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Evaluating a Breast Abnormality During Lactation (Breast-Feeding)
If a worrisome breast lump or abnormality is found after birth when a woman is
breast-feeding, diagnostic mammography and/or other breast imaging exams should not be
delayed. Mammography is considered safe and can be accurate for women who are
breast-feeding when performed with care. Some suggest that the breast should be completely
emptied of milk immediately before the mammogram, either via nursing or breast pump. This
decreases the density through which the x-rays must penetrate and helps improve image
quality.
It is important to keep in mind that imaging tests are not foolproof and may not detect
a mass even when it can be felt during a physical examination. Approximately 10% to 15% of
breast masses are missed with mammography or ultrasound (sonography) in women who are not
lactating, and this percentage can be as high as 25% in the denser, larger, lactating
breast. For this reason, a breast abnormality detected during lactation will often need to
be biopsied to determine whether it is cancerous or benign.
Fine needle aspiration (FNA) involves using a thin
needle to sample fluid or cells from the breast. FNA is often used to identify or drain
cysts (collections of fluid). Other biopsy methods, such as core
needle biopsy or open surgical biopsy, can also be
performed safely. However, these more invasive methods are usually reserved for cases when
the diagnosis cannot be made by other, less invasive means. This is because milk fistulas
(abnormal passages of milk) or collections of milk in the breast may result when a biopsy
is performed on a lactating breast. Nevertheless, milk fistulas are rarely a problem and
are more of an inconvenience compared with the more dangerous possibility of an
undiagnosed breast cancer. If a biopsy is performed and a collection of milk does result,
it can easily be drained by fine needle aspiration in the physician’s office.
Most of the breast problems encountered during breast-feeding are inflammatory or
infectious complications rather than breast cancer. Nasopharyngeal organisms (such as a
cold virus) from the infant’s mouth, sinuses, and other air passages can be a common
source of infection in breast-feeding women.
Common breast-feeding problems include:
- Inadequate milk supply
- Blocked milk duct
- Breast engorgement
- Breast mastitis (infection)
- Nipple discharge
- Nipple confusion
- Breast pain
- Nipple soreness
- Inverted or flat nipples
 Click here for more information about these problems
and how they can be treated.
A Breast Cancer Diagnosis During Pregnancy
While a diagnosis of breast cancer during pregnancy can be quite distressful, it is not
necessary to terminate the pregnancy unless the woman chooses. A woman’s chances of
surviving breast cancer are the same regardless of whether the pregnancy is terminated or
not, although more treatment options may be available if the pregnancy is ended. The
occurrence of breast cancer itself during pregnancy does not appear to harm the fetus.
However, some of the tests and treatments may increase the risk of malformation or
miscarriage of the fetus; the risk varies depending on the stage (trimester) of the
pregnancy.
It is not necessary to
terminate the pregnancy if breast cancer is diagnosed. |
If a pregnant woman is diagnosed with breast cancer, her team of cancer
specialists will first need to determine the stage of the cancer. Staging
breast cancer includes accurately measuring the size of the tumor and the extent to which
it may have spread within the breast and/or to other locations. In addition to imaging
exams such as ultrasound (sonograms), blood tests will typically be performed to determine
whether the cancer has spread to other organs in the body (such as the bone, liver, or
lung). In some cases, physicians may test for breast cancer markers, such as CEA or CA 15-3, which may be elevated in women with
breast cancer. However, blood markers may be less accurate in early-stage breast cancers
or in pregnant women and may not be helpful. While chest x-rays are
performed during pregnancy to determine whether the cancer has spread to the lungs and
other areas, certain tests such as CT scans are not typically
performed on pregnant women because of their higher radiation exposure.
