Abstract
Breast cancer is the most common malignant tumor among women. This paper focuses on the various aspects of breast cancer among women. The paper briefly examines the various treatment options available for women diagnosed with breast cancer at any stage of pregnancy. The paper further examines the risk factors to breast cancer, birth defects, and chances of relapsing after delivery, how treatments affect fertility, and Survival Rate Female/Fetus. The paper outlines radiotherapy, chemotherapy, and surgery as the main treatment options for breast cancer available for women diagnosed with breast cancer. In terms of birth defects, the paper outlines some of the defects that are commonly experienced as a result of administration of some treatment options. In this case, three main defects, all attributed to Tamoxifen, are discussed. They include goldenhar syndrome, Pierre Robin Sequence and ambiguous genitalia.
Introduction
Breast cancer is the malignant tumor that develops from the cells in the breast tissues. It presents many complications when diagnosed in women during pregnancy. Breast cancer is said to be associated with pregnancy if it is diagnosed during any stage of pregnancy and within a number of years after delivery (Lyons, Schedin, Borges, 2009). In this case, it is termed pregnancy-associated or PABC (Lyons, Schedin, Borges, 2009). Breast cancer is mainly common among women. As a matter of fact, many people believe that only women are susceptible to it. For instance, a study by Thomas (2010) involving twenty eight English-speaking male subjects found that 80% of the participants were not aware that men too are susceptible to breast cancer. On the contrary, studies show that men, especially at the age of eighties are susceptible to male breast cancer.
Many studies now show that the prevalence of female breast cancer is on the rise. For instance, studies predicted that this type of cancer could affect 40,000 women living in the United States in 2009 (Lyons, Schedin, Borges, 2009). In addition, there is almost 1 out of 3000 cases of cancer associated with pregnancies (Amant et al., 2010). Breast cancer is the most common malignancy being diagnosed during pregnancy (Cardonick, 2010). Most of these studies also attribute the rising prevalence of pregnancy-related breast cancer to the increased trend among women to postpone childbearing. For instance, Cardonick et al. (2010), Amant et al. (2010), and Johansson et al. (2011) all acknowledge that the current rise in prevalence of female breast cancer detected during pregnancy is attributed to the rising tendency among women to postpone child bearing. Considering the rising trend among women to postpone child bearing, the incidence rates of pregnancy-related breast cancer are likely to continue increasing. Consequently, there is a need for increased awareness of management of the condition during pregnancy.
Treatment Options
Women diagnosed with cancer during pregnancy are faced with many challenges. The condition poses harm to both the mother and fetus. Consequently, women tend to fear for their expected babies and themselves. Indeed, some women opt to procure abortion for fear of the consequences attributed to the condition itself or the treatments received for the condition. Once diagnosed with breast cancer in the course of their pregnancy, women should seek medical assistance in order to ensure positive obstetric and fetal outcome. In this case, they should select the most appropriate treatment method based on their situation and preference.
Several treatment options are available for women with breast cancer detected during pregnancy. Some of the available options are; chemotherapy, surgery, and radiotherapy. Once a woman is diagnosed with breast cancer while still in the first trimester stage of the pregnancy, she should choose whether to terminate the pregnancy or conserve it to delivery. However, a woman should get proper counselling on the option chosen and the expected outcome of the condition. It is also highly recommended that treatments should be initiated soon after breast cancer is diagnosed unless delivery is already predicted and planned for in the next 2 to 4 weeks (Amant et al., 2010).
Surgery
Surgery is recommended during the first, second, and third trimesters (Amant et al., 2010). In this case, multidisciplinary approach involving anesthesiologists, breast surgeons, and obstetricians is recommended. This approach helps achieve maternal and fetal wellbeing during and after surgery. Breast conserving surgery, radical modified mastectomy, and sentinel lymph node dissection are all recommended (Amant et al., 2010).Women who experience persistent fetal distress should choose early delivery before surgery is initiated. Anesthetics are used in the surgical procedures. In addition, this option involves monitoring of intraoperative fetal heart rate. Intraoperative fetal heart rate provides the basis on which early fetal compromise can be detected (Amant et al., 2010). The guidelines recommended for the surgery of breast cancer in pregnant women are similar to those recommended for non-pregnant women with breast cancer.
