Pregnant With Breast Cancer
By Julie Auton
One of the most exciting events in a woman’s life—pregnancy--can quickly turn sour when it's complicated with a breast cancer diagnosis. This seemingly incongruous state of a healthy baby forming along with a dreaded disease developing is uncommon, yet more physicians are handling patients with this dual condition. Whereas in the past, a cancer diagnosis dramatically limited positive outcomes for both mother and child, today's treatment options for cancer make pregnancy possible. What has not changed, however, is the tough decisions pregnant women must face in battling the disease.
We recently spoke with three Atlanta healthcare professionals about issues and challenges of breast cancer during pregnancy. Dr. Paul Browne, MD, is an OBGYN and Director of Maternal-Fetal Medicine at DeKalb Medical Center in metropolitan Atlanta. Dr. Browne is a specialist in maternal-fetal medicine, including high risk pregnancies. Ruth O’Regan, MD, is a Medical Oncologist with the Winship Cancer Institute at Emory Healthcare in Atlanta. Joyce King Ph.D, Family Nurse Practitioner and Certified Nurse Midwife is an Assistant Professor at the Emory University School of Nursing and a two-time breast cancer survivor.
Is breast cancer among young women (pre-menopausal) more common today?
(Browne) You are seeing more women with breast cancer who are pregnant, but not because there’s an increase in cancer among young women. Instead, improved cancer therapies are allowing more women to survive treatment and, therefore, are giving them the option of having children.
(O’Regan) Breast cancer in younger women is rare, fortunately. However, I have treated patients as young as 18.
(King) Incidences of breast cancer for younger women and for older women are not increasing, although the public’s awareness of the disease is much greater than it used to be. Age remains the number one risk factor in developing breast cancer-- the average age of diagnosis is 65. You hear statistics that one in eight women are diagnosed with breast cancer, but that's if they live to be 90 years old. The risk of developing breast cancer at 30, for example, is much lower—it’s one in 2,500.
In fact, breast cancer rates for women of all ages increased in the 1970s and '80s, but stabilized in the '90s and have remained at that level since then.
Another factor besides age in developing breast cancer is delaying pregnancy. More women today are postponing pregnancy until they are older, and it's been well documented that never being pregnant or delaying pregnancy is a significant risk factor.
Early detection is critical for surviving cancer.
When do you advise young women to start breast self-exam and other screening measures?
(O'Regan) A young woman should start performing a self-exam as soon as she starts going to a gynecologist for a clinical exam. It is important for young women to conduct self-exams at an early age. Cysts are common in teenagers, so it's good to become familiar with their breast tissue. With regular screening, it's easier to spot any abnormality.
Although insurance coverage of mammograms typically begins at age 40, screening should be determined based on family history. The consensus among national health provider groups for people with a first-degree relative with the disease (a mother or sister) is to start mammograms in the mid thirties.
I advise women to use more than one technique in screening for cancer—a monthly self-exam, yearly checkups with a healthcare professional and annual mammograms--so cancer can be detected before it's too late to treat.
(King) Start when you have breasts. I've known of a 22-year-old woman who already had a large mass, so she probably had cancer since she was a teenager because cancer develops slowly. The American Cancer Society recommends a monthly breast self-exam.
The major concern women have with self-exams is they don’t know how to conduct it properly. The method of doing a breast self-exam has changed. Instead of doing circular motions around the breasts, a linear method is now recommended. You start under your arm and go up and down towards your sternum.
The American Cancer Society also recommends that women start having mammograms annually at age 40. For a first- degree relative who was diagnosed under 50, it’s recommended you get mammogram 10 years before they were diagnosed. For example, if your mother was diagnosed at age 45, you should start getting mammograms at 35.
Breasts are denser in younger women which reduces the accuracy of mammograms. A mammogram is 75% accurate under the age of 50. After 50, the results are 80% effective. But mammography, along with a professional exam, is still the best method for detecting breast cancer at an early stage.
What about the birth control pill? Does it have any affect on breast cancer?
(King) The U.S. Public Health Service Task Force, which looks at preventative healthcare, has no opinion--which means, it doesn't see any evidence that self-exams are harmful or helpful. There are no good studies that say it decreases mortality.
