Management of breast cancer diagnosed during pregnancy: global perspectives

ABSTRACT

Introduction

Pregnancy-associated breast cancer (PABC) encompasses breast cancer diagnosed during pregnancy (BCP) or postpartum (PPBC). BCP is especially challenging with concerns regarding maternal and fetal safety synchronously. This review provides a comprehensive global view to optimize care of this unique entity. Areas covered Published literature and practices across the globe including real world published data from the first Indian registry are thoroughly reviewed to derive inferences. Diagnostic delays are common with resultant upstaging and inferior outcomes. Sonography-mammography and a biopsy with immunohistochemistry for estrogen, progesterone and HER-2neu receptors is mandatory. Multidisciplinary specialist teams are critical for trimester dependent management. Stage-wise surgical and systemic treatment remains largely similar to that of the nonpregnant women. Anthracyclines- and taxane-based chemotherapy is found to be safe after the 1st trimester. Frequent fetal and maternal monitoring is required to minimize complications. Chemotherapy should stop three weeks prior to the delivery to prevent peripartum infection/bleeding. Anti- Her-2 targeted therapy, endocrine therapy and radiation therapy are administered post-delivery. Iatrogenic premature delivery leads to poor neurocognition and should be avoided. Expert opinion Stage-wise outcomes are similar to that of non-pregnant patients with breast cancer, and underscores the importance of early detection especially in low- and middle-income countries. Global collaborations are warranted

Areas covered

Published literature and practices across the globe including real world published data from the first Indian registry are thoroughly reviewed to derive inferences. Diagnostic delays are common with resultant upstaging and inferior outcomes. Sonography-mammography and a biopsy with immunohistochemistry for estrogen, progesterone and HER-2neu receptors is mandatory. Multidisciplinary specialist teams are critical for trimester dependent management. Stage-wise surgical and systemic treatment remains largely similar to that of the nonpregnant women. Anthracyclines- and taxane-based chemotherapy is found to be safe after the 1st trimester. Frequent fetal and maternal monitoring is required to minimize complications. Chemotherapy should stop three weeks prior to the delivery to prevent peripartum infection/bleeding. Anti- Her-2 targeted therapy, endocrine therapy and radiation therapy are administered post-delivery. Iatrogenic premature delivery leads to poor neurocognition and should be avoided.

Expert opinion

Stage-wise outcomes are similar to that of non-pregnant patients with breast cancer, and underscores the importance of early detection especially in low- and middle-income countries. Global collaborations are warranted.

KEYWORDS:

• Breast cancer during pregnancy (PrBC)
• Low-Middle-income countries (LMIC)
• global Oncology
• outcomes
• multidisciplinary care
• prematurity
• neurocognition
• fetal safety
• maternal safety
• teratogenicity

Article highlights

• Pregnancy-associated breast cancer (PABC) is a rare entity, an unmet need with challenges of safeguarding maternal and fetal outcomes.

• There is a dearth of high-quality randomised evidence and guidelines in both the categories, breast cancer diagnosed during pregnancy (BCP) and postpartum period (PPBC).

• PABC often presents with aggressive biology and delayed diagnosis with resultant compromised outcomes.

• Stage, biology and age-matched oncologic and obstetric outcomes may be similar to nonpregnant breast cancer and normal pregnancy.

• Hence, awareness towards early diagnosis and optimal treatment is warranted.

• National and international collaboration is required to streamline care and create awareness for early diagnosis.

• Appropriate trimester dependent multi-speciality management with avoidance of premature deliveries is critical.

Declaration of interest

HS Rugo has received research support for clinical trials through the University of California from; Pfizer, Merck, Novartis, Lilly, Roche, Odonate, Daiichi, Seattle Genetics, Eisai, Macrogenics, Sermonix, Astra Zeneca, Ayala, OBI and Gilead. HS Rugo has also received honoraria from Puma, Mylan and Samsung.

J Bajpai has received research support for clinical trials through Tata Memorial Centre from; Eli Lilly, Novartis, Roche, Samsung Bioepis co. Ltd, Paxman Coolers Ltd, Sun Pharma. J Bajpai has served in a leadership role for Novartis, has served in an advisory role for the Immuno-Oncology Society of India (IOSI), is Founder General Secretary of the Indian Society of Medical and Paediatric Oncology (ISMPO), is an Executive Committee member of Teenage & Young Adult Cancer Foundation (TYAcan), is a Founder Member and Joint Secretary for the Indian cooperative Oncology network (ICON)- Managing Committee Member.

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contribution statement

All the authors significantly contributed for the manuscript; this manuscript has been drafted, read and approved by all the authors, the requirements for authorship have been met.

Additional information

Funding

This paper received no funding.