Vele vrouwen weten niet dat het geven van borstvoeding na eerdere borstkankerbehandelingen mogelijk en veilig kan zijn. Het slagen van borstvoeding na borstkanker hangt van vele factoren af. Waarbij de behandelingen in de anamnese de belangrijkste variabelen zijn. Welke invloed de verschillende behandelingen hebben, wordt in dit artikel kort aangehaald.
Borstkanker in de reproductieve periode
Borstkanker is de meest voorkomende kanker bij vrouwen in de reproductieve leeftijd. Wereldwijd is zo’n 6 % van de borstkankerpatiënten jonger dan 40 jaar. Jaarlijks komt dit neer op ca. 125 000 vrouwen (International Agency for Research on Cancer, 2019). Uit onderzoek van Ferlay et al. (2018) bleek dat België de hoogste incidentie aan borstkanker heeft van Europa, namelijk 154,7 gevallen per 100 000 vrouwen. In 2017 was het percentage borstkankerpatiënten onder de 40 jaar 9,75% (Alles over kanker, 2020).
Ongeveer 50% van deze vrouwen heeft nog een kinderwens, waardoor ook de mogelijkheid om borstvoeding te geven in deze groep nader bekeken moet worden (Pauluch-Simon et al., 2017).
Geen verhoogde risico op herval
De angst om te hervallen blijft bij vele vrouwen de meest prominente angst na borstkanker. Het is een veel gemelde reden waarom deze vrouwen bij een zwangerschap na borstkanker kiezen voor kunstvoeding. Uit onderzoek is echter gebleken dat vrouwen die borstvoeding geven na een vroegere borstkankerdiagnose, geen hoger risico zouden hebben op herval ten opzichte van vrouwen die kunstvoeding geven. Zij zouden zelfs eerder een verminderd risico op herval hebben (Johnson & Mitchell, 2019; Lambertini et al., 2018; Pagani & Azim, 2012).
Het is dus geen reden om vrouwen na een vroegere borstkanker diagnose te ontmoedigen, maar eerder aan te moedigen en informeren over hun opties.
Daarnaast kan de vrouw ook tijdens de zwangerschap en lactatie gescreend worden voor borstkanker. Door de fysiologische veranderingen aan de borst kan de screening wel wat moeilijker verlopen (Haliloglu, Ustuner, & Ozkavukcu, 2019). Het is dan ook essentieel dat een ervaren zorgverlener dit uitvoert. Deze kan de borst onderzoeken aan de hand van een echografie, mammografie of MRI (Johnson, Lewis, & Mitchell, 2020). Er wordt aangeraden om de vrouw voor de mammografie in te lichten dat de hogere densiteit van de lacterende borst zorgt voor een hoger vals positieve ratio vergeleken met een niet lacterende borst.
Succesratio
In de wetenschappelijke literatuur is er een grote spreiding te bemerken qua succesratio’s: 7,7 tot 90,9% (1). Dit is enerzijds te wijten aan de verschillende behandelingen overheen de onderzoeken. Anderzijds aan de studieopzet en kleine steekproefgroottes. De onderzoeken omtrent de slaagkans van borstvoeding na borstkanker zijn namelijk overwegend case studies of retrospectieve onderzoeken. Deze zijn wel kwalitatief, maar gerichtere en prospectieve onderzoeken hebben een grotere bewijskracht.
(1: Azim et al., 2009; Azim et al., 2010; Connel et al., 2006; Dow, Harris, & Roy, 1994; Gorman et al., 2009; Kim et al., 2017; Lambertini et al., 2018; Stopenski, Aslam, Zhang, & Cardonick, 2017; Tralins, 1995)
Therapie afhankelijk
Het lacteren van de borst is mogelijk na de meeste behandelingen. Een absolute uitzondering hierop is de bilaterale mastectomie. Bij een mastectomie wordt 95% van het borstklierweefsel verwijderd waardoor lactatie niet meer mogelijk is (Johnson & Mitchell, 2019). Na een unilaterale mastectomie kan de vrouw echter wel nog borstvoeden langs de contralaterale kant (2). Aangezien zij slechts één borst heeft om haar zuigeling te voeden, kan zij mogelijks meer hindernissen ervaren (Azulay Chertok et al., 2020; Linkeviucite et al., 2019).
