Once the diagnosis of pregnancy-associated breast cancer is confirmed and staging complete, treatment must proceed without delay. Any delay increases the risk of metastasis from 5% to 10%.5 Establishing the gestational age of the fetus at the time of diagnosis is important, as this is a determining factor in choosing treatment options. Histologically, tumors in these patients are typically poorly differentiated, ER/PR negative, and HER2-positive.9
Surgery Traditional treatment regimens consisting of surgery (eg, lumpectomy, mastectomy, or radical mastectomy) combined with other modalities (eg, radiation, chemotherapy, hormone therapy, or biological therapy) must be tailored to the patient with regard to safety of the fetus. Surgery is the recommended primary treatment and can be performed without risk to the fetus.7 To avoid postsurgical radiation, a modified radical mastectomy is the procedure of choice; however, breast-conserving surgery can be considered if diagnosis is made in the second or third trimester.7 Further treatment options should include axillary dissection because of the high-risk of metastasis.7
Radiation therapy External beam radiation to the breast, thoracic wall, and axilla are deferred until after delivery of the fetus, due to the risk of fetal exposure to internal radiation scatter.5 Radiation-induced deficits include microcephaly, urinary system defects, eye abnormalities, and skeletal deformities.
Chemotherapy The risk for spontaneous abortion and/or fetal malformations is higher if treatment involves chemotherapy administered during the first trimester. In the event that chemotherapeutic agents are needed, the preference is to administer chemotherapy during the second and third trimesters when organ development is complete; however, the fetus should still be monitored closely because approximately 50% of fetuses in cases of pregnancy-associated breast cancer are still at risk for intrauterine growth restriction, preterm delivery, or low birth weight.5,7 In addition to holding chemotherapy until the later trimesters, it should be discontinued at least 3 weeks before delivery to allow sufficient time for the mother and fetus to recover from myelosuppression, thus reducing the risk of hemorrhage and infection(s).5,7
The goal of chemotherapy in pregnancy-associated breast cancer is to minimize disease recurrence and prolong progression- free survival.5 Dose-attenuated chemotherapy may be the standard recommendation given the hemodynamic status of the woman (ie, increased plasma volume may cause peak drug concentrations to decrease, which affects drug clearance).5 During the second and third trimesters, doxorubicin, epirubicin, 5-fluorouracil, and cyclophosphamide are relatively safe to administer to patients with pregnancyassociated cancer.5,7,9 Tamoxifen (a selective estrogen receptor modulator) is contraindicated in pregnancy due to the increased risk of fetal harm and death.
The necessity of multidisciplinary care cannot be undermined in the management of women with breast cancer diagnosed during pregnancy. The anxiety, fear, and trauma that encapsulate women with this diagnosis, combined with concern for their unborn fetus, makes the management of this disease extend beyond that of physical care. Nurses are key to serving as mediators between the different disciplines that play a role in the care of these patients. Nurses must continue to educate themselves and their patients about the signs and symptoms of breast cancer, and the significance of completing a thorough initial examination.7 The rarity of this illness does not prohibit the incidence; therefore, pregnancy-associated breast cancer requires a personalized approach to managing treatment with careful and deliberate consideration for the mother and the unborn fetus.7
Nurses are at the forefront of providing wholistic oncology care that addresses the physical, psychological, and spiritual needs of these patients. A greater understanding of how the physiologic changes that occur during pregnancy complicate this disease and a timely diagnosis, the limitations to treatment options, and safe protocols for fetal protection will lead to better overall outcomes in this patient population.8
The literature does not support or even prove that aborting the fetus in the setting of a breast cancer diagnosis improves survival for the affected mother. Survival outcomes for both nonpregnant and pregnant women with breast cancer are equal. Despite the prognosis in these women being indeterminate, termination of pregnancy may be considered in extreme emergent cases of advanced disease. But given that this is the exception rather than the rule, pregnancy-associated breast cancer is no longer a buzzword heard in the distant discussions of the examination room.
The prevalence and incidence of breast cancer in pregnant women are being weaved into the realm of everyday practice. The complexity of cancer in itself is enough in the absence of pregnancy; however, when two lives are impacted by the burden of cancer, the stakes are higher. The more versed we become in the biology of this disease in this subset of patients, the better we can provide cancer care that is multidisciplinary, comprehensive, and in-depth. Pregnancy-associated breast cancer is becoming more prevalent due to current cultural choices in regard to childbearing. As a discipline, oncology can no longer regard pregnancy-associated breast cancer as an abnormally rare cancer.
Jia Conway is a nurse practitioner at Cancer Care Associates of York, in York, Pennsylvania.
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