1
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Loibl S, Azim HA, Bachelot T, Berveiller P, Bosch A, Cardonick E, Denkert C, Halaska MJ, Hoeltzenbein M, Johansson ALV, Maggen C, Markert UR, Peccatori F, Poortmans P, Saloustros E, Saura C, Schmid P, Stamatakis E, van den Heuvel-Eibrink M, van Gerwen M, Vandecaveye V, Pentheroudakis G, Curigliano G, Amant F. ESMO Expert Consensus Statements on the management of breast cancer during pregnancy (PrBC). Ann Oncol 2023; 34:849-866. [PMID: 37572987 DOI: 10.1016/j.annonc.2023.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/14/2023] Open
Abstract
The management of breast cancer during pregnancy (PrBC) is a relatively rare indication and an area where no or little evidence is available since randomized controlled trials cannot be conducted. In general, advances related to breast cancer (BC) treatment outside pregnancy cannot always be translated to PrBC, because both the interests of the mother and of the unborn should be considered. Evidence remains limited and/or conflicting in some specific areas where the optimal approach remains controversial. In 2022, the European Society for Medical Oncology (ESMO) held a virtual consensus-building process on this topic to gain insights from a multidisciplinary group of experts and develop statements on controversial topics that cannot be adequately addressed in the current evidence-based ESMO Clinical Practice Guideline. The aim of this consensus-building process was to discuss controversial issues relating to the management of patients with PrBC. The virtual meeting included a multidisciplinary panel of 24 leading experts from 13 countries and was chaired by S. Loibl and F. Amant. All experts were allocated to one of four different working groups. Each working group covered a specific subject area with two chairs appointed: Planning, preparation and execution of the consensus process was conducted according to the ESMO standard operating procedures.
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Affiliation(s)
- S Loibl
- GBG c/o GBG Forschungs GmbH, Neu-Isenburg; Centre for Haematology and Oncology Bethanien, Frankfurt am Main, Frankfurt; Goethe University Frankfurt, Frankfurt am Main, Frankfurt, Germany.
| | - H A Azim
- Breast Cancer Center, School of Medicine, Tecnologico de Monterrey, San Pedro Garza Garcia, Nuevo Leon, Mexico
| | - T Bachelot
- Department of medical oncology, Centre Léon Bérard, Lyon, France
| | - P Berveiller
- Department of Gynecology and Obstetrics, Poissy-Saint Germain Hospital, Poissy; UMR 1198 - BREED, INRAE, Paris Saclay University, RHuMA, Montigny-Le-Bretonneux, France
| | - A Bosch
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund; Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - E Cardonick
- Cooper Medical School at Rowan University, Camden, USA
| | - C Denkert
- Philipps-University Marburg and Marburg University Hospital (UKGM), Marburg, Germany
| | - M J Halaska
- Department of Obstetrics and Gynaecology, Third Faculty of Medicine, Charles University in Prague and Universital Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - M Hoeltzenbein
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Clinical Pharmacology and Toxicology, Embryotox Center of Clinical Teratology and Drug Safety in Pregnancy, Berlin, Germany
| | - A L V Johansson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Cancer Registry of Norway, Oslo, Norway
| | - C Maggen
- Department of Obstetrics and Prenatal Medicine, University Hospital Brussels, Brussels, Belgium
| | - U R Markert
- Placenta Lab, Department of Obstetrics, Jena University Hospital, Jena, Germany
| | - F Peccatori
- Gynecologic Oncology Department, European Institute of Oncology IRCCS, Milan, Italy
| | - P Poortmans
- Iridium Netwerk, Antwerp; University of Antwerp, Antwerp, Belgium
| | - E Saloustros
- Department of Oncology, University General Hospital of Larissa, Larissa, Greece
| | - C Saura
- Medical Oncology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - P Schmid
- Cancer Institute, Queen Mary University London, London, UK
| | - E Stamatakis
- Department of Anesthesiology, 'Alexandra' General Hospital, Athens, Greece
| | | | - M van Gerwen
- Gynecologic Oncology, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam; Department of Child and Adolescent Psychiatry and Psychosocial Care, Amsterdam UMC, University of Amsterdam; Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - V Vandecaveye
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - G Pentheroudakis
- European Society for Medical Oncology (ESMO), Lugano, Switzerland
| | - G Curigliano
- Division of Early Drug Development, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - F Amant
- Gynecologic Oncology, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam; Division Gynaecologic Oncology, UZ Leuven, Belgium
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2
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Tesch ME, Partridge AH. Treatment of Breast Cancer in Young Adults. Am Soc Clin Oncol Educ Book 2022; 42:1-12. [PMID: 35580291 DOI: 10.1200/edbk_360970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Although breast cancer is rare and understudied in adults age 40 and younger, recent epidemiologic data show an increasing incidence of breast cancer among young women in the United States and ongoing inferior long-term outcomes. Given breast cancers arising at a young age are more likely to present at advanced stages and to have aggressive biology, multimodal treatments are often indicated. Elevated local recurrence risks and greater propensity for germline cancer predisposition mutations can impact local therapy choices. Recently, escalated systemic therapy regimens for triple-negative breast cancer incorporating immunotherapy, de-escalated anti-HER2 therapy, and emerging targeted agents, including CDK4/6 inhibitors and PARP inhibitors, for early-stage disease may be employed in younger and older patients alike, with some special considerations. Prognostic genomic signatures can spare low-risk young women with hormone receptor-positive breast cancer adjuvant chemotherapy, but management of intermediate-risk patients remains controversial. Ovarian function suppression and extended endocrine therapy are improving outcomes in hormone receptor-positive breast cancer, but treatment adherence is a particular problem for young patients. Young women may also face greater challenges in long-term survivorship, including impaired fertility, difficulties in psychosocial adjustment, and other treatment-related comorbidities. Consideration of these age-specific issues through dedicated multidisciplinary strategies is necessary for optimal care of young women with breast cancer.
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3
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Breast Cancer in Pregnancy. Obstet Gynecol Clin North Am 2022; 49:181-193. [DOI: 10.1016/j.ogc.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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4
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Silverstein J, Post AL, Chien AJ, Olin R, Tsai KK, Ngo Z, Van Loon K. Multidisciplinary Management of Cancer During Pregnancy. JCO Oncol Pract 2021; 16:545-557. [PMID: 32910882 DOI: 10.1200/op.20.00077] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cancer during pregnancy is relatively rare but is increasing in frequency in countries in which the maternal child-bearing age continues to rise. The complexities of medical decision making are underscored by the need to weigh the potential benefits of any intervention for the mother against the risks to the fetus. A majority of diagnostic evaluations can be performed safely in the setting of pregnancy and should not be delayed. Noninvasive prenatal testing that shows discordance with fetal karyotype can be a clue to an underlying maternal malignancy. After diagnosis, a multidisciplinary team should formulate a care plan for both the mother and the fetus. Key topics for discussion should include the mother's prognosis, standard treatment plan, and predictions of how modifications for a continuing pregnancy will affect the treatment plan and overall prognosis. In the context of this knowledge, frank discussions about pregnancy termination should be addressed with the patient, if appropriate. Selection of a plan for oncologic management in the case of a pregnant woman is based on the type of cancer, the tumor biology, and the tumor stage. Additional complexities for pregnant patients are typically related to the gestational age of the fetus, the dynamic physiologic changes of pregnancy, and the limited safety data for administration of most anticancer therapies during pregnancy. In this article, we summarize data related to different classes of anticancer therapies as well as considerations for the management of selected cancers. Finally, we provide some key principles that should be considered in the management of patients with cancer during pregnancy.