The treatment of breast cancer during pregnancy should not be delayed unless a woman is
within 2 to 3 weeks from her delivery date. Radiation, chemotherapy, and drug therapy are not typically given during pregnancy because they
can potentially harm the fetus. However, recent studies show that women who receive
chemotherapy during the second or third trimesters of pregnancy (after the first three
months) still have good chances of having healthy babies. In more than one study, women
who received chemotherapy during the second or third trimesters of pregnancy had live
births and only a few had complications from the chemotherapy, such as early labor and low
birth weight. However, the long-term effects of exposure to chemotherapy drugs during
pregnancy are less well-studied and should be discussed in detail with treating
physicians.
Surgery is commonly performed during pregnancy for a variety of conditions, and if
proper care is taken during anesthesia and after surgery, generally no harm comes to the
fetus. Typically, a mastectomy is recommended if breast cancer is diagnosed during the
first or second trimester of pregnancy (the first six months). Mastectomy
involves surgically removing the entire breast and often some or all of the axillary
(underarm) lymph nodes. Mastectomy often prevents the need
for radiation treatment. Chemotherapy or drug therapy is typically delayed until later in
the pregnancy or after delivery, although the risks and benefits must be carefully
weighted.
If breast cancer is diagnosed during the third trimester of pregnancy (the final three
months), either mastectomy or breast-conserving therapy (i.e., lumpectomy)
with lymph node removal may be performed as needed. Lumpectomy involves only removing the
cancerous tumor and a surrounding margin of normal breast tissue. Radiation, chemotherapy,
or drug therapy is usually delayed until after childbirth. Women who receive chemotherapy
or other drug therapies after childbirth should not breast-feed because the drugs could be
passed through the breast milk. Breast reconstruction
is not typically performed until after childbirth and lactation, when the breasts return
to their normal size and milk production has ceased completely.
Pregnancy After Breast Cancer
A number of women who have successfully undergone treatment for breast cancer wish to
have further pregnancies. Stage for stage, breast cancer during pregnancy has a similar
prognosis (outcome) to that of breast cancer in young, non-pregnant women. According to
recent studies, women who have been successfully treated for breast cancer in the past do
not usually experience fertility problems unless chemotherapy is administered as part of
the treatment. Pre-menopausal women treated with chemotherapy should be aware that the
treatment can cause infertility and/or premature menopause, especially in older
pre-menopausal woman (typically in their forties) who are already naturally less fertile
and closer to menopause. The hormonal and
metabolic changes that occur during pregnancy do not typically pose any increased risk of recurrent breast cancer, although studies in this area
continue.
One study led by Dr. Priscilla Velentgas of the University of Seattle found that women
who became pregnant after being diagnosed with Stage I or Stage II invasive breast cancer were not at greater risk of
recurrent breast cancer than survivors that did not become pregnant. Further research has
since confirmed the study. Additionally, neither the number of pregnancies nor the time
lapsed between treatment for breast cancer and pregnancy appear to have any noticeable
effect on long-term breast cancer prognosis.
For women diagnosed with early-stage breast cancer, pregnancy is usually reasonable two
or more years after diagnosis and treatment. However, some women may be advised to have
children sooner if they are older and there are other considerations. Several details such
as cancer type, degree of metastasis (spread), and amount of radiation and/or chemotherapy
received should be considered before advising a woman whether it is safe to become
pregnant after breast cancer. For example, those at higher risk for an early recurrence
may be advised to wait and be closely observed prior to attempting a pregnancy. If a
pregnancy is successful after having been treated for breast cancer, some women who have
had radiation therapy on one breast find that a sufficient amount of milk for
breast-feeding cannot be produced by the irradiated (treated) breast. However, the other,
normal breast can often produce enough milk to enable breast-feeding.
Women with Stage IV (metastatic) breast cancer or recurrent
tumors may not be good candidates for future pregnancies. Chemotherapy may also have an
adverse effect on the ovaries and lead to fertility problems or a higher rate of
spontaneous miscarriages. However, each individual is different, and all pre-menopausal
women should discuss the issue of future pregnancies with their physicians before their
initial breast cancer treatment if they are interested in having children after treatment.
In some cases, women may wish to consider banking eggs prior to treatment (particularly
chemotherapy) if they wish to have children in the future.
Additional Resources and References
Updated: November 13, 2007
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