By Stephanie Kanowitz | The Washington Post

Pam Crum was 22 weeks pregnant with her second daughter when she noticed a lump and redness in one of her breasts. She wasn't alarmed immediately.
It was probably just mastitis — a treatable breast tissue infection — the Falls Church resident thought. Or maybe it was some side effect of pregnancy. "But it still looked odd," says Crum, who was 42 at the time.

Her obstetrician told her to wait two weeks to see if the problem went away. By her next appointment, the mass had grown. Two weeks after that, Crum started chemotherapy for breast cancer.

"Of course my reaction was, ‘I haven't had coffee, I'm not having wine, no chocolate, I'm going to have chemotherapy?'?" Crum says. It seemed crazy to be worried about caffeine when she'd be bombarding her body with drugs and having surgery.

But she delivered a healthy baby girl — with a full head of hair, despite the fact that Crum was bald from the chemo.

Now 51, Crum has been in remission since finishing 10 months of treatment in 2005. She's still dealing with the disease, however, in her position with the Inova Breast Care Institute. She coordinates a mentorship program throughout the network of Northern Virginia locations that matches breast cancer survivors with newly diagnosed patients.

Through her work, Crum has met a handful of other women who have also been diagnosed with pregnancy-associated breast cancer (PABC).

Up to 20 percent of breast cancers in women younger than 30 are associated with pregnancy, says Lisa McGrail, assistant clinical professor of medicine at the George Washington University School of Medicine and Health Sciences. And PABC is growing in frequency, she adds.

The reasons why aren't well understood, says Erica Mayer, a breast oncologist at the Susan F. Smith Center for Women's Cancers at Dana-Farber Cancer Institute in Boston.

"It's not the high level of estrogen during pregnancy that's driving cancer development," Mayer says.

But hormones might play a role for woman diagnosed postpartum, McGrail says: "It may have something to do with the stopping of lactation and when the cells change at the cessation of lactation. We do know that there's a transient increased risk of breast cancer in the postpartum period. That's for everybody."

Breast cancers that are diagnosed postpartum may be more aggressive and have a slightly inferior prognosis, Mayer says. Additionally, postpartum moms might mistake a tumor for a lump caused by a clogged milk duct or normal changes from pregnancy.

"Because changes in the breast are common during pregnancy and postpartum, it does create a situation where a cancer may progress a little further along in a woman with pregnancy-associated breast cancer than it would in someone who is not pregnant," Mayer says.

It's rare for doctors to discuss the potential risk for cancer with pregnant patients — Crum says her doctor never raised the possibility at all. It's standard to conduct a full breast and pelvic exam at the first prenatal visit. After that, it's up to patients to be vigilant.

"If you see something about your breast that just doesn't seem right, go see your doctor and press them, ask questions and really push them to see if there is something going on," Crum says.

When women are diagnosed with PABC during gestation, steps can be taken immediately. Standard treatments such as surgery and some chemotherapies are safe for expectant moms, McGrail says, although radiation must wait until after childbirth.

For Crum at the time, being a cancer patient and the mother of a newborn (and a 3 1/2-year-old) meant balancing terror with pure joy.

"You have new life along with a life that is threatened," says Crum, who coped by focusing on the present. "If no one was sick, if no one was in the hospital, if we were all sleeping in our beds under the same roof, that was a good day.

"It really wasn't until a year later or a couple of years later, I look back and think, ‘Wow, that was really something. How did we do that?'?"

Vital Stats

More than 230,000 women were diagnosed with breast cancer last year, according to the National Cancer Institute. Symptoms include swelling, pain, skin changes and nipple discharge. Lumps are the most common sign. Get step-by-step instructions for doing monthly self-exams from the National Breast Cancer Foundation.