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Affiliation(s)
- Jordyn Silverstein
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Annalisa L Post
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - A Jo Chien
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA.,Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Rebecca Olin
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA.,Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Katy K Tsai
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA.,Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Zoe Ngo
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA.,Department of Pharmacy, University of California, San Francisco, San Francisco, CA
| | - Katherine Van Loon
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA.,Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco, San Francisco, CA
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5
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Breast cancer during pregnancy: retrospective institutional case series. Radiol Oncol 2021; 55:362-368. [PMID: 33939895 PMCID: PMC8366736 DOI: 10.2478/raon-2021-0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 03/29/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Pregnancy associated breast cancer is a rare disease. It presents a unique entity of breast cancer with aggressive phenotype. The main aim was to evaluate how the international guidelines were followed in daily practice. PATIENTS AND METHODS Data concerning patients' and tumours' characteristics, management, delivery and maternal outcome were recorded from institutional electronic database. In this paper a case series of pregnant breast cancer patients treated at single tertiary institution between 2007 and 2019 are presented and the key recommendations on managing such patients are summarized. RESULTS Fourteen patients met the search criteria. The majority of tumours were high grade, triple negative or HER2 positive, two patients were de novo metastatic. Treatment plan was made for each patient by multidisciplinary team. Eight patients were treated with systemic chemotherapy with no excess toxicity or severe maternal/fetal adverse effects. In all but two patients, delivery was on term and without major complications. Only one event, which was not in whole accordance with international guidelines, was identified. It was the use of blue dye in one patient. CONCLUSIONS Women with pregnancy associated breast cancer should be managed like non-pregnant breast cancer patients and should expect a similar outcome, without causing harm to the unborn child. To achieve a good outcome in pregnancy associated breast cancer, a multidisciplinary approach is mandatory.
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6
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Jyoti B, Bharat C, Ankita N, Munita B, Sudeep G. Pregnancy on tamoxifen: Case-report and review of literature. South Asian J Cancer 2020; 5:209-210. [PMID: 28032092 PMCID: PMC5184762 DOI: 10.4103/2278-330x.195347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Bajpai Jyoti
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Chauhan Bharat
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Nachanker Ankita
- Department of Radiotherapy, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Bal Munita
- Department of Surgical Pathology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Gupta Sudeep
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
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7
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Paris I, Di Giorgio D, Carbognin L, Corrado G, Garganese G, Franceschini G, Sanchez AM, De Vincenzo RP, Accetta C, Terribile DA, Magno S, Di Leone A, Bove S, Masetti R, Scambia G. Pregnancy-Associated Breast Cancer: A Multidisciplinary Approach. Clin Breast Cancer 2020; 21:e120-e127. [PMID: 32778512 DOI: 10.1016/j.clbc.2020.07.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/07/2020] [Accepted: 07/14/2020] [Indexed: 01/20/2023]
Abstract
The diagnosis of breast cancer (BC) during pregnancy is uncommon. It has varied among different studies from 1:10,000 to 1:3000 of all pregnancies, with a median age of 33 years. Pregnancy-associated BC represents a challenge in terms of clinical management to guarantee both maternal and fetal security in choosing the right treatment. This situation is complex and requires a multidisciplinary approach, including the surgeon, anesthesiologist, oncologist, radiotherapist, psychologist, and maternal-fetal medicine specialist. In the present review, we examined the management of pregnancy-associated BC, focusing on pathophysiologic background, risk factors, diagnosis, staging procedures, anesthesia, surgical management, and systemic treatment.
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Affiliation(s)
- Ida Paris
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Danilo Di Giorgio
- Gynaecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Luisa Carbognin
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giacomo Corrado
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giorgia Garganese
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Gynaecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianluca Franceschini
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alejandro Martin Sanchez
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Rosa Pasqualina De Vincenzo
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cristina Accetta
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniela Andreina Terribile
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefano Magno
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alba Di Leone
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Sonia Bove
- Gynaecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
| | - Riccardo Masetti
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Scambia
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
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8
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Macdonald HR. Pregnancy associated breast cancer. Breast J 2020; 26:81-85. [PMID: 31943583 DOI: 10.1111/tbj.13714] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 10/14/2019] [Indexed: 02/06/2023]
Abstract
Pregnancy associated breast cancer (PABC) defined as breast cancer occurring during pregnancy or within the first 1-2 years postpartum. Delay in diagnosis is common. Treatment is timed around gestational age. Surgery and chemotherapy are considered safe after the first trimester. Radiation, anti-her-2, and endocrine therapy are delayed until after delivery due to adverse fetal effects. Iatrogenic prematurity likely causes most long-term fetal sequelae. Multi-disciplinary care and social support are critical for patients and families with PABC.
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Affiliation(s)
- Heather R Macdonald
- Hoag Hospital, Newport Beach, California.,Keck School of Medicine, University of Southern California, Los Angeles, California
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9
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Buonomo B, Brunello A, Noli S, Miglietta L, Del Mastro L, Lambertini M, Peccatori FA. Tamoxifen Exposure during Pregnancy: A Systematic Review and Three More Cases. Breast Care (Basel) 2019; 15:148-156. [PMID: 32398983 DOI: 10.1159/000501473] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 06/13/2019] [Indexed: 12/16/2022] Open
Abstract
Tamoxifen is frequently used as adjuvant treatment in premenopausal patients with hormone receptor-positive early breast cancer. According to guidelines, the use of nonhormonal barrier contraception is recommended during tamoxifen treatment and up to 3 months after its interruption prior to attempting conception. Nevertheless, when conception occurs inadvertently during tamoxifen treatment, the effects on the fetus and on the course of pregnancy are still not completely known. Here, we report 3 cases of young women who accidentally became pregnant while taking tamoxifen and perform a systematic review of the literature to provide more elements for better and clear multidisciplinary counselling of women facing this challenging situation.
