Episode 153 Breast Cancer in Pregnancy

In this episode I am joined once again  by incredible obstetric physicians Professor Catherine Nelson-Piercy & Dr Melanie Nana. This time we are discussing breast cancer in pregnancy & some fantastic work they have been doing to standardise and improve care for women in this situation. We also discuss the fabulous charity Mummy's Star.

Want to know more?
https://www.mummysstar.org/
Breast cancer infographic
https://www.mummysstar.org/_files/ugd/2dde0d_6790930c3e5a47ccb875a63683dfaa10.pdf

You can contact Cathy or Melanie on Twitter @nelson_piercy & @Melanie_Nana1 

Thank you all for listening,  My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth.
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Its easy to explore my back catalogue of episodes, I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Instagram @TheObsPod and email me on TheObsPod@gmail.com Please also check out #MatExp matexp.org.uk for ideas about how to improve maternity experience.
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Transcript

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Florence 0:00

Hello, my name's Florence. Welcome to the Obspod. I'm an NHS obstetrician, hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife, maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case, and for that matter anyone else that's interested, the obspod is for you. Episode one five three Breast Cancer in Pregnancy. In today's episode, I am once again joined by the fantastic Professor Catherine Nelson Pearcy and Dr. Melanie Nana, both obstetric physicians. And today's conversation is a follow-on from last week's episode, but we're going to focus on one particular topic, which is breast cancer in pregnancy. So let's jump straight in where we left off last week. So one of the reasons that we kind of got together is I saw Melanie was tweeting about a new breast cancer in pregnancy infographic. And this immediately caught my attention. So cancer in pregnancy comes up in the embrace report. And breast cancer, I guess, is the commonest cancer in pregnancy. Would that be correct?

SPEAKER_00 2:00

Yeah, so I think breast cancer accounts for about 40% of all cancers that are diagnosed in pregnancy or in the 12 months following pregnancy.

Florence 2:10

Yeah, and I have looked after over the years a number of women with breast cancer in pregnancy. And again, I think it's that fear thing. Obstetrically, I'm fearful, I don't know anything about cancer and oncology, and the oncologists are, oh my goodness, this is a whole different ball game because there's a baby involved. And obviously, treatment also not only depends on the cancer itself, but also the stage of pregnancy at which diagnosis is made. And there's that very, very complex balance between potentially life-saving treatment for this woman versus the fact that she wants to protect her baby. So I was really interested, and that's how we kind of got connected. So tell us a bit more about how that project started as a project.

SPEAKER_00 3:04

So it was when I was doing the clinical fellowship at St. Thomas's. And I think I can't actually really remember how it started, Kathy, but I think we saw a patient and experienced exactly what you described, Lawrence. People asking different questions about should we do this investigation? Is it safe to do staging? So is it safe to know now that we know that the patient's got breast cancer, is it safe to do the investigations that you would normally do to look to see whether it's spread? And can we, you know, can we what treatment is appropriate in pregnancy? When should we deliver all of those questions that come up from different members of the team? And there is a huge wealth of data. I know when I go to Kathy's course, Professor Amant had does a wonderful lecture summarising all of the safety of the different treatments. And I think as a trainee, I realised that there's lots more that we could do than I realised. Um as you mentioned, the Embrace report, when I go back to staging, they found that a number of women who have cancer in pregnancy don't get the appropriate staging. And if you don't do the appropriate staging, you know, you can give inappropriate treatments, you can deliver babies early when it's not necessary. So we kind of agreed as a team that if there was a one sort of shop, stop, shop uh reference guide where we could put the main bits of information that we kind of brought together from the whole MDT. So there was someone from each area. So there was an obstetrician, there was an oncologist, there was a radiologist, all in that group, so that we could basically provide a best practice summary on two pages, which has been well used, I think.

