From OncoLog, January 2004, Vol. 49, No. 1
DiaLog: Treating Breast Cancer during Pregnancy
by
Karin M.E.H. Gwyn, M.D., Assistant Professor
Richard L. Theriault, D.O., Professor
Department of Breast Medical Oncology
Since 1989, more
than 50 pregnant women with breast cancer—the largest known prospective
cohort—have been enrolled in a treatment protocol at M. D. Anderson Cancer Center. What follows is a summary of what we have learned.
A review of our experience found mammography (with abdominal shielding)
and breast ultrasonography in pregnant women to be quite effective at
diagnosing abnormalities and assessing the extent of local disease. A
core biopsy of the lesion is the method we most commonly use to diagnose
invasive breast cancer. These biopsies should be interpreted by a pathologist
familiar with the changes that occur in the breast during pregnancy.
Patients with clinically advanced breast cancer should be evaluated for
metastatic disease. Our approach is a chest X-ray (with abdominal shielding),
ultrasonography of the liver, and magnetic resonance imaging, without
contrast, of the spine after the first trimester. Because of concerns
about radiation exposure, we try to avoid using computed tomography and
bone scans.
Treating a pregnant woman with breast cancer requires a team of professionals
that includes specialists in maternal and fetal health. Ultrasonography
is used to determine fetal age and development and the expected date of
delivery because they have a significant impact on treatment planning.
Breast surgery can usually be performed with minimal risk to the fetus.
The radiation therapy required to complete breast conservation surgery
is contraindicated during pregnancy, although breast conservation is possible
in women who are diagnosed in the third trimester or whose cancer warrants
preoperative chemotherapy.
The indications for systemic therapy are the same as those in a nonpregnant
patient. We believe that combination chemotherapy with 5-fluorouracil,
doxorubicin, and cyclophosphamide is generally safe in the second and
third trimesters. We avoid chemotherapy during the first trimester because
the risk of fetal exposure is too high. We also avoid the use of methotrexate,
an abortifactant, and we do not use taxanes or tamoxifen because their
safety in pregnant patients has not been established.
The limited data available do not support the belief that pregnancy termination
improves the survival of patients with breast cancer. However, in cases
of known or suspected fetal teratogenesis or if maternal health is in
jeopardy, it may be appropriate.
We continue to evaluate and treat pregnant women with breast cancer as
part of our ongoing clinical protocol and to follow up on both our patients
and their children to determine the effectiveness of therapy as well as
the long-term effects of in utero chemotherapy exposure.
For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789.
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