Pregnancy and Breast Cancer - RCOG

1 Pregnancy and Breast CancerGreen top Guideline No. 12 March 2011 Preg nan cy and Breas t CancerThi s ti tle was fi rs t publi shed as RCOGad vice in 1997and subsequent ly as a Gre en-t op Guideli ne in January20 04. This do cu me nt is th e seco nd editionof the gu idelineand update s the andscopeThis document aims to pro vi de cli nical gui danceto heal th pro fe ssi on als ca rin g for womenof childbearingage witha di agno si s or history of brea st managementof pregnancyin re lationto breastcanceris mu lti dis ci pl guideline wi ll be of valueto obstetriciansand gynae col ogists, fertilityspe cial istsand mi dw iv es as we ll as on co lo gistsand ro undBrea st cance r is the most common ca nc er in females,witha lifet im e ris k of one in ninein the UK, and isth e lea dingcau se of dea th in wo me n aged35 5 4 teenperce nt of cases are diagnosed bef ore theage of 45 ye ars.

2 Thu s brea st can ce r affe cts almost500 0 womenof rep rod uc tive ag e in the UK an twe en 1991and 199 7 th ere we re case s of bre as t cancerin women pe r 10 000 li ve bir ths ,1,2al though whenbreastcancer is dia gnosedin womenaged30 yearsor less, 10 20%of casesmaybeass oc iat ed wi th pre gn an cy or oc cur within1 e pro gnosis of bre ast ca ncer is improving,with5-yearsurvivalaround80% for the un der 50s ag e gro up;how eve r, th e sur vivalrate may be lower in ver y young eat ment of pr eg na nc y- ass oci ate d cance rshouldbe in a mu lt idisciplinary te am ac cording to standardUK gu ideli nes4within clusi on of th e obstetrictea m as core mem ber er tha n 10% of women diag nosedwithbreastcanc er sub seq uentlybecome preg nant,5,6but increa sin gnum ber s of womenare se ekin g pre gnancyfoll owi ng tre womenpresenting wit h breastca ncerof te n ha ve fertility-relate d co ncerns7 9an d needwel l-i nfo rme d dis cus sio ns on fe rtil ity, pre gnan cyand la cta tio n aft er brea st ca ncer and the av ailabilityof fertilityprese rva tion procedur es.

3 Cationandas sessmentofevidenceTh is gu ide line was deve lope d in acco rdancewithstandardmeth odol og y for pr oducingRCOGG reen-topGu ideli ne ,Pubmed,all EBMrevi ews (Cochrane CR CT, Co chra ne Databaseof Sys tematicReviews,Metho dolo gy re gi ster ,ACP jo ur na l clu b, DARE,HTA,Maternityan d In fa nt Ca re), EMB ASE and TRIP weresea rch ed fo r re levant rand omi sed con trolledtrials,syst ematicreviews and met a-an alyses,co hort stu dies andca se stu die s. The se ar ch was res trictedto articlespu blishedbetween 2002 an d December2009,updatedfromthe or iginal sea rch for the searchter ms inc lud ed were: breastneo pl asms , b rea st cance r , pregna ncy , pregna nc y complications , b reastcan cer an d fe rt ility , mastectomy , brea st -fe eding , lac tati on , contraceptio n , fertility and inf erti lity.

4 Abstractswereus ed to identifykey ion al Libr ary for He althand the NationalGuidelinesClear ing Ho use weresearchedfor relevantguid eli nes .In contrast to the ext ens ive lit er atu re on treatment of breastca ncer,ther e is no lev el 1 evidenceonpr eg na nc y and somewell-designed observati on al stu di es. Thus,recommendationsfo r prac tic e are li mite d to grad e C/Dbut , wherepossible,recommenda tion s are basedon , an d explicitlylink ed to, th e evi den ce th at supports ing evidence are highlightedand ann otat ed as goodpra cti ce po int s . is theoptimalmanagementofbreastcan cerdiagnosed duringpre gnancy? y it se lf doesnot ap pea r to worsenthe prognosisfor wome n diagn ose d in pregn ancycom par ed with non-p regnantcontrolsmatched for ag e and st age10(prov ide d tha t stan dardtre at me nt gui deli nes for th e brea st cancerare adheredto ).

5 Ho wev er, as Pregnancy - asso ciatedbreas t canceroccursin a you nge r popula tion whoma y havefe atur es tha t car ry a higher risk of me tastasessuchas high -gr ad e tumoursand estrogenrece ptornega ti ve tu mo urs, th ese yo un ger wo menmay be exp ectedto hav e an in fe rior progn osis .11, presen ting witha Breast lumpdu ring pre gnancy sho ul d be referredto abre as t sp ec ia lis t teamand anyimaging or furtherte sts should be con ductedincon jun ct ion wi th the mult idisciplinar y agn osi s may be difficult in womenwhoare pregnantor la cta ti ng. Womenpres ent ing wi th a bre ast lum pdu ri ng pre gnancyshou ld be re ferred to a breastspe ci alist tea m and an y imagingor furthertest s sh ou ldbe co nductedwithinthe br eas t multi di sciplinary tea m.

