Pregnancy And Tubular Carcinoma

Introduction

Definition of tubular carcinoma 

Tubular carcinoma in the breast is a kind of cancer that tends to be different from other cancers due to its resemblance to normal cells. It grows and spreads more slowly than high-grade cancer, therefore accounting for approximately one to two per cent of invasive breast cancers.¹

It is made up of open lumina (the hollow part of tubes), which are well-differentiated tubular structures one cell layer thick, surrounded by abundant stroma. Tubular carcinoma is not aggressive. Therefore, it has a low rate of occurrence, spreads to axillary lymph nodes, and forms secondary tumours (metastases) at distant sites. Therefore, it is said that a pure tubular carcinoma carries a better prognosis. The diagnosis of tubular carcinoma is based on various tests carried out on a surgical specimen.

Overview of breast cancer during pregnancy

It could be very upsetting to find out that you have breast cancer while you are pregnant. You might get angry, depressed, sad, or even question yourself about what you might have done wrong.

The occurrence of breast cancer during pregnancy is rare, and research has reported it in 1 in about 3,000 pregnancies, most commonly AFABs (assigned female at birth) between the ages of 32 and 38 years old.⁷

In some cases, the AFABs opt to terminate their pregnancy, which might be helpful if there is a need for chemotherapy, as this can be done only after 3 months of pregnancy or if you are 14 weeks pregnant.

During pregnancy, there are usually changes in the breasts as they get ready for breastfeeding/chestfeeding. The breast tissue becomes more dense, with less fat and more connective tissue and breast cells, which makes it difficult to find changes such as lumps in the breast. Therefore several other procedures are carried out to detect cancer cells in the breast during pregnancy, these procedures are discussed later in this article.

Understanding tubular carcinoma

Characteristics and prevalence 

Tubular carcinoma is a form of breast cancer accounting for about one to two percent of all breast cancer diagnoses. It is classified as one of the invasive ductal carcinoma types, the most common type of breast cancer.

Here are some of the characteristics of tubular carcinoma:¹

• Tubular carcinoma is known for its well-defined tubular structures in the breast tissue; these tubules are formed by cancerous cells and are usually lined by a single layer of cells.
• Tubular carcinomas are also characterized by their small sizes. In some cases, the tumours measure less than 2 centimetres in diameter, which makes them to be regarded as low-stage cancers.
• The prognosis of tubular carcinoma is quite favourable compared to other types of invasive breast cancer, and this is due to its slow growth, well-defined borders and its lower rate of spreading to the lymph nodes and other parts of the body.
• They are hormone receptor-positive with a high receptor for oestrogen and progesterone which makes them react more to hormone-based therapies or treatments such as tamoxifen. This is in contrast to HER2-negative (i.e. hormone receptor-negative) tumours, where these hormones have no effect on disease progression.

Prevalence of tubular carcinoma

Tubular carcinoma, a relatively rare type of breast cancer, is often diagnosed in postmenopausal AFABs with records of about 1 - 2% occurrence. Although tubular carcinoma can occur in AFABs of any age it is quite common among those within the age of 50 to 70.

The main cause of tubular carcinoma is unknown, therefore it is assumed to be caused by either genetic or environmental factors just like every other form of breast cancer.

Mammograms, breast cancer screening, and medical breast examination can help in detecting tubular carcinoma at its early stage of occurrence and also help in the quick intervention of treatment.¹

Risk factors 

The following factors may increase your risk of developing tubular carcinoma of the breast.

Being overweight or obese 

According to a cancer research agency, a greater amount of body fat increases the occurrence of cancer in an individual. Adipose tissue, which is also known as fat tissue produces a large amount of oestrogen, which is linked to an increase in the risk of breast cancer. Obesity is also linked to increased levels of insulin in the blood hyperinsulinemia which precedes the occurrence of type 2 diabetes, another known cause of cancer.

