HJOG 2023, 22 (3), 109-117| doi: 10.33574/hjog.0532
Aneta Goga, Victoria Vivilaki, Ioanna Kyrkou, Maria Iliadou
Department of Midwifery, University of West Attica, Agiou Spyridonos 28, 12243 Egaleo, Greece
Correspondence: Maria Iliadou, Department of Midwifery, University of West Attica, Agiou Spyridonos 28, 12243 Egaleo, Greece, Tel.:+30 210 5387482, e-mail: email@example.com
Introduction: Breast cancer in pregnancy is diagnosed during pregnancy, during the first year after delivery or during lactation. It is one of the most common malignancies found in women. Although most women with breast cancer are postmenopausal, the number of premenopausal patients has been increasing in recent years. There are many issues related to the psychological management of gestational cancer that need to be addressed. Inadequate receipt of information and limited understanding of treatment options and outcomes may contribute to psychological distress in women. The purpose of this work was to record as closely as possible the data regarding the experiences and difficulties of breastfeeding in breast cancer patients, as well as breastfeeding outcomes.
Materials and Methods: A systematic review of articles was performed in Pubmed and Google Scholar databases, with language restrictions (only English papers) and without time limitation.
Results: The study included 7 qualitative studies. The participants invovlved were breast cancer survivors. They expressed all the difficulties related to breastfeeding and their need for emotional and psychological support.
Conclusions: The general conclusion that emerges is fear and uncertainty both for the mother herself and for her child, as well as anxiety, physical and psychological fatigue and changes in relationships in the family.
Key words: Breast cancer associated to pregnancy, breast cancer psychological factors, breast cancer and lactation, pregnancy related to breast cancer, psychooncology, breast cancer during pregnancy
Many women with breast cancer experience a painless, palpable lump or thickening of the breast skin. The “milk rejection sign” appears less often, which refers to the refusal of the infant to breastfeed by the patient with breast malignancy. Pregnancy has a dual effect on breast cancer risk: it transiently increases the risk after delivery, but decreases risk in later years.1 Regardless of a cancer history, the perinatal period is associated with increased stress.2 Breast cancer in pregnancy must be treated by a team of specialized doctors (mammologist, oncologist, pathologist, radiation therapist, psychologist, neonatologist), in collaboration with the obstetrician-gynecologist, will make the necessary decisions to protect the life of the mother and the child. The prognosis of breast cancer during pregnancy depends on the stage of the disease and is good for cases that are diagnosed at an early stage. In general, the occurrence of breast cancer during pregnancy does not have a negative effect on survival. Breastfeeding from the healthy breast should be encouraged.3
The prognosis for pregnant women with breast cancer is the same as for non-pregnant women. The widespread belief that conditions are worse during pregnancy is largely due to late diagnosis in pregnant women, while the disease progresses. As long as the diagnosis is made early and in the right way, pregnant women can also be successfully treated for breast cancer, with good results for them and safety for their children.4
Many studies have shown that breastfeeding lowers the risk of developing breast cancer.5,6Breastfeeding appears to be associated with a mother’s good physical and emotional health during delivery, lactation and throughout her future life. According to epidemiological studies, breastfeeding women reported seeking medical care less frequently than non-breastfeeding women, a lower incidence of respiratory, cardiovascular, and gastrointestinal diseases, and fewer symptoms related to emotional problems. Early breastfeeding of the breast area is one of the most important stimuli for the production of oxytocin, which is also responsible for the contraction of the uterus, accelerating the return of the organ to its normal size and reducing the possibility of postpartum bleeding and anemia. High levels of oxytocin can increase the pain threshold, reducing maternal distress and thus contributing to an increased feeling of love for the baby. Breastfeeding may also affect a mechanism that regulates cortisol secretion during the day, with a constant concentration of the hormone possibly reducing the risk of postpartum depression. Recent studies have shown that women who do not initiate or continue breastfeeding have a higher risk postpartum depression. There is an inverse correlation between these phenomena due to the hormonal and psychological conditions that occur during the first 6-8 weeks of parturition, as lactating hormone, oxytocin and prolactin can have anxiolytic effects.7
The time of pregnancy and childbirth (perinatal period) is a complex experience in a woman’s life, as a plethora of changes occur in her biology, physiology , and psychology. Various mental disorders can be triggered during the process of organism adaptation, based on the organic and mental substrate of each woman, as well as the supporting framework.