Chemotherapy
Chemotherapy has been widely used as a means of managing cancer for several years (Cornette, 2012). It is one of the options available for women diagnosed with breast cancer during their pregnancy period. This method can be recommended on the basis of the size of the tumor and its other biological aspects (Amant et al., 2010). Chemotherapy is also contraindicated in the first trimester since it is associated with miscarriage, major malformations, and even fetal death (Amant et al., 2010). Besides, chemotherapy leaves other organs such as hematopoietic system, the eyes, and the central nervous system vulnerable after its application. These effects imply that the chemotherapy impairs the processes taking place during organogenesis. Since organogenesis takes place in the first trimester, women should not choose chemotherapy as an option for managing breast cancer during the first trimester. However, administration of chemotherapy in the second trimester is recommended when carried out safely. By the second trimester, organogenesis has taken place hence the interference induced by chemotherapy is not experienced.
Chemotherapy dosage recommended for pregnant women is similar to the dosage recommended for non-pregnant women diagnosed with cancer. This fact holds despite the fact that pregnancy is associated with numerous physiological changes. It is expected that the physiological would alter the pharmacokinetics of cytotoxic drugs, thus necessitating the need to vary the dosage. However, given that no study has reported any pharmacokinetic change that would warrant the need for varying the dosage for pregnant women diagnosed with cancer, the recommendations followed by non-pregnant women are still applied overall.
In chemotherapy, several drugs are used. Such drugs include 5-fluorouracil (F)-doxorubicin (A), vinca alkaloids, and anthracyclines. Women can choose any of the regimens since no study has reported a special side effect, high toxicity level, or outcome of any of the regimens. According to a study involving prenatally-exposed children to maternal cancer treatment conducted by Cornette (2012), there is no association between exposure to chemotherapy and increased cardiac, CNS, and auditory morbidity. Therefore, proper administration of chemotherapy during the recommended trimester is safe and available for selection by women as a means of managing breast cancer during pregnancy. However, women are advised to follow all the provided guidelines in order to avoid effects that may arise following such incidences as overdoes or underdoes.
Radiotherapy
Radiotherapy is another option available for suffering from pregnancy-related breast cancer. This treatment involves the application of radiation to the area with the tumor in order to kill the cancerous cells. Radiotherapy is the most critical option of all the options for managing breast cancer in pregnancy. Radiotherapy can be administered either before or after delivery depending on certain circumstances of the mother. For instance, if the mother is diagnosed with breast cancer during the third trimester, radiotherapy is contraindicated since administering it in the late second or in the third trimester leads to the increase in the dose to a fetus (Amant et al., 2010). This increase in does to a fetus is attributed to the increased proximity of the fetus to the field of primary irradiation due to the increase in size of the fetus in the late second or third trimester (Amant et al., 2010). Therefore, radiotherapy is delayed for women diagnosed with breast cancer in the late second or in the third trimester until after delivery. Amant et al. (2010) state that radiotherapy is only recommended during the first and second trimester of pregnancy since it is relatively safer during this period. However, choosing this method requires advice and much information pertaining to the dangers associated with it.
Based on the recommendations for the various treatment options of the pregnancy-related breast cancer, women can identify the options that would ensure safe pregnancy outcome. The choice on which option to take should take into consideration the safety of the fetus during and after birth and that of the mother. Women should seek adequate help from physicians on all the aspects of each option. Regardless of the option one selects, all the guidelines should be followed strictly in order to safeguard the mother and the fetus.
Tamoxifen
Tamoxifen is a synthetic drug that functions as an antagonist. It is another means of managing breast cancer. However, tamoxufen use should be avoided during pregnancy since several birth defects have been reported among children born by mothers who use tamoxifen during pregnancy. Some of the birth defects attributed to the use of tamoxifen include goldenhar syndrome, Pierre Robin Sequence, and ambiguous genitalia (Amant et al., 2010).
Transtuzumad
This option is not recommended for pregnant women even though little research has been carried out on its effect. Therefore, there is still a need for further research on this method (Amant et al., 2010).
Risk Factors
Delayed child-bearing is one of the most prominent risk factors to pregnancy-related breast cancer. Studies have recorded a rising trend in the number of women opting to delay child bearing (Cardonick et al., 2010; Amant et al., 2010). The increase in the number of women delaying child-bearing and the increase in the prevalence of breast cancer during pregnancy indicate a positive correlation between the two variables. A possible explanation for this observed correlation is that women as women advance in age, their level of susceptibility to breast cancer increases. Pregnancy further raises the level of their risk to breast cancer.
Apart from delayed childbearing, several other risk factors to breast cancer have been reported. The study by Nelson and colleagues (2012) on female subjects aged from 40 to 49 years old reported identified the following as some of the risk factors to breast cancer: dense breasts on mammography, first-degree relatives with breast cancer, prior breast biopsy, second-degree relatives with breast cancer and heterogeneously dense breasts. Other risk factors identified in a study are; nulliparity, current usage of oral contraceptives, and age of thirty years or older at first birth (Nelson et al., 2012).
