Editing Breast cancer (section)

=== '''Breast cancer in pregnancy''' ===

** Important to mention to respect wishes of patient with respect to fetus and discuss at MDM. 
*** Early termination of pregnancy does not improve breast cancer outcomes.
*** Delaying oncological treatment until birth is not usually a good option
*** Breastfeeding is safe and feasible from both breasts afterwards
*** Customary to recommend delaying conception for 2 years after initial treatment
** More likely to be ER/PR negative and HER2 + or -; more commonly high-grade; more commonly locally advanced
** Any breast lump discovered during pregnancy/lactation should be evaluated with mammogram (shielded), USS and biopsy
*** Usually start off with USS, especially if presenting complaint was lump
*** MRI is difficult to interpret without gadolinium due to pregnancy-related changes, but gadolinium is probably harmful to fetus, especially in first trimester
** Staging
*** Common approach for node-positive disease: 
**** CXR with shielding
**** USS abdo/liver
**** MRI liver/chest/brain/other area as required - without gadolinium
**** Low-dose bone scan only if there are symptoms of bony metastases
** Local treatment options:
*** Mastectomy usually the safest option, especially early on in pregnancy - radiation can't be given during pregnancy
*** BCS may be an option later in pregnancy when RTX can be given post-partum without too much delay
** Regional treatment:
*** SLNB can be done safely with 99mTc sulfur colloid like normal, but not blue dye
*** ALND is usually performed for the positive axilla
** Systemic treatment
*** Start chemotherapy once the first trimester is over
**** Neoadjuvant anthracycline is safe starting the second trimester - doesn't cross the placenta - series of 197 women with no increased risk of complications of birth or development
**** Taxanes appear safe - growing evidence base
*** Don't recommend delaying systemic therapy until after delivery
** Contraindicated:
*** Trastuzumab is not given - causes oligohidramnios in 50%
*** Tamoxifen is not safe for fetus
*** Immunotherapy
*** Blue dye
*** Radiotherapy
** Most common approaches:
*** First trimester: 
**** Early: mastectomy + SLNB, followed by CTX in second trimester if required and hormonal/HER2 therapy post-partum
**** Advanced: mastectomy + ALND + CTX in second trimester and hormonal/HER2 therapy +/- RTx post-partum
*** Second or third trimester
**** Early cancer: BCS with post-partum RTx vs mastectomy. SLNB. Endocrine/HER2 therapy post-partum.
**** Advanced: neoadjuvant + mastectomy + ALND + adjuvant trastuzumab/endocrine post-partum