Breast Cancer in Pregnancy

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Breast Cancer

Breast Cancer in Pregnancy
Breast Cancer in Pregnancy

Breast cancer-related mortality has declined overall since the 1980s, but it remains the leading cause of cancer death in the United States among women in their prime childbearing years.1 Although rare, the occurrence of breast cancer during pregnancy is particularly frightening for women because it presents multiple challenges. Breast cancer affects approximately 1 in 3,000 pregnant women, with an average age of between 32 and 38 years.2-5 In the United States, nearly 5,000 cases of breast cancer during pregnancy were diagnosed in 2005.6 A study from California reported an incidence of breast cancer during pregnancy or within 1 year of delivery of 13 of every 100,000 births from 1992 through 1997.7 Adding age-associated increased risk to the trend toward later pregnancies explains the rising incidence seen in the United States and other high-income countries.2,8 In a population cohort from Sweden, the annual incidence of pregnancy-associated breast cancer per 100,000 deliveries increased from 16.0 in 1963 to 37.4 in 2002, coincident with older maternal ages.9

Diagnostic Challenges

Diagnosis of breast cancer during pregnancy is complicated by breast tenderness and other pregnancy-related changes that complicate detection of masses.2,10 Symptoms are attributed to pregnancy by clinicians and patients, leading to later diagnosis; as a result, women most commonly are diagnosed with Stage II or Stage III disease.2,4,5,11 In a retrospective study of 23 women treated in Texas, 60% had Stage III breast cancer at diagnosis and 30% had Stage II.3 Whether due to late diagnosis or other factors, breast cancer in pregnant women tends to have worse prognostic factors, including axillary lymph node involvement, poorly differentiated tumors, and more frequent hormone receptor-negative tumors than similar-aged women. About one-third of pregnant woman with breast cancer have HER-2 disease.12,13

The most common presentation of breast cancer during pregnancy is a palpable mass. To avoid missed diagnoses, any palpable mass that persists for more than 2 weeks should be investigated.10 Self-examination finds 84% of masses during pregnancy, and women should be counseled to perform routine breast self-exams for this reason.14 Other symptoms that can occur with less frequency than masses include breast swelling, breast erythema, pain, nipple discharge, and thickening, all of which are also common pregnancy-associated breast changes.3,4,10,14 

Ultrasound is recommended for further diagnosis of suspected breast cancer.4,13 Based on several studies, it accurately identifies up to 100% of malignancies.3,4,12 Mammography is less accurate than ultrasound, with a relatively high false-negative rate (10%-25%).2 Breast density does not affect findings in pregnant women any more than in similar-aged women; digital techniques improve visualization.3,4 Mammography using shielding limits fetal radiation exposure, but its use should be limited to detection of bilateral or other tumors, or follow up of suspicious ultrasound findings.2,4,10,13 Magnetic resonance imaging is not recommended in this setting, as there are limited data supporting its accuracy and safety.4,10

Biopsy is necessary to confirm the diagnosis and should be performed for any suspicious ultrasound or mammography finding. Core biopsy is preferred, as it provides more tissue for examination and recommended hormone receptor and HER-2 status assessment.4,12 Pathologists must be made aware that the sample is from a pregnant patient to avoid misdiagnosis.10,13 Staging techniques should minimize radiation exposure to the fetus; radiation-based techniques should be reserved for situations where staging will affect clinical management.12,13 When metastatic risk is low, staging may be held until after delivery.13

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