(King) Studies have shown that the birth control pill can decrease the risk for ovarian and endometrial cancer, whereas it has no impact on breast cancer. However, most women on birth control typically are being assessed by a healthcare professional on a regular basis, so they are being screened for breast cancer.
How does breast cancer impact pregnancy? Does cancer develop faster, for example? Can cancer affect the fetus?
(Browne) During pregnancy, enormous levels of progesterone and estrogen are released in the blood. This stimulates ER (estrogen-receptive)-positive tumors which grow faster in pregnant women than non-pregnant women.
Breast cancer also places the pregnant patient in a situation of undergoing treatment options that could adversely impact her child. Cancer treatment options, including surgery, radiation therapy and chemotherapy all pose potential risks to the fetus.
Chemotherapy, for example, infuses the body with poisons. It can cause miscarriage in early stages of pregnancy and poor growth of the fetus during late pregnancy. Surgery, such as a lumpectomy, requires the patient to go under anesthesia. And, anesthesia has been shown to be a risk factor for causing miscarriage. Radiation during pregnancy can cause the mother to miscarry in the first trimester, and also increases the child’s chance of developing cancer as they get older.
Another issue with cancer is that your body is sick, so it’s not a good incubator. Therefore, it doesn’t provide the best nutrition for the child. Other concerns are the medication can make the baby sick; cancer treatment often causes anemia since you don't carry oxygen well; and patients are more susceptible to infections. All of these things can have an adverse affect on the child.
As a result of each of these risks, women are faced with the tough decision of undergoing treatment or terminating the pregnancy. If they delay treatment to end of their pregnancy, their cancer may advance, decreasing their chances of survival.
(O’Regan) Breast cancer has no impact on the fetus. The fetus is protected from breast cancer because it cannot cross the placenta. However, other types of cancers can affect the fetus. There is placenta cancer, in which cancer originates in the placenta, but this is rare. Melanoma (skin cancer), however, is extremely common and can cross the placenta.
During pregnancy, breast cancer is harder to diagnose because breasts are larger and you can miss abnormalities in the tissue.
Your treatment options are also fewer for women who are pregnant. Radiation therapy, for example, is not an option for pregnant patients. With surgery, the only option is a mastectomy. You can’t do a lymph node dissection because you can’t use the blue dye to look at the lymph nodes. Some chemotherapy, such as adriomycin & cytocin, can be given in the second and third trimester with no risk to the fetus. During the first trimester, however, no chemo should be administered.
Another issue with cancer treatment is there’s an age-related risk of chemo putting women into early menopause, especially if the patient is in her forties. So, if a woman at 40 has cancer and still wants children, she can preserve her eggs. To accomplish this, she needs to receive high doses of estrogen to harvest the eggs to freeze. This, however, is not recommended since it takes several weeks of additional estrogen to harvest the eggs, and estrogen promotes tumor growth. So, these are huge issues to consider.
(King) The problem is that physical changes in the breasts during pregnancy can affect early detection, and there are difficulties in treatment of breast cancer.
Regarding detection: during pregnancy, breasts are larger, firmer and denser, which makes it more difficult for diagnosis through conventional means such as mammography. With dense breasts, it is preferable to use ultrasound to distinguish between cystic masses and solid masses. There are often problems as well with pregnant women developing hematomas from breast biopsies.
Treatment has added complications. If she undergoes surgery, pregnant women are more likely to have blood clots since there’s more coagulation during this time. In addition, she can’t have an axillary dissection of the centenal node because the dye has a chemical in it that can potentially harm fetus. Another complication is that during pregnancy, a woman’s lungs don’t expand as well, so she is more vulnerable to pneumonia post-surgery.
She must postpone radiation therapy until after delivery. And, there are certain chemo drugs she can take; however, the long term effects of chemo on the fetus are not known. Although we’ve been using chemo for more 20 years on pregnant women and it doesn’t appear to have affect on the child, but data is limited.
If the patient is far from term, she has the option for surgery and chemo. Depending on how close to term she is, she may undergo a C-section, which have associated risks. Or, she may have induced labor if she is close to term and the cancer is aggressive, so she can be treated for cancer.
Delaying cancer treatment entirely until she delivers the baby can cause problems. A six month delay in treatment, for example, can increase the chances of cancer metastasizing to the lymph nodes by five percent.
What are some common misconceptions about cancer and pregnancy?
