Breast Cancer and Pregnancy
Cancer is a type of disease which is characterized by uncontrollable cell growth. Currently, there is over 100 different type of cancers, and these types are classified according to the type of cells in which they initially grow. Cancer cause harm to body by leading to an uncontrollable cell division that forms masses of tissues known as tumors though types like leukemia disrupt normal blood functioning by leading to abnormal cell division in the blood stream. When tumor grows, it interferes with digestive and circulatory system in the body. The tumor is said to have metastasized, when it successfully spread to the other healthy body parts, invading and destroying them. Metastasis results to a severe condition that is very difficult to treat. This paper will major on breast cancer and pregnancy.
Breast cancers cases are very rare during the pregnancy period. Currently, the highest percentage of women prefer to give birth at the later age in life, and this has increased the chances of getting breast cancer as the risk increases as women get older. Due to this factor doctors expects cases of breast cancer to go up in future. Currently, in every one woman among a three thousand women has a breast cancer (Baghurst & Rohan, 1994). The most common type of cancer which is found in women during pregnancy and during breastfeeding within the first year after delivery is called pregnancy-associated breast cancer or gestation breast cancer.
Finding and detection of breast cancer during pregnancy
Breast cancer developed during the pregnancy is typically diagnosed at a later stage than it would then it would be diagnosed if the woman were not pregnant. This increases the likelihood of spreading to the other healthy lymph nodes. The high chances of spreading are due to the hormonal changes during pregnancy. During the pregnancy, the level of progesterone and estrogen goes up since the menstrual cycle does not occur. The prolactin hormone that tells the breast to get prepared for nursing also goes up during this period. This hormonal change causes the breast to change. The breast may become tender, large and lumpy. This makes the detection of lump resulting from the cancer hard until it becomes quite large (Gautherie & Gross, 1980).
Another reason that makes it hard to find the breast cancer during early pregnancy is due to the delay caused by the screening. The screening has to be delayed till a woman gives birth. Also due to pregnancy and breastfeeding the breast tissues becomes denser, and this also makes it difficult to find the early cancer on the mammogram. Similarities between the changes which occurs as a result of cancer and the normal changes which occurs during pregnancy lead to a confusion that makes it very difficult to find cancer. Therefore, delayed diagnosis of the breast cancer is biggest problem in during pregnancy.
Any change notice in your breast should be treated with a lot of seriousness. You should ensure that your doctor has tested you using relevant tests such as; mammogram or imaging tests like ultrasound or MRI. Any suspicious change in the breast should not be assumed to be a normal change during pregnancy.
It should be checked out and biopsied. Mammogram test is the best method of finding breast cancer and it is often advisable to all pregnant women to have mammogram test. This test can find most of the breast cancer. This test employs a subtle amount of radiation; this radiation is focused on the breast and hence it does not reach the other part of the body (Gautherie & Gross, 1980).). The lower part of the body is then shielded from the exposure of this rays by use of the lead shield and, therefore, no radiation reaching the womb.
Also during the early stages of pregnancy it is important to have early screening of breast health. In case any change or lump in the breast is found, it should be reported the doctor or nurse immediately. Always talk with your doctor or your nurse at the appropriate time to have breast examination and the best time to have next mammogram examination.
The staging and diagnostic of breast cancer
Breast biopsy during pregnancy: A biopsy is necessary when confirming whether the abnormal imaging test and new lump resulting from a breast is a breast cancer. When carrying out biopsy, a piece of tissue is removed from the area of concern. Then breast biopsy is then done using a needle. The biopsy can even be done to a pregnant lady, and it usually done as an outpatient process.
Doctors only use the medicine to numb the area which was involved in the biopsy and thus there is a little risk to the fetus. In case the needle biopsy do not provide the required results, a surgical biopsy is carried out. This process involves cutting off small piece of tissue from the breast through cutting. During the process, the patient is made to fall into a deep sleep by administering anesthesia (Beaumont, Tara & Leadbeater,2011). This process carries a small risk to the fetus.
Tests carried in order to learn the breast cancer stage
Once breast cancer have been found in a victim, a staging process is done. The staging process help in finding out whether the cancer cells have already spread to the other parts of the body or they are just spread within the tissues of the breast. This process is very essential to women with breast cancer during pregnancy since their cancer is generally found at late stages when it is at it advanced stages. The staging test is thus carried out in accordance to the victim’s case.
Some tests like magnetic resonance imaging (MRI) and ultrasound do not expose the fetus in the mother’s womb to radiations, and they are thus safe, and they are usually recommended during pregnancy. The dye, commonly used as a contrast material, in MRI sometimes crosses the placenta and hence this type of MRI is not recommended for use during the pregnancy (Cardonick, Dougherty, Grana, Gilmandyar, Ghaffar & Usmani, 2010). It has been linked to the cases of fetal abnormalities in the lab.