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Affiliation(s)
- Barbara Buonomo
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy.,Fertility and Procreation Unit, Division of Gynecologic Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - Antonella Brunello
- Medical Oncology 1 Unit, Department of Oncology, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | - Stefania Noli
- Fertility and Procreation Unit, Division of Gynecologic Oncology, European Institute of Oncology IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Loredana Miglietta
- U.O.C. Oncologia Medica 2, Department of Medical Oncology, Ospedale Policlinico San Martino, Genoa, Italy
| | - Lucia Del Mastro
- S.S. Sviluppo Terapie Innovative, Department of Medical Oncology, Ospedale Policlinico San Martino, Genoa, Italy.,Department of Internal Medicine and Medical Specialties (DIMI), School of Medicine, University of Genoa, Genoa, Italy
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DIMI), School of Medicine, University of Genoa, Genoa, Italy.,Clinica di Oncologia Medica, Department of Medical Oncology, Ospedale Policlinico San Martino - IST, Genoa, Italy
| | - Fedro Alessandro Peccatori
- Fertility and Procreation Unit, Division of Gynecologic Oncology, European Institute of Oncology IRCCS, Milan, Italy
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10
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Tamoxifen and pregnancy: an absolute contraindication? Breast Cancer Res Treat 2019; 175:17-25. [PMID: 30707336 DOI: 10.1007/s10549-019-05154-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 01/28/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Breast cancer is the most common malignancy among young women of reproductive age. Adjuvant treatment with tamoxifen reduces the risk of recurrence in hormone-sensitive breast cancer. However, the use of tamoxifen is considered contraindicated during pregnancy, because of a limited number of case reports demonstrating potential adverse effects on the fetus. The objective of this report is to give a more broad overview of the available data on the effect of tamoxifen exposure during pregnancy. METHODS A literature review was performed using PubMed and the databases of the Netherlands Pharmacovigilance Centre Lareb and of the International Network on Cancer, Infertility, and Pregnancy. RESULTS A total of 238 cases of tamoxifen use during pregnancy were found. Of the 167 pregnancies with known outcome, 21 were complicated by an abnormal fetal development. The malformations described were non-specific and the majority of cases concerned healthy infants despite exposure to tamoxifen. CONCLUSION There seems to be an increased risk of fetal abnormalities when taking tamoxifen during pregnancy (12.6% in contrast to 3.9% in the general population), but the evidence is limited and no causal relationship could be established. The possible disadvantage of postponing or discontinuing tamoxifen for the maternal prognosis is unclear. Patients should be counseled about the use of tamoxifen during pregnancy instead of presenting it as being absolutely contraindicated.
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Abstract
This article reviews some of the more common types of cancer that may be encountered during pregnancy. It reviews the unique challenges with the diagnosis and treatment of breast, cervical, hematologic, and colon cancers in pregnant patients.
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Affiliation(s)
- Anna McCormick
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226, USA.
| | - Erika Peterson
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226, USA
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12
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Martínez MT, Bermejo B, Hernando C, Gambardella V, Cejalvo JM, Lluch A. Breast cancer in pregnant patients: A review of the literature. Eur J Obstet Gynecol Reprod Biol 2018; 230:222-227. [PMID: 29728277 DOI: 10.1016/j.ejogrb.2018.04.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 04/16/2018] [Accepted: 04/22/2018] [Indexed: 12/12/2022]
Abstract
Breast cancer diagnosed during pregnancy is a rare occurrence at present; however, in recent years a trend towards delayed childbirth is generating an increase in its incidence. This situation requires a multidisciplinary approach involving obstetricians, oncologists and surgeons. In this review we analyse diagnostic methods, different possible treatments and long-term patient prognosis. We conducted a search for articles published in PubMed, or in abstract form from the San Antonio Breast Cancer Symposium (SABCS), the European Society for Medical Oncology (ESMO), and the American Society of Clinical Oncology (ASCO) annual meeting, using the search terms: "Breast cancer and pregnancy". Breast cancer occurring during pregnancy requires extra effort to offer patients the best multidisciplinary management. There is no difference in the pathology-based classification, but breast cancer during pregnancy seems to be associated with different patterns of gene expression. Chemotherapy and surgery are generally safe and well-tolerated by patients during the second and third trimesters of pregnancy. The poorer prognosis could be attributed mainly to a delay in diagnosis and because breast cancer in young patients is a more aggressive disease. Finally, balancing the health of mother and child must be paramount.
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Affiliation(s)
- María Teresa Martínez
- Medical Oncology and Hematology Unit, Health Research Institute INCLIVA, University of Valencia, The Centre of Networked Biomedical Cancer Research (CIBERONC), Spain.
| | - Begoña Bermejo
- Medical Oncology and Hematology Unit, Health Research Institute INCLIVA, University of Valencia, The Centre of Networked Biomedical Cancer Research (CIBERONC), Spain
| | - Cristina Hernando
- Medical Oncology and Hematology Unit, Health Research Institute INCLIVA, University of Valencia, The Centre of Networked Biomedical Cancer Research (CIBERONC), Spain
| | - Valentina Gambardella
- Medical Oncology and Hematology Unit, Health Research Institute INCLIVA, University of Valencia, The Centre of Networked Biomedical Cancer Research (CIBERONC), Spain
| | - Juan Miguel Cejalvo
- Medical Oncology and Hematology Unit, Health Research Institute INCLIVA, University of Valencia, The Centre of Networked Biomedical Cancer Research (CIBERONC), Spain
| | - Ana Lluch
- Medical Oncology and Hematology Unit, Health Research Institute INCLIVA, University of Valencia, The Centre of Networked Biomedical Cancer Research (CIBERONC), Spain
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13
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Peccatori FA, Lambertini M, Scarfone G, Del Pup L, Codacci-Pisanelli G. Biology, staging, and treatment of breast cancer during pregnancy: reassessing the evidences. Cancer Biol Med 2018; 15:6-13. [PMID: 29545964 PMCID: PMC5842335 DOI: 10.20892/j.issn.2095-3941.2017.0146] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Breast cancer is one of the most frequently diagnosed malignancies during pregnancy. Here, we review the management of women with breast cancer during pregnancy (BCP), focusing on biology, diagnosis and staging, local and systemic treatments, obstetric care and long-term follow-up of children with prenatal exposure to anticancer treatments.
