{"product_id":"breast-cancer-during-pregnancy-a-patients-guide-to-the-2023-esmo-expert-consensus","title":"Breast Cancer During Pregnancy: A Patient's Guide to the 2023 ESMO Expert Consensus","description":"\u003cp\u003eIn 2022, the European Society for Medical Oncology (ESMO) brought together 24 breast cancer experts from 13 countries to answer difficult questions about treating breast cancer during pregnancy (PrBC). Randomized controlled trials cannot be done in pregnant patients. So the panel built its recommendations from the best available observational studies, registry data, and expert opinion. The panel recorded how many experts agreed with each statement. The panel concluded that breast cancer found during pregnancy is a distinct disease from cancer found after delivery. The panel concluded that prognosis is similar to other young patients of the same stage and subtype when treatment is adequate. The panel concluded that standard anthracycline- and taxane-based chemotherapy regimens can be given after 12 to 14 weeks of pregnancy. Chemotherapy remains absolutely contraindicated in the first trimester, when exposure carries up to a 20% risk of major birth defects.\u003c\/p\u003e\n\n\u003ch1\u003eESMO Expert Consensus Statements on the management of breast cancer during pregnancy\u003c\/h1\u003e\n\n\u003ch2\u003eTable of Contents\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\u003ca href=\"#ddn-key-points\"\u003eKey Points\u003c\/a\u003e\u003c\/li\u003e\n\n  \u003cli\u003e\u003ca href=\"#background\"\u003eWhy This Research Matters\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#methods\"\u003eHow the Consensus Was Developed\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#working-groups\"\u003eThe Three Expert Working Groups\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#pregnancy-vs-postpartum\"\u003eQuestion 1: Is Cancer During Pregnancy Different From Cancer After Delivery?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#rising-trend\"\u003eQuestion 2: Why Are More Cases Being Diagnosed?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#genomic-tests\"\u003eQuestion 3: Can Genomic Tests Guide Treatment in Hormone-Receptor-Positive Disease?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#imaging-local\"\u003eQuestion 4: Which Imaging Tests Diagnose and Stage the Tumor Itself?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#imaging-staging\"\u003eQuestion 5: How Should the Whole Body Be Checked for Spread?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#biology\"\u003eQuestion 6: Are These Tumors Biologically Different?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#prognosis\"\u003eQuestion 7: Is the Prognosis Worse Than for Other Young Patients?\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#chemotherapy-timing\"\u003eChemotherapy Timing: Why the First Trimester Matters\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#implications\"\u003eWhat This Means for Patients\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#limitations\"\u003eLimitations of This Work\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#recommendations\"\u003ePractical Recommendations\u003c\/a\u003e\u003c\/li\u003e\n  \u003cli\u003e\u003ca href=\"#ddn-faq\"\u003eFrequently Asked Questions\u003c\/a\u003e\u003c\/li\u003e\n\u003cli\u003e\u003ca href=\"#source\"\u003eSource Information\u003c\/a\u003e\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003c!-- ddn:keypoints:start --\u003e\n\u003ch2 id=\"ddn-key-points\"\u003eKey Points\u003c\/h2\u003e\n\u003cul\u003e\n\u003cli\u003eBreast cancer during pregnancy is biologically distinct from cancer after delivery; the panel recommended studying the two groups separately, with all 24 experts agreeing.\u003c\/li\u003e\n\u003cli\u003eChemotherapy is contraindicated in the first trimester, when exposure carries up to a 20% risk of major birth defects; it can be given after 12 to 14 weeks.\u003c\/li\u003e\n\u003cli\u003eBreast ultrasound is the first-line imaging test for the tumor and lymph nodes; contrast-enhanced MRI should be avoided because of gadolinium exposure to the fetus.\u003c\/li\u003e\n\u003cli\u003eWhen adequately managed, prognosis is similar to other young patients of the same stage and subtype; this statement carried the strongest evidence level in the report.\u003c\/li\u003e\n\u003cli\u003eBecause evidence is limited, the panel stressed that patient and partner preferences must carry extra weight in every treatment decision.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003c!-- ddn:keypoints:end --\u003e\n\n\n\u003ch2 id=\"background\"\u003eWhy This Research Matters\u003c\/h2\u003e\n\n\u003cp\u003eBreast cancer diagnosed during pregnancy, referred to by doctors as \u003cstrong\u003ePrBC\u003c\/strong\u003e, is rare. It is also one of the hardest situations in oncology, because two patients are involved at once: the mother and the unborn child. Any treatment decision has to serve both.\u003c\/p\u003e\n\n\u003cp\u003eRandomized controlled trials (studies where patients are randomly assigned to different treatments) cannot ethically be run in pregnant women. That means the evidence base is thin. Advances in breast cancer treatment outside pregnancy often cannot simply be copied into pregnancy, because a drug that helps the mother may harm the fetus.