(O’Regan) There are a number of misconceptions, but a primary one is that women can never get pregnant again if they have cancer treatment. This is untrue—in fact, many patients become pregnant after breast cancer. However, that’s not always the case.
I recommend women treated for breast cancer to wait two years until anther pregnancy because that’s when there’s the highest chance of reoccurrence. Also, taking tamoxifin after treatment will postpone the time a woman can get pregnant. Take, for example, a 36-year-old woman with no kids and has ER-positive breast cancer. If she takes five years of tamoxifin, she will be 41 when she’ll be able to get pregnant again--and it’s increasingly difficult to conceive at that age.
(Browne) The biggest myth is that women can have the full spectrum of treatment during pregnancy. That’s not true—they can’t have all the treatment and be pregnant. If they choose treatment, it has to be altered to take into consideration the pregnancy.
What are the dangers of being younger and battling cancer? Is it more aggressive in younger women because of increased estrogen levels in their bodies? Does it tend to go undetected among younger women so it ends up being more advanced?
(Browne) Breast cancer is more difficult to diagnose using any screening method during pregnancy. The breasts change and become denser. This is also true during breast feeding. Therefore, it’s harder to identify a small tumor; exams are less accurate. Patients expect breasts to be different so if they feel something, they dismiss it as pregnancy-related and not a problem. My advice is that if you have any concerns, get it checked out with a general exam. And, don't stop breast self-exams during pregnancy.
(King) Younger women tend to have more aggressive cancers. First of all, they are more likely to have tumors that are not sensitive to estrogen, so they can’t take tamoxifin, which can block the estrogen effect.
Secondly, they tend to have more HER-2 positive tumors, which, by nature, are more aggressive.
What special precautions do pregnant women need to take if they have cancer? What do they need to avoid?
(Browne) Pregnant women with cancer should pay more attention to their nutrition. They need, for example, more protein to repair their bodies and feed their baby.
And with chemo, the primary treatment, they should take added precautions to prevent infection, to which they are more vulnerable.
(King) They first must avoid radiation therapy as well as radiology procedures such as MRI, brain scans, bone scans and liver scans. Some diagnostic techniques can increase the risk of miscarriage or inhibit fetus growth. Some procedures and therapies can also increase the risk of childhood malignancy and leukemia as well as birth defects.
Are there activities patients need to do, such as special diet or other considerations, since their body is undergoing stress from both pregnancy and cancer?
(King) This is very individualized, but the general rule is take care of yourself by eating a well-balanced diet, exercising, getting plenty of rest and continuing to take prenatal vitamins.
(Browne) Patients who have dealt with this situation the best have relied on a strong support system of family and friends. I highly recommend patients to take advantage of counseling and support groups –which hospitals with cancer centers offer.
How does a woman balance advice from their OB and their oncologist?
(Browne) In most cases, there is no disagreement between physicians since there is well-accepted treatment advice. A high-risk OB should coordinate care between both the OB and oncologist since they deal with this issue on a regular basis. Whereas, an OB rarely handles patients with cancer and an oncologist rarely handles pregnant patients.
(King) You need to assign one person to be in charge; otherwise, the patient gets confused. It should be managed by the maternal fetal medicine specialist since they are trained to take care of high risk pregnancies.
Is there anything else women need to know about pregnancy and breast cancer?
(Browne) I advise patients in this scenario to seek second opinions before committing to treatment. This is an enormous life decision for a woman to make—to forego treatment and risk her life, or terminate the pregnancy, or modify treatment during pregnancy-- so she should have more than one person giving her advice. If she receives a different opinion, then she has more information to make an informative decision. If the second opinion confirms the first, she can be more confident she’s doing the right thing.
My second piece of advice is I’ve often noticed that when a pregnant woman is diagnosed with cancer, she tends to have negative feelings about her pregnancy—that since she has cancer, her pregnancy can’t possibly go well. As a result, she doesn’t bond with her child because she believes that if she doesn’t get excited, then miscarries, that somehow it won’t be as devastating—but it makes no difference. It will be painful whether she gets excited or not. And, this negative attitude robs a woman of the chance to celebrate having a child.
In the majority of cases we’ve treated in my practice within the last 15 to 20 years, most babies have survived and there weren’t problems. It’s a scary time and there are problems associated with treatment, but overall, there have been good outcomes.