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Affiliation(s)
| | - Matteo Lambertini
- Gynecologic Oncology Department, European Institute of Oncology, Milan 20141, Italy
| | - Giovanna Scarfone
- Gynecologic Oncology Department, European Institute of Oncology, Milan 20141, Italy
| | - Lino Del Pup
- Gynecologic Oncology Department, European Institute of Oncology, Milan 20141, Italy
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14
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Shachar SS, Gallagher K, McGuire K, Zagar TM, Faso A, Muss HB, Sweeting R, Anders CK. Multidisciplinary Management of Breast Cancer During Pregnancy. Oncologist 2017; 22:324-334. [PMID: 28232597 DOI: 10.1634/theoncologist.2016-0208] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 08/18/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Although breast cancer during pregnancy (BCDP) is rare (occurring with only 0.4% of all BC diagnoses in female patients aged 16-49 years), management decisions are challenging to both the patient and the multidisciplinary team. MATERIALS AND METHODS Experts in breast cancer at the University of North Carolina conducted a targeted literature search regarding the multidisciplinary treatment approaches to BCDP: medical, surgical, and radiation oncology. Supportive care, including antiemetic agents, and imaging approaches were also reviewed. RESULTS Review of the literature revealed key points in the management of BCDP. Surgical management is similar to that in nonpregnant patients; pregnant patients may safely undergo breast-conserving surgery. Recommendations should be tailored to the individual according to the clinical stage, tumor biology, genetic status, gestational age, and personal preferences. Anthracycline-based chemotherapy can be safely initiated only in the second and third trimesters. The rate of congenital abnormalities in children exposed to chemotherapy is similar to the national average (approximately 3%). Dosing of chemotherapy should be similar to that in the nonpregnant patient (i.e., actual body surface area). Antihuman epidermal growth factor receptor 2 therapy, radiation, and endocrine treatment are contraindicated in pregnancy and lactation. Care should include partnership with obstetricians. The literature regarding prognosis of BCDP is mixed. CONCLUSION To maximize benefit and minimize risk to the mother and fetus, an informed discussion with the patient and her medical team should result in an individualized treatment plan, taking into account the timing of the pregnancy and the stage and subtype of the breast cancer. Because BCDP is rare, it is essential to collect patient data in international registries. The Oncologist 2017;22:324-334 IMPLICATIONS FOR PRACTICE: Breast cancer during pregnancy is a major ethical and professional challenge for both the patient and the multidisciplinary treatment team. Although the oncologic care is based on that of the non-pregnant breast cancer patient, there are many challenges from regarding the medical, surgical and radiation oncology and obstetrical aspects of care that need to be considered to deliver the safest and best treatment plan to both the mother and developing fetus.
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Affiliation(s)
- Shlomit Strulov Shachar
- Department of Medicine, Division of Hematology-Oncology
- Lineberger Comprehensive Cancer Center
- Division of Oncology, Rambam Health Care Campus, Haifa, Israel
| | | | | | - Timothy M Zagar
- Lineberger Comprehensive Cancer Center
- Department of Radiation Oncology
| | - Aimee Faso
- Department of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Hyman B Muss
- Department of Medicine, Division of Hematology-Oncology
- Lineberger Comprehensive Cancer Center
| | - Raeshall Sweeting
- Department of Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Carey K Anders
- Department of Medicine, Division of Hematology-Oncology
- Lineberger Comprehensive Cancer Center
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15
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Shlensky V, Hallmeyer S, Juarez L, Parilla BV. Management of Breast Cancer during Pregnancy: Are We Compliant with Current Guidelines? AJP Rep 2017; 7:e39-e43. [PMID: 28255521 PMCID: PMC5330794 DOI: 10.1055/s-0037-1599133] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction The purpose of this study was to evaluate the management of patients with breast cancer in pregnancy treated at the Advocate Health Care, to determine whether these patients were treated according to guidelines for pregnant patients, which aim to maximize both fetal and maternal outcomes. Methods A retrospective chart review was performed at the Advocate Lutheran General Hospital, Christ Medical Center, and Illinois Masonic Medical Center from 2002 to 2012 on patients diagnosed with breast cancer during pregnancy using ICD-9 (International Classification of Diseases - 9th version) codes. Results Eleven patients between 12 and 37 weeks' gestation matched the search criteria. One patient terminated the pregnancy. Patients in our study were treated appropriately according to guidelines with the following exceptions. Trastuzumab was used in one patient during pregnancy which likely caused the oligohydramnios resulting in an induction of labor at 33 weeks. Three patients were delivered preterm between 34 and 36 weeks without an obstetric indication. Two patients underwent sentinel node biopsy. Conclusion The diagnosis of breast cancer in pregnancy is an infrequent but devastating diagnosis that is likely to increase. Although sentinel lymph node biopsy is not generally recommended in pregnancy, this may be an outdated guideline as using a low-dose lymphoscintigraphic technique appears to be safe in pregnancy.
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Affiliation(s)
- Victoria Shlensky
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Advocate Lutheran General Hospital, Park Ridge, Illinois
| | - Sigrun Hallmeyer
- Division of Hematology and Oncology, Center for Advanced Care, Advocate Lutheran General Hospital, Park Ridge, Illinois
| | - Lourdes Juarez
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Advocate Lutheran General Hospital, Park Ridge, Illinois
| | - Barbara V Parilla
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Advocate Lutheran General Hospital, Park Ridge, Illinois
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16
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Unexpected pregnancy during tamoxifen treatment: a case report and review of the literature. CASE REPORTS IN PERINATAL MEDICINE 2016. [DOI: 10.1515/crpm-2015-0077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
We report a patient who became pregnant while on tamoxifen treatment for breast cancer and who elected to continue her pregnancy. The normal child was delivered except for a right renal pelvicaliceal dilatation. The use of tamoxifen in pregnancy is complex, but is not necessarily associated with fetal harm. The relatively high frequency of severe congenital abnormalities indicates that it is prudent to stop tamoxifen before pregnancy.
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17
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Boland MR, Tatonetti NP. Investigation of 7-dehydrocholesterol reductase pathway to elucidate off-target prenatal effects of pharmaceuticals: a systematic review. THE PHARMACOGENOMICS JOURNAL 2016; 16:411-29. [PMID: 27401223 PMCID: PMC5028238 DOI: 10.1038/tpj.2016.48] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 04/15/2016] [Accepted: 05/02/2016] [Indexed: 12/18/2022]
Abstract
Mendelian diseases contain important biological information regarding developmental effects of gene mutations that can guide drug discovery and toxicity efforts. In this review, we focus on Smith–Lemli–Opitz syndrome (SLOS), a rare Mendelian disease characterized by compound heterozygous mutations in 7-dehydrocholesterol reductase (DHCR7) resulting in severe fetal deformities. We present a compilation of SLOS-inducing DHCR7 mutations and the geographic distribution of those mutations in healthy and diseased populations. We observed that several mutations thought to be disease causing occur in healthy populations, indicating an incomplete understanding of the condition and highlighting new research opportunities. We describe the functional environment around DHCR7, including pharmacological DHCR7 inhibitors and cholesterol and vitamin D synthesis. Using PubMed, we investigated the fetal outcomes following prenatal exposure to DHCR7 modulators. First-trimester exposure to DHCR7 inhibitors resulted in outcomes similar to those of known teratogens (50 vs 48% born-healthy). DHCR7 activity should be considered during drug development and prenatal toxicity assessment.
