Fighting breast cancer while pregnant

“You need to come in for a biopsy,” Zoila Leiva of Whittier, Calif. recalls her doctor’s office explaining. “It’s a mass and you need to get it checked.”

Leiva just 38 years old— and 17 weeks pregnant with twins.

The year before her diagnosis, she had breast augmentation surgery. When she became pregnant a few months later, she noticed a small lump in her breast. She had a mammogram and an ultrasound and was told it was a benign cyst that would eventually disappear.

Leiva had a miscarriage but became pregnant again and noticed that the lump had grown larger. She had another ultrasound and two weeks later, got the results: stage 3C breast cancer that had also spread to her lymph nodes.

“[The oncologist] recommended I have an abortion because at that point they didn’t know whether the cancer had spread to the lungs, liver or kidneys and there was no way of knowing because I was pregnant,” she said.

Feeling scared and confused, Leiva went to an abortion clinic. Yet after listening to the physician explain the three-day procedure, she changed her mind.

“I said to myself ‘If I don’t die of cancer, I’m going to die of depression knowing that I killed these two babies just to save my life,’” she remembered. “If it’s God’s will to take my life then so be it, but I’m going to have these babies.”

Leiva went for several more opinions and all of the doctors agreed. She was past her first trimester and chemotherapy would not harm her babies.

Leiva had four rounds of chemotherapy while she was pregnant and delivered her sons at 32 weeks in spring 2008. They were larger than doctors expected, eating and breathing on their own and spent just two weeks in the neonatal intensive care unit (NICU).

“They shocked everyone,” Leiva said.

After six additional rounds of chemotherapy, radiation, a bilateral mastectomy and reconstruction surgery, Leiva went into remission in 2009. Today, her 6-year-old sons are healthy and active and doing well in school.

“It’s a miracle,” she said.

Breast cancer is common during pregnancy.
According to the American Cancer Society, breast cancer is found in about 1 in every 3,000 pregnant women. It’s also the most common type of cancer found during pregnancy, breastfeeding and within the first year of delivery.

However, pregnancy does not cause breast cancer to develop. It’s simply that women between the ages of 15 and 44 who develop breast cancer are also of reproductive age and are more likely to be pregnant, said Dr. Michael Pearl, professor and director of the division of gynecologic oncology and director of women’s cancer services for the Stony Brook University Cancer Center in New York.

Pregnant women also tend to be diagnosed in later stages than women who are not. This is primarily a result of breast changes during pregnancy.  Pregnant women’s breasts are usually larger, more tender and feel different than they did prior to pregnancy, so women and their doctors may not feel a lump.

There’s also a concern about exposure to radiation so pregnant women are not usually evaluated as aggressively.  What’s more, providers are often hesitant to order a biopsy or mammography because women are presumed to be young and healthy during pregnancy, Pearl said.

Chemotherapy is relatively safe.
“Breast cancer is a very manageable disease even if it has spread,” said Dr. Jane Kakkis, medical director of breast surgery at MemorialCare  Breast Center at Orange Coast Memorial Medical Center in Fountain Valley, Calif. Kakkis performed Leiva’s mastectomy.

At one time, chemotherapy was thought to increase the risk for miscarriage, premature delivery or birth defects.  Yet after the first trimester, research shows that chemotherapy is relatively safe and terminating a pregnancy will not improve a woman’s prognosis, Pearl said.

In fact, toddlers who were exposed to chemotherapy in utero had the same mental development and heart function as those who were not, according to a study presented at the European Society for Medical Oncology’s conference in September.  A second study found that children and adults who were exposed to radiation in utero had no adverse effects.

Chemotherapy, however, is not without risks. Babies born to moms treated with chemotherapy may be smaller. They’re usually delivered early, especially if treatment is deemed to be safer if administered after the baby is born.  Also, if the chemotherapy crosses the placenta, it may cause the baby to have a low white blood cell count.

What are other options?
When deciding on a treatment plan, it’s important to consider what impact the treatment could have on the pregnancy and how the pregnancy will affect treatment. If the woman does not wish to have a child and the pregnancy could complicate the management of the cancer, then she may consider terminating the pregnancy.

“If it’s a desired pregnancy, then we work around that,” Pearl said.

There are several treatment options depending on the stage of the cancer, how far along the pregnancy is and the woman’s preferences. For example, women may opt for a lumpectomy and chemotherapy and then delay radiation until after delivery.

A mastectomy may not be necessary and reconstruction can always be done after delivery too.

“The least amount of surgery should be done in order to clear the cancer,” Kakkis said.

The same goes for a bilateral mastectomy.

“Only the cancer side should be addressed during the pregnancy and the other side should be left alone to minimize the risk of complications,” she said.

For women who need radiation, a shield and other types of technology can ensure that the treatment is administered precisely.

“There’s still going to be some scatter dose, but it should be low enough that it shouldn’t have a significant impact on the baby,” Pearl said.

Hormone and targeted therapy drugs are never safe during pregnancy.

Additionally, women who are diagnosed with inflammatory breast cancer— an aggressive form of the disease—should be treated immediately because the illness could worsen.

It takes a village.
Experts say women who have breast cancer and become pregnant should always get multiple opinions and make sure they feel confident with the physicians they choose.

“This is a challenging clinical situation and you don’t want to deal with a doctor who doesn’t do enough breast cancer treatment to know how to negotiate the pathway with a patient,” Kakkis said.

“If a woman is diagnosed with cancer during pregnancy, it’s crucial for her to be evaluated and managed by a multi-disciplinary team,” Pearl said. “It isn’t just the oncologist.”