M. D. Anderson Cancer Center
Cancer Newsline Audio Podcast Series
Date: September 1, 2008
Duration: 0 / 13:14
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Welcome to Cancer Newsline a weekly podcast series from The University of Texas Cancer Center M. D. Anderson Cancer Center in Houston, Texas. The aim of Cancer Newsline is to help you stay current with the news on cancer research and the rapidly changing advanced in cancer diagnosis, treatment and prevention. We also hope to provide you with the latest information on reducing your family risk of being diagnosed with cancer. My name is Leonard Zwelling; I’m a professor of medicine and pharmacology here in M. D. Anderson and today we will be talking with Dr. Jennifer Litton and Dr. Richard Theriault both from the Department of Medical Breast Oncology. Dr. Litton is an assistant professor and Dr. Theriault is a full professor. We will be talking about the issues of pregnancy and fertility and both of these things during and after pregnancy.
As women are delaying child birth the incidence of breast cancer and pregnancy and the issue of future pregnancy after treatment for breast cancer must be considered when discussing treatment of breast cancer with young women. We will also address the diagnosis and treatment and of breast cancer concurrent with pregnancy. The affects on the children exposed to cancer treatments in utero and the potential for future pregnancies.
Good afternoon Dr. Litton, Dr. Theriault. Lets start with the obvious thing is it really common to have a diagnosis of breast cancer during pregnancy?
No, it’s uncommon. In a study in California which match pregnancy with cancer diagnosis the likelihood of breast cancer during pregnancy was 1.3 per ten thousand live births. So it’s very uncommon. Other data suggest it’s 1 in 3,000 pregnancies to 3 and 10,000. So its not something your will not see everyday in the practice.
More common in older women?
Well, yeah our median age is more then 35. So women I’ll oldest patient is 42 but it can occur at any age especially, when women who have a hereditary predisposition to developing breast cancer.
Breast cancer that is diagnosed in pregnant women identical non-pregnant women with breast cancer. Is there any difference in them? I know there with estrogen receptor statues. Is there any difference?
From what were seeing it appears to be people that are being diagnosis at the same age. So really the age is what driving the cancer diagnosis and the treatment and the tumor type.
Pre-menopausal l verses post-menopausal breast cancer is a big issue obviously all these women are pre-menopausal. Does the distribution of cancer match what you see in most in pre-menopausal then?
It’s does match and what we learning in recent data last week. Show that something we known for a long time is that women diagnosed under 35 have more aggressive cancers and it’s biologically different and now that where able to looks at things on a molecular level that’s really baring out.
But there is no big difference between the breast cancer you see in pregnant women and non-pregnant women.
Correct.
Obviously the first question is whether to terminate the pregnancy. When a women finds out she is pregnant and has cancer. What’s the answer to that question?
No, it’s a personal choice. A termination of pregnancy has no impact on the outcome of the breast cancer treatment. So the decision to be made is to weather to proceed with treatment while pregnant. Delay treatment while pregnant or terminate the pregnancy and proceed as you would without a pregnancy type diagnosis. Most of the women who come to us, come because they want to maintain their pregnancy. But it has no negative impact on the impact.
That’s very important. The second thing that comes to mind is we all know that once the diagnosis is made there are a fair number of imaging studies that need to be made. To find out where the cancer may or may not be. Is there a danger to that in a pregnant woman and does a pregnant women have to undergo some special manipulation because of the imaging that needs to be done?
Absolutely, we do tailor the imaging to the pregnant breast cancer patient. We try to avoid things like CAT scans because of the amount of radiation that would affect the fetus. We… mammograms we do proceed with and they are safe with shielding. As well as ultrasounds we try to use ultrasounds to evaluate the liver to look for metastatic disease there as well as MRI to which have been pregnant women for a long time to look for disease in spine or bone. Which are likely places for metastatic disease to occur.
So you can get a good assessment of the women stage from the beginning. Surgery, how do you time the surgery for a woman with breast cancer and visa vie the pregnancy.
So it really makes no difference. The outcome of the surgery is related to the location of the surgery. So intra-abdominal surgeries during pregnancy are more risky. Then lets say thyroid surgery in the neck or breast surgery and if you look at the series of published studies the major risk is that you have intra-uterine growth retardation in other words you have a small baby, but most of the time these are from women who are sick. So we don’t know if sickness makes a difference or the surgery makes a difference and in our own series we operated first trimester to third trimester. Without any undue complications.
Does that include plastic surgery if the woman desires it?
We haven’t done any plastic and reconstruction surgery because most of the women are in the active phase of receiving systemic therapy so we will delay that to a later point.
Radiation therapy is the cornerstone of the treatment of breast cancer, does that have to be delayed during pregnancy?
We do, we do delay it until after the delivery and it's not a delay of the radiation because by the time… during the pregnancy they are receiving their chemotherapy and they're receiving their surgery so we're not delaying it but we do it after.
That’s the sixty-four thousand dollar question of course is the chemotherapy. When we were in medical school; well at least when I was in medical school in the dark ages, people were concerned about the fact that chemotherapy with a baby on board, so that has been proven to not to be the case.