Excessive alcohol consumption 

The risk of breast cancer increases by 3-10% per 10 grams of alcohol per day.² This is thought to be primarily hormonally driven because the metabolism or breakdown of alcohol components in the body, which increases the level of oestrogen in AFABs who haven’t experienced a period for over a year, i.e., postmenopausal AFABs.

Having a family history of breast cancer 

Of all the risk factors of tubular carcinoma, heredity is one of those that can't be changed. Five to ten per cent of breast cancer cases are known to be hereditary. In this case, there's a mutation of the breast cancer gene (BRCA1 and BRCA2), which is meant to protect you from getting breast cancer. The mutation or change in BRCA1 and BRCA2 is passed on from a parent to you.

In healthy cells, the breast cancer genes are meant to produce proteins that repair damaged DNA but the moment they become mutated, abnormal cell growth occurs, which makes them liable to cause breast cancer.

Breast cancer related to heredity occurs more in AFABs at the age of 55 and above.

Having your first baby after the age of 35

The birth of a first child at an older age of about 35 and above puts them at a higher risk of developing breast cancer compared to AFABs, who give birth to their first child at a younger age. This is because breast cells tend to grow rapidly during pregnancy.  Also, there could be genetic damage in the breast cells before pregnancy. 

Never having kids also puts a category of AFABs at higher risk of breast cancer.

Not breastfeeding your baby 

Research has it that breastfeeding/chest-feeding helps to decrease the risk of having breast cancer as there is less exposure to oestrogen, which is the main entity that propels the growth of breast cancer. Also, breastfeeding makes breast cells resistant to changes (mutation) that can cause breast cancer. It plays an important role in eliminating lifestyles that aggravate the occurrence of cancer, such as smoking, drinking etc.

Diagnosis during pregnancy

Challenges and considerations 

Tubular carcinoma is a challenging situation for both the patient and their medical team. Some of the challenges associated with tubular carcinoma during pregnancies are the challenges that occur during diagnosis, as the tumour may be small and not felt during a breast exam or palpation. This often causes a delay in the diagnosis of cancer in pregnant individuals due to an increase in the size and density of the breast tissue.³ As a result of this, pregnant breast cancer patients usually appear for medical intervention at an advanced stage of tubular carcinoma involving the axillary lymph node.

Safe diagnostic procedures

The delayed diagnosis of breast cancer during pregnancy makes it hard for ordinary breast exams or palpation to detect lumps. Therefore, the cancer gets to an advanced stage before it is detected.

Safe diagnostic procedures are applied for early detection to ensure early treatment and save lives. Some of these procedures include:

Mammography 

This is done using a mammogram which shows the X-ray picture of the breast. Mammograms are used to detect early signs of breast cancer.

In carrying out this procedure, certain measures are put in place to ensure a great X-ray result.

• Do not have a mammogram a week before your period, as your breast tends to be soft or swollen.
• Do not wear deodorant, perfume or powder to avoid the procedure showing up a white spot on the X-ray. 
• Ensure you are in comfortable clothing like a top and skirt or pants, as you will need to undress from your waist up.

Ultrasonography 

This uses high-frequency sound to produce an in-depth image of internal organs and tissues. This procedure is known for its safe and painless characteristics, even during pregnancy. It helps to effectively view images in the chest, thereby helping to detect any growth or foreign object close to the body's surface, such as the breast. Also, ultrasonography helps to differentiate between cystic and solid breast masses.

Breast MRI 

Also known as magnetic resonance imaging, a device that uses radio waves and strong magnetic rays to detect a picture of the inner part of the breast.

It is used to screen for breast cancer in AFABs who have a high risk of breast cancer development. This is done along with mammograms.

Biopsy 

In this procedure, a small piece of breast tissue is removed from the affected area. The sample is then checked in the lab for cancerous cells.

