Breast Cancer and Pregnancy
General Information(Symptoms and Diagnosis)
Stages
Treatment
General Information about Breast Cancer and Pregnancy
Key Points
- Breast cancer is a disease in which malignant (cancer)
cells form in the tissues of the breast.
- Sometimes breast cancer occurs in women who are pregnant or
have just given birth.
- Signs of breast cancer include a lump or change in the
breast.
- It may be difficult to detect (find) breast cancer early in
pregnant or nursing women.
- Breast exams should be part of prenatal and postnatal care.
- Tests that examine the breasts are used to detect (find)
and diagnose breast cancer.
- If cancer is found, tests are done to study the cancer
cells.
- Certain factors affect prognosis (chance of recovery) and
treatment options.
Breast
cancer is a disease in which malignant (cancer) cells form in the
tissues of the breast.
The breast is made up of lobes and ducts. Each breast has 15 to
20 sections called lobes. Each lobe has many smaller sections called lobules. Lobules end in
dozens of tiny bulbs that can make milk. The lobes, lobules, and bulbs
are linked by thin tubes called ducts.
Anatomy of the female
breast. The nipple and areola are shown on the outside of the breast.
The lymph nodes, lobes, lobules, ducts, and other parts of the inside
of the breast are also shown.
Each breast also has blood vessels and lymph vessels. The lymph
vessels carry an almost colorless fluid
called lymph. Lymph
vessels carry lymph between lymph
nodes. Lymph nodes are small bean-shaped structures that
are found throughout the body. They filter substances in lymph and help
fight infection and
disease. Clusters of lymph nodes are found near the breast in the axilla (under the arm),
above the collarbone,
and in the chest.
Sometimes
breast cancer occurs in women who are pregnant or have just given
birth.
Breast cancer occurs about
once in every 3,000 pregnancies.
It occurs most often between the ages of 32 and 38.
Signs
of breast cancer include a lump or change in the breast.
These and other signs may be caused by
breast cancer or by other conditions.
Check with your doctor if you have any of the following:
- A lump or thickening in or near the breast or in the
underarm area.
- A change in the size or shape of the breast.
- A dimple or puckering in the skin of the breast.
- A nipple
turned inward into the breast.
- Fluid, other than breast milk, from the nipple, especially
if it's bloody.
- Scaly, red, or swollen skin on the breast, nipple, or areola (the dark area of
skin around the nipple).
- Dimples in the breast that look like the skin of an orange,
called peau d'orange.
It
may be difficult to detect (find) breast cancer early in pregnant or
nursing women.
The breasts usually get
larger, tender, or lumpy in women who are pregnant, nursing, or have
just given birth. This occurs because of normal hormone changes that take
place during pregnancy. These changes can make small lumps difficult to
detect. The breasts may also become denser. It is more difficult to
detect breast cancer in women with dense breasts using mammography. Because these
breast changes can delay diagnosis,
breast cancer is often found at a later stage
in these women.
Breast
exams should be part of prenatal and postnatal care.
To detect breast cancer,
pregnant and nursing women should examine their breasts themselves.
Women should also receive clinical
breast exams during their regular prenatal and postnatal
check-ups. Talk to your doctor if you notice any changes in your
breasts that you do not expect or that worry you.
Tests
that examine the breasts are used to detect (find) and diagnose breast
cancer.
The following tests and
procedures may be used:
If
cancer is found, tests are done to study the cancer cells.
Decisions about the best
treatment are based on the results of these tests and the age of the
unborn baby. The tests give information about:
- How quickly the cancer may grow.
- How likely it is that the cancer will spread to other parts
of the body.
- How well certain treatments might work.
- How likely the cancer is to recur
(come back).
Tests may include the
following:
- Estrogen
and progesterone receptor test
: A test to measure the amount of estrogen and progesterone (hormones) receptors
in cancer tissue. If there are more estrogen and progesterone receptors
than normal, the cancer is called estrogen
and/or progesterone receptor
positive. This type of breast cancer may grow more
quickly. The test results show whether treatment to block estrogen and
progesterone given after the baby is born may stop the cancer from
growing.
- Human
epidermal growth factor type 2 receptor (HER2/neu) test :
A laboratory test
to measure how many HER2/neu genes
there are and how much HER2/neu protein
is made in a sample of tissue. If there are more HER2/neu genes or
higher levels of HER2/neu protein than normal, the cancer is called HER2/neu positive. This type
of breast cancer may grow more quickly and is more likely to spread to
other parts of the body. The cancer may be treated with drugs that target the
HER2/neu protein, such as trastuzumab
and pertuzumab,
after the baby is born.