\u003c\/p\u003e\n\n\u003cp\u003eThe incidence (number of new cases) of breast cancer in young women has been rising. At the same time, some questions about pregnant patients remain genuinely controversial. To address this gap, ESMO held a virtual consensus-building process in 2022. The goal was to produce expert statements on topics that the current ESMO Clinical Practice Guideline could not cover with solid evidence.\u003c\/p\u003e\n\n\u003cp\u003eThe panel was explicit about one thing: because hard evidence is lacking, the patient's own preferences and those of her partner must carry extra weight in every treatment decision.\u003c\/p\u003e\n\n\u003ch2 id=\"methods\"\u003eHow the Consensus Was Developed\u003c\/h2\u003e\n\n\u003cp\u003eTwenty-four leading experts from 13 countries took part. The process was chaired by Dr. Sibylle Loibl and Dr. Frédéric Amant. Experts were assigned to working groups, each covering a defined subject area with two appointed chairs.\u003c\/p\u003e\n\n\u003cp\u003ePlanning, preparation, and execution followed ESMO's standard operating procedures. Importantly, the group did \u003cstrong\u003enot\u003c\/strong\u003e perform a systematic literature search. Instead, they reviewed the available evidence and built statements by expert discussion.\u003c\/p\u003e\n\n\u003cp\u003eEvery statement in the document carries two ratings:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eA \u003cstrong\u003elevel of evidence\u003c\/strong\u003e and strength of recommendation, shown in parentheses after the statement (for example, \u003cem\u003eIII\u003c\/em\u003e or \u003cem\u003eV\u003c\/em\u003e). The panel used the Infectious Diseases Society of America–United States Public Health Service grading system.\u003c\/li\u003e\n  \u003cli\u003eA \u003cstrong\u003epercentage of expert consensus\u003c\/strong\u003e, calculated from the number of votes in agreement or disagreement. Experts who abstained were counted as neither.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eThe final manuscript was reviewed and approved by all panel members. The panel openly acknowledged that the overall lack of high-level evidence means many statements rest on expert opinion rather than on trial results.\u003c\/p\u003e\n\n\u003ch2 id=\"working-groups\"\u003eThe Three Expert Working Groups\u003c\/h2\u003e\n\n\u003cp\u003eThe methods section describes three working groups, each with two chairs. The published summary of the process also refers to four groups; the three detailed groups were:\u003c\/p\u003e\n\n\u003col\u003e\n  \u003cli\u003e\n\u003cstrong\u003eGroup 1 — Incidence, epidemiology, biology and pathology, diagnostic work-up, staging and risk assessment, prognosis.\u003c\/strong\u003e Chairs: Vincent Vandecaveye and Fedro Peccatori.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eGroup 2 — Clinical pharmacology of systemic agents during pregnancy: management of localized disease and (neo)adjuvant therapies, and management of systemic (advanced) disease.\u003c\/strong\u003e Chairs: Giuseppe Curigliano and Peter Schmid.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eGroup 3 — Obstetric care, fetal and newborn follow-up and outcomes, metastases to the fetus, management of pregnancy during anticancer therapy, lactation, and psychological support.\u003c\/strong\u003e Chairs: Elyce Cardonick and Mathilde van Gerwen.\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003cp\u003eThe statements below come from Working Group 1, plus one key statement on chemotherapy timing from the pharmacology group.\u003c\/p\u003e\n\n\u003ch2 id=\"pregnancy-vs-postpartum\"\u003eQuestion 1: Is Cancer During Pregnancy Different From Cancer After Delivery?\u003c\/h2\u003e\n\n\u003cp\u003e\u003cstrong\u003eThe panel's answer: yes.\u003c\/strong\u003e Breast cancers diagnosed in the postpartum period (after childbirth) are biologically distinct from those diagnosed during pregnancy. The panel recommended that future studies study each group separately rather than lumping them together (evidence level III).\u003c\/p\u003e\n\n\u003cp\u003eAll 24 experts agreed, with 0 disagreements — a 100% consensus.\u003c\/p\u003e\n\n\u003cp\u003ePregnancy-related breast cancer is defined as cancer diagnosed during pregnancy or within one year after delivery. Childbirth at any age causes a short-term increase in breast cancer risk right after delivery, followed by a lower risk in the first few years afterward.\u003c\/p\u003e\n\n\u003cp\u003eWhy does the distinction matter? The mammary gland is a highly dynamic tissue. It reaches its peak functional state during lactation, when it produces milk and provides immune protection to the baby. When breastfeeding stops, the extra tissue built during pregnancy and lactation is no longer needed, and the gland shrinks back toward its pre-pregnancy state. Doctors call this process \u003cstrong\u003epostpartum involution\u003c\/strong\u003e.