SPEAKER_01 4:35

So hopefully I think for this this is an area where it's the extreme, right? So we've talked about knowing which medications are safe or not in pregnancy, and here we are talking about chemotherapy in pregnancy. So it's it it makes sense that everybody would assume that that is not safe. But the the fundamental thing to understand is that if you give it after organogenesis, after the first trimester, the baby's all formed and the chemotherapy is not going to cause malformations. But oncologists, if you go back to what you were saying before about the specialist physicians not understanding anything about pregnancy, oncologists assume that it's okay to deliver a baby at 32 weeks and then they can get on and treat the cancer. They do not understand the grave implications of prematurity for that baby in the short and the long term. So it's it's the best example there is of the oncologist wanting to treat the cancer and the obstetrician not having the confidence to say to the oncologist, well, just a minute, there's a baby here, and we need to give this mother a well-healthy baby at term. You you could, you know, for an obstetrician to say to an oncologist, go ahead and give your chemotherapy, that you know, that that's not gonna happen. So it really is a the best example of where you're balancing the risk to the baby from the drugs versus the benefit to the mother and the baby of giving the drugs. And with with with breast cancer, it's it is very easy to demonstrate in Professor Amon's work because he's actually followed up the babies and shown that they do much better if you give them the chemotherapy and deliver them at term. And that, although not logical to what most people would think, you're giving very powerful drugs, cyclophosamide, which everyone knows is teratogenic, you give that to the baby, and and the babies uh are better born at term exposed to chemotherapy than they are delivered preterm, even a little bit preterm. So Melanie's infographic is fabulous because it's for obstetricians and oncologists and women. And as she said, the staging issue is vital. There are cases in embrace and cases that I've been aware of where the mother has breast cancer, she's given surgery, assuming that is localized, it's then found out that it's disseminated. She's been given unnecessary big surgery with with wide local excision and lymph node clearance when it was already in her lungs or her liver or her bones. That's just awful. Or she's given the wrong chemotherapy. Uh, you know, she's not given uh near adjuvant, and she she should have been given palliative. So there are all sorts of examples. And you know, you'd be familiar with the argument about you know not radiating the baby, but we do CT scans of the chest all the time. Yeah. Why wouldn't we do a CT scan to look for for lung mess? It's completely bananas, and yet then the oncologists say, Oh, well, clearly I can't do a CT, so I'll, you know, I'll just do a chest x-ray and that'll be enough. So the the section of the infographic dealing with with radiation, and in Belgium, where where Fred Amand works, he does total body MRIs to do staging. That's not available everywhere in the UK, but you know, everyone should know that you can CT the head because we do it all the time, CT the lungs because we do it all the time, you can even CT the abdomen if she's early in pregnancy, you can do the upper abdomen, look at the liver. Um, but uh you can certainly do an MRI and do proper staging. And that is a very common mistake we see, or you know, the the assumption that it's it's okay not to stage, the assumption that it's okay to delay chemotherapy, the assumption that it's okay to deliver preterm, and women end up getting the wrong care.

Florence 8:41

Yeah, I think the staging thing definitely, from all the lectures and things I've ever been to, that consistent theme is we should investigate as if a woman wasn't pregnant, you know, whether that's PE or whether that's breast cancer. And that still isn't a message that is clearly heard by everybody. I definitely encounter that. And I encounter that also when I request a CT or an X-ray, that I get the radiology department going, this woman's pregnant. Do you know? Has she signed this consent form? Has she done this, that, and the other? And it's like, oh my God, you know, I am trying to give her care. Obviously, I'm an obstetrician, I know she's pregnant. I have made a conscious decision that this is the right thing to do. So I'm not surprised that staging goes by the wayside because again, we're we're not thinking clearly, but I'm really interested in what you said about the babies do better with chemotherapy. And there's so much evidence now about even late preterm has a big impact on brain development and those developmental milestones for babies, you know, later in life, that that makes complete sense. And I've definitely been involved in caring for women and felt kind of pressurized into maybe a birth at 34 weeks and things like that, even though, yes, I know it makes a difference. For me, the infographic is perfect because I'm just not a person that can wade through massive guidelines. So the fact it's on two pages and it's really clear is really beneficial. But I think also it comes back to what we were talking about in terms of being able to look after people locally, because as a hospital, we might see a woman with breast cancer and pregnancy every once in a while. Whereas you can see, or we can use this to make sure that one woman that we've seen in the last have many years gets the right standard of treatment. You mentioned, Melanie, that it it's kind of being well received. Have you had some feedback from people using it?

