Breast Cancer Screening, Diagnosis, and Management During Lactation
by Anne Eglash MD, IBCLC, FABM
Oncolactation, according to the American Society of Breast Surgeons (ASBrS), is the intersection of lactation and oncology screening, diagnosis and management. Pregnancy-related breast cancer (PABC) has been defined as breast cancer occurring during or within a year after pregnancy or lactation. However, breast cancer diagnosed up to 5 years postpartum is generally more aggressive than other presentations.
PABC is on the rise because of women giving birth at later ages.
The ASBrS’s oncolactation resource guide covers details on screening, diagnosis, and breast cancer treatment.
Breast cancer screening, if indicated based on age or risk profile, should not be delayed due to pregnancy or lactation. Ultrasound is considered the first-line diagnostic study to evaluate a mass during lactation, although mammography may also be recommended based on the clinical scenario.
For individuals diagnosed with breast cancer during lactation, breastfeeding from the affected breast will not harm their child. Lactation during radiation and breast surgery may continue on the unaffected breast, while down-regulation of milk production is recommended in the affected breast. The guideline advises to avoid breastfeeding from the affected breast during radiation treatment. It is not necessary to wean from the affected breast for the purpose of breast surgery, and the risk of post-operative fistula is very low.
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- All breast imaging modalities are safe during lactation and don’t require interruption of breastfeeding.
- Immunotherapy for breast cancer is considered safe during lactation.
- Lactating women at high risk for breast cancer should hold off on their next MRI until after weaning due to the poor sensitivity of MRI during lactation.
- Titanium clip placement in association with breast biopsy should be avoided during lactation.
- Fine needle biopsy is preferred over core needle biopsy during lactation, to prevent the risk of milk fistula.
- If a core needle is used for breast biopsy, the biopsy site should be sutured closed to prevent prolonged milk leakage.
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Abstract
No abstract is available.
The American Society of Breast Surgeon’s Resource Guide on Oncolactation is a clear, concise outline of appropriate management for breast cancer screening, diagnosis and management among people who are lactating, and should be shared with all healthcare team members who diagnose and treat breast cancer.
The guideline suggests that there is insufficient information about the safety of immunotherapy in breastmilk for infants, despite these being large molecules. Lactating women at high risk for breast cancer should continue MRI screening during lactation. Titanium clip placement is safe during lactation and core needle biopsy is not contraindicated during lactation. Any milk leakage from the biopsy site will diminish over a few or several days and does not require surgical closure.
I would like to highlight the topic of mammography for work up of a breast lesion during lactation. The guideline suggests that ultrasound is the first-line diagnostic imaging study for pregnant and lactating women with a palpable mass or other concerning symptoms, and that mammography can provide additional information as indicated. I wish they added that diagnostic breast imaging during lactation is the same as that for nonlactating individuals, as per the Academy of Breastfeeding Medicine Protocol #31 on Radiology and Nuclear Medicine Studies in Lactating Women. I am concerned that masses during lactation may arouse less suspicion for breast cancer, and without appropriately aggressive evaluation, breast cancer diagnosis could be delayed. In addition, one published manuscript suggests the addition of ultrasound to routine mammogram screening during location due to the greater difficulty interpreting mammography during lactation.