\u003c\/p\u003e\n\n\u003cp\u003ePostpartum breast cancer (PPBC), diagnosed up to 10 years after a pregnancy, is linked with a worse prognosis. Researchers believe the breast environment during involution can encourage tumors to grow and spread. Involution is marked by massive cell death (apoptosis), wound-healing activity, and suppression of T-cells (a type of immune cell).\u003c\/p\u003e\n\n\u003cp\u003eTreatment decisions then diverge. For cancer during pregnancy, doctors must individualize care according to disease stage and tumor biology, exactly as in any other breast cancer, \u003cem\u003eand\u003c\/em\u003e must factor in gestational age and fetal safety. For postpartum cancer, there is no fetus to protect. Standard, full-intensity treatment for high-risk disease is mandatory.\u003c\/p\u003e\n\n\u003cp\u003eThe panel added a practical point. A woman's number of pregnancies (parity) and her age at first and last delivery should be carefully recorded in the medical history of every breast cancer patient. These details inform prognosis.\u003c\/p\u003e\n\n\u003ch2 id=\"rising-trend\"\u003eQuestion 2: Why Are More Cases Being Diagnosed?\u003c\/h2\u003e\n\n\u003cp\u003e\u003cstrong\u003eThe panel's answer:\u003c\/strong\u003e The rising trend of delaying childbearing to later in life appears to be the most likely explanation for the increasing diagnosis of breast cancer during pregnancy (evidence level III).\u003c\/p\u003e\n\n\u003cp\u003eAgain, 24 experts agreed and 0 disagreed — 100% consensus.\u003c\/p\u003e\n\n\u003cp\u003eBreast cancer incidence in premenopausal women is increasing across many populations. Most, but not all, studies have found a rising incidence of pregnancy-associated breast cancer.\u003c\/p\u003e\n\n\u003cp\u003eThe trend in PrBC depends on two things at once: the underlying rate of breast cancer in the population, and patterns of childbearing. Breast cancer risk increases with age. So if women postpone pregnancy into the years when breast cancer becomes more common, the number of pregnancies complicated by breast cancer will rise, regardless of any other trend.\u003c\/p\u003e\n\n\u003cp\u003eStudies that adjusted for age found the increase in PrBC to be less pronounced. The panel also considered \"confounding factors\" — conditions linked to both higher pregnancy rates and higher breast cancer rates. If the number of women in these overlapping groups grows, recorded incidence can rise for that reason too.\u003c\/p\u003e\n\n\u003ch2 id=\"genomic-tests\"\u003eQuestion 3: Can Genomic Tests Guide Treatment in Hormone-Receptor-Positive Disease?\u003c\/h2\u003e\n\n\u003cp\u003e\u003cstrong\u003eThe panel's answer:\u003c\/strong\u003e Genomic assays — laboratory tests that read the activity of multiple genes in a tumor to estimate recurrence risk — can be considered to help decision-making in pregnant women with node-negative, estrogen-receptor-positive (ER+) breast cancer. However, patients must be told about the limitations of these tests and the weak evidence in pregnancy (evidence level V).\u003c\/p\u003e\n\n\u003cp\u003eThe vote was 21 in agreement, 1 against, and 2 abstentions — 95.45% consensus.\u003c\/p\u003e\n\n\u003cp\u003eNo study has specifically tested how well commercially available genomic signatures predict outcomes in women diagnosed during pregnancy. Only one study examined gene expression using the GENE70 signature, and it found no difference between the groups compared.\u003c\/p\u003e\n\n\u003cp\u003eEven outside pregnancy, experts debate how well these genomic tests perform in young patients and whether they can reliably identify women who can safely skip chemotherapy. Yet critical analyses point to their clinical usefulness in this age group.\u003c\/p\u003e\n\n\u003cp\u003eThis matters because ER+ tumors in young women are different from those in older women. Most are the highly proliferative \u003cstrong\u003eluminal-B genotype\u003c\/strong\u003e — a subtype whose cells divide quickly and which benefits more from chemotherapy. Only an estimated 15% to 20% of breast cancers in young women are luminal-A, the subtype where endocrine (hormone) therapy alone would be enough.\u003c\/p\u003e\n\n\u003cp\u003eData are missing for pregnant patients with early-stage ER+ disease. Even so, the panel said genomic testing could reasonably be considered in patients with no lymph node involvement (pN0) to confirm a low-risk situation. If low risk is confirmed, hormone therapy alone might be appropriate — but it must be delayed until after delivery.\u003c\/p\u003e\n\n\u003ch2 id=\"imaging-local\"\u003eQuestion 4: Which Imaging Tests Diagnose and Stage the Tumor Itself?\u003c\/h2\u003e\n\n\u003cp\u003e\u003cstrong\u003eThe panel's answer:\u003c\/strong\u003e Breast ultrasound is the first-line imaging test for assessing the primary tumor and for staging the lymph nodes in the armpit (axillary) and above the collarbone (supraclavicular) regions (evidence level III). It is complemented by mammography, or in selected cases by magnetic resonance imaging (MRI) with a diffusion-weighted sequence. This helps define how far the tumor extends and whether there are multiple tumor areas (evidence level IV).\u003c\/p\u003e\n\n\u003cp\u003eThe vote was 23 in agreement, 0 against, and 1 abstention — 100% consensus.