SPEAKER_00 11:18

Yeah, so I mean, we hadn't published it. You know, medical journals typically publish papers. This is this is quite different to that. So yeah, obvious spot for it. So I think you know, it's important that we mention Mummy Star website and charity. So this is a fantastic charity who look after women who have cancer in or around pregnancy. Um, and they provide lots of information and education on their website, and they kindly agreed to host it for us.

Florence 11:44

Yes.

SPEAKER_00 11:44

So um, I think we had meant we we do regular teaching within all of the maternal medicine networks and wider kind of obstetric circles, and it had been mentioned a couple of times, and then you know how things work these days. You see on social media someone sends it to another person, and people as far reaching as South Africa had used it and mentioned this is where you have to be. So, yeah, the feedback has been helpful, I think, uh positive. And I think you know, we tried to cover what we talk about in terms of contraception afterwards, and what about breastfeeding, and just hopefully helpful for the women as well to be able to kind of empower them to understand that sometimes the care doesn't need to be so different, and their experience doesn't have to be as different as they might expect. And we will continue to share it with those who will think will benefit from it.

Florence 12:33

You mentioned also, so we talked about it being the commonest cancer in pregnancy, but just kind of overall, so you've said that it's two women diagnosed in pregnancy every day in the UK, and that that's increasing, is that right?

SPEAKER_00 12:49

Yeah, so that's um so two women a day in pregnancy or in the 12 months after the pregnancy. Um, and over the last 40 years, the number of women who've been diagnosed with breast cancer in and around pregnancy has doubled. Um, and there's probably a number of different reasons for this. So the first is that, as you mentioned earlier, Florence, women are delaying pregnancy to a later age. Um so you have an increased risk of having developed a cancer prior to that. Women are entering pregnancy with more risk factors for cancer. So, for example, the number of women who, you know, obesity as a trend is increasing in the UK and beyond both in pregnant women and non-pregnant women. And some of the tests that they do now in early pregnancy, so there's obviously a you know huge advances being made in the testing for prenatal testing, is now able to pick up some of these cancers when they're doing that. So I think there's a combination of women more likely to develop cancer in pregnancy, and also we're more likely to find it in pregnancy. Um, and although we've talked about, you know, people aren't doing investigations and staging, I think when I looked at the data, it looked like more people are doing those things. So we're more likely to diagnose it, I think, at the moment. So that's probably where we're seeing the increase in incidence.

SPEAKER_01 14:06

Also, because women are older, Florence. Yeah. The more likely you are to have breast cancer.

Florence 14:12

Yeah. I definitely see women coming to clinic, and it's quite interesting actually, because again, it's that overlap with the GPs, because I'll have women and I'll say to them at the end of an appointment, I always say, Have you got anything else you want to ask me? And they'll go, Oh, well, I've got this problem with my breast, but I you know, maybe I need to make an appointment with the GP for that, and I'll be immediately, you know, tell me about it, let me have a look, what is it? And we've got a really great one-stop breast clinic, which I'm sure many other units have, but I don't know if women feel like they can't talk to their obstetrician about a breast problem, or whether GPs realize that in pregnancy, you know, not all breast changes are physiological. Um, so that kind of diagnosis, I don't know whether you've got any data on that being delayed or being problematic because there are changes in the breast anyway.

SPEAKER_00 15:19

Yeah, there are very good data to suggest that there is a delay in diagnosis. So there's there's a number of studies that have looked at it's probably about six months later in some patients that a diagnosis has been made. And therefore, you get more women presenting in pregnancy with more aggressive disease because it's had time to spread. So I think, you know, from an education point of view, you know, we need to continue to encourage women to just check their breasts monthly like we do outside of pregnancy, and also just alert to those, you know, there are a lot of overlapping symptoms. People feel tired in pregnancy, people, you know, there are alterations in the breast that might make them feel more lumpy. But I think if the the guidance that has come from the Royal College says that if that has persisted for two weeks and there's no, you need to be, as you mentioned, referred to one of those fast track clinics. And I think it only 20% of those women will have something abnormal, but that doesn't matter because it's simple ultrasound, it does no harm. Um, and if it helps us find the patients who do need treat early treatment, and that's going to make a difference to their both their pregnancy and their long-term outcome, that's of vital importance.