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Affiliation(s)
- M R Boland
- Department of Biomedical Informatics, Columbia University, New York, NY, USA.,Observational Health Data Sciences and Informatics, Columbia University, New York, NY, USA
| | - N P Tatonetti
- Department of Biomedical Informatics, Columbia University, New York, NY, USA.,Observational Health Data Sciences and Informatics, Columbia University, New York, NY, USA.,Department of Systems Biology, Columbia University, New York, NY, USA.,Department of Medicine, Columbia University, New York, NY, USA
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18
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Miyamoto S, Yamada M, Kasai Y, Miyauchi A, Andoh K. Anticancer drugs during pregnancy. Jpn J Clin Oncol 2016; 46:795-804. [PMID: 27284093 DOI: 10.1093/jjco/hyw073] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 05/17/2016] [Indexed: 11/12/2022] Open
Abstract
Although cancer diagnoses during pregnancy are rare, they have been increasing with the rise in maternal age and are now a topic of international concern. In some cases, the administration of chemotherapy is unavoidable, though there is a relative paucity of evidence regarding the administration of anticancer drugs during pregnancy. As more cases have gradually accumulated and further research has been conducted, we are beginning to elucidate the appropriate timing for the administration of chemotherapy, the regimens that can be administered with relative safety, various drug options and the effects of these drugs on both the mother and fetus. However, new challenges have arisen, such as the effects of novel anticancer drugs and the desire to bear children during chemotherapy. In this review, we outline the effects of administering cytotoxic anticancer drugs and molecular targeted drugs to pregnant women on both the mother and fetus, as well as the issues regarding patients who desire to bear children while being treated with anticancer drugs.
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Affiliation(s)
- Shingo Miyamoto
- Department of Medical Oncology, Japanese Red Cross Medical Center, Shibuya, Tokyo
| | - Manabu Yamada
- Department of Gynecology, Japanese Red Cross Medical Center, Shibuya, Tokyo, Japan
| | - Yasuyo Kasai
- Department of Gynecology, Japanese Red Cross Medical Center, Shibuya, Tokyo, Japan
| | - Akito Miyauchi
- Department of Gynecology, Japanese Red Cross Medical Center, Shibuya, Tokyo, Japan
| | - Kazumichi Andoh
- Department of Gynecology, Japanese Red Cross Medical Center, Shibuya, Tokyo, Japan
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19
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Breast cancer in pregnancy: A brief clinical review. Best Pract Res Clin Obstet Gynaecol 2015; 33:79-85. [PMID: 26616726 DOI: 10.1016/j.bpobgyn.2015.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 10/22/2015] [Indexed: 11/20/2022]
Abstract
As global wealth increases and demographic changes similar to Europe and North America start affecting other societies, the global breast cancer epidemic will coincide with a delayed maternal age during first and subsequent pregnancies. Breast cancer in pregnancy will continue to increase, and standardized treatment strategies are required to be developed. This study will review current diagnostic and treatment approaches.
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20
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21
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Koca E, Kuzan TY, Babacan T, Turkbeyler IH, Furkan S, Altundag K. Safety of tamoxifen during pregnancy: 3 case reports and review of the literature. Breast Care (Basel) 2014; 8:453-4. [PMID: 24550755 DOI: 10.1159/000357321] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Emre Koca
- Hacettepe University Cancer Institute, Ankara
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22
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Weisz B, Meirow D, Schiff E, Lishner M. Impact and treatment of cancer during pregnancy. Expert Rev Anticancer Ther 2014; 4:889-902. [PMID: 15485322 DOI: 10.1586/14737140.4.5.889] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cancer is the second most common cause of death in the reproductive years and complicates up to one in 1000 pregnancies. When cancer is diagnosed during pregnancy, the management strategy must take into account both the mother and developing fetus. In this article, the four most common malignancies diagnosed in pregnant patients--cervical and breast cancer, malignant melanoma and lymphoma--will be reviewed, with an emphasis on the impact of the diagnosis and management on the pregnant patient and the developing fetus.
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Affiliation(s)
- Boaz Weisz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.
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23
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Abstract
Approximately 1 in 1,000-2,000 pregnancies are complicated by cancer. Today, different treatment options are considered as safe during pregnancy: chemotherapy, radiotherapy, surgery, or a combination of these. Surgery is considered safe during all trimesters of pregnancy; radiotherapy can be administered during the first and the second trimester, and chemotherapy after the first trimester of pregnancy. The placenta, acting as a barrier between the mother and the fetus, plays a key role in the safe administration of chemotherapy during pregnancy. A few studies have investigated the short- as well as the long-term health, general development, and cognitive and cardiac outcomes on children exposed to chemotherapy in utero. In general, these results were reassuring. Nevertheless, better safety data are required. This means data with longer follow-up periods and comparison with appropriate control groups. Moreover, important biasing factors should be taken into account when interpreting these results. Firstly, a great proportion of children were born prematurely due to the maternal condition. Preterm birth in general has been associated with cognitive impairment. Secondly, cancer during pregnancy is clearly a stressful situation, and maternal stress is associated with attention deficits. In sum, we state that chemotherapy can be administered safely after the first trimester of pregnancy. Moreover, iatrogenic prematurity in order to start postpartum administration of chemotherapy should be avoided. Nonetheless, decisions concerning treatment in these specific cases should always be made in a multidisciplinary setting with internationally recognized expertise in the coexistence of cancer and pregnancy.
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Affiliation(s)
- Jana Dekrem
- Lab of Experimental Gynaecology, University Hospitals Leuven, Katholieke Universiteit Leuven, Leuven, Belgium
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24
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Abstract
Pregnancy-associated breast cancer is defined as breast cancer diagnosed during pregnancy or in the first postpartum year. Breast cancer is one of the more common malignancies to occur during pregnancy and, as more women delay childbearing, the incidence of breast cancer in pregnancy is expected to increase. This article provides an overview of diagnosis, staging, and treatment of pregnancy-associated breast cancer. Recommendations for management of breast cancer in pregnancy are discussed.
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Affiliation(s)
- Iris Krishna
- Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Emory University School of Medicine, 69 Jesse Hill Jr Drive, Southeast, Atlanta, GA 30303, USA.