\u003c\/p\u003e\n\n\u003cp\u003eUltrasound comes first because it immediately separates obviously benign findings, such as cysts and galactoceles (milk-filled cysts), from solid breast lumps that need a core biopsy. In non-pregnant women, ultrasound has a sensitivity (ability to correctly detect cancer) of 80.1% and a specificity (ability to correctly rule cancer out) of 88.4%.\u003c\/p\u003e\n\n\u003cp\u003eAn additional mammogram, taken as a single mediolateral oblique view, is indicated to look for microcalcifications (tiny calcium deposits) or tissue distortion when the first assessment already suggests cancer.\u003c\/p\u003e\n\n\u003cp\u003eUltrasound is also the primary method for assessing enlarged lymph nodes in the armpit and around the collarbone. Reported sensitivity in non-pregnant women ranges from 26.4% to 92%, and specificity from 55.6% to 98.1%. Adding an ultrasound-guided core biopsy or fine-needle aspiration cytology (FNAC, where a thin needle samples cells) of the lymph nodes improves the accuracy of determining node status before surgery. Sensitivity of ultrasound-guided FNAC ranges from 36% to 86.4%, with specificity from 95.7% to 100%. Because a positive FNAC result is so reliable, it is very useful for planning removal of the axillary lymph nodes.\u003c\/p\u003e\n\n\u003cp\u003eOne important caution: the natural changes in breast tissue during pregnancy reduce the accuracy of all these imaging methods.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eContrast-enhanced breast MRI should be avoided.\u003c\/strong\u003e Exposure of the fetus to gadolinium contrast raises the risk of rheumatological, inflammatory, or skin conditions, and of stillbirth or newborn death. Instead, adding diffusion-weighted imaging (DWI) allows MRI without contrast. For regional lymph node staging, non-contrast MRI with DWI has sensitivities of 72.4% to 97% and specificities of 54.4% to 91.7%. For detecting multiple tumor sites or cancer in the opposite breast, sensitivity is 75.7% to 78.9%. Even so, non-contrast breast MRI is rarely needed and serves mainly as a supplement to ultrasound.\u003c\/p\u003e\n\n\u003cp\u003eOn shielding: the need for lead shielding during diagnostic and staging scans is best discussed with the radiologist. Modern equipment aims the beam precisely, without fetal harm. When the beam is less precise, fetal shielding is advised.\u003c\/p\u003e\n\n\u003ch2 id=\"imaging-staging\"\u003eQuestion 5: How Should the Whole Body Be Checked for Spread?\u003c\/h2\u003e\n\n\u003cp\u003e\u003cstrong\u003eThe panel's answer:\u003c\/strong\u003e The locoregional tumor stage (how far the cancer has spread locally) determines the staging strategy during pregnancy. Chest X-ray and abdominal ultrasound are easily accessible for initial screening. If results are inconclusive, or if the risk of spread is high, additional imaging is suggested. That imaging is non-contrast MRI with DWI of the full spine, pelvic bones, and liver, combined with a chest CT scan. When whole-body MRI with diffusion-weighted sequence (WB-DWI\/MRI) is available at the treating center, it is recommended as a single-step staging method (evidence level III).\u003c\/p\u003e\n\n\u003cp\u003eThe vote was 22 in agreement, 0 against, and 2 abstentions — 100% consensus.\u003c\/p\u003e\n\n\u003cp\u003eThe initial tumor stage and the pathology report generally decide how much imaging is needed. Most patients with early breast cancer are unlikely to benefit from extensive staging.\u003c\/p\u003e\n\n\u003cp\u003eExtra imaging should be considered when risk factors are present:\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003eClinically positive axillary lymph nodes\u003c\/li\u003e\n  \u003cli\u003eLarge tumors, for example larger than 5 cm in diameter\u003c\/li\u003e\n  \u003cli\u003eAggressive tumor biology, such as triple-negative tumors, HER2-positive tumors, or luminal tumors with a high Ki67 score (a marker of fast cell division)\u003c\/li\u003e\n  \u003cli\u003eClinical or laboratory signs that cancer has spread\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eCurrent international guidelines disagree on how and when to scan for metastases in the most commonly affected sites: bone, liver, and lungs. Chest X-ray and liver ultrasound are quick and easy, but they have relatively low sensitivity for detecting lung and liver metastases and cannot detect cancer in the bones at all.\u003c\/p\u003e\n\n\u003cp\u003eWhen metastatic disease is strongly suspected, staging is expanded. Non-contrast MRI with DWI of the spine, pelvis, and liver is combined with low-dose CT of the chest. Chest CT offers superior sensitivity with minimal radiation exposure to the fetus. In an updated meta-analysis (a study combining results of many studies), skeletal MRI with DWI showed high pooled sensitivity and specificity for bone metastases. This was better than bone scintigraphy (a nuclear bone scan). Liver MRI with DWI performs as well as contrast-enhanced MRI for finding liver metastases.