- Multigene tests: Tests in
which samples of tissue are studied to look at the activity of many
genes at the same time. These tests may help predict whether cancer
will spread to other parts of the body or recur (come back).
- Oncotype
DX : This test helps predict whether stage I or stage II breast cancer that
is estrogen receptor positive
and node-negative
will spread to other parts of the body. If the risk of the cancer
spreading is high, chemotherapy
may be given to lower the risk.
- MammaPrint
: This test helps predict whether stage I or
stage II breast cancer that is node-negative will spread to other parts
of the body. If the risk of the cancer spreading is high, chemotherapy
may be given to lower the risk.
Certain
factors affect prognosis (chance of recovery) and treatment options.
The prognosis (chance of recovery) and treatment
options depend on the following:
- The stage of the cancer (the size of the tumor and whether it is in
the breast only or has spread to other parts of the body).
- The type of breast cancer.
- The age of the unborn baby.
- Whether there are signs or symptoms.
- The patient's general health.
Stages of Breast Cancer
Key Points
- After breast cancer has been diagnosed, tests are done to
find out if cancer cells have spread within the breast or to other
parts of the body.
- There are three ways that cancer spreads in the body.
- Cancer may spread from where it began to other parts of the
body.
- The following stages are used for breast cancer:
- Stage 0 (carcinoma in situ)
- Stage I
- Stage II
- Stage IIIA
- Stage IIIB
- Stage IIIC
- Stage IV
After
breast cancer has been diagnosed, tests are done to find out if cancer
cells have spread within the breast or to other parts of the body.
The process used to find
out if the cancer
has spread within the breast
or to other parts of the body is called staging.
The information gathered from the staging process determines the stage of the disease. It is
important to know the stage in order to plan treatment.
Some procedures may
expose the unborn baby to harmful radiation
or dyes. These procedures are done only if absolutely necessary.
Certain actions can be taken to expose the unborn baby to as little
radiation as possible, such as the use of a lead-lined shield to cover
the abdomen.
The following tests and
procedures may be used to stage breast
cancer during pregnancy:
- Sentinel
lymph node biopsy : The removal of the sentinel lymph node during surgery. The sentinel lymph
node is the first lymph node
to receive lymphatic drainage from a tumor.
It is the first lymph node the cancer is likely to spread to from the
tumor. A radioactive
substance and/or blue dye is injected
near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes.
The first lymph node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for
cancer cells. If
cancer cells are not found, it may not be necessary to remove more
lymph nodes.
- CT
scan (CAT scan): A procedure that makes a
series of detailed pictures of areas inside the body, taken from
different angles. The pictures are made by a computer linked to an x-ray machine. This
procedure is also called computed tomography, computerized tomography,
or computerized axial tomography.
- Bone
scan : A procedure to check if there are
rapidly dividing cells, such as cancer cells, in the bone. A very small
amount of radioactive material is injected into a vein and travels through the
bloodstream. The radioactive material collects in bones with cancer and
is detected by a scanner.
- PET
scan (positron emission tomography scan): A
procedure to find malignant
tumor cells in the body. A small amount of radioactive glucose (sugar) is injected
into a vein. The PET scanner rotates around the body and makes a
picture of where glucose is being used in the body. Malignant tumor
cells show up brighter in the picture because they are more active and
take up more glucose than normal cells do.
- MRI
(magnetic resonance imaging): A procedure that uses a
magnet, radio waves,
and a computer to make a series of detailed pictures of areas inside
the body, such as the brain. This procedure is also called nuclear
magnetic resonance imaging (NMRI).
- Ultrasound
exam: A procedure in which high-energy sound waves
(ultrasound) are bounced off internal tissues or organs, such as the
liver, and make echoes. The echoes form a picture of body tissues
called a sonogram.
The picture can be printed to be looked at later.
- Chest
x-ray : An x-ray of the organs and bones
inside the chest. An x-ray is a type of energy beam that can go through
the body and onto film, making a picture of areas inside the body.
There
are three ways that cancer spreads in the body.
Cancer can spread
through tissue, the
lymph system, and
the blood:
- Tissue. The cancer spreads from where it began by growing
into nearby areas.
- Lymph system. The cancer spreads from where it began by
getting into the lymph system. The cancer travels through the lymph vessels to other parts
of the body.