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25
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Zagouri F, Psaltopoulou T, Dimitrakakis C, Bartsch R, Dimopoulos MA. Challenges in managing breast cancer during pregnancy. J Thorac Dis 2013; 5 Suppl 1:S62-7. [PMID: 23819029 DOI: 10.3978/j.issn.2072-1439.2013.05.21] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 05/28/2013] [Indexed: 12/13/2022]
Abstract
Pregnancy-associated breast cancer (PABC) is defined as breast cancer occurring anytime during gestation, lactation or within one year after delivery. The optimal management of pregnant women with breast cancer is challenging and not well established; the main concern is the effect of the drugs on the developing fetus and long-term complications after in utero exposure to anti-cancer drugs. Surgical resection is the mainstay of treatment for early breast cancer diagnosed during pregnancy. Modified radical mastectomy is standard of care in first trimester, whereas breast-conserving surgery (lumpectomy with lymph node dissection) can be performed preferably in the second and third trimester. Of note, breast-conserving surgery is not contraindicated per se during the first trimester, but owing to the potential impact of delaying radiotherapy. Radiation therapy is not favored during pregnancy. Moreover, tamoxifen is contraindicated during pregnancy; the agent has been associated with birth defects in up to 20% of exposures. Chemotherapy is generally contraindicated during the first trimester because of the possible damage to organogenesis. Anthracyclines-based regimens are the most widely used is breast cancer treatment and were been shown to be associated with favourable safety profile when administered during pregnancy. As for taxanes, more limited data is available. The use of trastuzumab is contraindicated during pregnancy, given the apparent risk of oligo- and/or anhydramnios as well as the unknown long-term sequelae on the fetus. It is obvious that, diagnosis of breast cancer during pregnancy adds complexity to cancer treatment recommendations. In all cases, a multidisciplinary therapeutic approach among obstetricians, gynaecologists, surgical oncologists, radiation oncologists, medical oncologists, pediatricians and hematologists is clearly warranted.
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Affiliation(s)
- Flora Zagouri
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, University of Athens, Athens, Greece; ; Comprehensive Cancer Center Vienna, Department of Medicine I/Division of Oncology, Medical University of Vienna, Austria
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26
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A case of delivery of healthy infant in breast cancer patient incidentally treated with goserelin acetate and tamoxifen during pregnancy. Breast Cancer 2013; 23:164-166. [PMID: 23636905 DOI: 10.1007/s12282-013-0469-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 04/09/2013] [Indexed: 10/26/2022]
Abstract
In September 2000, a 32-year-old woman presented to our hospital with a right breast mass. In September 2000, she underwent pectoral muscle-preserving mastectomy for the treatment of right breast cancer. Pathologyy results revealed a mucinous carcinoma 27 × 20 × 18 mm in size accompanied by an extensive intraductal component. The tumor was staged as T2 N1M0 stage IIB and found to be estrogen receptor-positive, and 6 cycles of postoperative adjuvant chemotherapy consisting of 5-fluorouracil, epirubicin, and cyclophosphamide were carried out. Goserelin acetate plus tamoxifen was prescribed from April 2001 to March 2005. Since the patient received tamoxifen from April 2005 and eumenorrhea started in June 2006, goserelin acetate plus tamoxifen was started in August 2006. The patient was determined to be 25 weeks pregnant by abdominal ultrasonography in February 2007. This meant that she had been taking goserelin acetate plus tamoxifen for 6 months without realizing she was pregnant. She gave birth to a girl by cesarean section in May 2007. No abnormalities, including anomaly of the genitalia, were seen, and the subsequent growth of the infant was also satisfactory. We here report this case and a brief review of the literature.
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27
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Miscellaneous syndromes and their management: occult breast cancer, breast cancer in pregnancy, male breast cancer, surgery in stage IV disease. Surg Clin North Am 2013; 93:519-31. [PMID: 23464700 DOI: 10.1016/j.suc.2012.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Surgical therapy for occult breast cancer has traditionally centered on mastectomy; however, breast conservation with whole breast radiotherapy followed by axillary lymph node dissection has shown equivalent results. Patients with breast cancer in pregnancy can be safely and effectively treated; given a patient's pregnancy trimester and stage of breast cancer, a clinician must be able to guide therapy accordingly. Male breast cancer risk factors show strong association with BRCA2 mutations, as well as Klinefelter syndrome. Several retrospective trials of surgical therapy in stage IV breast cancer have associated a survival advantage with primary site tumor extirpation.
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28
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Selig BP, Furr JR, Huey RW, Moran C, Alluri VN, Medders GR, Mumm CD, Hallford HG, Mulvihill JJ. Cancer chemotherapeutic agents as human teratogens. ACTA ACUST UNITED AC 2012; 94:626-50. [DOI: 10.1002/bdra.23063] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 06/29/2012] [Accepted: 07/04/2012] [Indexed: 12/11/2022]
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29
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30
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Abstract
Breast cancer staging and treatment are possible during pregnancy, and should be defined in a multidisciplinary setting. Tumour biology, tumour stage, and gestational stage at diagnosis determine the appropriate approach. Surgery for breast cancer is possible during all trimesters of pregnancy. Radiotherapy is possible during pregnancy but, dependent on the fetal dose received, can result in poor fetal outcomes. The decision to give radiotherapy should be made on an individual basis. Evidence increasingly supports administration of chemotherapy from 14 weeks' gestation onwards. New breast cancer treatments might be applicable to pregnant patients, but tamoxifen and trastuzumab are contraindicated during pregnancy. Cancer treatment during pregnancy will decrease the need for early delivery and thus prematurity, which is a major concern in management of breast cancer in pregnancy.
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Affiliation(s)
- Frédéric Amant
- Multidisciplinary Breast Cancer Center, Leuven Cancer Institute, Katholieke Universiteit Leuven, Belgium.
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31
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Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIMITTEL IN SCHWANGERSCHAFT UND STILLZEIT 2012. [PMCID: PMC7271212 DOI: 10.1016/b978-3-437-21203-1.10002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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32
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McGrath SE, Ring A. Chemotherapy for breast cancer in pregnancy: evidence and guidance for oncologists. Ther Adv Med Oncol 2011; 3:73-83. [PMID: 21789157 DOI: 10.1177/1758834010392445] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
It has been estimated that up to 3.8% of breast cancers may be diagnosed in women who are pregnant, with an estimated 1 in 3000-3500 deliveries occurring in women with breast cancer. Owing to the lack of large randomized trials available to guide our clinical practice, our decisions regarding adjuvant systemic management are based on retrospective analyses, case reports and a small number of prospective studies. A tailored approach to treatment is required with careful consideration given at all stages to the needs of the mother and risks to the foetus. Management is critically influenced by the stage of pregnancy, especially the first trimester. Anthracycline-based chemotherapy may be administered during the second and third trimesters, with apparently few short-term implications. Limited data shows the taxanes may also be given with few adverse events at these stages. Weekly fractionation regimens may allow closer monitoring of pregnancy with prompt termination of agents, if necessary. Data concerning the long-term risks of systemic anticancer treatment are limited. All stages of patient management should be discussed within a multidisciplinary team and a clear consensus of treatment options communicated to the mother. Delaying chemotherapy until after delivery may be reasonable in some cases, but where the delay is likely to be prolonged, a decision must be made on the basis of risks versus benefits.