Treatment options during pregnancy

Surgical options 

Surgery is one of the standard treatments used to treat pregnant AFABs with breast cancer. The affected breast and lymph nodes (in case the cancer has metastasised to them) are removed. When it comes to surgery on the breast in relation to cancer, there are different types of surgeries, which include:

• Modified radical mastectomy: this is the removal of the whole affected breast, which includes the nipple, areola and the skin covering the breast
• There is also breast-conserving surgery, done to remove the cancerous part of the breast and, in some cases, some normal tissues around it but not the entire breast.

Chemotherapy

This is a cancer treatment that involves the use of drugs to stop the growth of cancerous cells by preventing cell division or by killing the cells entirely. In some cases, chemotherapy is also given after surgery to kill cancer cells that may be left.

Chemotherapy medication is either taken orally (by mouth) or intravenously (injected into the vein). It is important to know that chemotherapy is not administered during the first 3 months of pregnancy because it may cause early labour or low birth weight.

Radiation 

In this procedure, X-rays of high energy are used to kill the cancer cells to stop them from growing.

Hormonal therapy 

This is often used to treat breast cancer that grows due to hormones. In this case, medications that inhibit the hormones (e.g. oestrogen) from merging with the cancerous cells are used.

Prognosis and outcomes

Prognostic factors 

Prognostic factors are the characteristics of a person in relation to the cancer which include its stages, grade and size. A prognostic factor determines how cancer will respond to treatment and the possibility of re-occurrence. Prognostic factors of breast cancer include:

• Stage: this indicates how much cancer is in the breast and the rate at which it has spread
• Size: tumours which are 5cm or more in size are likely to reoccur after treatment compared to smaller tumours 
• Grade: this is based on how the cancer cells look compared to the normal cells. A low-grade cancer cell looks similar to a normal cell, while a high one looks way different from normal cells. So, low-grade tumours have a better prognosis than high-grade tumours.
• Age: the younger you are, the greater the risk of breast cancer recurrence due to higher-grade tumours 
• Cancer cells that spread from the breast to the lymph nodes have a higher risk of occurring again, which makes them a favourable prognosis.

Impact on treatment outcomes 

Research shows that postoperative radiotherapy is a favourable prognostic factor in patients with breast cancer as this helps to kill or stop the cancerous cells from growing. Thereby making the recurrence of these cancer cells impossible or difficult.

Patient support and management

Emotional and psychological support 

The diagnosis of breast cancer is a traumatic event as it tends to affect the quality of life, relationships with others, productivity and socialisation. It is also associated with psychological difficulties like anxiety, anger, poor mood, aggression and feelings of isolation.

With all of this that they go through, it is important to support them by being with them throughout the journey, encouraging them to go through every medical process, and listening to them talk. At the same time, respecting their privacy.⁵

Pregnancy management during treatment 

Certain breast cancer treatments are avoided for a while or till after delivery to ensure a safe foetal and maternal outcome. These include suspending chemotherapy until after 3 months of pregnancy. Radiation is also postponed until after delivery, and axillary dissection is performed instead of a sentinel lymph node resection. ⁶

Summary 

Tubular carcinoma is said to be different from the other types of breast cancer due to its resemblance to normal cells and the fact that it spreads and grows slower than high-grade cancer, which spreads rapidly. So tubular carcinoma only accounts for about 1 to 2% of invasive breast cancers. 

Some categories of AFABs, such as those with delay in their first childbirth, those with a family history of breast cancer, those who do not breastfeed their babies, those who are obese and those who consume more alcohol, are at higher risk of having tubular carcinoma. It is quite difficult to diagnose tubular carcinoma during pregnancy because it is very difficult to feel the cancer lumps during examination. Therefore, other procedures such as mammograms, breast MRIs, ultrasonography and biopsy are carried out to detect them.

The prognosis of tubular carcinoma is established based on the stage, size, grade, age and how well the tumour metastasises.

Tubular carcinoma is treated using chemotherapy, radiation, hormonal therapy and surgery.

AFABs who have been diagnosed with tubular carcinoma tend to experience low moods with feelings of isolation, anxiety, depression, anger, etc. Therefore, it is important to show them support, respect, privacy and care during this period.