26- year-old Deepika Gopnarayan was recently treated at Jupiter Hospital, Baner, Pune for Pregnancy Associated Breast Cancer (PABC), a special variant of cancer that can complicate 1 in 3000 pregnancies. Treating breast cancer during pregnancy requires balancing oncologically effective treatments for the mother, with the safe delivery of a healthy baby. A highly skilled team of Breast Surgeons, Oncologists, Obstetricians, and Pediatricians at Jupiter Hospital’s Cancer Institute was involved in forming a multidisciplinary treatment plan. The patient underwent chemotherapy during pregnancy, a vacuum-assisted vaginal delivery at full term, oncoplastic breast surgery after delivery followed by radiation, in what can be described as comprehensive multidisciplinary care.
The diagnosis came as a big surprise to Deepika and Sugat who were expecting their first child. When Deepika first noted a lump in her breast, it did not immediately raise alarms. She had no family history of cancer and knew she had a benign (non-cancerous lump) fibroadenoma in the same area of the breast diagnosed several years ago. The initial assumption was that it was this fibroadenoma that was growing as expected during pregnancy. However, when the lump grew from 1 cm to over 5 cm over a few weeks, her Obstetrician, Dr Jyoti Aggrawal knew that this needed a specialist care.
When Dr Pranjali Gadgil, Breast Surgeon at Jupiter hospital evaluated Deepika, the lump was almost 5.5 cm . She noted that the fibroadenoma she had before, was nearby but not related to the new growth. Deepika underwent a core needle biopsy in the breast clinic and diagnosis of “Pregnancy associated Breast Cancer” was made.
A diligent diagnostic workup with any new breast symptom is imperative irrespective of the patients age, family history or confounding circumstances such as pregnancy or breastfeeding. According to Dr. Gadgil, the PABC is a rare disease that occurs in 1 in 3000 pregnancies and often tends to be aggressive type of breast cancer. It can grow rapidly under influence of hormones and growth factors that abound in pregnancy. Average age of women who have PABC is 32-38 years of age. Deepika was only 26 years old at diagnosis which is a particularly young age of presentation. There are also some constraints to treating breast cancer when a patient is pregnant. Radiation cannot be given at anytime during pregnancy. Chemotherapy cannot be administered during the first trimesterduring crucial phases of development. We want to avoid general anesthesia for surgery very early in pregnancy and as the mother nears term” she added.
As Deepika’s tumor was large and high grade, prompt initiation of treatment was necessary. We discussed her case on our tumor board and counseled the young couple about the options.
Jupiter Hospital’s Medical Oncologist Dr Tushar Patil and Breast Cancer Surgeon Dr Pranjali Gadgil planned to administer Deepika chemotherapy during pregnancy and before surgery- an approach called “Neoadjuvant Chemotherapy.”
“There were several reasons that influenced our decision. Although Deepika was in her 2nd trimester and surgery could have been performed first, a 5.5 cm tumor would have necessitated complete removal of the breast called ‘mastectomy’. In patients who we plan a mastectomy, we usually perform reconstructive surgery to replace the removed breast in the same setting. However, when we operate on pregnant women, we want to minimize the exposure of the fetus to anaesthesia and hence would have deferred reconstruction to a later time. A mastectomy without reconstruction for a 26-year-old would have been a tough surgery to cope with,” explained Dr Gadgil.
Deepika received 12 cycles of weekly chemotherapy during the pregnancy under the care of Dr Tushar Patil. “Contrary to common belief, modern-day chemotherapy for breast cancer can safely be administered during the 2nd and 3rd Trimester. Deepika handled chemotherapy without major complications. Her husband Sugat was very supportive and the couple had a very positive approach throughout treatments,” said Dr Patil.
Dr Jyoti Aggrawal monitored the development of the fetus, Careful medication, Dietary advice and Psycological counselling, helped the growth of the baby and Dr Pranjali Gadgil monitored the response of the tumor during Deepika’s visits for chemotherapy. The tumor which was almost 5.6 cm when we started the chemotherapy, was downsized to less than 2 cm providing evidence of good treatment effect.
While Deepika received chemotherapy, she also underwent genetic counselling with Dr Gadgil and underwent genetic testing for BRCA and related genetic defects. Deepika’s genetic testing reports however were normal.
Two weeks after completing her 12th cycle of chemo, Deepika completed her last trimester and delivered a healthy baby boy at 39 weeks of gestation. Although Deepika had prolonged labour and more than usual blood loss, Dr Aggrawal was able to conduct a vaginal delivery. Paediatrician Dr Shrinivas Tambe attended to the baby at delivery. “The baby was normal birth weight at 3.3 kg and we checked to ensure there were no developmental anomalies. The baby was discharged without additional intensive care or medical treatments.” Dr Tambe said.
Deepika was able to re-start her remaining 4 cycles of chemotherapy three weeks after her delivery. After completion of the chemotherapy, she was evaluated for surgical planning by Breast Surgeon, Dr Pranjali Gadgil. As the tumor had reduced in size with the chemotherapy effect, a mastectomy was no longer necessary and a smaller operation was now feasible. Deepika underwent an oncoplastic breast conservation surgery with a local rotational flap along with removal of lymph nodes in the armpit. Describing the surgery Dr Gadgil elaborated “This oncoplastic technique of surgery enables us to remove adequate extent of the tumor-bearing area, yet preserves the aesthetic appearance of the remaining breast without any deformity”
“A diagnosis of breast cancer was initially overwhelming and the long treatment journey was at times tiring. However the doctors and staff at Jupiter Hospital supported us as family and the hospital had become a second home for us. We had a skilled team of doctors who were always approachable, communicative and worked as a team. We had confidence in their care approach and trusted their judgement completely said Deepika and her husband Sugat Gopnarayan. Deepika is now completing radiation treatment under the care of Dr. Vikas Kothavade, Radiation Oncology department at Jupiter Hospital. Since she has left sided breast cancer, subsequently heart lies in close proximity of the target area of radiation, she is receiving treatment with a special technique called as breath hold technique (gating), due to which we are able to reduce the radiation dose to the heart significantly and consequently minimize radiation induced heart related side effects in future. After radiation, she will be scheduled for regular visits with her oncologists. The pediatricians are happy with the baby’s growth and development and the parents are excited to start their parenting journey.