\u003c\/p\u003e\n\n\u003cp\u003eWB-DWI\/MRI is an emerging option. It identifies the primary tumor and stages nodal and distant metastases more accurately in a single step than conventional staging, particularly in pregnant patients with breast cancer. It is highly accurate for bone, liver, and peritoneal (abdominal lining) metastases. It also detects additional lymph node metastases regardless of node shape. WB-DWI\/MRI should only be supplemented by an unenhanced chest CT if lung nodules seen on MRI are unclear.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAbout radiation:\u003c\/strong\u003e nuclear imaging tracers expose the fetus to relatively low radiation. But standard hybrid imaging that combines a nuclear scan with CT raises the total dose to between 10 and 50 mGy (milligray, a unit of radiation dose). For that reason, low-dose PET\/CT (positron emission tomography combined with CT) and bone scintigraphy are recommended only as second-line options. They should be used selectively, when distant findings remain unresolved and the benefit to the mother clearly outweighs the risk to the fetus, or when MRI is not available. The staging plan is best discussed jointly with the radiologist and a medical physicist. The goal is to keep fetal exposure as low as possible, with a cumulative dose of 100 mGy treated as the maximum.\u003c\/p\u003e\n\n\u003ch2 id=\"biology\"\u003eQuestion 6: Are These Tumors Biologically Different?\u003c\/h2\u003e\n\n\u003cp\u003e\u003cstrong\u003eThe panel's answer:\u003c\/strong\u003e Only limited biological differences exist in tumors diagnosed during pregnancy. So far, these differences do not appear to have an important impact on how patients are managed (evidence level III).\u003c\/p\u003e\n\n\u003cp\u003eThe vote was 21 in agreement, 1 against, and 2 abstentions — 95.45% consensus.\u003c\/p\u003e\n\n\u003cp\u003eSeveral studies have compared standard clinical and pathological features between pregnant and young non-pregnant breast cancer patients. Histological grade (how abnormal the cells look) and subtype were consistently comparable between the two groups.\u003c\/p\u003e\n\n\u003cp\u003eA few studies noted a tendency toward a higher proportion of estrogen-receptor-negative (ER−) tumors in pregnant patients, but the differences barely reached statistical significance. The largest study compared 311 pregnant patients with 865 non-pregnant patients. In that study, the proportion of ER− tumors was almost double in the pregnant group: \u003cstrong\u003e53.4% versus 25.5%\u003c\/strong\u003e — roughly 53 in 100 compared with 26 in 100.\u003c\/p\u003e\n\n\u003cp\u003eTumors diagnosed during pregnancy were also shown to have high levels of RANK ligand (RANKL, receptor activator of nuclear factor-kappa B ligand). These findings highlight how pregnancy may change the breast's microscopic environment, which in turn alters tumor biology.\u003c\/p\u003e\n\n\u003cp\u003eAt the genomic level, the pattern of common somatic mutations (gene changes acquired during life, such as in TP53 and PIK3CA) appears comparable between pregnant and age-matched non-pregnant patients. However, whole-genome sequencing analysis showed a higher frequency of non-silent mutations (changes that alter protein structure). Whole-genome sequencing analysis also showed more mutations in the mucin gene family. Whole-genome sequencing analysis also showed enrichment for a mismatch repair deficiency mutational signature (a pattern of DNA damage typical of defective DNA repair).\u003c\/p\u003e\n\n\u003cp\u003eThe clinical meaning of these findings is not clear. One possibility is that certain pre-existing subclones (small groups of tumor cells) gain a growth advantage during pregnancy.\u003c\/p\u003e\n\n\u003ch2 id=\"prognosis\"\u003eQuestion 7: Is the Prognosis Worse Than for Other Young Patients?\u003c\/h2\u003e\n\n\u003cp\u003e\u003cstrong\u003eThe panel's answer: no — provided the cancer is adequately managed.\u003c\/strong\u003e The prognosis of breast cancer diagnosed during pregnancy is similar to that of young breast cancer patients with the same stage and disease subtype (evidence level II). This was the strongest level of evidence assigned to any statement in this group.\u003c\/p\u003e\n\n\u003cp\u003eHistorically, many studies reported that pregnancy-associated breast cancer had a worse prognosis than non-pregnancy breast cancer. A nationwide registry-based study of 234 patients diagnosed with PrBC between 1970 and 2018 found a hazard ratio (HR) of death of 1.80, with a 95% confidence interval (CI) of 1.43 to 2.28. A hazard ratio of 1.80 means the risk of death at any given time was about 80% higher in that group than in the comparison group.\u003c\/p\u003e\n\n\u003cp\u003eA more recent large meta-analysis of 76 studies found an HR of death of 1.46 (95% CI 1.12 to 1.90) for patients with PrBC.\u003c\/p\u003e\n\n\u003cp\u003eBut the panel pointed to a key flaw in those older analyses. Patients were not necessarily treated adequately during pregnancy, and some analyses included cancers diagnosed within one year after delivery — mixing in postpartum cases with their poorer outlook.