Chest x-rays are also safe for use in pregnant women since the belly is shielded from the radiations. This test helps in making the decision on the mode of treatment.
There are some tests that are likely to expose the fetus to radiations. This type of tests is often not recommended for a pregnant woman especially if the cancer is just within the breast. This criteria includes the bone scan, CT (computed tomography) and the PET test. In case any of this test have to be done to a pregnant mother, the doctor tries to adjust the mode of doing them in order to limit the exposure of radiations to the fetus.
Currently, there have not been a reported any case of a breast cancer being transferred from the mother to the fetus. But in some cases, cancer may reach the placenta if its treatment is delayed (Berrington de González & Reeves, 2005). If such a situation occurs, the amount of nutrients which fetus receives from the mother is affected.
The treatment of breast cancer during pregnancy.
Treatment of the breast cancer during the pregnancy is recommended according to the following factors:
- The location of the tumor.
- According to the decision of the woman.
- How far has the cancer spread to other body parts.
- The size of the tumor.
- What the woman prefers.
The primary goal of treating breast cancer is the same whether the woman is pregnant or not. The primary goal is to control the cancer from spreading to other body parts. But for the case of a pregnant woman and extra care must be observed in order to prevent exposure of radiation to the growing fetus. Thus, the process is more complex in case of a pregnant woman.
The safest method of cancer treatment during the pregnancy is through surgery of the breast. In this method, there is no any risk of exposure to radiations to the fetus since no radiations used. Other methods used in the treatment of breast cancer includes target therapy, hormone therapy, radiation, and chemotherapy. If given in later stages, chemotherapy is also considered to safe for a pregnant woman but not in early stages. If chemotherapy has to be given to a pregnant woman at early stages, she must be asked to terminate the pregnancy especially in case of a severe breast cancer like inflammatory breast cancer (Berrington , Berg, Visvanathan & Robson, 2009). The delay in it treatment might result to harm in the mother.
Research have reported that termination of mother’s pregnancy in order to carry out cancer treatment does not improve the prognosis of a woman (Morrow & Jordan, 2003). This is discussed in details under the topic of survival rates after breast cancer. Though this study consists some fault, ending the pregnancy is not the best remedy when breast cancer is found. Families need to know the merit and the demerit of all the options before making the final decision. There is a number of variety of treatment choices to choose from. These treatment options are as discussed below.
Treatment methods of breast cancer
Surgical operation may done in order to remove the cancer and all the nearby lymph nodes in the breast. This is considered the safest method of cancer treatment during pregnancy. The method is mostly used for the treatment of any woman with a breast cancer including pregnant women. The treatment, in this case, involves removing part of the breast that contains the cancer (breast-conserving surgery) or the removal of the entire breast process known as mastectomy. For pregnant women with breast cancer, mastectomy is the often used method because carrying the breast-conserving surgery will led to a need for radiation therapy thereafter (Hochwald, Lambeth, Taylor, Kimberly, Taylor and Danielle 2011).
Radiotherapy is not advisable for pregnant women with breast cancer since it can affect the fetus, but it can be delayed till after delivery. Delaying too long to give the radiation can in turn increase the chances of cancer getting back. For cases of cancer that is in late pregnancy, delay in radiation therapy may have no effect on the outcome. Since radiation therapy is given after chemotherapy, a patient who is getting chemotherapy after the surgery may not have any delay in radiation treatment. But for cancers found during early stages of pregnancy mastectomy it can used since there is a long delay before starting radiation.
After the removal of the tumor from the breast, lymph nodes from the armpits must also be removed in order to check the spread of cancer . An example is an auxiliary lymph node dissection. This process involves the removal of most of the lymph node under the armpit. Another procedure for testing cancer spread is SNLB (sentinel lymph node biopsy), this one is optional and it’s dependent on how long is your pregnancy and your cancer stage (Koren, Lishner ; Farine, (1996). The procedure uses dye and tracers to locate the nodes that are most likely to be infected with cancer cells. This process allows the doctor to remove few number of cells. SNLB is recommended for use in later pregnancies since blue dyes, and radioactive tracer used in the procedure might affect the fetus.
Surgical operation for breast cancer is much safe to the fetus, but there are moments in pregnancy when the anesthesia administered to a patient during operation becomes risky to the fetus. Due to this risk, it is advisable for several doctors such as surgeon and high-risk obstetrician to work together in order to decide the best moment to do surgery during pregnancy. In case the surgeon is carried out during the later period of pregnancy, the obstetrician must be available in order to deal with any problem occurring in the fetus during surgery. Jointly, this doctors will decide the best drug and technique to be used in order both mother and the fetus will not be affected by surgery.