- Blood. The cancer spreads from where it began by getting
into the blood. The cancer travels through the blood vessels to other parts
of the body.
Cancer
may spread from where it began to other parts of the body.
When cancer spreads
to another part of the body, it is called metastasis.
Cancer cells break
away from where they began (the primary
tumor) and travel through the lymph system or blood.
- Lymph system. The cancer gets into the lymph system,
travels through the lymph vessels, and forms a tumor (metastatic tumor) in another
part of the body.
- Blood. The cancer gets into the blood, travels through the
blood vessels, and forms a tumor (metastatic tumor) in another part of
the body.
The metastatic tumor is
the same type of cancer as the primary tumor. For example, if breast cancer spreads to the
bone, the cancer cells in the bone are actually breast cancer cells.
The disease is metastatic breast cancer, not bone cancer.
The
following stages are used for breast cancer:
This section describes
the stages of breast cancer.
The breast cancer stage is based on the results of testing that is done
on the tumor and lymph nodes removed during surgery and other tests.
Stage
0 (carcinoma in situ)
There are 3 types of breast carcinoma in situ:
Stage
I
Stage I breast cancer. In
stage IA, the tumor is 2 centimeters or smaller and has not spread
outside the breast. In stage IB, no tumor is found in the breast or the
tumor is 2 centimeters or smaller. Small clusters of cancer cells
(larger than 0.2 millimeter but not larger than 2 millimeters) are
found in the lymph nodes.
In stage I, cancer has formed. Stage I
is divided into stages IA and IB.
- In stage IA,
the tumor is 2 centimeters or smaller.
Cancer has not spread outside the breast.
- In stage IB,
small clusters of breast cancer
cells (larger
than 0.2 millimeter
but not larger than 2 millimeters) are found in the lymph nodes and either:
- no tumor
is found in the breast;
or
- the tumor is 2 centimeters
or smaller.
Stage
II
Stage II is divided into
stages IIA and IIB.
- In stage IIA:
- no tumor
is found in the breast
or the tumor is 2 centimeters
or smaller. Cancer
(larger than 2 millimeters)
is found in 1 to 3 axillary
lymph nodes or in the lymph
nodes near the breastbone
(found during a sentinel lymph
node biopsy); or
- the tumor is larger than 2 centimeters but not larger
than 5 centimeters. Cancer has not spread to the lymph nodes.
Stage IIA breast
cancer. No tumor is found in the breast and cancer is found in 1 to 3
axillary lymph nodes or lymph nodes near the breastbone (left panel);
OR the tumor is 2 centimeters or smaller and cancer is found in 1 to 3
axillary lymph nodes or lymph nodes near the breastbone (middle panel);
OR the tumor is larger than 2 centimeters but not larger than 5
centimeters and has not spread to the lymph nodes (right panel).
- In stage IIB,
the tumor is:
- larger than 2 centimeters
but not larger than 5 centimeters. Small clusters of breast cancer cells (larger than 0.2 millimeter but not larger
than 2 millimeters) are found in the lymph
nodes; or
- larger than 2 centimeters but not larger than 5
centimeters. Cancer has spread to 1 to 3 axillary
lymph nodes or to the lymph nodes near the breastbone (found during a sentinel lymph node biopsy);
or
- larger than 5 centimeters. Cancer has not spread to the
lymph nodes.
Stage IIB breast
cancer. The tumor is larger than 2 centimeters but not larger than 5
centimeters and small clusters of cancer cells (larger than 0.2
millimeter but not larger than 2 millimeters) are found in the lymph
nodes (left panel); OR the tumor is larger than 2 centimeters but not
larger than 5 centimeters and cancer is found in 1 to 3 axillary lymph
nodes or lymph nodes near the breastbone (middle panel); OR the tumor
is larger than 5 centimeters and has not spread to the lymph nodes
(right panel).
Stage
IIIA
Stage IIIA breast cancer.
No tumor is found in the breast or the tumor may be any size and cancer
is found in 4 to 9 axillary lymph nodes or lymph nodes near the
breastbone (left panel); OR the tumor is larger than 5 centimeters and
small clusters of cancer cells (larger than 0.2 millimeter but not
larger than 2 millimeters) are found in the lymph nodes (middle panel);
OR the tumor is larger than 5 centimeters and cancer is found in 1 to 3
axillary lymph nodes or lymph nodes near the breastbone (right panel).
