ABM Clinical Protocol #34: Breast Cancer and Breastfeeding

Abstract

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Background

Breast cancer is the most common malignancy in women worldwide, with 1 in 20 women developing the disease during her lifetime. It represents the leading cause of cancer deaths and disability-adjusted life-years among women. In addition, breast cancer imparts significant morbidity to women and children through its impacts on breastfeeding.

Breast cancer treatments may affect breastfeeding in multiple ways. Breastfeeding women diagnosed with breast cancer may require medications or therapies that decrease milk production or are contraindicated during lactation. Women treated for breast cancer before or during pregnancy may have reduced lactational capacity due to surgical removal of breast tissue and/or irreversible effects of prior therapies. Given these unique challenges and the multitude of health risks associated with not breastfeeding, women with a new or remote breast cancer diagnosis require unique support of lactation.

The aim of this protocol is to guide clinicians in the delivery of optimal care of breastfeeding women as it relates to breast cancer, from screening to diagnosis, treatment, and survivorship. Throughout this protocol, the quality of evidence, based on the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence (Levels 1–5), is noted in parentheses.

Recommendations

Screening breastfeeding women for breast cancer

Limited evidence exists regarding breast cancer screening in the breastfeeding population ( Box E1 ). The American College of Radiology recommends continuation of routine screening depending on the anticipated duration of breastfeeding and the individual’s lifetime risk of breast cancer (Level 4). However, guidelines for routine breast cancer screening of nonlactating women vary between nations, and controversy exists regarding screening eligibility, method, and interval (Level 1).

Box E1

Screening Breastfeeding Women for Breast Cancer Key Points and Recommendations

Breastfeeding women do not need to abstain from routine breast cancer screening due to lactational status, but may decide to defer screening if they plan to wean in a few months.
The decision to screen breastfeeding women should be individualized, and related to personal lifetime risk of breast cancer.
All radiologic modalities used for breast cancer screening are safe during lactation.
The lactating breast has a unique radiographic appearance.
Breastfeeding or expressing breast milk before a screening study is recommended to reduce density and improve examination sensitivity.
Supplemental imaging may be beneficial during lactation.

Expert consensus guidelines have been published for breast cancer screening of breastfeeding women at increased risk of breast cancer due to deleterious BRCA mutations (Level 4). These guidelines advise that women planning to breastfeed for at least 6 months continue routine screening, whereas those anticipating a shorter duration of breastfeeding may elect to defer mammography and/or magnetic resonance imaging (MRI) until 6 to 8 weeks after weaning.

Mammography, breast ultrasonography, and contrast enhanced breast MRI are safe during lactation (Level 4). Lactating breasts have several physiologic differences relative to nonlactating breasts that impact their radiographic appearance: these include hypervascularity, dense parenchyma, and dilated lactiferous ducts containing residual breast milk (Level 4). Such differences may make interpretation of screening studies more challenging and increase the risk of false-positive results, thereby requiring additional imaging studies and biopsies (Level 4).

Breastfeeding or expressing breast milk immediately before the imaging examination reduces these differences and facilitates detection of abnormalities (Level 4). Utilization of supplemental imaging modalities can further optimize breast cancer screening in this population. Specifically, ultrasonography may offer the highest sensitivity (Level 4) and digital breast tomosynthesis (“3D mammography”) may be superior to conventional mammography (Level 4).

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