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Alpuim Costa D, Nobre JG, de Almeida SB, Ferreira MH, Gonçalves I, Braga S, Pais D. Cancer During Pregnancy: How to Handle the Bioethical Dilemmas?-A Scoping Review With Paradigmatic Cases-Based Analysis. Front Oncol 2020; 10:598508. [PMID: 33425755 PMCID: PMC7787159 DOI: 10.3389/fonc.2020.598508] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/17/2020] [Indexed: 12/29/2022] Open
Abstract
Ethical issues that arise during the care of a pregnant woman with cancer are challenging to physicians, policymakers, lawyers, and the bioethics community. The main purpose of this scoping review is to summarize existing literature regarding the bioethical dilemmas when a conflict arises in the maternal-fetus dyad, like the one related to cancer and pregnancy outcomes. Moreover, we illustrate the decision-making process of real-life case reports. Published data were searched through the PubMed and Google Scholar databases, as well as in grey literature, using appropriate controlled keywords in English and Portuguese. After identification, screening, eligibility and data extraction from the articles, a total of 50 was selected. There are several established ethical frameworks for conflict resolution and decision-making. Pragmatic theoretical approaches include case-based analysis, the ethics of care, feminist theory, and traditional ethical principlism that scrutinizes the framework of autonomy, justice, beneficence, and non-maleficence. In addition, society and practitioner values could mediate this complex ethical interplay. The physician must balance autonomy and beneficence-based obligations to the pregnant woman with cancer, along with beneficence-based obligations to the fetus. Ethical challenges have received less attention in the literature, particularly before the third trimester of pregnancy. Best, unbiased and balanced information must be granted both to the patient and to the family, regarding the benefits and harms for the woman herself as well as for the fetal outcome. Based on a previously validated method for analyzing and working up clinical ethical problems, we suggest an adaptation of an algorithm for biomedical decision-making in cancer during pregnancy, including recommendations that can facilitate counseling and help reduce the suffering of the patient and her family.
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Affiliation(s)
- Diogo Alpuim Costa
- CUF Oncologia, Haematology and Oncology Department, Lisbon, Portugal.,NOVA Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal
| | | | | | | | - Inês Gonçalves
- Hospital CUF Almada, Emergency Department, Almada, Portugal
| | - Sofia Braga
- CUF Oncologia, Haematology and Oncology Department, Lisbon, Portugal.,NOVA Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal.,Hospital Professor Doutor Fernando Fonseca EPE, Oncology Department, Amadora, Portugal
| | - Diogo Pais
- Ethics Department, NOVA Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal
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Leonardi M, Cecconi A, Luraschi R, Rondi E, Cattani F, Lazzari R, Morra A, Soto S, Zanagnolo V, Galimberti V, Gentilini O, Peccatori F, Jereczek-Fossa B, Orecchia R. Electron Beam Intraoperative Radiotherapy (ELIOT) in Pregnant Women with Breast Cancer: From in Vivo Dosimetry to Clinical Practice. Breast Care (Basel) 2017; 12:396-400. [PMID: 29456472 PMCID: PMC5803713 DOI: 10.1159/000479862] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The aim of this study was to confirm our preliminary results with in vivo dosimetry in non-pregnant breast cancer patients receiving electron beam intraoperative radiotherapy (ELIOT) and to report on the first treatment in a pregnant woman. PATIENTS AND METHODS Following our previous experience, 5 non-pregnant patients receiving ELIOT to the tumor bed after breast-conserving surgery (BCS) were studied with thermoluminescent dosimeters positioned in the subdiaphragmatic region, within the uterus, and in the ovarian region. In December 2011, the first pregnant breast cancer patient underwent BCS and ELIOT (21 Gy at 90% isodose) during the 15th week of gestation. RESULTS The mean dose to the subdiaphragmatic external region in the 5 non-pregnant patients was 5.57 mGy, while pelvic measurements were below 1 mGy. The actual dosimetry of the pregnant patient showed a mean subdiaphragmatic dose of 4.34 mGy, a mean suprapubic dose of 1.64 mGy, and mean ovarian doses of 1.48 mGy (right-sided) and 1.44 mGy (left-sided). The expected dose to the fetus was estimated as 0.84 mGy (0.004% of the prescribed dose). CONCLUSION ELIOT as an anticipated boost to the breast could be considered in pregnant women in the early second trimester, postponing whole-breast irradiation after delivery.
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Affiliation(s)
- Maria Leonardi
- Advanced Radiotherapy Center, European Institute of Oncology, Milan, Italy
| | - Agnese Cecconi
- Scientific Direction, European Institute of Oncology, Milan, Italy
- University of Milan, Milan, Italy
| | - Rosa Luraschi
- Unit of Medical Physics, European Institute of Oncology, Milan, Italy
| | - Elena Rondi
- Unit of Medical Physics, European Institute of Oncology, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, European Institute of Oncology, Milan, Italy
| | - Roberta Lazzari
- Advanced Radiotherapy Center, European Institute of Oncology, Milan, Italy
| | - Anna Morra
- Advanced Radiotherapy Center, European Institute of Oncology, Milan, Italy
| | - Santos Soto
- Medica Sur Hospital Breast Center, Mexico City, Mexico
| | - Vanna Zanagnolo
- Gynecologic Cancer Surgery, European Institute of Oncology, Milan, Italy
| | | | - Oreste Gentilini
- Breast Cancer Surgery, European Institute of Oncology, Milan, Italy
- Current address: Breast Surgery Unit, San Raffaele University Hospital, Milan, Italy
| | - Fedro Peccatori
- Fertility and Procreation Unit, European Institute of Oncology, Milan, Italy
| | - Barbara Jereczek-Fossa
- Advanced Radiotherapy Center, European Institute of Oncology, Milan, Italy
- University of Milan, Milan, Italy
| | - Roberto Orecchia
- Scientific Direction, European Institute of Oncology, Milan, Italy
- University of Milan, Milan, Italy
- National Center of Oncology Hadrontherapy (CNAO foundation), Pavia, Italy
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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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