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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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Crown A, McCartan D, Curry MA, Patil S, Kamer S, Goldfarb S, Gemignani ML. Pregnancy-associated breast cancer: does timing of presentation affect outcome? Breast Cancer Res Treat 2023; 198:283-294. [PMID: 36662395 DOI: 10.1007/s10549-022-06833-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/01/2022] [Indexed: 01/21/2023]
Abstract
PURPOSE Pregnancy-associated breast cancer (PABC) comprises breast cancer diagnosed during the gestational period or within 12 months postpartum. While the incidence of PABC appears to be increasing, data regarding prognosis remain limited. METHODS Here we evaluate clinicopathologic features, treatments, and clinical outcomes among women with stage 0-III PABC diagnosed between 1992 and 2020. Comparisons were made between women who were diagnosed with PABC during gestation and those who were diagnosed within 12 months postpartum. RESULTS A total of 341 women were identified, with a median age of 36 years (range 25-46). The pregnancy group comprised 119 (35%) women, while 222 (65%) women made up the postpartum group. Clinicopathologic features were similar between groups, with most patients being parous and presenting with stage I and II disease. Treatment delays were uncommon, with a median time from histologic diagnosis to treatment of 4 weeks for both groups. Recurrence-free survival was similar between groups: 67% at 10 years for both. While 10-year overall survival appeared higher in the postpartum group (83% versus 78%, p = 0.02), only the presence of nodal metastases was associated with an increased risk of death (hazard ratio 5.61, 95% CI 2.20-14.3, p < 0.001), whereas timing of diagnosis and receptor profile did not reach statistical significance. CONCLUSION Clinicopathologic features of women with PABC are similar regardless of timing of diagnosis. While 10-year recurrence-free survival is similar between groups, 10-year overall survival is higher among women diagnosed postpartum; however, timing of diagnosis may not be the driving factor in determining survival outcomes.
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Affiliation(s)
- Angelena Crown
- Department of Breast Surgery, True Family Women's Cancer Center, Swedish Cancer Institute, Seattle, WA, USA
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Damian McCartan
- Department of Breast Surgery, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Michael A Curry
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sabrina Kamer
- Department of Obstetrics and Gynecology, Albany Medical Center, Albany, NY, USA
| | - Shari Goldfarb
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Van Assche IA, Lemiere J, Amant F, Van Calsteren K. Direct and indirect effects on child neurocognitive development when maternal cancer is diagnosed during pregnancy: What do we know so far? Crit Rev Oncol Hematol 2022; 179:103824. [PMID: 36174901 DOI: 10.1016/j.critrevonc.2022.103824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/23/2022] [Accepted: 09/23/2022] [Indexed: 11/25/2022] Open
Abstract
Cancer during pregnancy threatens the lives of mother and foetus and its incidence is rising, making it an emerging medical challenge. Evidence on the direct impact of cancer therapies on neonatal outcomes resulted in general guidelines for maternal treatment that safeguards foetal development. Less focus has been placed on indirect factors, in pre- and postnatal periods, that may exert long-term impacts specifically on child neurocognition. Foetal development, in the context of maternal cancer during pregnancy, may be influenced directly by exposure to cancer diagnostics and (co-)treatment, or indirectly through maternal inflammation, malnutrition, hormonal fluctuations, prematurity, and psycho-biological stress. Maternal stress and insecure mother-infant bonding related to postpartum cancer treatment may further impact child cognitive-behavioural development. Understanding the independent and synergistic effects of the factors impacting neurocognitive development creates the opportunity to intervene during the oncological treatment to improve the child's long-term outcome, both by medical and psychosocial care and support.
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Affiliation(s)
- Indra A Van Assche
- Department of Development and Regeneration: Woman and Child, KU Leuven, Belgium.
| | - Jurgen Lemiere
- Department of Oncology: Pediatric Oncology, KU Leuven, Belgium; Department of Pediatrics: Pediatric Hemato-Oncology, University Hospitals Leuven, Belgium.
| | - Frédéric Amant
- Department of Oncology: Gynaecological Oncology, KU Leuven, Belgium; Department of Obstetrics and Gynaecology: Gynaecological Oncology, University Hospitals Leuven, Belgium; Center for Gynaecologic Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | - Kristel Van Calsteren
- Department of Development and Regeneration: Woman and Child, KU Leuven, Belgium; Department of Obstetrics and Gynaecology: Foetomaternal Medicine, University Hospitals Leuven, Belgium.