After the surgery operation, a patient is given several more other treatments depending on the cancer’s stage. These treatments include radiation, chemotherapy, and hormone therapy. This procedures helps minimize the risk of cancer coming back. This is usually called adjuvant treatment and it is sometimes carried after the mother has delivered.
The other method of treatment is chemotherapy. This procedure is used alongside with the surgery usually as an adjuvant treatment for earlier stages of breast cancer. It is also carried out by itself to cure more advanced cancers. During the first trimester of the pregnancy, chemotherapy is never used since this is the period when the fetus; internal organs are developing. When chemo is used during this period there is a very high chances of miscarriage (Baysinger, 2010). The safety of chemotherapy treatment during this stage has not yet been found or studied.
For a couple of years, it has been believed that the use of chemotherapy will have to harm the fetus despite the period of pregnancy when it is given. Further studies have currently shown that the particular type of chemotherapy drugs do not affect the fetus during the fourth through the ninth month of pregnancy i.e. during the second and third trimester. They can only increase the risk of early birth but not affecting the baby. The research is being carried out to find out whether this treatment can have a long term effect to the baby or not.
When an early cancer in a pregnant woman needs chemotherapy, it is typically delayed until the pregnancy is in its second trimester. If the cancer is found when the woman is at her third semester, the chemotherapy will be delayed until the woman drivers. In some cases, the birth is usually induced some few weeks before the actual delivery period in order to prevent the spread of cancer. Chemotherapy plan is also used in the treatment of women with an advanced cancer.
A pregnant woman should not be given chemotherapy within the first three weeks or after thirty-five weeks as this could lower the mother’s blood count. Giving chemo during this period increases the chances of mother infecting the newborn baby during birth and also can result in excessive bleeding. Delaying chemotherapy during the last few weeks of delivery allows the blood count of the mother to return to normal before the birth of the baby and hence little chance of affecting the new-born.
Another method of treatment is radiotherapy. The method is used to prevent the risk of cancer coming back after carrying out the breast-conserving test. The radiations used during this period are dangerous, and they can harm the fetus during any time of pregnancy. These radiations can result to harm like slow fetal growth, miscarriage, birth defect or even increasing the risk of childhood cancer. Due to this harms radiotherapy is never used during the pregnancy period.
Pregnant women who choose to undergo partial mastectomy or even lumpectomy may undergo the surgery but then wait until they deliver in order to get radiation therapy. This mode of treatment is usually not advisable since waiting for so long before the induction is done increases the chances of cancer getting back.
Another treatment method is hormone therapy. This mode of treatment is usually done as adjuvant treatment after surgery. It is also used as the treatment for advanced breast cancer in women whose breast cancer has positive receptor hormone. The types of drugs used for early cancer treatment in hormone therapy includes exemestane, anastrozole, tamozifen and letrozole (Ogden, 2004). Other different types of drugs are used in hormone therapy for treatment of advanced breast cancer. Hormone therapy should be delayed until the woman gives birth. This is because when used during pregnancy it can affect the fetus.
And lastly there is biological treatment or the use of targeted drugs. The following types of drugs are used includes trastuzumad (Herceptin), lapatinib (tykerb) and bevacizumab (Avastin).
Trastuzumad (Herceptin) is an antibody that targets and destroys all the cancer cells that are HER2-positive. Lapatinib (Tykerd) normally targets the HERB2 protein. This drug is used in the treatment of an advanced metastatic breast cancer. Bevacizumab (Avastin) drug usually starves the tumor by stops the cancer cell from attracting new blood vessels.
Breastfeeding during cancer treatment
Women who had just delivered babies and were yet to be treated for the breast cancer are normally advised by doctors, not breastfeed their babies. If there is a planned surgery, stopping breastfeeding will make the breast smaller by reducing the blood flow to the breast. This also reduce the risk of the cancer spreading to other body parts and also prevent breast milk collection in the biopsy.
The targeted drug therapy, chemo, and hormone can be passed to the infant through the milk during breastfeeding. For the mother under these treatments, breastfeeding is not recommended. It is advisable for a woman to enquire from their doctor or health team on the appropriate time to start breastfeeding. If you have stopped breastfeeding for a while and you want to start it back again, you need to seek assistance from breastfeeding expert.