\u003c\/p\u003e\n\n\u003cp\u003eThe largest case-control study to date supports this. It included 311 patients diagnosed with PrBC and 865 non-pregnant controls, all receiving similar treatments regardless of pregnancy status. The HR for overall survival was \u003cstrong\u003e1.06 (95% CI 0.66 to 1.68)\u003c\/strong\u003e — essentially no difference. Similar results came from a series of 58 triple-negative pregnancy-associated cancers, where a matched analysis with 92 non-pregnant patients found no survival difference. A recent study of more than 600 patients with PrBC treated with chemotherapy during pregnancy supports these earlier findings.\u003c\/p\u003e\n\n\u003cp\u003eSo, if adequately treated, pregnant breast cancer patients appear to have a highly comparable prognosis to other patients of the same age and stage.\u003c\/p\u003e\n\n\u003cp\u003eThe situation is different for postpartum breast cancer. There, the involuting breast and its unusual immunological environment are believed to be responsible for a worse outlook. That is why treating high-risk postpartum disease at full standard intensity is essential.\u003c\/p\u003e\n\n\u003ch2 id=\"chemotherapy-timing\"\u003eChemotherapy Timing: Why the First Trimester Matters\u003c\/h2\u003e\n\n\u003cp\u003e\u003cstrong\u003eThe panel's answer:\u003c\/strong\u003e Chemotherapy is contraindicated (must not be given) in the first trimester of pregnancy, to avoid interfering with organ formation (evidence level V). The fetal benefit of delaying treatment until the second trimester must be balanced against the risk to the mother. Although starting chemotherapy earlier is associated with impaired fetal growth, children do reach their developmental milestones. Chemotherapy can therefore be given during the second and third trimesters.\u003c\/p\u003e\n\n\u003cp\u003eEarly exposure to chemotherapy has been associated with up to a \u003cstrong\u003e20% risk of major malformations\u003c\/strong\u003e — about 20 in every 100 pregnancies exposed. The risk of congenital malformations is increased only during the first 12 weeks of pregnancy.\u003c\/p\u003e\n\n\u003cp\u003eAfter 12 to 14 weeks of gestation, a number of chemotherapy drugs are safe and feasible to give. Standard (neo)adjuvant regimens based on anthracyclines and taxanes (chemotherapy drug families) can be administered just as they would be outside pregnancy.\u003c\/p\u003e\n\n\u003cp\u003eAfter 35 weeks of gestation, chemotherapy on a 3-weekly schedule is usually discouraged, so that the mother's blood counts can recover and delivery can be planned safely.\u003c\/p\u003e\n\n\u003cp\u003eThis is a balancing act, and the panel stressed that decisions should be made together with the patient, weighing the maternal risk of waiting against the fetal risk of treating.\u003c\/p\u003e\n\n\u003ch2 id=\"implications\"\u003eWhat This Means for Patients\u003c\/h2\u003e\n\n\u003cp\u003eThe overall message is reassuring, with clear boundaries. A breast cancer diagnosis during pregnancy is not automatically a worse diagnosis than the same cancer in a non-pregnant woman of the same age. This holds as long as treatment follows the standard, full-intensity approach appropriate to the stage and tumor type.\u003c\/p\u003e\n\n\u003cul\u003e\n  \u003cli\u003e\n\u003cstrong\u003eTiming matters more than anything else.\u003c\/strong\u003e Chemotherapy must wait until after the first trimester. After 12 to 14 weeks, standard anthracycline- and taxane-based regimens can be used.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eUltrasound leads the way for imaging.\u003c\/strong\u003e It is the first-line test for both the breast lump and the lymph nodes.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eContrast-enhanced MRI is off the table\u003c\/strong\u003e because of gadolinium exposure to the fetus, but non-contrast MRI with diffusion-weighted imaging is a safe alternative in selected cases.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eStaging should be proportionate.\u003c\/strong\u003e Most early breast cancers do not need extensive scanning. High-risk features trigger expanded staging.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eHormone therapy alone is not an option during pregnancy.\u003c\/strong\u003e Even when genomic testing suggests low risk, endocrine therapy must be deferred until after delivery.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDocument your pregnancy history.\u003c\/strong\u003e Parity and age at first and last delivery affect prognosis and should be part of every breast cancer patient's record.\u003c\/li\u003e\n\u003c\/ul\u003e\n\n\u003cp\u003eBecause evidence in this field is limited, the panel emphasized that the values and preferences of the patient and her partner should weigh heavily in shared decision-making.\u003c\/p\u003e\n\n\u003ch2 id=\"limitations\"\u003eLimitations of This Work\u003c\/h2\u003e\n\n\u003cp\u003eIt is important to be clear about what this document is and is not.\u003c\/p\u003e\n\n\u003col\u003e\n  \u003cli\u003e\n\u003cstrong\u003eNo randomized trials exist\u003c\/strong\u003e and none can be conducted in pregnant patients. The evidence base is therefore limited and, in some areas, conflicting.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eNo systematic literature search was performed.