6 Women should havea de signatedkey wo rker,usu ally a breastcare nur se. Ul trasoun d is usedfi rst to ass ess a dis crete lu mp, but if canceris con firmed,mammo grap hy is necessary(w ith fetal shiel din g) to assess the exten t of diseaseand the con tralateralbrea st. Tissue diag nosisis withultrasound-gu idedbiopsyfor histologyrathe r thancy tology,as proliferativecha nge du rin g pregnancyre nde rs cytologyinc onclusivein ma ny to lo gy is simil ar to tha t in age-matche d non -pregnant co un te rpar ts: his tol ogicalgrade,re cept or status and humanepi dermalgrowthfa ctor re ce pt or 2 (HE R2 ) inf orm trea me tas tases is conducted only if there ishi gh clinic al su spi cionand sh ouldcomp rise chestX-r ay and liv er ult rasoundif possible.

7 Gadolinium -en ha nce d magnetic re sonance im ag ing is not recommen ded un less thereis a specificneedfo r it toin ves tig ate a clin ical pr ob lem ; th ere are li mi ted dat a for the use of this imagingmethodin Pregnancy ,alt houghno ad vers e effects of ga dolinium on the fet us havebee n re por te kerssuch asCA1 5-3 ,CEA an d CA125 are not use d in ear ly breastcancerand ma y be misl ea dingin pre gna ncy, and areno t re com me nde e scan ning andpelvic X-rayco mputed to mogra phyare notrecommendedbecause of the possible eff ect of ir radiation on the women whoare not pr egnant, X- ra y com putedtomograph y (C T) and isotopebonescanare thepref err ed me tho ds of investigationto establishor excludemet as tas es.

8 These met hods are no t appropriatein wo me n who ar e preg na nt, in wh om che st X-rayand liverul tras oun d ar e thereis con cernab ou t bone in volv eme nt, a plain film of the relevantar ea and/ or magnet ic reson anceim agin g to minimisera dia tio n ex po sureto th e fetusis ationof terminationof pr egnancyThe de cisi on to continuethe pr egn an cy shouldbe bas ed on car eful di scussionof thecanc er prognosi s, tr eat ment and futurefertility with th e wom an an d her partnerandmu lt id is ci pl in ary team . during pr egnancyThe mult idi sci pl inaryteamrev iew outcomesh ouldbe for warded to the obstetricteaman d fami ly doct or. Evidencelevel2+/3 Surgi ca l tr ea tmentincluding lo co -regi ona l clearance ca n be undertak en in all trim ng su rger y or mastectomy can be considered, bas ed on tumourcharacteristicsandbr eas t siz e, fo llowing multidisciplin ary tionsho uld be del aye d toav oid prolo ngedana esthesiaan d to al low op timalsymmetrisation of the tine l nodeass essment usin g ra dioisotopescintigrap hy doe s not caus e sign if icantuter inera dia ti on ,14but blu e dye is no t re co mmended as the effe ct upon the fet us is un kn own.

9 Sentinelnodebi op sy is indi catedin wo menwhohavea negativeresu lt fro m a preo perative axill aryul tra sou nd and needle biop sy. If the axillais positive,ax il lar y cle aran ce is in dica dio the rap y is con traindicated un til delivery unlessit is life sav ing or to pre serv e orga n fun ctio n (e . ina l co rd com pression). If ne cessary ,ra dio therapycan be con sid er ed withfetalshieldingor, dependingon gest ati onalage ,early el ec tive de live ry couldbe discussed. Routine bre as t/chestwal l radiotherapycanbe de fer re d unti l afterdel iver tem ic che mot herapyis co ntra indicated in the first trimesterbec aus e of a highrate of fetalab nor mali ty,bu t is saf e fromthe second tr imes ter and should be off eredacco rdin g to protocolsdefi ne d by the ris k of breastca nc er relapse an d mort alit y.

10 Ant hra cyline regimensare sa fe; the reare fe wer data on taxa ne s,wh ich sho uld be rese rvedfor hig h-risk (n od e-p os itive)or met ast aticdi 17 Sta nd ar d ant iemetics inc luding5HT3serotoninanta go ni st s and de xam ethasonesh ouldbe us ed. Thereare no da ta on a neurokininrecp tor antagonist wit h very highef fic acy inchemo the rapy -ind uc ed re is no evidencefor an incr eas ed ra te of second-trimestermi sca rri age or fet al growthrestrictio n, org an dysf unctionor lon g-te rm adv erseout come withth e us e of ch em ot hera py .17, 18 For wom en in wh om tumo ur cha ract eri stic s, definedby imagingand co re bio psy, mea n tha t chemotherapyis indicate d, a de ci sionmay be ma de to offerneoadjuv ant chemothe rapybefo re surg ery to al low tumourdownstagi ng an d to fa cilitatesurgery.