The purpose of this work was to record as closely as possible the data regarding the experiences and difficulties of breastfeeding in breast cancer patients, as well as breastfeeding outcomes. To prepare the research, a systematic review of articles in the existing literature was carried out.
Materials and Methods
A systematic literature review was performed from June 2022 to October 2022 to investigate the experiences and difficulties of breastfeeding in patients with breast cancer. The search strategy involved reviewing published articles related to the purpose of the study. Our systematic review followed the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We searched published articles with the following databases: PubMed/Medline and Google Scholar , with language restrictions (only English papers) and without time limitation.
The search terms used were: breast cancer associated to pregnancy, breast cancer psychological factors, breast cancer and lactation, pregnancy related to breast cancer, psychooncology, breast cancer during pregnancy.
The Critical Appraisal Skills Programme (CASP) Systematic Review Checklist 201725 was used to evaluate the quality of each article. This technique supports in verifying the reliability of research and, consequently, confirms that the selected literature was suitable for inclusion in the current review. Critical Appraisal Checklists were used as a guide and aide memoire to thoroughly and methodically examine studies in order to assess their reliability, value, and relevance in a specific context.8
We found 136 papers in the databases PubMed/Medline and Google Scholar. After manual screening of the titles and abstracts of the 136 studies, 89 studies were excluded. Therefore, a total of 47 studies were included for further evaluation. After next screening, 40 studies were excluded and only 7 articles were included in the systematic review (Figure 1). The methodological characteristics of included studies are presented in Table 1.
Figure 1. Search plot diagram.
Gorman et al.9 conducted a qualitative survey of breast cancer survivors’ experiences with breastfeeding. They sampled 11 breast cancer survivors who had a child after their diagnosis and treatment. Study participants were highly motivated to breastfeed, but faced significant challenges. They described problems that are not unique to women with breast cancer, but they faced them to a much greater degree because they relied primarily or entirely on one breast. This study revealed the need for improved access to information and support and greater sensitivity to the barriers faced by breast cancer survivors. Ten of the study participants breastfed their children, and all discussed significant breastfeeding challenges. Chief among them was the lack of adequate milk supply because they relied primarily on one breast. All study participants who breastfed reported that it was physically and emotionally very difficult. Several women expressed frustration with the experience of low milk supply, which is why many started taking nutritional supplements. Physically challenged women also reported many physical challenges from feeding on only one side, including pain and physical appearance. Some of these challenges were physical (single breast, secondary health problems), others psychological (fear of failing to provide the best care for their child, fear of relapse, reduced confidence in bodily functions) or social (prejudice and prejudice from relatives, friends and professionals health), but some were common challenges for all breastfeeding mothers.8 Anxiety about breastfeeding was something that many women reported experiencing during pregnancy, generally stemming from concerns about having a sufficient milk supply. Despite the physical and emotional challenges the women faced, in the end, they reported being glad they had the experience. Additionally, several mothers discussed their beliefs that breastfeeding may be beneficial to their own health, possibly reducing the risk of breast cancer recurrence.9
Connell et al.10 also reported that decisions about breastfeeding were difficult for many women. However, these authors reported that women’s anxiety was largely related to fear of recurrence. Participants in this study discussed fear of recurrence in relation to pregnancy, but only one participant identified this fear as a factor in her decision about breastfeeding. Several participants in this study reported that they spoke to a healthcare provider, typically an oncologist or obstetrician, about whether it would be possible and safe for them to breastfeed. Overall, women reported that their physicians encouraged them to breastfeed, but they did not provide additional education or support for breastfeeding. Some women looked to other sources for information; a few participants mentioned looking online, one went to a breastfeeding class, and others looked at breastfeeding books. Participants reported that information specific to breast cancer survivors was unavailable. Appointments such as prenatal visits would provide a valuable opportunity for providers to discuss the specific concerns and needs of breast cancer survivors who are interested in breastfeeding. This would also be an ideal time to connect women with support services that they might need postpartum, such as lactation consultation and breastfeeding support groups.10