Pulling all the treatment plans together
Sometimes a challenge may occur during the treatment. This is when the best-known treatment for the mother conflicts with the well-being of the unborn baby. This may makes it very difficult for a pregnant woman, who has a breast cancer, to make a choice. When such a scenario occurs, it is advisable for one to know all her treatment plans and then consult an expert. Your obstetrician must work with your radiation oncologist, surgeon ecologist and all the other experts involved in your treatment. A psychologist or counselor should also be among the health team in order to provide the required emotional support.
The survival chances after breast cancer during pregnancy
All discussed, it is very difficult to find, diagnose and cure breast cancer during pregnancy. Researchers have found that outcome resulting from non-pregnant and pregnant women diagnosed with the breast cancer are the same, but not all scholars who agreed with the findings. A research conducted it year 2013 studied more than three hundred women diagnosed with breast cancer during pregnancy. During the 5 years research, the researchers compared the survival rates in women during the same stage in which the breast cancer was detected and when they were not pregnant (Ali, Gupta, Sehgal, ; Vogel, 2012). The disease-free survival chance was found to be slightly higher in non-pregnant women than in pregnant women.
Some doctors recommend ending of the pregnancy for women with advanced breast cancer. This is because they tend to believe that termination of pregnancy will help slow the advancement of more breast cancer. Researchers have found it hard to conduct research on this area due to lack of proper and unbiased studies (Azim, Bellettini, Liptrott, Armeni, Dell’Acqua, Torti, ; Peccatori, 2010). Ending the pregnancy increases the simplicity of cancer treatment that is in contrast to the older studies that reported that ending the mother’s pregnancy does not improve cancer outcome neither does it improve mother’s overall treatment.
Studies have not also shown whether the delayed treatment of breast cancer in pregnant women have an effect on the breast cancer outcome. This area has also proved very difficult for the researchers to study.
And finally, breast cancer itself have not been shown that it can affect the baby.
References
Ali, S. A., Gupta, S., Sehgal, R., ; Vogel, V. (2012). Survival outcomes in pregnancy-associated breast cancer: a retrospective case-control study. The breast journal, 18(2), 139-144.
Azim, H. A., Bellettini, G., Liptrott, S. J., Armeni, M. E., Dell’Acqua, V., Torti, F., … ; Peccatori, F. (2010). Breastfeeding in breast cancer survivors: pattern, behavior and effect on breast cancer outcome. The Breast, 19(6), 527-531.
Baghurst, P., ; Rohan, T. (1994, January 15). High-fiber diets and reduced risk of breast cancer. International Journal of Cancer, 56(2), 173-176. Retrieved November 15, 2011, from http://onlinelibrary.wiley.com/doi/10.1002/ijc.2910560204/abstract.
Baysinger, C. L. (2010). Imaging during pregnancy. Anesthesia ; Analgesia, 110(3), 863-867.
Beaumont, Tara, Leadbeater (2011) Treatment and Care of Patients with Metastatic Breast Cancer.
Berrington de González, A., ; Reeves, G. (2005, August 31). Mammographic screening before age 50 years in the UK: comparison of the radiation risks with the mortality benefits. British Journal of Cancer, 2005(93), 590-596. Retrieved from http://www.nature.com/bjc/journal/v93/n5/full/6602683a.html.
Berrington de Gonzalez, A., Berg, C., Visvanathan, K., ; Robson, M. (2009, January 27). Estimated Risk of Radiation-Induced Breast Cancer From Mammographic Screening for Young BRCA Mutation Carriers. Journal of the National Cancer Institute, 101(3), 205-209. Retrieved from http://jnci.oxfordjournals.org/content/101/3/205.full.
Cardonick, E., Dougherty, R., Grana, G., Gilmandyar, D., Ghaffar, S., ; Usmani, A. (2010). Breast cancer during pregnancy: maternal and fetal outcomes. The Cancer Journal, 16(1), 76-82.
Gautherie M, ; Gross, C. (1980). Breast thermography and cancer risk prediction. Cancer, 45(1), 6-51. Retrieved November 15, 2011, from http://www.ncbi.nlm.nih.gov/pubmed/7351006?dopt=AbstractPlus=f1000,f1000m,isrctn.
Hochwald, Lambeth, Taylor, Kimberly, Taylor, Danielle (2011) The Black Woman’s Guide to Breast Cancer.
In Riker, A. I. (2014). Breast disease: Comprehensive management.
[bookmark: _GoBack]Koren, G., Lishner, M., ; Farine, D. (1996). Cancer in pregnancy: Maternal and fetal risks. Cambridge: Cambridge University Press.
Morrow, M., ; Jordan, V. C. (2003). Managing breast cancer risk. Hamilton: BC Decker Inc.
Ogden, J. (2004). Understanding breast cancer. Chichester, England: J. Wiley.