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Sella T, Exman P, Ren S, Freret TS, Economy KE, Chen WY, Parsons HA, Lin NU, Moy B, Tung NM, Partridge AH, Tayob N, Mayer EL. Outcomes after treatment of breast cancer during pregnancy including taxanes and/or granulocyte colony-stimulating factor use: findings from a multi-institutional retrospective analysis. Breast Cancer Res Treat 2022; 194:597-606. [PMID: 35715538 DOI: 10.1007/s10549-022-06621-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 04/30/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Guidelines support comparable treatment for women diagnosed with breast cancer during pregnancy (PrBC) and nonpregnant women with limited case-specific modifications to ensure maternal-fetal safety. Experience during pregnancy with modern agents, such as taxanes or granulocyte colony-stimulating factors (GCSF), is limited. PATIENTS AND METHODS We retrospectively identified a multi-institutional cohort of PrBC between 1996 and 2020. Propensity score analyses with multiple imputation for missing variables were applied to determine the associations between chemotherapy exposures during pregnancy, with or without taxanes or GCSF, and a compound maternal-fetal outcome including spontaneous preterm birth, preterm premature rupture of membranes, chorioamnionitis, small for gestational age newborns, congenital malformation, or 5-min Apgar score < 7. RESULTS Among 139 PrBC pregnancies, 82 (59.0%) were exposed to chemotherapy, including 26 (31.7%) to taxane and 18 (22.0%) to GCSF. Chemotherapy use, in general, and inclusion of taxane and/or GCSF, specifically, increased over time. Pregnancies resulting in live singleton births (n = 123) and exposed to chemotherapy were as likely to reach term as those that were not (59.5% vs. 63.6%, respectively, punadjusted = 0.85). Among women treated with chemotherapy, propensity score-matched odds ratios (OR) for the composite maternal-fetal outcome were not significantly increased with taxane (OR 1.24, 95% CI 0.27-5.72) or GCSF (OR 2.11, 95% confidence interval (CI) 0.48-9.22) with similar effects in multiple imputation and sensitivity models. CONCLUSION The judicious increased use of taxane chemotherapy and/or growth factor support during pregnancy was not associated with unfavorable short-term maternal-fetal outcomes. While these findings are reassuring, case numbers remain limited and continued surveillance of these patients and progeny is warranted.
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Affiliation(s)
- Tal Sella
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
| | - Pedro Exman
- Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - Siyang Ren
- Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Taylor S Freret
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Katherine E Economy
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Wendy Y Chen
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
| | - Heather A Parsons
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
| | - Beverly Moy
- Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Nadine M Tung
- Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
| | - Nabihah Tayob
- Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Erica L Mayer
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA.
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Najafi S, Ansari M, Kaveh V, Haghighat S. Comparing the efficacy and side-effects of PDLASTA® (Pegfilgrastim) with PDGRASTIM® (Filgrastim) in breast cancer patients: a non-inferiority randomized clinical trial. BMC Cancer 2021; 21:454. [PMID: 33892670 PMCID: PMC8066442 DOI: 10.1186/s12885-021-08197-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 04/15/2021] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND The objective of this study was to compare the efficacy and side effects of a single dose (Pegfilgrastim or PDL) or repeated six daily injections (Filgrastim or PDG) during chemotherapy courses in breast cancer patients in a non-inferiority clinical trial. METHODS In this randomized clinical trial, 80 patients were recruited and allocated randomly to two equal arms. In one group, a single subcutaneous dose of PDL was injected the day after receiving the chemotherapy regimen in each cycle. The second arm received a subcutaneous injection of PDG for six consecutive days in each cycle of treatment. The side effects of GCF treatment and its effect on blood parameters were compared in each cycle and during eight cycles of chemotherapy. RESULTS Hematologic parameters showed no significant differences in any of the treatment courses between the two study groups. The comparison of WBC (p = 0.527), Hgb (p = 0.075), Platelet (p = 0.819), Neutrophil (p = 0.575), Lymphocyte (p = 705) and ANC (p = 0.675) changes during the eight courses of treatment also revealed no statistically significant difference between the two study groups. Side effects including headache, injection site reaction and muscle pain had a lower frequency in patients receiving PDL drugs. CONCLUSION It seems that PDL is non-inferior in efficacy and also less toxic than PDG. Since PDL can be administered in a single dose and is also less costly, it can be regarded as a cost-effective drug for the treatment of chemotherapy-induced neutropenia. TRIAL REGISTRATION IRCT20190504043465N1 , May 2019.