\u003c\/strong\u003e The panel built statements through expert discussion rather than a formal, exhaustive review of every published study.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eMany statements rest on expert opinion.\u003c\/strong\u003e The panel itself highlighted the \"expert opinion level\" of the statements and openly reported agreement percentages and abstentions for this reason.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eLevels of evidence vary.\u003c\/strong\u003e The prognosis statement (level II) is stronger than several imaging and treatment statements (levels III to V).\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eGenomic testing in pregnancy is unproven.\u003c\/strong\u003e No study has validated these tests specifically in pregnant patients.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eImaging accuracy is reduced in pregnancy\u003c\/strong\u003e because breast tissue changes naturally during this time.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eSome topics go beyond this report.\u003c\/strong\u003e Obstetric care, fetal and newborn follow-up, breastfeeding, psychological support, and the full pharmacology discussion were handled by other working groups and are not detailed here.\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003ch2 id=\"recommendations\"\u003ePractical Recommendations\u003c\/h2\u003e\n\n\u003cp\u003eBased on the panel's statements, here is what patients and their care teams should expect:\u003c\/p\u003e\n\n\u003col\u003e\n  \u003cli\u003e\n\u003cstrong\u003eAsk for a multidisciplinary team.\u003c\/strong\u003e The panel stressed that the staging strategy should be discussed with a radiologist and medical physicist to minimize fetal radiation exposure, with 100 mGy as the maximum cumulative dose.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eExpect ultrasound first, plus a single-view mammogram\u003c\/strong\u003e when cancer is suspected, and non-contrast MRI with diffusion-weighted imaging only in selected cases.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDo not expect contrast-enhanced MRI.\u003c\/strong\u003e Gadolinium should be avoided during pregnancy.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eExpect limited staging unless risk factors are present\u003c\/strong\u003e — positive axillary nodes, tumors larger than 5 cm, aggressive biology (triple-negative, HER2-positive, or high Ki67), or signs of spread.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003ePlan chemotherapy for the second and third trimesters.\u003c\/strong\u003e Avoid it entirely in the first 12 weeks.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDiscuss genomic testing carefully\u003c\/strong\u003e if you have node-negative, ER-positive disease. It may help, but it is not proven in pregnancy.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eDelay hormone therapy until after delivery,\u003c\/strong\u003e even if testing suggests you are low risk.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eKnow that postpartum disease is different.\u003c\/strong\u003e If cancer is found within a year after delivery — or up to 10 years later — full standard treatment for high-risk disease is required.\u003c\/li\u003e\n  \u003cli\u003e\n\u003cstrong\u003eMake decisions as a team.\u003c\/strong\u003e The panel explicitly stated that patient and partner preferences are especially important when evidence is scarce.\u003c\/li\u003e\n\u003c\/ol\u003e\n\n\u003c!-- ddn:faq:start --\u003e\n\u003ch2 id=\"ddn-faq\"\u003eFrequently Asked Questions\u003c\/h2\u003e\n\u003ch3\u003eI was just diagnosed with breast cancer while pregnant. Is my prognosis worse than for other young women?\u003c\/h3\u003e\n\u003cp\u003eAn international expert panel concluded that, when the cancer is adequately managed, prognosis is similar to other young breast cancer patients with the same stage and subtype. This statement carried the strongest evidence level assigned in the report. Older analyses that suggested worse outcomes often included patients not adequately treated during pregnancy or mixed in postpartum cases, which have a poorer outlook.\u003c\/p\u003e\n\u003ch3\u003eCan I have chemotherapy during pregnancy, and when is it safe to start?\u003c\/h3\u003e\n\u003cp\u003eChemotherapy is contraindicated in the first trimester because exposure then carries up to a 20% risk of major birth defects. After 12 to 14 weeks, standard anthracycline- and taxane-based regimens can be given as they would be outside pregnancy. After 35 weeks, a three-weekly schedule is usually discouraged so blood counts can recover and delivery can be planned safely.\u003c\/p\u003e\n\u003ch3\u003eWhat imaging tests will I have to diagnose and stage the cancer during pregnancy?\u003c\/h3\u003e\n\u003cp\u003eBreast ultrasound is the first-line test for the tumor and for lymph nodes in the armpit and above the collarbone. It is complemented by mammography, or in selected cases by MRI with a diffusion-weighted sequence. Contrast-enhanced MRI should be avoided because gadolinium exposure to the fetus raises risks. Staging is usually limited unless risk factors such as positive nodes or a large tumor are present.