In general I would say yes, but it’s also drug specific and we think trimester specific. So the fetus is at the greatest risk during the first trimester, the first thirteen weeks of development and there are certain drugs that are bad at that time. Some that cause abortions for example are fetal malformations in our own series in drugs that we use after first trimester we had no major complications. No substantial fetal malformations and no untoward delivery complications. So can it be done safely? Yes, and it seems peculiar because you tell women don’t smoke, don’t drink, don’t breathe the air in Harris County and then we say but we are going to give you a little chemotherapy to kill your cancer. Laugh.
Laughs.
So it seems incongruous but practically it works out well for the women and so far for the kids.
So the women with breast cancer during the pregnancy do as well with women of the same age and with the same type of cancer who are not pregnant.
They do, and in fact they do really well with the chemotherapy and in fact they tend to tolerate the chemotherapy better then the women who are not pregnant patients. We're not sure why that is, I’ll sure would like to bottle it! Laugh… But they do quite well!
Laugh. Then of course they next big question is how do the children do who are born? Does the pregnancy go normally? Is the birth normal? What about the kid, subsequently and also in long term?
The deliveries have gone quite well and the children have done very well. We have updated our group last was two years ago with fifty-seven patients. Of those, three had congenital issues one was Downs Syndrome, and that occurs long before you even talk about chemotherapy. One had urethral reflux and another one had club foot. All of those, we do not believe, are related to chemotherapy.
So the incidence of those abnormalities is what it would be in the population.
But the children are all developing quite well. There are only two that require special needs, one was the child with Down Syndrome but are doing well in school and the only data we have long term is from a group in Mexico of 84 children that are followed who were exposed to chemotherapy when there mothers where being treated for leukemia or lymphoma, and today they are doing quite well with no long term cardiac problems or neuro-cognitive problems. It has not been effectively looked at in breast cancer patients.
Can these women breast feed?
Usually not, because generally the chemotherapy continues after delivery and chemotherapy drugs many of them are excreted in breast milk. So the infant would then get exposure to chemotherapy. We recommend that they not do that.
Let’s turn the question around a little bit. What about a woman who had breast cancer then successfully treated for breast cancer. Can that woman become pregnant safely?
Assuming her ovaries are still functioning, yes. The answer is yes, she may become pregnant. I generally recommend as a personal preference that they wait two to three years because that’s the highest risk years when the cancer could come back. Most people don’t, they just go and get pregnant who cares about the doctor right? They want to have a baby. So the question does it increase the risk of the breast cancer coming back or does it increase the chance of dying from breast cancer and the answer appears to be no. Jennifer has reviewed the data on that recently from the retrospectives and whatever studies and maybe she wants to comment.
Sure, in fact, from what we have seen from the literature that’s been published, it that it not only does it not increase your risk occurrence but it seems to decrease your risk of occurrence.
About forty to fifty percent which is we have no clue as to why that would be.
Whether you have gone nine months without ovulation could be part of it. That you’re somehow also treating anti estrogen.
Are there any other cancers that are prevalent during pregnancy?
Sure, thyroid cancer would be one, cervix cancer would be one, leukemia and lymphomas, but none to be as frequent as breast cancer and whether that's just a peculiarity of aging, an increase incident of breast cancer, or whether it's truly related phenomenon we don’t know.
The one thing we have not touched upon is psychological needs of these patients. Obviously there is a very mixed emotions here. First the joy of having a pregnancy, and the sorrow of trying to handle a difficult disease. So how do you deal with that, are there a special group of folks here that are experts at this?
I think that the key is a multidisciplinary approach and have a good communication between the patient the medical oncologist, surgical oncologist we also have our colleagues from maternal fetal medicine from a collaborating hospital and good communication between all of them. The patient really needs to get the best information that we have available to make the decision that’s best for her and we just try to help her as much as possible.
Do the obstetrician carry these as high risk pregnancies?
We send them to high risk maternal fetal medicine people. However, there impression is that there not really high risk. More then half the women have regular vague deliveries. They have planned caesarians in we haven’t had but one patient who had preeclampsia she had preeclampsia with her first pregnancy also. So they don’t consider them high risk except by age.
Excellent, excellent! Are there any other points either of you would like to make about this fascinating subject. I think in the past people would have not imagined. I think in the past people would have terminated the pregnancy or not treated the patient.
I think that’s the biggest take home message that there is a choice to get another opinion. We will continue to work towards getting more information about the children who are exposed to chemotherapy in utero. But all of our preliminary information the information we gathered to date is that it can be done and it can be done safely with no risk to the mother and the fetus.
Dr. Theriault, Dr. Litton. Thank you for your time. Listeners if you have any questions about anything you heard today please contact M. D. Anderson at 1-877-MDA-6789 or online www.mdanderson.org/ask. Thank you for listening this episode of Cancer Newsline. Again this is a weekly series please tune in again next week for our next episode of this series. You can do so by visiting www.mdanderson.org/newsroom and click subscribe from the menu. Or subscribe for free through Apple iTunes and the M. D. Anderson iTunes University page you can get there directly by typing www.mdanderson.org/itunes .
Thank You.
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