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Affiliation(s)
- Sophie E McGrath
- Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, UK
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33
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Braems G, Denys H, De Wever O, Cocquyt V, Van den Broecke R. Use of tamoxifen before and during pregnancy. Oncologist 2011; 16:1547-51. [PMID: 22020212 DOI: 10.1634/theoncologist.2011-0121] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
For premenopausal patients with receptor-positive early breast cancer, administration of tamoxifen for 5 years constitutes the main adjuvant endocrine therapy. During pregnancy, tamoxifen and its metabolites interact with rapidly growing and developing embryonic or fetal tissues. Information about tamoxifen and pregnancy was gathered by searching PubMed. In addition, we had access to the records of the pharmaceutical company AstraZeneca. Because these observations are retrospective and other therapies and diagnostic measures are possible confounders, a causal relationship was not established between tamoxifen treatment and pregnancy outcome. The records from AstraZeneca documented three live births with congenital anomalies and four live births without congenital anomalies related to tamoxifen treatment before pregnancy. Tamoxifen therapy during pregnancy resulted in 16 live births with congenital malformations and a total of 122 live births without malformations. The 122 live births without malformations included 85 patients from a prevention trial that did not record a single anomaly, whereas the AstraZeneca Safety Database alone reported 11 babies with congenital malformations of 44 live births. Additionally, there were: 12 spontaneous abortions, 17 terminations of pregnancy without known fetal defects, six terminations of pregnancy with fetal defects, one stillbirth without fetal defects, two stillbirths with fetal defects, and 57 unknown outcomes. The relatively high frequency of severe congenital abnormalities indicates that reliable birth control during tamoxifen treatment is mandatory. After tamoxifen use, a washout period of 2 months is advisable based on the known half-life of tamoxifen. In case of an inadvertent pregnancy, risks and options should be discussed.
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Affiliation(s)
- Geert Braems
- Department of Gynecologic Oncology, Ghent University Hospital, Ghent, Belgium.
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34
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Amant F, Deckers S, Van Calsteren K, Loibl S, Halaska M, Brepoels L, Beijnen J, Cardoso F, Gentilini O, Lagae L, Mir O, Neven P, Ottevanger N, Pans S, Peccatori F, Rouzier R, Senn HJ, Struikmans H, Christiaens MR, Cameron D, Du Bois A. Breast cancer in pregnancy: recommendations of an international consensus meeting. Eur J Cancer 2011; 46:3158-68. [PMID: 20932740 DOI: 10.1016/j.ejca.2010.09.010] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 09/03/2010] [Indexed: 01/09/2023]
Abstract
PURPOSE To provide guidance for clinicians about the diagnosis, staging and treatment of breast cancer occurring during an otherwise uncomplicated pregnancy. METHODS An international expert Panel convened to address a series of questions identified by a literature review and personal experience. Issues relating to the diagnosis and management of breast cancer after delivery were outside the scope. RESULTS There is a paucity of large and/or randomized studies. Based on cohort studies, case series and case reports, the recommendations represent the best available evidence, albeit of a lower grade than is optimal. RECOMMENDATIONS In most circumstances, serious consideration should be given to the option of treating breast cancer whilst continuing with the pregnancy. Each woman should ideally be referred to a centre with sufficient expertise, given a clear explanation of treatment options. Most diagnostic and staging examinations can be performed adequately and safely during pregnancy. Treatment should however be adapted to the clinical presentation and the trimester of the pregnancy: surgery can be performed during all trimesters of pregnancy; radiotherapy can be considered during the first and second trimester but should be postponed during the third trimester; and standard chemotherapies can be used during the second and third trimester. Since neonatal morbidity mainly appears to be related to prematurity, delivery should not be induced before 37 weeks, if at all possible. CONCLUSIONS The treatment of breast cancer in pregnancy should be executed by experienced specialists in a multidisciplinary setting and should adhere as closely as possible to standard protocols.
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Affiliation(s)
- Frédéric Amant
- Multidisciplinary Breast Center, Leuven Cancer Institute, UZ Gasthuisberg, Katholieke Universiteit Leuven, Belgium.
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35
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Breast cancer in pregnancy. Eur Surg 2011. [DOI: 10.1007/s10353-011-0595-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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36
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Lawrenz B, Banys M, Henes M, Neunhoeffer E, Grischke EM, Fehm T. Pregnancy after breast cancer: case report and review of the literature. Arch Gynecol Obstet 2011; 283:837-43. [PMID: 21221981 DOI: 10.1007/s00404-010-1829-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 12/21/2010] [Indexed: 12/28/2022]
Abstract
Despite breast cancer diagnosis and treatment, women of childbearing age often desire a pregnancy. Since the average age of women giving birth for the first time is increasing, many young patients diagnosed with breast cancer have not started or completed their family planning. Thus, gynecologists and oncologists are confronted more often with the question of childbearing after breast cancer. Current data from retrospective trials do not suggest an increased risk of a recurrence or progress of the disease associated with pregnancy after stage-adjusted treatment. Also, the risk of fetal malformations and damage to the fetus after chemotherapy and/or hormone therapy seems similar to that in the general population. Women who receive chemotherapy are advised to wait at least 6 months before they attempt to conceive. The question whether to become pregnant must be discussed individually with the patient, based on tumor characteristics, stage of the disease and patient's wishes.
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Affiliation(s)
- Barbara Lawrenz
- Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstrasse 7, 72076 Tuebingen, Germany
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37
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Abstract
The treatment of breast cancer diagnosed during pregnancy presents a challenging situation for the patient, family, and caregivers. Case series have demonstrated the efficacy and safety of using anthracycline-based chemotherapy during the second and third trimesters. Additionally, patients should be seen, evaluated, and treated in a multidisciplinary setting with facilitated communication among the medical oncologist, surgical oncologist, obstetrician, radiation oncologist, pathologist, and radiologist. This review details the available data regarding the diagnosis and management of the pregnant breast cancer patient.
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Affiliation(s)
- Jennifer K Litton
- Department of Breast Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA.
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38
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Abstract
Currently, it is estimated that approximately one in every 3,000 births are from women who have or are being treated for breast cancer. Although rare, the incidence of pregnancy-associated breast cancer (PABC) is increasing as women are delaying childbirth. Diagnostic and treatment recommendations have been mainly based on evidence from retrospective single institutional and collective series and expert consensus, as randomized trials on this entity are understandably lacking. PABC is often associated with a poor outcome, but this is mainly due to delay in diagnosis and initiation of treatment. For the most part, women with PABC should be managed like non-pregnant breast cancer patients and should expect a similar outcome, without causing harm to the unborn child. Increased awareness and knowledge of how to assess symptomatic breast problems in pregnancy and a specialized multidisciplinary team approach for established PABC is likely to improve outcomes. This review analyses the evidence on the diagnosis, treatment and prognosis of patients with PABC.
