Association Between Postpartum Breast Cancer Diagnosis and Metastasis and the Clinical Features Underlying Risk | Breast Cancer | JAMA Network Open | JAMA Network
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    Original Investigation
    January 11, 2019

    Association Between Postpartum Breast Cancer Diagnosis and Metastasis and the Clinical Features Underlying Risk

    Author Affiliations
    • 1Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
    • 2Translational Research Program and Human Biology Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
    • 3Knight Cancer Institute, Oregon Health & Science University, Portland
    • 4Young Women’s Breast Cancer Translational Program, University of Colorado Anschutz Medical Campus, Aurora
    • 5Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
    • 6Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland
    • 7University of Colorado Cancer Center, Aurora
    • 8School of Public Health, Department of Medical Informatics & Clinical Epidemiology, School of Medicine, Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health & Science University, Portland
    JAMA Netw Open. 2019;2(1):e186997. doi:10.1001/jamanetworkopen.2018.6997
    Key Points español 中文 (chinese)

    Question  Is there an increased risk for metastasis of breast cancers that are diagnosed in young women post partum that extends beyond 5 years from the last childbirth, and what association do standard clinical prognostic factors have with metastatic risk in these young women when categorized by parity?

    Findings  In a cohort study of 701 women 45 years or younger with breast cancer, those with stage I or II cancer diagnosed up to 10 years post partum had an increased risk for distant metastasis, with both estrogen receptor–positive and estrogen receptor–negative disease significantly affected.

    Meaning  Postpartum status may be a prognostic indicator in young women with breast cancer and should be routinely identified, as up to 45% of women 45 years or younger with breast cancer fall into this category and could be at increased risk for metastasis.


    Importance  In women 45 years or younger, breast cancer diagnosis after childbirth increases the risk for metastasis and death, yet limited data exist to define this window of risk and associated prognostic factors.

    Objective  To assess the window of elevated risk for metastasis following a postpartum breast cancer (PPBC) diagnosis and whether clinical prognostic factors are associated with the increased risk.

    Design, Setting, and Participants  This multicenter cohort study conducted using cases from the Colorado Young Women’s Breast Cancer Cohort diagnosed between January 1, 1981, and December 31, 2014, included 701 women 45 years or younger with stage I to III invasive breast cancer for whom parity data, including time of last childbirth, were available. Data analysis was conducted from July 1 to September 30, 2017. This study involved a tertiary care academic hospital–based breast center and its regional affiliates with cases from the greater Rocky Mountain region.

    Exposures  Primary exposures were prior childbirth or no childbirth, time between most recent childbirth and breast cancer diagnosis, and time between breast cancer diagnosis and metastasis.

    Main Outcomes and Measures  The primary outcome was distant metastasis–free survival.

    Results  A total of 701 women 45 years or younger from the greater Rocky Mountain states region were included in the analysis; mean (SD) age at diagnosis was 37.9 (5.1) years. Breast cancer diagnosis within 10 years after parturition was associated with elevated risk for metastasis, particularly in women with stage I or II disease. In addition, women with PPBC diagnosed within 10 years of a completed pregnancy that was estrogen receptor–positive showed distant metastasis–free survival similar to that of nulliparous patients with estrogen receptor–negative cancer, and women with estrogen receptor–negative PPBC had further reduced metastasis-free survival. Moreover, women with PPBC had increased lymphovascular invasion and lymph node involvement. In addition, tumor-associated Ki67 positivity identified 129 patients with luminal B cancer in the cohort that, independent of parity status, had poorer prognosis compared with patients with luminal A cancer, although it did not reach statistical significance.

    Conclusions and Relevance  Diagnosis of PPBC within 10 years post partum appears to be associated with an increased risk for metastasis. This increased risk was highest in stages I and II cancer at diagnosis and present in both patients with estrogen receptor–positive and estrogen receptor–negative cancer, persisting in estrogen receptor–positive cases for up to 15 years after diagnosis. Postpartum breast cancer diagnoses were not associated with increased Ki67 index but were associated with increased lymphovascular invasion and lymph node involvement compared with breast cancer in nulliparous patients.