Vele borstkankerbehandelingen veroorzaken een verminderde tot afwezige melkproductie. Dit is het geval bij lumpectomie, radiotherapie en chemotherapie (Azim et al., 2010; Gorman et al., 2009).
Een borsttumor kan ook via lumpectomie en oncoplastische borstchirurgie (OBS) verwijderd worden. Beide operaties trachten zoveel mogelijk borstklierweefsel te behouden en het tepel-areolacomplex te sparen (Kaviani et al., 2020). Er zijn nog onvoldoende onderzoeken gevoerd naar het effect van OBS op lactatie om een onderbouwde conclusie te nemen.
Na radiotherapie kan ongeveer 50% van de vrouw melk produceren in de bestraalde borst (Leal et al., 2013). Zuigelingen prefereren echter vaak de onbestraalde borst. Dit komt hoogstwaarschijnlijk door de verminderde melkproductie en bemoeilijkte aanhap bij de bestraalde borst (Azim et al., 2010, Azulay Chertok et al., 2020).
Lactatie na chemotherapie kan veilig zijn (Pagani & Azim, 2012). Idealiter zit er minstens 3 weken tussen de laatste dosis chemotherapie en de lactatie (Salani, Billingsley, & Crafton, 2014). Indien de vrouw nog adjuvante chemotherapie krijgt in het postpartum, moet er gekeken worden welke medicatie zij inneemt aangezien sommige cytostatica potentieel toxische effecten hebben voor het kind (Pistilli et al., 2013). Bij hormoontherapie mag er geen borstvoeding gegeven worden, aangezien de toxische stoffen in de moedermelk terecht komen (Azulay Chertok et al., 2020).
Momenteel loopt er ook nog een prospectief onderzoek waarbij bekeken wordt of het uitstellen van chemo- en hormoontherapie voor de kinder- en borstvoedingswens veilig is. De resultaten van dit onderzoek zullen komend najaar geanalyseerd worden (Partridge et al., 2021).
(2: Al-Mohsen & Jamal, 2020; Barco, del Carmen Vidal, García, & Giménez, 2015; Kim et al., 2017; Michaels & Wanner, 2013)
Begeleiding
Vrouwen die borstvoeding geven na eerdere borstkankerbehandelingen kunnen meer hindernissen ervaren bij de lactatie. Zo hebben zij meer moeite om een volledige lactatie op gang te krijgen of hun zuigeling aan de borst te leggen. De begeleiding van een vroedvrouw of lactatiekundige om de borstvoeding te optimaliseren is bij deze vrouwen dan ook een onmisbare factor voor een goede lactatie (Azulay Chertok et al., 2020; Michaels & Wanner, 2013).
Idealiter spreekt de vroedvrouw of lactatiekundige reeds prenataal met de vrouw af om haar individuele situatie te bespreken. Zo kan zij een beeld vormen van welke invloeden er zullen zijn op de lactatie en kunnen huidige behandelingen en bezorgdheden reeds bekeken worden. De vroedvrouw kan haar ook informeren over de mogelijke extra controles tijdens de zwangerschap en lactatie, zoals mammografieën (Johnson et al., 2020). Tenslotte kan de vroedvrouw met haar bekijken wat haar doelen en verwachtingen zijn. Zij kunnen eventueel samen reeds een concreet postpartum plan opstellen (Linkeviciute et al., 2019).
Indien u meer informatie over dit onderwerp wenst te lezen, kan u de gelijknamige bachelorproef waarop dit artikel gebaseerd is, raadplegen via de mediatheek Kantienberg in de Artevelde hogeschool te Gent. De uitgebreidere brochure kan u via onderstaande link kan raadplegen: https://drive.google.com/file/d/1j8Yj6MWpxHrfKHZtVUGhIb0VSkq_TMAv/view?…
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