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Affiliation(s)
- Safa Najafi
- Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran
| | - Maryam Ansari
- Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran
| | - Vahid Kaveh
- Department of Hematology and Medical Oncology, Firoozgar Hospital, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Shahpar Haghighat
- Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran.
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Berends C, Maggen C, Lok CAR, van Gerwen M, Boere IA, Wolters VERA, Van Calsteren K, Segers H, van den Heuvel-Eibrink MM, Painter RC, Gziri MM, Amant F. Maternal and Neonatal Outcome after the Use of G-CSF for Cancer Treatment during Pregnancy. Cancers (Basel) 2021; 13:cancers13061214. [PMID: 33802196 PMCID: PMC8001066 DOI: 10.3390/cancers13061214] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/17/2021] [Accepted: 03/08/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Treatment of pregnant cancer patients should adhere as much as possible to standard treatment protocols in order to safeguard maternal prognosis. The use of Granulocyte colony-stimulating factor (G-CSF) can be indicated for dose dense chemotherapy in high risk breast cancer patients or for the treatment or prevention of neutropenic fever, which can be an important threat for maternal and fetal survival. However, as evidence is still scarce, physicians are still reluctant to the use of G-CSF during pregnancy. In this series, the International Network of Cancer, Infertility and Pregnancy (INCIP) reports on 42 pregnant patients who received G-CSF during oncological treatment. Reported maternal and neonatal complications are acceptable; however, a continuous evaluation of clinical practice is necessary as the limited data in numbers and follow-up do not allow robust conclusions. Abstract Data on the use of Granulocyte colony-stimulating factor (G-CSF) in pregnant cancer patients are scarce. The International Network of Cancer, Infertility and Pregnancy (INCIP) reviewed data of pregnant patients treated with chemotherapy and G-CSF, and their offspring. Among 2083 registered patients, 42 pregnant patients received G-CSF for the following indications: recent chemotherapy induced febrile neutropenia (5; 12%), dose dense chemotherapy (28, 67%), poly chemotherapy (7, 17%), or prevention of neutropenia at delivery (2; 5%). Among 24 women receiving dose dense chemotherapy, three (13%) patients recovered from asymptomatic neutropenia within 5 days. One patient developed pancytopenia following polychemotherapy after which the pregnancy was complicated by chorioamnionitis and intrauterine death. Nineteen singleton livebirths (49%) were born preterm. Sixteen neonates (41%) were admitted to the Neonatal Intensive care Unit (NICU). No neonatal neutropenia occurred. Two neonates had congenital malformations. Out of 21 children in follow-up, there were four children with a motor development delay and two premature infants had a delay in cognitive development. In conclusion, the rate of maternal and neonatal complications are similar to those described in (pregnant) women treated with chemotherapy. Due to small numbers and limited follow-up, rare or delayed effects among offspring exposed to G-CSF in utero cannot be ruled out yet.
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Affiliation(s)
- Claudia Berends
- Center for Gynecological Oncology Amsterdam, Antoni van Leeuwenhoek—Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; (C.B.); (C.A.R.L.); (M.v.G.); (V.E.R.A.W.)
| | - Charlotte Maggen
- Department of Oncology, KU Leuven, 3000 Leuven, Belgium;
- Department of Obstetrics and Prenatal Medicine, Vrije Universiteit Brussel (VUB), University Hospital of Brussels, 1090 Brussels, Belgium
| | - Christianne A. R. Lok
- Center for Gynecological Oncology Amsterdam, Antoni van Leeuwenhoek—Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; (C.B.); (C.A.R.L.); (M.v.G.); (V.E.R.A.W.)
| | - Mathilde van Gerwen
- Center for Gynecological Oncology Amsterdam, Antoni van Leeuwenhoek—Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; (C.B.); (C.A.R.L.); (M.v.G.); (V.E.R.A.W.)