In stage IIIA:
- no tumor
is found in the breast
or the tumor may be any size. Cancer
is found in 4 to 9 axillary
lymph nodes or in the lymph
nodes near the breastbone
(found during imaging tests
or a physical exam);
or
- the tumor is larger than 5 centimeters.
Small clusters of breast cancer
cells (larger
than 0.2 millimeter
but not larger than 2 millimeters) are found in the lymph nodes; or
- the tumor is larger than 5 centimeters. Cancer has spread
to 1 to 3 axillary lymph nodes or to the lymph nodes near the
breastbone (found during a sentinel
lymph node biopsy).
Stage
IIIB
Stage IIIB breast cancer.
The tumor may be any size and cancer has spread to the chest wall
and/or to the skin of the breast and caused swelling or an ulcer.
Cancer may have spread to up to 9 axillary lymph nodes or the lymph
nodes near the breastbone. Cancer that has spread to the skin of the
breast may be inflammatory breast cancer.
In stage IIIB, the tumor may be any size and cancer has spread to the chest wall and/or to the
skin of the breast
and caused swelling or an ulcer.
Also, cancer may have spread to:
- up to 9 axillary
lymph nodes; or
- the lymph nodes
near the breastbone.
Cancer that has spread
to the skin of the breast may also be inflammatory
breast cancer. See the section on Inflammatory Breast
Cancer for more information.
Stage
IIIC
Stage IIIC breast cancer.
No tumor is found in the breast or the tumor may be any size and may
have spread to the chest wall and/or to the skin of the breast and
caused swelling or an ulcer. Also, cancer has spread to 10 or more
axillary lymph nodes (left panel); OR to lymph nodes above or below the
collarbone (middle panel); OR to axillary lymph nodes and lymph nodes
near the breastbone (right panel). Cancer that has spread to the skin
of the breast may be inflammatory breast cancer.
In stage IIIC, no tumor is found in the breast or the tumor may be
any size. Cancer may have spread to the skin of the breast and caused
swelling or an ulcer
and/or has spread to the chest
wall. Also, cancer has spread to:
- 10 or more axillary
lymph nodes; or
- lymph nodes
above or below the collarbone;
or
- axillary lymph nodes and lymph nodes near the breastbone.
Cancer that has spread
to the skin of the breast may also be inflammatory
breast cancer. See the section on Inflammatory Breast
Cancer for more information.
For treatment, stage
IIIC breast cancer is divided into operable
and inoperable
stage IIIC.
Stage
IV
Stage IV breast cancer. The
cancer has spread to other parts of the body, such as the brain, lung,
liver, or bone.
In stage IV, cancer has spread to other organs of the body, most
often the bones, lungs,
liver, or brain.
Inflammatory Breast Cancer
In inflammatory breast cancer, cancer has spread to the
skin of the breast and the breast
looks red and swollen and feels warm. The redness and warmth occur
because the cancer cells
block the lymph vessels
in the skin. The skin of the breast may also show the dimpled
appearance called peau d'orange
(like the skin of an orange). There may not be any lumps in the breast
that can be felt. Inflammatory breast cancer may be stage IIIB, stage IIIC, or stage IV.
Treatment Option Overview
Key Points
- Treatment options for pregnant women depend on the stage of
the disease and the age of the unborn baby.
- Three types of standard treatment are used:
- Surgery
- Radiation therapy
- Chemotherapy
- Ending the pregnancy does not seem to improve the mother's
chance of survival.
Treatment
options for pregnant women depend on the stage of the disease and the
age of the unborn baby.
Three
types of standard treatment are used:
Surgery
Most pregnant women with breast cancer have surgery to remove the breast. Some of the lymph nodes under the arm
may be removed and checked under a microscope
for signs of cancer.
Types of surgery to
remove the cancer include:
- Modified radical
mastectomy: Surgery to remove the whole breast that has
cancer, many of the lymph nodes under the arm, the lining over the
chest muscles, and sometimes, part of the chest
wall muscles. This type of surgery is most common in
pregnant women.
Modified radical
mastectomy. The dotted line shows where the entire breast and some
lymph nodes are removed. Part of the chest wall muscle may also be
removed.
- Breast-conserving
surgery: Surgery to remove the cancer and some normal tissue around it, but not
the breast itself. Part of the chest wall lining may also be removed if
the cancer is near it. This type of surgery may also be called
lumpectomy, partial mastectomy, segmental mastectomy, quadrantectomy,
or breast-sparing surgery.