Florence 16:28

You're absolutely right with that, just not ignoring anything, realizing that in pregnancy, you know, it's nine months of your life, something else might happen, um, and you need to check it out.

SPEAKER_01 16:40

Yeah, the other thing, Florence, of course, is you know, we've thrown the baby out with the bath water, like not checking the urine. When when I was a medical student, it was absolutely routine that all women got examined, and that would often include a breast examination. I don't know if you remember those days, you're probably too young.

Florence 16:57

Yes, no, I do. And we used to listen to everybody's chest in case they had undiagnosed cardiac disease at booking.

unknown 17:05

Yeah.

Florence 17:06

Yeah, I don't know where that went.

SPEAKER_01 17:08

Well, it went out like with lots of other things, um, like dipping the urine. But the point is, as uh just to re you know, because we're talking to midwives as well, and they women, if they don't want to mention it to their obstetrician, they may um mention it to their to their midwife. And so I think empowering midwives to empower women to stress the importance of self-examination, because I mean the commonest thing we get in pregnancy is a lump in the breast, which is in the axilla, which is nearly always the normal auxiliary tale of pregnancy. But unless you are used to feeling what normal breasts feel like in pregnancy, like listening to normal hearts, you won't then be able to spot what's different. Yes. These are clinical skills that all obstetricians and all midwives should be completely competent to do. But the the woman who really know the person who really knows is the woman herself. So stressing the importance of knowing what your breasts feel like and how that changes in pregnancy is is super important.

Florence 18:08

Yeah. Thank you very much, both of you. It's been such a pleasure to talk to you both. It's been fantastic to have the opportunity to record you both.

SPEAKER_01 18:20

Thank you, Florence. Thank you for having us.

Florence 18:24

Now for this week's zesty bit. For me, I think this comes in two parts. The first part is the importance of taking seriously any worry or concern a woman has. If she comes to you and tells you that she's been worried about her breasts, whether that's antenatally or in the postnatal period, examine her and don't be afraid to refer her to your local breast clinic. Scanning many women who don't have breast cancer is the way we'll find that small number that do and that need our attention. The other thing is, if you do have a woman with breast cancer in pregnancy, not only is there this wonderful resource that's now being produced by Melanie, but also there's the most fantastic charity, Mummy Star, which has all sorts of resources for both professionals and women and families who are encountering cancer during their pregnancy, whether that be breast cancer or any other form of cancer. I'm going to put links in the show notes. Please go and explore, because as Melanie said in the zesty bit of our previous episode, there are so many resources out there. And the whole purpose of me recording this episode and Kathy and Melanie giving up their time so generously is to raise awareness and get those resources out there to the right people, the right healthcare professionals that are caring for women, and also to women and families themselves, so that they know the standard of care they should be able to expect. So it's been a real privilege to record these two episodes with Kathy and Melanie. And I hope you found them as informative and interesting as I have. I very much hope you found this episode of the Obspod interesting. If you have, it'd be fantastic if you could subscribe, rate, and review on whatever platform you find your podcasts, as well as recommending the Obspod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalogue from clinical topics, my career and journey as an obstetrician and life in the NHS more generally. I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary. If you found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the programme notes where I've attached some links. If you want to get in touch to suggest topics for future episodes, you can find me at the Obsipod on Twitter and Instagram and you can email me theobsipod at gmail.com. Finally, it's very important to me to keep the Obsipod free and accessible to as many people as possible. But it does cost me a very small amount to keep it going and keep it live on the internet. So if you've enjoyed my episodes and by chance you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link to buy me a coffee. Don't feel under any obligation. But if you'd like to contribute, you now can. Thank you for listening.