In the study of Chertok et al.,11 mothers shared their perceptions, barriers and experiences regarding infant feeding. Four themes were identified: the miracle of motherhood after breast cancer, medical misinformation or lack of available information contributing to mothers’ concerns, feeding challenges after breast cancer, and the desire for support in feeding the infant rather than pressure.11
Azim et al.12 performed a survey among breast cancer patients who completed their pregnancy following breast cancer management to examine their lactation behaviors and its effect on breast cancer outcome. Out of 32 women identified, 20 were reachable and accepted to take the questionnaire. Ten women initiated breastfeeding, 4 stopped within one month and 6 had long-term success with a median period of 11 months (7–17 months). The latter were all previously subjected to breast conserving surgery and received qualified lactation counselling at delivery. The main reasons for not initiating breastfeeding were “uncertainty regarding maternal safety” and “a priori unfeasibility” expressed either by the obstetrician or by the oncologist. At a median follow-up of 48 months following delivery, all 20 women were alive with two relapses; one in each group (i.e., lactating and non-lactating). This analysis adds to the limited available evidence on the feasibility and safety of breastfeeding in breast cancer survivors. Proper fertility and survivorship counselling is crucial and requires more attention in breast cancer clinics.12
In the study of Higgins & Haffty13, there were 11 patients at stage I (n=7) or stage II (n=3) breast cancer, who had breast-conserving therapy (lumpectomy ). Seven of them received irradiation and 3 patients received chemotherapy. Most women were able to breastfeed successfully from the untreated breast, while milk production was lower in the treated breast and lactation was likely to be more difficult among women who had an incision near the areola-nipple complex.13
Kim et al.14 studied women with invasive breast cancer (n=15). Seven of them received breast-conserving surgery and 5 had total mastectomy. The results have shown that 12 women (80.0%) reported no difficulties in breastfeeding and they used the contralateral breast for breastfeeding.
In the study by Faccio et al.,15 four main themes were identified: fears and concerns, meaning of motherhood, mother-fetal relationship and partner support. In all topics, differences between prime interest and compound interest are reported. Women with gestational breast cancer described fear for their own and their child’s survival. Women with previous breast cancer recall opposite feelings. All women with experience of breast cancer perceived breastfeeding as fundamental and the inability to do so caused concern.
There are identified many reports that describe breast cancer survivors’ experiences with breastfeeding. Although those who breastfed faced many barriers, they were generally positive about their experiences and encouraged other breast cancer survivors, who may be interested in breastfeeding not to let breast cancer stop them from trying. Milk supply was an important issue for most. Difficulties associated with having only one breast to breastfeed, including lower milk supply, physical pain, and exhaustion, were significant barriers for this group of breast cancer survivors. Anxiety about breastfeeding and lack of support for breastfeeding was something many women reported experiencing during pregnancy, generally stemming from concerns about adequate milk supply. Potential interventions include professional support through lactation consultants trained to meet the unique challenges of breast cancer survivors, encouraging spousal/partner support, and support from other breast cancer survivors who have breastfed. Breastfeeding is a struggle for many women and even more so for breast cancer survivors, who usually only have one breast to breastfeed.9 Understanding the experiences of women who have given birth after breast cancer can help women in similar situations know they are not alone, locate resources, access peer support, and seek advice on infant feeding based on evidence from health care providers involved in their care.11Fear of disease recurrence due to pregnancy, worry of harm to the fetus, inability to care for the baby, anxiety of the neglected child, and fear of harm to the baby due to disruption of the family structure were among the factors that led to reluctance to become pregnant. Lack of access to timely and complete information, fear of infertility and harm to the fetus in the event of pregnancy caused painful concerns about pregnancy. Fatigue resulting from the long treatment period and complications during pregnancy caused an unprecedented psychological impact on patients and their families.16,17
The general conclusion that emerges is fear and uncertainty both for the mother herself and for her child, as well as anxiety, physical and psychological fatigue and changes in relationships in the family. It is recommended that appropriate pregnancy and lactation advice be handled more thoroughly in breast cancer centers. This would improve these women’s quality of life and assist them in returning to their usual lives.