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands;
| | - Ingrid A. Boere
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands;
| | - Vera E. R. A. Wolters
- Center for Gynecological Oncology Amsterdam, Antoni van Leeuwenhoek—Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; (C.B.); (C.A.R.L.); (M.v.G.); (V.E.R.A.W.)
| | - Kristel Van Calsteren
- Department of Obstetrics and Gynecology, University Hospitals Leuven, 3000 Leuven, Belgium;
- Department of Development and Regeneration—Unit Woman and Child, KU Leuven, 3000 Leuven, Belgium
| | - Heidi Segers
- Department of Pediatric Hemato-Oncology, UZ Leuven, 3000 Leuven, Belgium;
| | | | - Rebecca C. Painter
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, Amsterdam Reproduction and Development, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands;
| | - Mina Mhallem Gziri
- Department of Obstetrics, Cliniques Universitaires St Luc, UCL, 1200 Sint-Lambrechts-Woluwe, Belgium;
| | - Frédéric Amant
- Center for Gynecological Oncology Amsterdam, Antoni van Leeuwenhoek—Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; (C.B.); (C.A.R.L.); (M.v.G.); (V.E.R.A.W.)
- Department of Oncology, KU Leuven, 3000 Leuven, Belgium;
- Center for Gynecological Oncology Amsterdam, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-20-512-29-75
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Wolters V, Heimovaara J, Maggen C, Cardonick E, Boere I, Lenaerts L, Amant F. Management of pregnancy in women with cancer. Int J Gynecol Cancer 2021; 31:314-322. [PMID: 33649001 PMCID: PMC7925815 DOI: 10.1136/ijgc-2020-001776] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 01/04/2023] Open
Abstract
As the incidence of cancer in pregnancy has been increasing in recent decades, more specialists are confronted with a complex oncologic–obstetric decision-making process. With the establishment of (inter)national registries, including the International Network on Cancer, Infertility and Pregnancy, and an increasing number of smaller cohort studies, more evidence on the management of cancer during pregnancy is available. As fetal, neonatal, and short-term pediatric outcomes after cancer treatment are reassuring, more women receive treatment during pregnancy. Prenatal treatment should adhere to standard treatment as much as possible to optimize maternal prognosis, always taking into account fetal well-being. In order to guarantee the optimal treatment for both mother and child, a multidisciplinary team of specialists with expertise should be involved. Apart from oncologic treatment, a well-considered obstetric and perinatal management plan discussed with the future parents is crucial. Results of non-invasive prenatal testing are inconclusive in women with cancer and alternatives for prenatal anomaly screening should be used. Especially in women treated with chemotherapy, serial ultrasounds are strongly recommended to follow-up fetal growth and cervical length. After birth, a neonatal assessment allows the identification of any cancer or treatment-related adverse events. In addition, placental histologic examination aims to assess the fetal risk of metastasis, especially in women with malignant melanoma or metastatic disease. Breastfeeding is discouraged when systemic treatment needs to be continued after birth. At least a 3-week interval between the last treatment and nursing is recommended to prevent any treatment-induced neonatal effects from most non-platinum chemotherapeutic agents.
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Affiliation(s)
- Vera Wolters
- Department of Gynecology, Antoni van Leeuwenhoek Nederlands Kanker Instituut, Amsterdam, The Netherlands
| | | | - Charlotte Maggen
- Department of Obstetrics and Gynecology, University Hospitals Leuven and Department of Oncology, KU Leuven, Leuven, Belgium
| | - Elyce Cardonick
- Department of Obstetrics and Gynecology, Cooper University Health Care, Camden, New Jersey, USA
| | - Ingrid Boere
- Department of Medical Oncology, Erasmus MC Cancer Centre, Rotterdam, The Netherlands
| | | | - Frédéric Amant
- Department of Gynecology, Antoni van Leeuwenhoek Nederlands Kanker Instituut, Amsterdam, The Netherlands .,Department of Oncology, KU Leuven, Leuven, Belgium
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Zagouri F, Dedes N, Papatheodoridi A, Liontos M, Dimopoulos MA. Supportive medication in cancer during pregnancy. BMC Pregnancy Childbirth 2020; 20:747. [PMID: 33261562 PMCID: PMC7706269 DOI: 10.1186/s12884-020-03432-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 11/16/2020] [Indexed: 02/08/2023] Open
Abstract
While pregnancy-related malignancies are quite rare, their incidence is increasing and thus affecting more and more women nowadays. Their management, however, with both chemotherapy and supportive agents remains quite challenging and it seems crucial to define the optimal treatment for this special population. Concerning supportive medication, it is clinically significant to determine whether commonly used agents, including Granulocyte Colony-Stimulating Factors, Erythropoiesis-stimulating agents, Bisphosphonates, Anticoagulation agents, Antiemetics and Glucocorticoids are indeed effective in ameliorating chemotherapy side effects. Meanwhile, it is of great importance that the administration of any of these agents is safe for both mother and fetus. This review aims to provide a précis of the current literature regarding both safety and efficacy of all categories of supportive medication during pregnancy.