Many studies have found that mammographic density of breast is the most prominent risk factor to breast cancer. In a study by Nelson and colleagues (2012), mammographic density reported a 2-fold increase in the risk for breast cancer among women aged from 40 to 49 years. A cross-sectional study by Boyd and colleagues (2012) reported findings similar to those reported in a study by Nelson and colleagues. According to Boyd et al., breast density on mammography is strongly correlated with the risk for breast cancer. Genetic factors also influence the risk of breast cancer among women. In a study by Nelson and colleagues (2012), a strong association between having a first-degree relative with breast cancer and the risk of breast cancer was established. In this case, having a first-degree relative with breast cancer increased the risk of the disease by two-fold (Nelson et al., 2012). The two studies indicate that genetic factors bear the main influence on the risk for breast cancer. However, these findings do not indicate that there is no preventive measure that women with first-degree relatives suffering from breast cancer can put in order to lower their chances for developing breast cancer. On the contrary, they have control over other predisposing factors to breast cancer such as the use of oral contraceptives. It is also important to note that genetic factors are aided by other factors in the development of breast cancer. Therefore, genetically-predisposed women to breast cancer who fail to minimize their level of exposure to other risk factors for the disease exhibit an even higher risk for developing the disease.
Birth Defects
Birth defects associated with pregnancy-related breast cancer are mainly attributed to the treatment options chosen by the mothers during pregnancy. They are mainly caused by failure to choose the recommended treatment option. Some of the birth defects include among others; goldenhar syndrome, Pierre Robin Sequence, and ambiguous genitalia. All these defects are attributed to tamoxifen (Amant et al., 2010).
A child born with Pierre Robin Sequence exhibits the following characteristics: a smaller than normal jaw, breathing difficulties, and a tongue that falls back in the throat. Goldenhar syndrome involves deformities of the face (Millichap, 2013). A baby born with this defect presents with the following characteristics: a condition called microtia characterized by the presence of partially-formed ear or the absence of ear, a mouth with one corner higher than the other, a missing eye, and chin closure to the partially-formed ear (Bull et al., 2001; McNeil, 2009). Ambiguous genitalia is manifested differently in male and female victims. In males, the defect presents the following features: a small penis that resembles an enlarged clitoris, a small scrotum that separated by like labia, and abnormal position of the urethral opening. On the other hand, the defect may show the following features in female children: enlarged clitoris resembling a small penis, fused labia that may look like a scrotum, and misplaced position of the urethral opening (Brodsky, 2010). Defects may also result from overdose of radiation for mothers who choose radiotherapy.
Apart from delivery of a baby with defects, inappropriate treatment options may also result into premature birth. Consequently, emphasis is put on the need to be keen in selecting treatment options for managing cancer during pregnancy. In addition, fetal development should be regularly monitored while the mother is on treatment for breast cancer. Women should also take great note of their stage of pregnancy before selecting a treatment option for breast cancer.
Chances of Relapsing After Delivery
Getting pregnant following diagnosis of breast cancer is recommended. Studies have confirmed that women who conceive after being diagnosed with breast cancer have higher survival rates than their counterparts who choose not to conceive after being diagnosed of breast cancer. For instance, a study by Azim et al (2011) found that women who choose to conceive following their diagnosis of breast cancer exhibit higher survival rates. However, few studies have been conducted to compare
How Treatments Affect Fertility
Infertility is associated with most cancer therapies. Indeed, infertility is one of the most devastating consequences of most treatments options available for breast cancer. In this case, infertility mainly results from the damage caused to the ovary which results into decreased potential for reproduction among the females. The age of the victim and the dosage of pelvic radiation are some of the factors that influence the degree of damage caused to the ovary following the administration of chemotherapy or radiotherapy. The mechanism with which cancer therapy damage the female reproductive systems are not clearly understood. However, further research is essential in this area.
Breastfeeding
There are few guidelines recommended for breastfeeding for women who choose to breastfeed. For women who choose chemotherapy as an option for managing cancer during pregnancy, immediate breastfeeding after undergoing chemotherapy is not recommended especially if safety data is not available (Amant et al., 2010). In addition, milk production inhibition is recommended breastfeeding in order to prevent the accumulation of lipophilic agents as taxanes (Amant et al., 2010).
Survival Rate Female/Fetus
All the available treatment options for breast cancer in pregnant women have reported positive maternal and fetal outcome after delivery. Some studies show that women who choose to conceive following diagnosis with breast cancer have shown increased rates of survival (Van Calsteren et al., 2010; von Minckwitz et al., 2012). However, maternal and fetal outcomes of the various treatment options for breast cancer differ depending on the level of compliance by the mother.
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