44. Breast cancer & pregnancy.
termination should be recommended if the diagnosis is made in pregnancy.
|b.||tumours diagnosed in pregnancy tend to be more advanced than those in the non-pregnant.||True|
radiotherapy in pregnancy carries zero fetal risk with expert screening.
|d.||termination should be recommended if unplanned pregnancy occurs in a woman who has previously been treated for breast cancer.||False|
|e.||women planning pregnancy after treatment for breast cancer should be advised to wait for one year before conceiving.||False|
|f.||women planning pregnancy after treatment for breast cancer should take 5mg. folic acid.||False|
|g.||Tamoxifen can be continued safely during pregnancy.||False|
The RCOG has issued guidelines on breast cancer in relation to pregnancy.
There are obviously not huge numbers of patients who have been followed up for decades, but enough to give a reasonably positive opinion.
If the tumour is diagnosed in pregnancy, it tends to be more advanced.
Probably due to later diagnosis.
Breast lumps are common in pregnancy and may not generate the same diagnostic urgency.
Mammography is less sensitive in premenopausal women, compared with postmenopausal and pregnancy exaggerates this.
Best off with early needle or excision biopsy.
The dilemma is what treatment.
Lumpectomy + local radiotherapy is a common package.
Even with the best screening, the baby will get a dose of radiation and the more advanced the gestation, the greater this will be.
In the third trimester a compromise may be reached in which the radiotherapy is deferred for the safety of the baby, but this is less attractive in earlier pregnancies.
Clearly, detailed discussions about risk/ benefit need to take place with the woman and her family.
The woman who has had breast cancer is advised to wait 3 years before pregnancy.
Obviously her age will temper this, but it is believed to minimise the risk.
There is no evidence that pregnancy itself stimulates recurrence.
The aim of waiting is to ensure that the natural history of the particular tumour is not one of recurrence.
The longer she goes from initial treatment without problems, the smaller the risk of recurrence.
As there is no evidence that pregnancy worsens the outlook per se, there are no grounds for recommending termination.
Many women will opt for termination on the basis that they have enough to cope with dealing with cancer.
Others will not want to bring a child into the world with a risk that it could be motherless at an early age.
The counselling should allow for these attitudes without falsely justifying termination on the grounds that it reduces recurrence risk.
As always, women are individuals with unique circumstances.
Tamoxifen has been shown to be teratogenic in animals with some parallels with stilboestrol.
It might be perfectly safe, but we will probably need to wait for reports of inadvertent conception with continued Tamoxifen consumption before we can know.
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