FIT IN CONSULTANTS

By Harika Palabatla and Prabhat Prakash

New Delhi: Pregnancy brings joy and happiness to a mother and the family, but at the same time, it can turn into uncertainty and fear, if the mother is diagnosed with breast cancer. Breast cancer during pregnancy or one year postpartum is a unique challenge to the mother and the baby. The diagnosis of pregnancy-associated breast cancer (PABC) represents a unique challenge for the patient, her caregivers, and the treating physicians

According to a nationwide Dutch study- PABC cases occur approximately once in every 3000 pregnancies. PABC is commonly defined as breast cancer diagnosed during or within one year after pregnancy, and it accounts for up to 6.9 per cent of all breast cancers in women younger than 45 years old. In women below the age of 35, the proportion of PABC even rises up to 15.6 per cent. The incidence of PABC has increased markedly during the last decades and is expected to rise further, particularly in developed countries, due to the increasing age of (first) childbearing and an ongoing increase of young-onset breast cancer.

PABC is generally recognised as a particularly aggressive type of cancer for several reasons: occurrence in a younger population, an advanced T stage at diagnosis, a high rate of lymph node involvement, higher grade tumours, a negative estrogen (ER)- and progesterone (PR)-receptor status, and a higher rate of HER2 overexpression. These characteristics, usually common in breast cancer at a young age, are however described to differ in percentages of occurrence in PABC. In addition, gestational physiologic alterations in the breast commonly result in a delayed diagnosis of breast cancer and thereby more advanced stages. Furthermore, whether these cancers arise before or during pregnancy, and whether they are stimulated by the high hormonal environment of pregnancy, is currently unknown.

The lack of a comprehensive understanding of the interaction between pregnancy and breast carcinogenesis indicates the need for more insights into the development of PABC, which may ultimately lead to personalised PABC treatment.

Age factor crucial in PABC

The risk of PABC incidence varies with age, a study by Nurses’ Health Study found that ages both at first birth and at subsequent births have a long-term influence on breast cancer incidence. The incidence density for parous women was greater than for nulliparous women for 20–30 years after the time of the first birth. However, cumulative incidence up to age 70 years was about 20 per cent lower, 10 per cent lower, or 5 per cent higher for parous versus nulliparous women if their first birth was at age 20, 25, or 35 years, respectively.

Commenting on age as a factor, Dr Suneetha Mulinti, Senior Consultant Radiation Oncologist, American Oncology Institute shared, “This happens usually at the age of 30 or 35 if at all the patient is pregnant, otherwise breast cancer is a disease usually, which happens after 50 years by the time these patients must have already completed their families. I have noticed maybe one out of 100 breast cancers during pregnancy.”

Dr Mulinti further added, “When there is wear and tear phenomenon in the ducts, because of repeated exposure to the oestrogen hormone, there is a risk of PABC. If a woman gets pregnant between the age of 25-30, at this age progesterone is predominant in women. Progesterone is the hormone that supports pregnancy and breastfeeding. This can help in the protection against breast cancer. However, nowadays women are becoming more career oriented and postponing their childbearing age to almost 30 years. At this age, more amount of oestrogen affects the breasts, which can increase the risk of PABC.”

PABC causes, symptoms

During pregnancy women undergo many hormonal changes in the body, they experience changes in their breasts such as swelling and tenderness, however, most women neglect that as a part of pregnancy, but these may result in lumps.

Speaking to ETHealthworld, Dr Tejas Shah, Consultant & Head, Molecular Diagnostics, Krsnaa Diagnostics said, “PABC typically is present with a firm, painless, and a palpable mass. Additional presentations include unilateral breast enlargement with skin thickening, pilling of the skin, nipple retraction, nipple discharge and hemorrhagic discharge.”

PABC is also associated with behavioural and biological changes, commenting on the causes of PABC, Dr Mulinti said, “As everything is cyclical, more fat can convert into oestrogen, and then oestrogen can again go and act in the breast, which can lead to the disease, hence other than hormonal changes, obesity and a sedentary lifestyle are the common causes of PABC.”

