnancies and is expected to rise in developed countries. PABC represents a unique clinical scenario which requires a delicate balance of risks and benefits for both maternal and fetal well-being. Currently, there is paucity of data regarding the short- and long-term outcomes of in-utero exposure to anti-neoplastic agents. In general, when possible, treatment for PABC should follow the same guidelines as in non-pregnant patients. Surgery, including sentinel lymph node biopsy, is possible during all trimesters of pregnancy. Radiotherapy is contraindicated during pregnancy, although it might be considered in highly selected patients based on risk-benefit assessment. Evidence supports that administration of chemotherapy may be safe during the second and third trimesters, with cessation of treatment three weeks prior to expected delivery. Currently, hormonal therapy and anti-HER2 agents are contraindicated during pregnancy and should be postponed until after delivery. Prematurity is associated with worse neonatal and long-term outcomes, and thus should be avoided. While current data on the long-term effects of anti-neoplastic treatments are reassuring, grade of evidence is lacking, hence additional large prospective studies with long-term follow-up are essential to rule out any treatment-induced adverse effects.

Keywords: breast cancer; chemotherapy; neonatal outcomes; pregnancy.

Figure 1

Management of pregnancy-associated breast cancer (PABC) patients.

Figure 2

Recommended time line for various anti-neoplastic modalities. Surgery is potentially safe at all phases. Chemotherapy is recommended from week 14 (to allow a ’safe period’ after organogenesis) and should be discontinued around week 35 until after delivery to avoid myelosuppression at time of delivery. Hormonal therapy (HT), radiation therapy (RT), and targeted therapy (anti-HER2) should be postponed until after delivery. SLNB—sentinel lymph node biopsy.

Figure 3

Possible documented neonatal outcomes following in-utero exposure to hormonal therapy (red) [65], targeted therapy (black) [72], and chemotherapy-related long-term outcomes (blue) [73,74].