INTRODUCTION

Breast cancer is the most common cancer affecting women in Nigeria accounting for up to 50% of all cancer cases.¹ The role of human error in causing adverse events in the delivery of medical care was highlighted in the 1990s by Reason² who broadly classified human error into failures of execution, termed slips and lapses, and failures of intention, termed mistakes. There is the need for obstetrical care providers to be familiar with the presenting signs and symptoms.^3,4 Pregnancy associated breast cancer (PABC) is defined as breast cancer diagnosed during pregnancy or up to 1 year of delivery.^3,4 It is a common malignancy in pregnant women and accounts for 3% of breast cancers in women worldwide.^5,6 It is responsible for about 21% of all premenopausal breast cancer diagnosis found in women in Nigeria.⁷ Over 90% of patients with breast cancer in pregnancy or during lactation present with a palpable mass, and most often (84%) these are self-reported by patients.^1,3,7,6 The management of PABC can be challenging because of the difficulties associated with its diagnosis and treatment.^1-6 The clinical manifestation may be obscured by the physiologic changes of pregnancy and lactation, and breast engorgement and density of the breast may make radiologic investigations misleading.⁸ Presence of rapidly dividing cells of the pregnant or lactating breast that mimic malignant features may also alter pathologic decisions.⁹ The treatment of PABC is also hindered by conflict between fetal and maternal wellbeing.^4,6,7,8 Symptoms of PABC are often recognized later than their non-pregnant counterparts, and this may be adduced to the fact that many pregnant women interpret pathologic bodily changes as being physiologic.^4,6,7,8 Although PABC is not a rare event, reports are scanty because of the challenges associated with the study population. Majority of the available reports are review articles and case reports.^5,7.8,10 In this retrospective study, we report our experience with the management of PABC in a tertiary health centre in Nigeria highlighting some errors leading to delay in referral and treatment which were caused the referring doctors.

LITERATURE REVIEW

Judgmental errors are usually discussed at conferences and are referred to as “errors” that are the result of inadequate knowledge or failure to employ knowledge². These errors include failure to obtain appropriate consultation and failure to order the proper tests or to interpret them properly.^2,3 The obvious way to correct these deficiencies is education.^4,6,8,10 We as surgical educators spend inordinate amounts of time in such educational pursuits.^8,9,11 If there are unhappy consequences that are predictable, such as the death of terminally ill patients, we spend relatively little time in discussion.¹¹

The incidence of PABC is said to be increasing and is related to the increasing age at first pregnancy due to postponed childbearing for academic reasons.^1,5,7,8 Delayed first birth is a risk factor for breast cancer.^1,5,7,8,11 Every year of increase in the age of first delivery above 25 years leads to a 3.5% to 5% increase in lifetime breast cancer risk.^10,11 It has been shown that the incidence rate of breast cancer jumps to a higher level during and just after each pregnancy and the protective effect of pregnancy on breast cancer is not seen till 10 to 15 years after.^10-12 A delay in diagnosis increases the risk of lymph node involvement by up to 1.8% with every month delay.¹² The delay in presentation is usually due to the mass being attributed to normal breast physiologic changes.^5,7,11,12 Despite the difficulty in diagnosis of PABC, due to the effects of pregnancy on the breast, several investigative modalities with high specificity and sensitivity are available to aid the diagnosis.^8,9,13 Each should be interpreted with care and the presence of false positives and negatives should be entertained if investigative findings are incongruent with the clinical outlook.^8,9,13 Breast masses may be masked on mammography due to engorgement and increased density of the breast¹³; even though the amount of radiation exposure to mammography is small and inconsequential,¹³ Many workers believe ultrasound is the preferred radiological modality of choice especially in the first trimester.^13-15

Depending on the clinical scenario, PABC patients and their providers may be confronted with the choice to either proceed with local control or to initiate systemic treatment.^4,16 For patients diagnosed with early-stage PABC, both breast conservation and mastectomy are considered viable surgical options.¹⁷ Termination of pregnancy was a routine protocol in the management of PABC for about 2 decades ago.¹⁷ Reasons adduced are that the continuous hormonal milieu of the pregnant state encouraged rapid growth of the tumour and aborting the embryo/foetus may slow the progression of the disease.¹⁷ Recent studies have debunked this.^17-19 There has been no difference in outcome in patients who have had termination of pregnancy on account of PABC and their counterparts who did not have termination of pregnancy and is therefore strongly discouraged for such purposes.^11,16 If maternal outcomes are not negatively impacted by the pregnancy itself, continuation of pregnancy seems not only reasonable but also recommended.^11,15,17,19 Nevertheless, in cases of advanced disease stage (stage III or IV) or for high-grade or aggressive primary tumours diagnosed in the early first trimester, termination of pregnancy may be considered (on account of teratogenic risk of chemotherapy during the first trimester.¹⁷ Chemotherapy should be deferred until after the first trimester (after 14 weeks) when organogenesis is considered complete (10 weeks).¹⁷ The rate of malformations is up to 14% if chemotherapy is given in the first trimester¹⁷ and even higher with combination chemotherapy.¹⁷ However, if administered in the second or third trimester, the rate of malformation mirrors the baseline population’s 3% risk of congenital malformations.¹⁸ At least 3 weeks between a cycle of chemotherapy during pregnancy and delivery are recommended.¹⁹ Reports of oncologic outcomes after chemotherapy during versus after pregnancy suggest that delaying systemic treatment in PABC patients may worsen prognosis.¹⁹ Nettleton et al. found that by delaying chemotherapy by 3–6 months, the risk of metastases was increased by 5%–10%.¹²

Literature has suggested that the chemotherapeutic regimen of choice in PABC is adriamycin-based chemotherapy and this regimen has been adjudged to be safe in pregnancy.²⁰ Hormonal treatment of PABC is contraindicated.^19-21 Tamoxifen is associated with Goldenhar syndrome and ambiguous genitalia.²¹

PATIENTS AND METHOD

This was a retrospective observational study to present PABC cases with adverse events that presented in our Centre from January 2019 to January 2021. In this context, a sample size analysis was not performed, as there were no data to indicate baseline rates of human error in our surgical caseload. All cases of PABC records of age of patient, the duration of pregnancy when symptoms were noticed first, diagnosis made, previous care given and outcome.

RESULT

Seven cases were seen during the period of study. Ages ranges from 28 – 37 years with average of 35.4. All cases presented with history of lumps noticed during pregnancy, 4 cases within first trimester, 2 cases second and 1 in the third. Five were on the right breast, 2 cases left and 1 bilateral. All had histological diagnosis made at onset of the noticing of the lumps at peripheral Health Centres. All had no care given as they were advised not to have treatments for fear of adverse effects on the babies by the obstetrical care providers at peripheral Health Centres. All cases presented to us at very advanced stages 2 – 3 months after delivery as shown by clinical pictures in Figs 1 of 0ne of the cases in this study. All were placed on hormonal and chemotherapy cyclically to down stage the disease process for possible surgical interventions. 4 cases declined treatment due to financial reasons, 1 had a dose of chemotherapy and 2 had 2 doses and where are all lost to follow up.