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Affiliation(s)
- Flora Zagouri
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece.
| | - Nikolaos Dedes
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece
| | - Alkistis Papatheodoridi
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece
| | - Michael Liontos
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece
| | - Meletios Athanasios Dimopoulos
- Haematology - Oncology Unit, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Vasilissis Sofias 80, 11528, Athens, Greece
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Lee GE, Rosenberg SM, Mayer EL, Borges V, Meyer ME, Schapira L, Come SE, Partridge AH. Contemporary management of breast cancer during pregnancy and subsequent lactation in a multicenter cohort of young women with breast cancer. Breast J 2019; 25:1104-1110. [PMID: 31318125 DOI: 10.1111/tbj.13431] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 02/11/2019] [Accepted: 02/11/2019] [Indexed: 01/25/2023]
Abstract
The incidence of breast cancer diagnosed during pregnancy is increasing. We sought to characterize patient, treatment, pregnancy and lactation factors among young women with newly diagnosed breast cancer during pregnancy in a prospective cohort study. We identified all women who were pregnant when diagnosed with invasive breast cancer among those enrolled in the Young Women's Breast Cancer Study (NCT01468246), and collected details on pregnancy, birth and lactation from surveys, and treatment information medical record review. Of 1302 enrolled participants, 976 women with invasive breast cancer completed full baseline surveys, among whom 39 (4.0%) patients reported being pregnant at diagnosis. Median age at diagnosis was 34 years (range: 25-40), with stage distribution: I, 28%; II, 44%; III, 23%; and IV, 5%. 74% of patients (29/39) had grade 3 tumors, 59% (23/39) ER-positive, and 31% (12/39) HER2-positive disease. 23 (59%) had surgery during pregnancy, 4 (17%) during the first trimester. Among the women who had surgery during pregnancy, 61% (14/23) underwent lumpectomy, 35% (8/23) unilateral, and 4% (1/23) bilateral mastectomy. All patients who had chemotherapy (51%, 20/39) received it in second and third trimesters, and had ACx4. There were 31 live births, 2 spontaneous, and 5 therapeutic abortions. Among live births, 16 (41%) were before 37 weeks of gestation. Three women reported breastfeeding. Within 6 months after delivery, comprehensive staging in 13 patients showed upstaging in four patients. In a contemporary cohort of young women with breast cancer, pregnancy at diagnosis is relatively uncommon. Treatment during pregnancy can generally be consistent with standard surgical and chemotherapy approaches, with attention to timing of therapies. Longer-term outcomes including effects of some timing issues including delayed use of anti-HER2 therapy on patient outcomes warrant further research.
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Affiliation(s)
- Guek Eng Lee
- Medical Oncology, National Cancer Centre Singapore (NCCS), Singapore
| | | | - Erica L Mayer
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Virginia Borges
- School of Medicine, University of Colorado, Denver, Colorado
| | - Meghan E Meyer
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lidia Schapira
- Department of Medicine, Stanford University Medical Center, Palo Alto, California
| | - Steven E Come
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ann H Partridge
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Rojas KE, Bilbro N, Manasseh DM, Borgen PI. A Review of Pregnancy-Associated Breast Cancer: Diagnosis, Local and Systemic Treatment, and Prognosis. J Womens Health (Larchmt) 2018; 28:778-784. [PMID: 30481102 DOI: 10.1089/jwh.2018.7264] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The incidence of pregnancy-associated breast cancer (PABC) increases as more women choose to delay childbearing and the population-based incidence of breast cancer rises. Reliably and safely staging PABC is necessary to choose between starting with local or systemic therapy. With regard to local therapy, both lumpectomy and mastectomy can be considered depending on gestational age and the stage at diagnosis. By mirroring nonpregnant treatment regimens as much as possible, chemotherapy may improve long-term oncologic outcomes while allowing for surgical downstaging during pregnancy. Delaying treatment due to misconceptions regarding risk of local and systemic therapy most certainly worsens oncologic outcomes, and most neonatal morbidity is related to gestational age at delivery and not in utero exposures. Pregnancy itself was once considered an independent risk factor for worse outcome, but the prognosis of these patients is not significantly different than nonpregnant counterparts of a similar age.