Nature of cancer treatment as per pregnancy trimester

For patients diagnosed with breast cancer during the time of pregnancy, the cancer is categorised by first trimester, second trimester, and third trimester. Patients in their first trimester are advised to terminate the pregnancy so that cancer treatment isn’t delayed. During the second and third trimesters, treatment is delayed so that the child is not affected by the cancer treatment but not delaying the major part of cancer treatment.

Commenting on the course of treatment advised during pregnancy Dr Mulinti mentioned, Usually, most of the patients presented are almost in the second or close to the third trimester. This is the time when we cannot risk losing the child. So, this is the stage where we continue with the pregnancy and delay the treatment. A major part of the treatment like breast surgery or radiation cannot be delayed. Initially, treatment is started off with some chemotherapy drugs, these drugs are supposed to be a little safe, even if the patient is bearing a child at that time. Even if the drug crosses the placental barrier, it will not be harmful to the child.”

The major problem with breast cancer is that it metastasizes to different parts of the body, there are chances that it might trip to other parts of the body while delaying treatment till the delivery of the child. Containing the disease can reduce the incidence of cancer in other parts of the body and it also controls the disease in the local breast.

“Sometimes, if at all, the patient requires surgery, it is done during the second trimester. Delaying the treatment and continuing with the pregnancy there is a chance of the cancer exploding. In that case, we try to plan off the second trimester because that is supposed to be relatively safer for anaesthesia during that time, otherwise, we start off with the chemotherapy. Once the patient has delivered the patient is kept on chemotherapy, or any kind of hormonal therapy, we usually advise the patients not to go for any breastfeeding, and we ask the patient to give formula feed because there is also a chance that these drugs might cross into the milk and be harmful to the child. The toxin substances might also exude into the milk, and that’s the reason why we usually suggest not to go for breastfeeding during treatment,” stated Dr Mulinti

Speaking about the risk of PABC during the trimesters Dr Shah said, “In a recent study that was specified by gestational trimester, an inferior outcome was found for patients diagnosed within the second and third gestational trimesters and during postpartum lactation, compared to the first trimester and non-lactating postpartum patients. PABC diagnosed in the postpartum years appears to have a more aggressive nature and typically worse outcomes. More data into the different breast cancer subgroups during pregnancy, the time after delivery and the postpartum period are therefore warranted.”

Breast cancer impact on milk production

A woman can be diagnosed with breast cancer in any of the three parts of the breast (lobules, ducts, connective tissue). So, breast cancer can directly affect breast milk. Breast cancer treatments can affect the breast milk supply and can create a negative effect on the baby.

Speaking about breastfeeding during breast cancer, Dr Sandip Bipte, Oncoplastic Breast Surgeon, PD Hinduja Hospital & Medical Research Centre, Khar and Apollo Cancer Centres, Navi Mumbai said, “PABC affects the milk production as the breast milk is diffused involving the breast gland and parenchyma. Since both organs are affected as a whole, medical professionals might ask the mother to stop breastfeeding.”

Adding to that Dr Shah said, “Women treated for breast cancer before or during pregnancy may have reduced lactation capacity due to surgical removal of breast tissue and/or irreversible effects of prior therapies. Breastfeeding women diagnosed with breast cancer may require medications or therapies that decrease milk production or are contraindicated during lactation.”

Reducing the risk of PABC

The major challenges are early detection of the disease as most cases are diagnosed in advanced stages. The other factor is the aggressive behaviour of PABC. Delayed detection of PABC can lead to severe health problems, Dr Bipte urged to ensure regular screening, “Measure your breasts every month, notice the slightest change in its appearance, its size, its tissues, nipples and its discharge etc. There is a need to create awareness among rural women about breast examination and breast cancer. For this, the availability of health experts for creating awareness and training midwives for early detection is highly imperative,” concluded Dr Bipte.

The probable causes of the increase in breast cancer risk after pregnancy are increased malignant transformation of breast cancer cells due to oestrogen, progesterone and growth hormones secreted during pregnancy, the immune suppressive effects of pregnancy and breast involution after pregnancy. As more women are delaying their childbearing age, the incidence of PABC is on the rise. There is a need to create awareness among women about breast examination and breast cancer.

Maintaining a good lifestyle is the best way to decrease the risk of the disease. Important safety precautions that can help lower the risk of breast cancer include keeping weight in check, regular exercise, consuming healthy food, intake of fruits & vegetables, and avoiding alcohol and smoking.