Breast-conserving
surgery. The tumor and some normal tissue around it are removed, but
not the breast itself. Some lymph nodes under the arm may be removed.
Part of the chest wall lining may also be removed if the cancer is near
it.
Even if the doctor
removes all of the cancer that can be seen at the time of surgery, the
patient may be given radiation
therapy or chemotherapy
after surgery to try to kill any cancer cells
that may be left. For pregnant women with early-stage
breast cancer, radiation therapy and hormone therapy are given
after the baby is born. Treatment given after surgery, to lower the
risk that the cancer will come back, is called adjuvant therapy.
Radiation
therapy
Radiation therapy is a
cancer treatment that uses high-energy x-rays
or other types of radiation
to kill cancer cells or keep them from growing. There are two types of
radiation therapy:
- External radiation
therapy uses a machine outside the body to send radiation
toward the cancer.
- Internal radiation
therapy uses a radioactive
substance sealed in needles, seeds,
wires, or catheters
that are placed directly into or near the cancer.
The way the radiation
therapy is given depends on the type and stage
of the cancer being treated.
External radiation
therapy is not given to pregnant women with early stage (stage I or II) breast cancer because it
can harm the unborn baby. For women with late stage (stage III or IV) breast cancer, radiation
therapy is not given during the first 3 months of pregnancy and is
delayed until after the baby is born, if possible.
Chemotherapy
Chemotherapy is a cancer
treatment that uses drugs
to stop the growth of cancer cells, either by killing the cells or by
stopping the cells from dividing. When chemotherapy is taken by mouth
or injected into a vein or muscle, the drugs
enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When
chemotherapy is placed directly into the cerebrospinal
fluid, an organ,
or a body cavity
such as the abdomen,
the drugs mainly affect cancer cells in those areas (regional chemotherapy). The
way the chemotherapy is given depends on the type and stage of the
cancer being treated.
Chemotherapy is usually
not given during the first 3 months of pregnancy. Chemotherapy given
after this time does not usually harm the unborn baby but may cause
early labor and low birth weight.
See Drugs Approved for
Breast Cancer for more information.
Ending
the pregnancy does not seem to improve the mother's chance of survival.
Because ending the
pregnancy is not likely to improve the mother's chance of survival, it
is not usually a treatment option.
Treatment Options by Stage
Early Stage Breast Cancer (Stage I and
Stage II)
Treatment of early-stage breast cancer (stage I and stage II) may include the
following:
- Modified radical
mastectomy.
- Breast-conserving
surgery followed by radiation
therapy. In pregnant
women, radiation therapy is delayed until after the baby is born.
- Modified radical mastectomy or breast-conserving surgery
during pregnancy followed by chemotherapy
after the first 3 months of pregnancy.
Late Stage Breast Cancer (Stage III and
Stage IV)
Treatment of late-stage breast cancer (stage III and stage IV) may include the
following:
- Radiation therapy.
- Chemotherapy.
Radiation therapy and
chemotherapy should not be given during the first 3 months of pregnancy.
Other Information About Pregnancy and Breast Cancer
Key Points
- Lactation (breast milk production) and breast-feeding
should be stopped if surgery or chemotherapy is planned.
- Breast cancer does not appear to harm the unborn baby.
- Pregnancy does not seem to affect the survival of women who
have had breast cancer in the past.
Lactation
(breast milk production) and breast-feeding should be stopped if
surgery or chemotherapy is planned.
If surgery is planned,
breast-feeding should be stopped to reduce blood
flow in the breasts
and make them smaller. Breast-feeding should also be stopped if chemotherapy is planned.
Many anticancer drugs,
especially cyclophosphamide
and methotrexate,
may occur in high levels in breast milk and may harm the nursing baby.
Women receiving chemotherapy should not breast-feed. Stopping lactation
does not improve the mother's prognosis.
Breast
cancer does not appear to harm the unborn baby.
Breast cancer cells do not seem to pass
from the mother to the unborn baby.
Pregnancy
does not seem to affect the survival of women who have had breast
cancer in the past.
For women who have had
breast cancer, pregnancy
does not seem to affect their survival. However, some doctors recommend
that a woman wait 2 years after treatment for breast cancer before
trying to have a baby, so that any early return of the cancer would be detected.
This may affect a woman's decision to become pregnant. The unborn baby
does not seem to be affected if the mother has had breast cancer.
-NIH