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Affiliation(s)
- Kristin E Rojas
- Department of Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Nicole Bilbro
- Department of Surgery, Maimonides Medical Center, Brooklyn, New York
| | | | - Patrick I Borgen
- Department of Surgery, Maimonides Medical Center, Brooklyn, New York
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11
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Vallurupalli M, Partridge AH, Mayer EL. Treatment of Breast Cancer During Pregnancy. CURRENT BREAST CANCER REPORTS 2017. [DOI: 10.1007/s12609-017-0256-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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12
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Abstract
PURPOSE OF REVIEW Cancer in pregnancy has become increasingly frequent. It has become clear that for specific cancers under well defined circumstances, oncological treatment in pregnancy can be well tolerated and feasible for both mother and fetus. Continued critical assessment of the available literature and registration of cancer in pregnancy cases and outcomes for mother and child are necessary to work toward implementing optimal cancer treatment during pregnancy. RECENT FINDINGS Physiologic changes in pregnancy may alter distribution and efficacy of systemic therapy. Data on systemic therapy including, chemotherapy, hormonal therapy, and targeted therapy during pregnancy are available but incomplete. Outcomes of fetuses exposed to chemotherapy in utero are generally reassuring, but new targeted therapies are mostly discouraged in pregnancy. SUMMARY Cancer treatment during pregnancy is possible, depending on type and timing of systemic therapy and treatment modality. Available data are reassuring with a modest increase in complications such as growth restriction and preterm birth. The effect of new targeted therapies is often still unclear and therefore discouraged.
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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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Loibl S, Schmidt A, Gentilini OD, Kaufman B, Kuhl C, Denkert C, von Minckwitz G, Parokonnaya A, Stensheim H, Thomssen C, van Calsteren K, Poortmans P, Berveiller P, Markert U, Amant F. Breast Cancer (Diagnosed) During Pregnancy: Adapting Recent Advances in Breast Cancer Care for Pregnant Patients. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_59] [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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15
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Treatment with granulocyte colony-stimulating factor in patients with repetitive implantation failures and/or recurrent spontaneous abortions. J Reprod Immunol 2015; 108:123-35. [DOI: 10.1016/j.jri.2015.01.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 01/07/2015] [Accepted: 01/27/2015] [Indexed: 11/17/2022]
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Maternal and neonatal outcomes of dose-dense chemotherapy for breast cancer in pregnancy. Obstet Gynecol 2013; 120:1267-72. [PMID: 23168749 DOI: 10.1097/aog.0b013e31826c32d9] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate the effect of dose-dense chemotherapy during pregnancy on maternal and neonatal outcomes. METHODS This is a retrospective cohort study in which women were identified from the international Cancer and Pregnancy Registry at Cooper Medical School at Rowan University in Camden, New Jersey. A chart analysis was completed and Fisher's exact test and independent t test were used in comparing patient outcomes. RESULTS Ten women received dose-dense chemotherapy, received every 2 weeks, and 99 women received conventional chemotherapy, received with at least 3-week intervals, for breast cancer during pregnancy. Birth weight, gestational age at delivery, rate of growth restriction, congenital anomalies, and incidence of maternal and neonatal neutropenia were not statistically different between the two groups. CONCLUSION In the small cohort of women in our registry, dose-dense chemotherapy does not appear to increase the risk of fetal or maternal complications.
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Cardonick E, Gilmandyar D, Somer RA. Maternal and Neonatal Outcomes of Dose-Dense Chemotherapy for Breast Cancer in Pregnancy. Obstet Gynecol 2012. [DOI: http:/10.1097/aog.0b013e31826c32d9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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