Disclosure of conflicts of interest
The authors report no conflicts of interest.
- Lambe M, Hsieh C, Trichopoulos D, Ekbom A, Pavia M, Adami H. (1994). Transient increase in the risk of breast cancer after giving birth. New England Journal of Medicine. 331;(1): 5-9.
- Vanstone R, Fergus K, Ladhani N. Reproductive concerns and fear of cancer recurrence: a qualitative study of women’s experiences of the perinatal period after cancer. BMC Pregnancy and Childbirth. 2021; 21:1-13
- Lymberopoulos H. (2022, 4 3). Breast Cancer and Pregnancy. Retrieved from www.iaso.gr: https://www.iaso.gr/blog/details/blogs/2020/04/13/karkinos-mastou-ke-kiisi-254
- Ferrari F, Faccio F, Peccatori F. Psychological issues and construction of the mother-child relationship in women with cancer during pregnancy: a perspective on current and future directions. BMC Psychol. 2018; 6(1), 1-4.
- Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50302 women with breast cancer and 96973 women without the disease. Lancet. 2002 Jul 20;360(9328):187–195.
- Bothou A, Zervoudis S, Iliadou M, Pappou P, Iatrakis, G, Tsatsaris G, et al. Breastfeeding and Breast Cancer Risk: Our Experience and Mini-review of the Literature. Materia socio-medica.2022; 34(1): 28.
- Del Ciampo L, Del Ciampo I. Breastfeeding and the Benefits of Lactation for Women’s Health. Rev Bras Ginecol Obstet. 2018, 40:354-359.
- Critical Appraisal Skills Programme. CASP Appraisal Checklists. Oxford, UK: CASP 2017; Accessed June 2022
- Gorman J, Usita P, Madlensky L. A qualitative investigation of breast cancer survivors’ experiences with breastfeeding. J Cancer Surviv. 2009;(3):181–191.
- Connell S, Patterson C, Newman B. A qualitative analysis of reproductive issues raised by young Australian women with breast cancer. Health Care for Women International. 2006;27(1):94–110.
- Chertok I, Wolf J, Beigelman S. Infant feeding among women with a history of breast cancer. Journal of Cancer Survivorship. 2020, pages356–362.
- Azim Jr, Santoro L, Pavlidis N. Safety of pregnancy following breast cancer diagnosis: A meta-analysis of 14 studies. European Journal of Cancer. 2011;47(1): 74-83.
- Higgins S, Haffty BG. Pregnancy and lactation after breast-conserving therapy for early stage breast cancer. Cancer. 1994;73(8):2175–2180.
- Kim I, Ryu JM, Paik HJ, et al. Fertility Rates in Young Korean Breast Cancer Patients Treated with Gonadotropin-Releasing Hormone and Chemotherapy. Journal of Breast Cancer. 2017;20(1):91-97.
- Faccio F, Mascheroni E, Ionio C. Motherhood during or after breast cancer diagnosis: A qualitative study. European Journal of Cancer Care. 2020;29(2):1-10.
- Henderson J, Alderdice F, Redshaw M. Factors associated with maternal postpartum fatigue: an observationalstudy. BMJ Open. 2019 Jul 27;9(7): e025927.
- Ghaemi S, Keshavarz Z, Tahmasebi S. Conflicts women with breast cancer face with: A qualitative study. J Family Med Prim Care. 2019;8(1): 27–36.