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39
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Koca T, Akgun Z, Yucel SB, Dag NZ, Teomete M. Pregnancy a short time after multimodal therapy for bilateral breast cancer: a case report and review of literature. J Oncol Pharm Pract 2010; 17:440-3. [PMID: 20858636 DOI: 10.1177/1078155210384755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pregnancy occurring after multimodal therapy in a woman with breast cancer with a 1-year follow-up period is a relatively rare condition and has been defined as pregnancy-associated breast cancer. A patient can become pregnant after chemotherapy for breast cancer while she is on tamoxifen. However, the effects of tamoxifen on fetus and on the course of the pregnancy are still unknown. Here, we present a 39-year-old woman treated with chemotherapy and radiotherapy for bilateral breast cancer, and who became pregnant while taking tamoxifen.
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Affiliation(s)
- Timur Koca
- Department of Radiation Oncology, Regional Training and Research Hospital, Erzurum, Turkey
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40
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Sánchez Martínez MC, Ruiz Simón A. Breast cancer during pregnancy. Breast Cancer Res Treat 2010; 123 Suppl 1:55-8. [DOI: 10.1007/s10549-010-1059-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Accepted: 07/08/2010] [Indexed: 11/29/2022]
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Abstract
Breast cancer is one of the most commonly diagnosed malignancies during pregnancy. Pregnancy-associated breast cancer (PABC) presents a challenging clinical situation. This article reviews the current evidence around the management of PABC and the safety of pregnancy after breast cancer. The trend towards later age at first childbirth has resulted in an increase in the number of breast cancer cases coexistent with pregnancy. The management of breast cancer during pregnancy requires a multidisciplinary team approach. Breast surgery can be safely performed during any trimester of pregnancy. Radiation therapy, if required, must be delayed until after delivery. The majority of patients with PABC require chemotherapy. The timing of delivery in relation to chemotherapy administration should be carefully considered. There is no evidence to date that pregnancy termination influences overall survival for the mother. To date, there is no clear evidence that subsequent pregnancy after breast cancer is associated with worse maternal survival. There is a suggestion that subsequent pregnancy may in fact be associated with an improved survival. However, the available studies are limited by potential biases.
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Affiliation(s)
- R Sasidharan
- Department of Medical Oncology, Auckland City Hospital , Auckland , New Zealand
| | - V Harvey
- Department of Medical Oncology, Auckland City Hospital , Auckland , New Zealand
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Azim HA, Peccatori FA, Pavlidis N. Treatment of the pregnant mother with cancer: a systematic review on the use of cytotoxic, endocrine, targeted agents and immunotherapy during pregnancy. Part I: Solid tumors. Cancer Treat Rev 2009; 36:101-9. [PMID: 20015593 DOI: 10.1016/j.ctrv.2009.11.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 11/05/2009] [Accepted: 11/15/2009] [Indexed: 01/14/2023]
Abstract
The association of cancer and pregnancy is increasingly encountered nowadays in clinical practice. Due to the relative rarity of the situation, it lacks a systematized approach. Different systemic therapies are used in managing cancer with uncertainty regarding the potential hazards they could pose on the pregnancy and/or the fetus. We have performed a systematic review of literature to identify all reports addressing cancer patients who were exposed to any of the known systemic therapies during the course of the pregnancy. The results were discussed in two parts; part I addresses pregnant patients with solid tumors while part I for those with hematological malignancies. In part I, we identified different solid tumors diagnosed and treated during the course of pregnancy. Breast cancer was the most commonly treated followed by ovarian cancer. Other tumors were treated as well including lung cancer, cervical cancer, sarcoma and melanomas. It is important to acknowledge the intent of therapy (palliative vs. curative) and the patients has to be properly counseled to reach an informed decision. We aim to provide a more robust consensus on how to approach these cases and provide a higher degree of evidence to support the safety of applying certain management strategies over the other.
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Affiliation(s)
- Hatem A Azim
- Department of Medical Oncology, National Cancer Institute, Cairo University, 55 Abdel Monem Riad Street, Mohandeseen, Cairo, Egypt.
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43
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Janni W, Hepp P, Nestle-Kraemling C, Salmen J, Rack B, Genss E, Schindlbeck C, Friese K. Treatment of pregnancy-associated breast cancer. Expert Opin Pharmacother 2009; 10:2259-67. [DOI: 10.1517/14656560903168906] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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44
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Litton JK, Theriault RL, Gonzalez-Angulo AM. Breast cancer diagnosis during pregnancy. ACTA ACUST UNITED AC 2009; 5:243-9. [PMID: 19392610 DOI: 10.2217/whe.09.2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Breast cancer diagnosed during pregnancy is a challenging situation for the patient and her medical team. As women are delaying childbirth, the incidence is expected to increase. Most of the data surrounding the diagnosis and treatment of cancer during pregnancy is in case reports and small cohort studies. However, the data continues to expand regarding the safety of systemic treatments during the second and third trimesters for both the mother and the fetus. In this article, the use of diagnostic imaging, procedures, surgery and chemotherapy are reviewed as well as prognosis and future pregnancies after the treatment for breast cancer.
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Affiliation(s)
- Jennifer K Litton
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030-4009, USA.
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45
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Affiliation(s)
- Sibylle Loibl
- Department of Medicine, Ambulantes Krebszentrum Frankfurt, Germany.
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46
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Lenhard MS, Bauerfeind I, Untch M. Breast cancer and pregnancy: Challenges of chemotherapy. Crit Rev Oncol Hematol 2008; 67:196-203. [DOI: 10.1016/j.critrevonc.2008.02.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Revised: 02/05/2008] [Accepted: 02/21/2008] [Indexed: 11/17/2022] Open
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47
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Successful pregnancy outcome with 5-flurouracil, epirubicin, cyclophospamide chemotherapy, and hemostatic radiotherapy with abdominal shielding for metastatic invasive intraductal breast carcinoma. Arch Gynecol Obstet 2008; 279:415-7. [DOI: 10.1007/s00404-008-0713-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Accepted: 06/10/2008] [Indexed: 10/21/2022]
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48
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Pereg D, Lishner M. Maternal and fetal effects of systemic therapy in the pregnant woman with cancer. Recent Results Cancer Res 2008; 178:21-38. [PMID: 18080440 DOI: 10.1007/978-3-540-71274-9_3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- D Pereg
- Department of Internal Medicine A, Meir Medical Center, Kfar Sava, Israel
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Wang CW, Horng SG, Chen CK, Wang HS, Huang HY, Lee CL, Soong YK. Ovulation induction with tamoxifen and alternate-day gonadotrophin in patients with thin endometrium. Reprod Biomed Online 2008; 17:20-6. [DOI: 10.1016/s1472-6483(10)60288-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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50
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Affiliation(s)
- S Aebi
- University Hospital Bern, Inselspital, Breast and Gynecologic Cancer Center, Switzerland
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