\u003c\/p\u003e\n\u003ch3\u003eCan genomic tests tell whether I can safely skip chemotherapy for hormone-receptor-positive disease?\u003c\/h3\u003e\n\u003cp\u003eGenomic assays can be considered for pregnant women with node-negative, estrogen-receptor-positive breast cancer, but patients must be told the evidence in pregnancy is weak. No study has specifically tested how well these tests predict outcomes in pregnancy. If testing confirms a low-risk situation, hormone therapy alone might be appropriate, but it must be delayed until after delivery.\u003c\/p\u003e\n\u003ch3\u003eIs breast cancer found during pregnancy different from cancer found after delivery?\u003c\/h3\u003e\n\u003cp\u003eYes. The panel concluded that breast cancers diagnosed during pregnancy are biologically distinct from those diagnosed after childbirth, and recommended studying the two groups separately. All 24 experts agreed. Postpartum breast cancer, diagnosed up to 10 years after a pregnancy, is linked with a worse prognosis, so full standard treatment for high-risk disease is required when it is found.\u003c\/p\u003e\n\u003ch3\u003eWhy are more cases of breast cancer during pregnancy being diagnosed?\u003c\/h3\u003e\n\u003cp\u003eThe panel concluded that delaying childbearing to later in life is the most likely explanation. Breast cancer risk increases with age, so if women postpone pregnancy into years when breast cancer is more common, more pregnancies will be complicated by it. Studies that adjusted for age found the increase less pronounced. All 24 experts agreed with this statement.\u003c\/p\u003e\n\u003ch3\u003eHow will my whole body be checked for spread, and what about radiation to my baby?\u003c\/h3\u003e\n\u003cp\u003eChest X-ray and abdominal ultrasound are used for initial screening. If results are inconclusive or risk is high, non-contrast MRI with diffusion-weighted imaging of spine, pelvis and liver plus chest CT is suggested. Whole-body MRI with diffusion-weighted sequence is recommended as a single-step method where available. The staging plan should be discussed with a radiologist and medical physicist, keeping cumulative fetal dose under 100 mGy.\u003c\/p\u003e\n\u003ch3\u003eI was diagnosed with breast cancer during pregnancy — when should I get a second opinion?\u003c\/h3\u003e\n\u003cp\u003eSeek a second opinion when the plan does not match the consensus standards for pregnancy: chemotherapy scheduled during the first 12 weeks, contrast-enhanced MRI, or hormone therapy before delivery. A review is also warranted if staging is extensive without high-risk features such as positive axillary nodes, tumors over 5 cm, or aggressive biology. A review is also warranted if genomic testing is used to justify delaying chemotherapy. Because evidence in pregnancy is limited and many recommendations rest on expert opinion, patient and partner preferences carry extra weight. Diagnostic Detectives Network provides independent expert second opinions.\u003c\/p\u003e\n\u003c!-- ddn:faq:end --\u003e\n\n\u003ch2 id=\"source\"\u003eSource Information\u003c\/h2\u003e\n\n\u003cp\u003e\u003cstrong\u003eOriginal article title:\u003c\/strong\u003e ESMO Expert Consensus Statements on the management of breast cancer during pregnancy\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors:\u003c\/strong\u003e S. Loibl, H. A. Azim Jr, T. Bachelot, P. Berveiller, A. Bosch, E. Cardonick, C. Denkert, M. J. Halaska, M. Hoeltzenbein, A. L. V. Johansson, C. Maggen, U. R. Markert, F. Peccatori, P. Poortmans, E. Saloustros, C. Saura, P. Schmid, E. Stamatakis, M. van den Heuvel-Eibrink, M. van Gerwen, V. Vandecaveye, G. Pentheroudakis, G. Curigliano, and F. Amant.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003ePublication:\u003c\/strong\u003e \u003cem\u003eAnnals of Oncology\u003c\/em\u003e, Volume 34, Issue 10, 2023, starting at page 849. Available online 10 August 2023. DOI: 10.1016\/j.annonc.2023.08.001. Copyright 2023 European Society for Medical Oncology, published by Elsevier Ltd.\u003c\/p\u003e\n\n\u003cp\u003e\u003cstrong\u003ePanel composition:\u003c\/strong\u003e 24 experts from 13 countries, chaired by S. Loibl and F. Amant. The consensus process followed ESMO standard operating procedures.\u003c\/p\u003e\n\n\u003cp\u003e\u003cem\u003eThis patient-friendly article is based on peer-reviewed research. It reflects the consensus statements and their reported levels of evidence and agreement. Because treatment during pregnancy depends on individual circumstances, patients should discuss all decisions with their own medical team.\u003c\/em\u003e\u003c\/p\u003e","brand":"DiagnosticDetectives.Com","offers":[{"title":"Default Title","offer_id":47458775728284,"sku":null,"price":0.0,"currency_code":"USD","in_stock":true}],"thumbnail_url":"\/\/cdn.shopify.com\/s\/files\/1\/0599\/5449\/5644\/files\/ddn-medical-article-breast-cancer-during-pregnancy-a-patients-guide-to-the-2023-esmo-expert-consensus-hero.png?v=1790201610","url":"https:\/\/diagnosticdetectives.com\/he\/products\/breast-cancer-during-pregnancy-a-patients-guide-to-the-2023-esmo-expert-consensus","provider":"DiagnosticDetectives.Com","version":"1.0","type":"link"}